Download Psychological Well Being of Child and Adolescent Refugee

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ychological Well Being of Child and Adolescent Refugee and Asylum Seekers:
verview of Major Research Findings of the Past Ten Years
epared 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
stract
s paper outlines major international research findings of the past ten years reflecting knowledge gathered about t
ychological health of child and adolescent refugee/asylum seekers. In doing so, several key areas of consistency
e identified. First, with the majority of research in this area centered on the prevalence of psychopathology, and
rticularly post-traumatic stress symptoms, it has been clearly demonstrated that refugee children and adolescents
e vulnerable to the effects of pre-migration, most notably exposure to trauma. Second, particular groups in this
pulation constitute higher psychological risk than others, namely those with extended trauma experience,
accompanied or separated children and adolescents, and those engaged in the uncertain process of sought
ylum. Third, certain risk and protective factors appear to exist that temper or aggravate poor psychological health.
ese include family cohesion, parental psychological health, individual dispositional factors such as adaptability,
mperament and positive self-esteem, and environmental factors such as peer and community support.
e research is less clear however in a number of areas. These include the mechanisms by which risk and protectiv
tors exacerbate and temper the effects of trauma and migration experience, as well as the role of culture as a
diator in the experience of trauma and migration.
spite being a perennial issue, circumstances of irregular migration across the world have only recently impelled
ychological interest into the mental health of refugee and asylum seekers. The Office of the United Nations High
mmissioner for Refugees (UNHCR) estimates that there are 22.3 million refugees worldwide. A refugee is someo
o "owing to well founded fear of being persecuted for reasons of race, religion, nationality or membership of a
rticular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fea
unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside that
untry of his former habitual residence as a result of such events, owing to such fear, is unwilling to return to it"
ticle 1A(2), Convention relating to the Status of Refugees (1951)). This definition is contrasted with that of an
ylum seeker, whose status as a refugee is yet to be formally determined by the host society (Human Rights and
ual Opportunity Commission, 2001). More importantly, these definitions are to be differentiated from that of an
onomic migrant whose mobilisation is voluntary and primarily motivated by improved material circumstances as
posed to human rights and safety (Morrow, 1994).
hile there is considerable and growing literature in the mental health of adult refugee/asylum seekers, current
earch acknowledges a lack of understanding in the mental health of child and adolescent refugee/asylum seeker
ybdahl, 2001; Hicks, Lalonde & Pepler, 1993; Hyman, Vu & Beiser, 2000). This is particularly the case regarding t
ntal health of child and adolescent refugee/asylum seekers in detention. This is surprising given that as many as
f the world's refugee population is comprised of children and adolescents (Cole, 1998). Such limited investigation
wever, may in part be due to the difficulties associated with population access, systematic sampling, cultural and
guage barriers, limited cross culturally validated measurement techniques, and wariness of parents and participa
rust researchers (Richman, 1993; Silove, Sinnerbrink, Field, Manicavasagar & Steel, 1997).
ough not all refugee and asylum seeking children and adolescents are subjected to these circumstances, experie
en claimed to be encountered by them include the violent death of a parent, injury/torture towards a family membe
ness of murder/massacre, terrorist attack(s), child-soldier activity, bombardments and shelling, detention, beating
d/or physical injury, disability inflicted by violence, sexual assault, disappearance of family members/friends, witne
rental fear and panic, famine, forcible eviction, separation and forced migration (Burnett & Peel, 2001; Davies & W
00).
her forms of trauma might include the endurance of political oppression, harassment and deprivation of human
hts and education (Burnett & Peel, 2001). Such experiences not only make refugee/asylum seeking populations
erogeneous, they also create vulnerability in children and adolescents due to their incomplete biopsychosocial
velopment, dependency, inability to understand certain life events (Kocijan-Hercigonja, Rijavec & Hercigonja, 199
d underdevelopment of coping skills (Ajdukovic & Ajdukovic, 1993).
s summary outlines major international research findings of the past ten years reflecting knowledge gathered abo
psychological health and well-being of child and adolescent refugee/asylum seekers. It incorporates a search of
rature from the psychINFO, Medline, BioMedNet, Academic Research Library, EBSCO, Proquest, Science Direct
d Wiley-Interscience databases using criteria restricted to articles from 1990 to date and in the English language.
arch terms included single and combined forms of the following descriptors: refugee camp, refugee detention,
prisonment, child and/or adolescent refugee, asylum seeker, displacement, Australia, development, long term
ects, long term stress, post-traumatic stress, stress, psychopathology, mental health, psychiatric effects and
ychological well being.
e review is divided into major sections of studied areas in the literature, namely post-traumatic stress disorder
TSD), co-existence of several symptoms and disorders (a term that broadly means serious problems), and risk
lnerability) and protective (resilience) factors at both pre- and post- migration phases. It should be noted that this
per does not aim to provide an exhaustive discussion of theoretical issues, methodological considerations (e.g.,
oblems in retrospective data collection) or treatment issues, but rather to highlight major findings and conclusions
s research. It should also be noted that the paucity of research in child and adolescent refugee/asylum seekers
cessitates at times reference to knowledge from adult populations. Where such reference is made, caution should
taken to avoid overgeneralisation of these findings to this new risk population of children and adolescents.
jor Research Findings
ost Traumatic Stress Disorder and Symptomology
ven that war and political violence are major causes of forced migration, many child and adolescent refugee and
ylum seekers migrate with a history of traumatic stress exposure (Almqvist & Brandell-Forsberg, 1997).
estigations directed at the evaluation of the impact of trauma on psychological well being in these groups have
edominantly focused on the prevalence of Post Traumatic Stress Disorder (PTSD) and/or its symptomology
chman, 1993; Weine, 2002).
st Traumatic Stress Disorder (PTSD) refers to a configuration of symptoms experienced after a traumatic event an
classified as an anxiety disorder, which may in nature be acute or chronic, and of short or long term duration
unningham & Cunningham, 1997).
ildren and adolescents who present with PTSD may exhibit symptoms of confused and disordered memory about
ents, repetitive play themes related to trauma, personality change, imitation of violent behaviour and pessimistic
pectations regarding survival (Hicks et al., 1993). Although symptoms vary across age groups, in preschoolers, th
e generally manifested in very high anxiety, social withdrawal and regressive behaviours. In school-aged children,
mptoms can include flashbacks, exaggerated startle responses, poor concentration, sleep disturbance, complaints
physical discomfort and conduct problems. In adolescents, symptoms may include acting out, aggressive
haviours, delinquency, nightmares, trauma and guilt over one's own survival (Hicks et al., 1993).
spite controversy surrounding the application of PTSD to refugee/asylum seeking children and adolescents (e.g.,
diagnostic approach 'medicalises' and 'westernises' emotional disturbance and 'pathologises' perfectly normal
actions to abnormal situations), investigations across various countries have shown that trauma symptomology is
mmon in refugee children and adolescents (Ajdukovic & Ajdukovic, 1993; Hjern, Angel, & Hoejer, 1991; Kinzie,
ck, Angell, Manson & Ben, 1986; Mollica, Poole, Son, Murray & Tor, 1997; Sack, Clarke & Seeley, 1996; Sack,
eley & Clarke, 1997).
hile the nature and extent of trauma exposure varies cross culturally, and from direct to indirect and single to
peated events, studies particularly document the prevalence of post-traumatic stress symptomology. Though not
nducted within the last ten years, the pioneering work of Kinzie et al. (1986) is cited frequently throughout the rece
rature. In this classical study, these authors interviewed 46 Cambodian refugees aged between 14-20, all of who
re exposed between the ages of 8-12 to starvation, separation, beatings and executions. Almost half of these
bjects having been exposed to trauma, exhibited PTSD symptoms alongside less effective adaptation, which was
nsidered to be within clinical range.
a larger study with 209 Cambodians aged between 13-25 resettled in the United States, Sack and colleagues
994) found an 18% prevalence rate of PTSD and an 11% rate of depressive disorder in their participants. High rat
psychiatric disorder were also observed in participants' parents, with 53% of mothers reporting symptoms consiste
h a PTSD diagnosis, and 23% with a diagnosis of depression. Amongst fathers of this sample, 29% indicated PTS
mptomology and 14% indicated depression.
amining the case records of 191 clients presenting for service and treatment at a torture and trauma rehabilitation
ntre in Australia, Cunningham and Cunningham (1997) identified patterns of torture and trauma experience and
mptomology. Of the six core patterns of symptomology revealed in the analysis, PTSD symptoms featured most
minantly. Saigh (1991) similarly administered the children's PTSD inventory to 840 Lebanese children aged
ween 9-12 living in Beirut. While violent traumatic exposure varied from direct to indirect among children, no
mparable differences were observed in PTSD scores. In all, 27% of these children met PTSD criteria, supporting t
w that children can be traumatised in numerous ways (Berman, 2001).
e relationship between trauma exposure and PTSD symptomology however is not confined to South East Asian a
banese children (Kinzie et al., 1986; 1989; Macksoud & Aber, 1996; Sack et al., 1994). Over recent years, such
dings have been established cross culturally among children and youth from regions such as:
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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).
hough studies have consistently linked trauma symptomology with the experience of trauma related events, which
e usually attributed to organised violence and war, fewer investigators have attempted to relate exposure to a
gnosis for PTSD. Hence, the focus on symptomology renders it unclear as to whether a complete diagnosis can b
plied to trauma experience (Green, et al., 1991). The implications of such issues are important to consider given t
sition of those seeking formal refugee status. Notwithstanding, Almqvist and Brandell-Forsberg (1997) are among
w researchers to demonstrate effectively the applicability of PTSD criteria to symptomology expressed in children.
milar diagnoses have been demonstrated by Schwarz and Kowalski (1991a).
e controversy noted throughout the literature relating to refugee children and adolescents and PTSD is whether it
totality of exposure to war related stress that is harmful, or whether in fact trauma responses are dependent on t
ure, type, amount and duration of exposure to stress (Athey & Ahearn 1991; Jensen & Shaw, 1993, cited in
rman, 2001; Mghir et al., 1995). Reviews of such studies indicate evidence for the suggestion that the greater the
ure and extent of exposure, the poorer one's psychological outcome in terms of onset and severity of PTSD
mptoms (Espino, 1991; Papageorgiou et al., 2000).
tending their diagnostic approach to trauma symptomology, Almqvist and Brandell-Forsberg (1997) also
estigated whether the amount of trauma exposure is related to the prevalence and stability of PTSD over time.
hilst finding it is possible to diagnose PTSD during initial stages of assessment and one year later, these authors
o found that one fifth of children directly exposed to organised violence and persecution (e.g., through assault on
rents or bomb attacks within 50 metres) were at risk for developing chronic states of PTSD.
milarly, though not drawing directly from a refugee but rather displaced and war exposed population, Macksoud an
er (1996) examined the relationship between the number and type of war traumas and psychosocial development
ong 224 Lebanese children aged between 10-16. Using measures of war exposure, war trauma, mental health,
SD and adaptation, these investigators assessed ten categories of war exposure. As predicted, the number and
e of traumatic exposure were positively related to PTSD symptoms. Children exposed to multiple traumas (e.g.,
elling, combat) and those who were bereaved, victimised by or had witnessed violent acts, showed more PTSD
mptoms than those who had not witnessed such acts. Moreover, depressive symptoms were more evident in
ldren who had experienced separation from their parents and displacement than those who remained with their
rents.
ding that 34% of adolescent and young adult refugees from Afghanistan met criteria for PTSD, major depression
h, Mghir et al. (1995) similarly demonstrated an association between the presence of these disorders and the tota
mber of events experienced. In her investigation of Khmer adolescent refugees exposed to community violence,
rthold (1995) also noted the impact of multiple traumas before and following resettlement in the US on PTSD.
nnerbrink and colleagues (1997) also examined the relationship between exposure to violence and mental health
come in Khmer adolescents in the USA. A quarter of these subjects partially or fully met criteria for PTSD with the
mber of violent events experienced predicting PTSD and level of functioning. Not only was pre-migration exposure
edictive of PTSD, the number of violent events exposed to across subjects' lifetime (i.e., time in Cambodia and US
o and more strongly predicted PTSD and level of functioning. This finding is noteworthy as it demonstrates the
mulative effect of trauma and its predisposing features to future distress and function (Sinnerbrink et al., 1997).
nigan and colleagues (1991, cited in Almqvist & Brandell-Forsberg, 1997) and Pynoos, Steinberg and Wraith (199
heir investigations of school-aged children have also shown a correlation between the amount of traumatic
posure and PTSD prevalence. The association between severity of exposure in terms of number and proximity of
perienced events and the presence of PTSD in children and adolescents has been supported in different cultures
luding Bosnian (Papageorgiou et al., 2000); Vietnamese (Mollica et al., 1997); Cambodian (Sack, Clarke & Seele
96); Palestinian (Garbarino & Kostelny, 1996; Thalbet & Vostanis, 1999), Middle Eastern (Montgomery, 1998) and
ntral American (Espino, 1991).
far, the studies reviewed have clearly outlined the shorter-term consequences of organised violence and war and
ir resultant traumatic outcomes for children and adolescents from a cross sectional perspective. Little research
wever, has been conducted into the evolution of PTSD symptoms and its long-term development and persistence
ugee/asylum seeking children and adolescents (Punamaki, 2001). The preliminary nature of longitudinal research
s area therefore, has produced equivocal findings. Nevertheless, there are some studies that demonstrate the
rsistence of PTSD symptoms across time.
e work of Kinzie et al. (1986; 1989) represents one of the few attempts to evaluate the persistence of PTSD over
veral years. As discussed earlier, these researchers examined the effects of massive trauma on 40 Cambodian
ugees who had been imprisoned for up to two years in concentration camps during the Pol Pot regime. All subjec
d endured separation from family, forced labour and starvation and many had witnessed killings and other forms o
ture. Four years after leaving Cambodia, up to 50% of subjects developed PTSD. Mild but prolonged, depressive
mptoms were evident in 38% of subjects. Results of a 3-year follow up with 30 of the 40 original subjects revealed
t although depressive symptoms had diminished, 48% of subjects still exhibited symptoms meeting the criteria fo
SD, supporting the notion that traumatic symptoms endure over time. Subjects with poorer PTSD outcomes also
owed poorer social adjustment. Six years following the initial study, 38% of subjects still exhibited PTSD criteria,
ugh there was a reduction in the rate of depression (Sack, Clarke, Him, Dickason, Goff, Lanham & Kinzie, 1993).
elve years after the initial study, 35% of subjects still exhibited criteria for PTSD and 14% had depression (Sack,
m & Dickason, 1999).
ese authors add increasing empirical weight to the idea that PTSD in children and adolescents can persist from
veral up to twelve years. These authors also note however, along with the prevalence of depression, the intensity
SD symptoms tend to diminish over time. Where depression was initially shown to co exist with PTSD symptoms,
pressive symptoms were no longer evident after six years. Such findings are important as they sustain the
oretical argument that PTSD symptoms are distinct from symptoms of depression and are indeed a manifestation
massive trauma, contrary to the result of resettlement stress (Sack et al., 1993; Sack et al., 1995). Despite the
rsistence of PTSD, participants in Sack et al's. (1993) study were generally adaptive. Most, for instance, were abl
pursue some forms of college education. As Kinzie et al. (1990) and Sack (1998) state though, the impact of traum
ikely to affect child development over time resulting in fluctuating symptom profiles of both PTSD and depression.
the more recent studies investigating the long-term consequences of trauma, Almqvist and Broberg (1999)
sessed the prevalence of PTSD in Iranian preschoolers following two and a half years of resettlement in Sweden.
r a fifth of children previously exposed to trauma, PTSD diagnoses remained stable. Supporting the argument tha
SD can be enduring, these authors also remarked on the problem of much research, which relies heavily on
rental interviews for data (Almqvist & Broberg, 1999; Geltman et al., 2000). In their interviews with both children a
rents, a significant difference was observed in the initial investigation, where according to parents, only 2% of
ldren met criteria for PTSD. When the children were interviewed however, 21% met PTSD criteria. That is, parent
re found to underestimate and/or deny symptoms of trauma re-experience in their children, a major criterion for
SD.
ough these findings might be attributable to parents' desires to protect their children, they demonstrate that paren
y also down play the presentation of symptoms in children. This is supported by arguments that PTSD is difficult
serve in young children due to problems in identifying avoidance symptoms, a further criterion of PTSD. Lastly,
cksoud and Aber (1996) and Ahmad et al. (1998) have also observed chronic/continuous PTSD in samples of
banese children exposed to single events in civil war and Iraqi Kurdish children respectively. The high level of PTS
rsistence in the above studies is consistent with general studies regarding children who develop PTSD following
posure to other trauma (McFarlane, 1987, cited in Hodes, 2000). Regarding the long-term effects of trauma, age a
time of traumatic experience does not appear to influence its persistence (Dreman & Cohen, 1990).
hould be noted that disagreement and inconsistencies regarding mental health in refugee populations does exist
spite evidence for poor psychological adaptation (Dybdahl, 2001; Beiser, Dion, Gotowiec, Hyman & Vu, 1995). Of
dies which have produced equivocal findings, Becker, Weine, Vojvoda and McGlashan (1999) investigated the
ychiatric sequelae of Bosnian adolescents after a year of resettlement to assess delayed PTSD onset. Of those
ially diagnosed with PTSD, none met criteria for diagnosis a year later and only one subject not previously
gnosed, displayed PTSD symptomology. Becker et al. (1999) concluded that the diminution of PTSD over time
ght reflect the fact that symptoms are transient and not representative of enduring psychopathology. Hence, while
re is evidence to support the chronic nature of PTSD in refugee children and adolescents, there is also evidence
ggest that such long-term effects may be mediated by other factors. Becker et al. (1999) did nevertheless observe
t the symptoms shown at one year follow up remained similar to the clusters of symptoms observed in their initial
estigation and that Bosnian adolescents had also remained with their parents, potentially offsetting PTSD
mptomology. Indeed, Ajdukovic and Ajdukovic (1998) cautioned that the child's exposure to extreme intense traum
n have delayed effects and can cause difficulties in psychological functioning in adulthood.
indicated above, parental psychological well-being is a key factor in the mental health of child/adolescent refugee
d asylum seekers (Papageorgiou et al., 2000; Sack et al., 1994). Research directed at parental and familial
uences has demonstrated that disorders associated with child and adolescent refugee experiences cluster in
milies. Sack, Clarke and Seeley (1995) for example, interviewed 118 Khmer adolescent refugees and one of their
rents (usually mother). These authors found that the risk for PTSD increased for adolescents when one parent
hibited PTSD. When environmental influences to this relationship such as separation/divorce of parents, therapeu
ervention and socio-economic status were examined, no significant impact was found.
hile such findings may underscore a genetic susceptibility to PTSD (Sack et al., 1995; Hodes, 2000), they also
plicate the role of learning factors in the concurrence of PTSD in children and their parents. Lukman and Bach-
rtensen (1995, cited in Hodes, 2000) provide support to the role of learning factors in PTSD and argue that such
established link between parent and childhood disorder that children of torture victims, who seek asylum in
ettlement countries, may have high levels of emotional and physical symptoms such as stomachache or headach
en when not exposed to the traumatic events themselves. Moreover, parents' own experience of persecution, war
lence, terrorism, powerlessness and exhaustion can compromise their ability to care for their children, increasing
ld/adolescent susceptibility to PTSD and other psychopathology (Sack et al., 1986). Garbarino, Kostelny and
brow (1991) and Richman (1993) further maintain that PTSD can be evident in multiple family members, particula
en marital relations are strained.
e findings observed above are consistent with Green et al. (1991) and Punamaki (2001) who argue that parental
pacity and family cohesion after traumatic exposure are of equal or greater importance in the post-traumatic stres
actions of young children. These authors provide evidence that family dysfunction before exposure may predispos
SD in children and adolescents. Drawing similar conclusions, Arroyo and Eth (1996) found that those children and
olescents in nuclear families were less likely to receive psychiatric diagnoses than those who lived alone or were
tered.
hile psychological problems in the family are significantly related to child psychopathology in refugee children and
olescents, the role of mothers appears to be particularly important as shown by Ajdukovic and Ajdukovic (1993) w
nd that mothers' emotional well-being best predicted emotional well being and adaptation in children.
far, consistent psychological outcomes have been reported in the literature for children and adolescents regardle
heir different experiences, backgrounds and cultures. While these consistencies in the literature are important to
ntify, the specific effects of culture have been largely unexamined across studies. The complex role that culture
ys in the psychological health of child and adolescent refugee and asylum seekers is highlighted by Rousseau,
apeau and Corin (1997). Comparing Central American and South East Asian refugee children, Rousseau et al.
997) showed that the impact of family factors on post-traumatic symptomology is mediated by contextual as well a
tural factors. In Central Americans, greater trauma exposure in families was found to be more related to family
nflict and depression, whereas in South East Asians, increased trauma exposure was found to be associated with
s parental depression.
oyo and Eth (1996) have similarly observed contrasting symptom profiles between Latin American and South Eas
an refugee children, where the former display more prevalent academic and conduct problems. While not
plicated, these differential findings across cultures reflect the need to investigate systematically cultural influences
child and adolescent mental health among the refugee and asylum seeking populations.
Co-existence of several disorders and symptomology
hough the majority of literature lies in the investigation of trauma sequelae and family psychopathology as a
diating and moderating factor of trauma, there have been investigations of other psychological outcomes among
ld and adolescent refugee/asylum seekers. It should be noted in any discussion of psychological problems
wever, that refugee and asylum seeking children and adolescents are more likely to have serious health problems
sociated with malnutrition, disease, physical injuries, brain damage and sexual or physical abuse (Westermeyer,
91). Hence, the influence of these potential health problems cannot be overlooked when considering psychologica
alth and disorder in this population (McCloskey & Southwick, 1996; Westermeyer, 1991).
multaneous presence of more than one disorder associated with PTSD is a common finding in the literature
ncerning the mental health of refugee children and adolescents. For example, Kinzie et al. (1986) noted depressio
d anxiety as problems most commonly associated with PTSD symptomology. Similarly, Hubbard, and colleagues
995) found that the existence of more than one disorder in their sample of 59 Cambodian adolescents and young
ults exposed to trauma as children. Of the 24% of adolescents and young adults that were diagnosed with PTSD,
% of these had at least one additional diagnosis, all being affective and anxiety related.
ing the Child Behavior Checklist (CBCL) [1], Sourander (1998) also found that in addition to PTSD, depression an
xiety were most common among their participants. When interviewed, most children also reported somatic
mplaints, uncertainty about the future and in some cases expressed suicidal thoughts. While the presence of anxi
not surprising given its overlap with PTSD, Clarke et al. (1993, cited in Hodes, 2000) note that depression may
mmonly occur due to ongoing adversity following resettlement.
usignant and colleagues (1999) present the results of a psychiatric epidemiological survey of 203 refugee
olescents aged between 13-19 from 35 different countries resettled in Canada. Using the Diagnostic Interview
sessment Scale [2] and global assessments of general functioning, these authors showed a 10% difference again
ugee adolescents in rates of psychopathology compared to normative data obtained from a province wide survey
ebec adolescents. 21% of participants displayed psychopathology in forms of simple phobia (25%), overanxious
order (13%), depression (5%); conduct disorders (6%) and attempted suicide (3%). Elevated rates of phobia and
eranxious disorder according to these authors were probably due to their association with PTSD. Females display
re psychopathology than boys in this sample with similar ratios evident in the Quebec survey, but neither age at
ival nor cultural differences were found to be significant factors. Despite the high rates of psychopathology when
mpared with a normative population, according to global functioning assessments, these adolescents had good
cial adaptation.
od adaptation following multiple traumas has also been reported by Berthold (1995) and Punamaki (2001). Such
expected findings of positive adaptation imply that while diagnosis does not always suggest severe functional
pairment (Sack, 1995), the changeability of dysfunction does, in fact, demand further investigation into the
chanisms that promote such adjustment.
cijan-Hercigonja, Rijavec and Hercigonja (1998) also investigated the existence of more than one disorder and
ernative problems in refugee and displaced children. They compared three groups of children aged between five
d fourteen. The first group comprised of Muslim refugee children from Bosnia and Herzegovina; the second of
placed children from Croatia and the third of non-displaced local children. Using structured interviews, coping and
ustment measures, self-rating behaviour scales, and anxiety and depression scales, these authors found significa
erences in the prevalence of eating disorders, with displaced children exhibiting more eating disorders than non-
placed and refugee children. Significant differences were also observed in sleeping disorders with more sleep
oblems found in displaced children followed by refugee and non-displaced children. Refugee children used
nificantly fewer coping strategies than displaced and non-displaced children and effectiveness of these strategies
re reported to be greater in displaced and non-displaced children. In terms of adjustment, displaced children were
s satisfied with their present situation than other children. Refugee children also felt generally worse than other
ldren and were less optimistic about the future. Displaced children were lower on anxiety than refugee children,
wever, no differences across the sample on depression measures were found.
hen Kocijan-Hercigonja et al. (1998) compared parent and child assessments, parents did not report their child's
gue, palpitation, breathing problems, trembling or crying, reinforcing earlier suggestions of the importance of
aining data directly from children. Kocijan-Hercigonja et al. (1998) attributed sleeping and eating problems in
placed children to the severity of trauma these children experienced. Furthermore, displaced children tended to
aluate their life at present as worse than others because of difficulties associated with camp life. Elevated anxiety
ugees was attributed to trauma whereas in displaced children, this was attributed to uncertainty in status and the
ure.
all, these findings highlight that children have negative beliefs and expectations about their futures, indicating
ential adjustment problems (Kocijan-Hercigonja et al., 1998). Obradovic and colleagues (1993) similarly
estigated 102 children and young people aged between 8-19 from Bosnia, Herzegovina and Croatia in collective
commodation. 88% reported feeling sadder than before the war, 87% reported being more worried and 62%
ported feeling more tense. Satisfaction from play was reduced in 65% of participants. Of the physical symptoms
ported, all increased following the war and included lack of appetite, disturbed sleep, excessive perspiration,
adaches, respiratory problems and gastric complaints.
heir investigation of varied psychological outcomes, Howard and Hodes (2000) note the distinction between
orders observed from neuropsychiatric origins (i.e., causes attributable to biological functioning) and those from
ychosocial ones (i.e., causes attributable to family and social processes). In their study of problems such as PTSD
nor affective disorders, anxiety, conduct, eating and sleep in three groups of refugee, immigrant and British childre
se researchers found that refugee children received more diagnoses of a psychosocial nature than the other two
oups of participants. While similar social impairment was observed across comparative groups, refugee children
re more isolated and disadvantaged. This tendency to manifest disorders of a psychosocial nature is consistent
h Rousseau, Drapeau and Corin (1996) who found a positive association between learning difficulties, academic
hievement and emotional problems in South East Asian and Central American refugee children in the US.
rthermore, the tendency of traumatised refugee children to report more psychological problems, diagnostic and
erwise (e.g., guilt, uncertainty) has been found to be associated with the occurrence of more daily stressors and
s perceived social support (Paardekooper, 1999). Although the exact rates of disorder and dysfunction tend to va
oss studies and frequently reaches 40% to 50% prevalence, there is nevertheless consensus across studies
estigating PTSD and other psychological problems, which show these rates to be much higher in refugee than no
ugee populations (Hodes, 2001)).
hough evidence is weighted towards PTSD related problems in refugee children and adolescents, some studies
ve nonetheless observed findings that challenge the relationship between trauma experience and stress outcome
ughry and Flouri (2001) for example, investigated the behavioural and emotional problems of 455 former
accompanied refugee children and youth aged between 10 and 22, three to four years after their repatriation to
etnam from refugee centres in Hong Kong and South East Asia. Collecting data using measures of internalising an
ernalising behaviour, self efficacy, trauma and social support, these authors found no differences between age
tched controls who never left Vietnam and repatriated children. Similarly, no differences between the groups were
served for perceived self-efficacy and the number and experience of social support. These authors concluded tha
exposed trauma and experience of living without parents in refugee camps did not lead to increased behavioural
d emotional problems in the immediate years following repatriation.
hile these findings may reflect adaptive capacities despite traumatic experience, they also pose additional question
garding the reliance of PTSD as a single outcome measure. Although alternative outcomes of trauma are currently
ng addressed by research into the presence of accompanying disorders and problems, the differential response t
uma that children and adolescents from different cultures may exhibit has been largely unexplored by research
ousseau, 1995). Equivocal findings in the research nonetheless, warrant further examination of the mediating
iables that are likely to diminish and potentiate adaptive capacity (Beiser, et al, 1995).
Risk (Vulnerability) and Protective (resilience) factors
Pre-Migration Risk and Protective factors
hough the dynamic interplay between various risk and protective factors in refugee psychological health is not full
derstood, there is widespread agreement that of those pre-migration factors that pose serious risk, trauma exposu
he single most identified (Berman, 2001). Alongside the associated existence or absence of parental
ychopathology, trauma has been discussed in detail above. Other major pre-migration risk factors include child
position, environmental factors, as well as individual and family functioning before the traumatic events.
ividual and family functioning before migration have been found to influence psychological outcome in refugee
ldren and adolescents. Almqvist and Broberg (1999) for instance, have suggested that family climate and cohesio
ore and after migration are the best predictors of mental health in children. These claims are supported by Green
(1991), Hicks et al. (1993), Rumbaut (1991) and Thabet and Vostanis (2000) who argue that family dysfunction,
rental incapacity, qualities of family life prior to exposure and resettlement are influential in post-traumatic stress
actions and adjustment in young children.
ychiatric disturbance in refugee children is also related to mental health difficulties experienced by other family
mbers prior to migration. As discussed earlier, parents' experiences of persecution, war violence, terrorism,
werlessness and exhaustion compromise their ability to care for children (Fox et al., 1994; Hicks et al., 1996;
tthey et al., 1999; Miller, 1996; Sack et al., 1986). Ajdukovic and Ajdukovic's (1993) study of the influence of
ternal mental health on children's stress reactions and stress indexes emphasised the emotional and behavioura
te of mothers as major mediators between children's traumatic experience and psychological functioning.
usseau et al. (1997) also argue that while the family enables a child to rediscover safety and security amidst
struction, parental stress on the other hand is conducive to destroying parent-child relationships due to parent
ysical and psychological unavailability.
ongside family and parental factors, child disposition and environmental factors prior to migration are also implicat
he psychological health of refugee children and adolescents. In their review of children's responses to stressful
uations, Garmezy and Rutter (1985) in addition to the protective role of families, highlight two other protective
tors - dispositional attributes of the child and a supportive environment. Regarding both factors, these authors
gue that a child's ability to respond to new situations, positive self-esteem and positive environmental support
ough strong peer relationships are protective.
ough age, gender and other individual characteristics such as social ability, coping style, temperament, good heal
d development have been shown to buffer against adverse life events, these characteristics are not systematically
cussed in relation to how they influence children affected by organised violence (Almqvist & Broberg, 1999). Good
mperament however, has been shown to decrease vulnerability to poor psychological outcome (Almqvist & Brober
99). Social support, especially from parents is emphasised as a factor of resilience during war in the literature, so
g as they are not pushed beyond stress-absorption capacities (Dybdahl, 2001; Garbarino et al, 1991).
Post-migration Risk and Protective factors
hile there are few empirical studies investigating unaccompanied children and adolescents and those separated
m family members, these populations are consistently argued to be at greater risk for psychiatric and mental heal
oblems than their accompanied peers (Ajdukovic & Ajdukovic, 1993, 1998; Hicks et al., 1993; Kinzie et al., 1986;
Closkey, Southwick, Fernandez-Esquer & Locke, 1996; Rumbaut, 1991; Servan-Schreiber, Le Lin & Birmaher,
98; Sourander, 1998). By definition, an unaccompanied refugee/asylum seeking minor is an individual under 18
ars of age who has been separated from both parents and is not being cared for by an adult who has a
ponsibility to do so (Sourander, 1998).
mong those studies focused directly on unaccompanied minors, Felsman, Leong, Johnson and Crabtree-Felsman
990) compared three groups of Vietnamese refugees encamped in the Philippines- adolescents, young adults and
accompanied minors. Whilst anxiety remained high across the three groups, young adults and unaccompanied
nors were over represented in clinical ranges on measures of psychological distress. The findings that children an
olescents accompanied by family members are less distressed than those who arrive accompanied by relatives
roborate the findings of Kinzie et al. (1986; 1989) who demonstrated that it was neither the amount nor type of
uma witnessed, nor the child's age or gender that predicted PTSD in Cambodian refugees. Psychiatric effects
her decreased in the presence of a nuclear family member. Although these refugees had lost an average of three
mily members, those who had been able to re-establish contact with at least one family member reported fewer
ustment problems than those without family contact.
urander (1998) examined traumatic events and emotional and behavioural symptoms of 46 unaccompanied refug
nors awaiting placement in an asylum centre in Finland. Having experienced a number of losses, separations and
eats, most of these minors exhibited symptoms of PTSD, depression and anxiety. Half of these children and
olescents were found to be functioning within clinical or borderline ranges on the Child Behaviour Checklist with
ldren aged younger than 15 years found to be particularly vulnerable.
ocedures related to awaiting asylum also contributed to elevated stress levels in these children and adolescents.
hen interviewed, they reported several complaints of physical nature, uncertainty about the future and suicidal
ughts. Sourander (1998) concluded that unaccompanied children and adolescents are highly vulnerable towards
otional and behavioural symptoms, which are exacerbated by asylum-seeking stress. In a systematic investigatio
unaccompanied Vietnamese Americans, McKelvey and Webb (1995) showed that high rates of psychopathology
or to forced migration were significantly exacerbated during stays in a processing centre in the Philippines. Findin
hese studies are pertinent as they reflect areas of research in unaccompanied samples and direct effects of the
ylum seeking process that are largely under investigated in the empirical literature.
usseau (1995) notes that the majority of unaccompanied children and adolescents are boys, reflecting either the
mily's or boy's decision, the goal of which is to remove them from war given their vulnerability to soldier activity and
ir ability to support the family in the future. Such realities underscore the increased risk to psychological health,
en the added burden faced by these children and adolescents.
e interaction between traumatic experience and multiple separations has also been noted to increase the
ychological risk to unaccompanied youth (Rousseau, 1995). Moreover, it has been suggested that unaccompanie
olescents and youths are particularly vulnerable as their increasing autonomy causes them to relive past
parations creating difficulties in adjustment (Lee, 1988, cited in Rousseau, 1995). According to the research in this
ea, adaptive strategies that are most effective with these populations are those that promote continuity with the pa
d balance the demands of the external reality (Rousseau, 1995). This is supported by research, which has shown
t unaccompanied children have better mental health outcomes when they are placed with foster families of the
me ethnic group (Linowitz & Boothby, 1988, cited in Rousseau, 1995; McCloskey & Southwick, 1996). Hicks et al.
993) particularly note the exacerbation of problems in unaccompanied children and adolescents when placed with
ults of dissimilar cultural backgrounds.
must be noted, however, that irrespective of whether substitute caregivers are of similar or dissimilar ethnic and
tural backgrounds, the vulnerability of these unaccompanied minors is evidenced by research that shows when
ural caregivers are substituted, antisocial behaviours may be exhibited(Kinzie et al., 1991).
ain, while the negative effects of separation and sole migration are evident in children and adolescents (Richman
93), there are some studies that report good adaptation following separation and unaccompanied migration
upinski et al., 1986; Rumbaut, 1991; Wolff et al., 1995). Krupinski et al. (1986) for example, found that while
paration contributes to difficulties experienced during the first year of resettlement, psychological problems are no
uenced by separation after this time. Additionally, Wolff et al. (1995) compared 4-7 year old Eritrean refugee
ldren and Eritrean children orphaned due to the loss of parents. Whilst emotional and behavioural distress was
perienced by children who had lost both parents, these children were found to function better than accompanied
ugee children on measures of cognition and language. Given the lack of generalisation in these findings and as is
case with trauma, little is known about how separation distress persists or diminishes over time in children and
olescents.
addition to separation and unaccompaniment, increased psychological risk also occurs as a result of the process
ught asylum (Silove et al., 1997; Sourander, 1998). This element constitutes particular risk as children and
olescents awaiting asylum are subjected to the compounded stress of being supervised and/or communal living w
ers outside their family/cultural group. Among adult populations, Sinnerbrink et al. (1997) assessed 40 adult asylu
ekers attending English classes at a community welfare centre in Sydney. These authors found that asylum seeke
perienced ongoing sources of severe stress including fears of being repatriated, barriers to social work services,
paration, and issues related to the process of refugee claims. More than a third of participants had difficulties
aining health services. Thus, salient aspects of the asylum seeking process may compound the stressors suffered
an already traumatised group (Sinnerbrink et al., 1997).
hilst noting difficulties in accessing samples of asylum seekers who have not been accorded residency status, Silo
al. (1997), interviewed and assessed trauma, anxiety, depression and living conditions in forty asylum seekers
ending a community resource centre in Sydney. In these subjects, high anxiety scores were associated with fema
nder, poverty, and problems with immigration officials. Loneliness and boredom were associated with anxiety and
pression. Of the 79% of the sample who had experienced a traumatic event, 37% obtained a PTSD diagnosis. Th
gnosis was significantly associated with greater exposure to pre-migration trauma, delays in application processin
aling with immigration officials, obstacles to employment, racism, loneliness and boredom.
garding children and adolescents in the process of sought asylum, the study of Ajdukovic and Ajdukovic (1993)
nds among very few in the published literature. These authors compared two groups of children who were uproot
d displaced together with their families into two different housing arrangements: those living with host families and
se living in communal shelters. According to parental reports, children in host families showed lower rates of stre
ated signs than those living in sheltered environments. 43% of those in homes showed no signs of abnormal
ctioning while 24% in shelters showed no signs. During displacement, the number of stress related symptoms in
st family children decreased for 25%, but symptoms decreased in only 10% of children in shelters. Nearly half of t
ldren in host families no longer experienced nightmares (47.6%) and more than half ceased their fearfulness (59%
% were no longer despondent and 24% were no longer unsociable. Among those in the collective shelter, 20% sti
owed aggression and 28% still showed despondent emotions.
ese authors also correlated difficulties in the adaptation of these displaced children and youth. They found that
se in shelter had significantly higher incidences of stress reactions than those in host families. These scores were
n correlated with their internal and environmental sources of stress. Results showed that childrens' stress indexe
re associated with mothers' ability to cope with displacement. Those mothers who reported adaptive problems,
rsened relations with children since displacement, negative perceptions of communal housing and burdened
nflicts also had children with higher stress indexes.
dukovic and Ajdukovic (1993) attributed their findings to the unfavorable living conditions in shelters where families
e generally larger with decreased socio-economic status and where displacement duration is longer or in occupied
ritory. They concluded that there is a considerable range of stress reaction in displaced children with a higher
idence of stress associated with mothers' poor ability to cope with the stresses of displacement. Similarly, in a
ge-scale survey of 600 Vietnamese children living in a refugee centre in Hong Kong, McCallin (1992) observed
xiety and depression in a majority of children surveyed, with pronounced effects among those children
accompanied.
gether, these findings corroborate that children and adolescents living in shelters, camps and processing centres
e subjected to increased risk for psychological dysfunction (Rudic, Rakic, Ispanovic-Radojkovic, Bojanin & Lazic,
93).
ough it is unclear which specific factors exist to exacerbate problems of well being in these particular risk groups,
me researchers have suggested that such negative psychological outcomes are attributed to the inability to maint
ditional mother and father roles, the loss of perceived control and learned helplessness (Garbarino & Kostelny,
96). Indeed where traditional roles are maintained and length of communal living, such as in refugee camps, is
creased, less adverse psychological effects have been observed (Markowitz, 1996; McKelvey & Webb, 1997).
ven the risk and protective factors of parental pressure, parental psychopathology and family problems in the pre-
gration period, it is not surprising that such factors also pose risk and protection in the period of post-migration.
nzie et al. (1986) for example have noted the protective effects of re-established parental contact following
gration. The protective presence of family is similarly noted by Arroyo and Eth (1996) who found that children and
olescents remaining in nuclear families were less likely to receive a psychiatric diagnosis than those who lived alo
were fostered. Similarly, Masser (1992) and Melville and Lykes (1992) have also found less emotional distress an
ter adjustment following migration in children who arrive with family members than children who survive the refug
ocess alone.
rental depression and anxiety secondary to trauma or to post- migration difficulties are also often associated with
re serious symptoms in children (Hjern, Angel & Jeppson, 1998; Meijer, 1985, cited in Rousseau, 1995). As show
Hjern et al's. (1998) study of Chilean and Middle Eastern refugee children in exile, important family life events suc
the birth of a sibling and divorce among parents play a significant role in the mental health of child and adolescen
ugee and asylum seekers.
culturative stress (that is stress due to difficulties associated with adapting to a new culture) also place
ugee/asylum seeking children and adolescents at greater psychological risk. For example, difficulties at school an
anguage acquisition have been shown to predict poor adaptation. In contrast, academic achievement as influence
language acquisition and good peer relations is predictive of good psychological outcomes (Rousseau, 1995).
re widely noted throughout the literature, however, are two important factors in the adaptation to a new culture tha
her increase or decrease susceptibility to poor mental health. First, conflict in the development of identity among
olescents has consistently been related to poor psychological adjustment (Rousseau, 1995). Second, even thoug
adaptive process to a new culture can make provision for good outcomes, it can also increase psychological
nerability through the creation of inter-generational stress.
ergenerational conflict arises when children and adolescents, particularly adolescents, adapt much faster than the
rents. As such, the authority of parents is often compromised by virtue of their dependence on children for langua
d cultural access to the host society. Lastly, high parental expectations have also been shown to significantly pred
a-personal conflict in refugee children and adolescents, thereby posing further risk to poor adaptation (Hyman, V
Beiser, 2000).
her factors to have a negative influence on the mental health in refugee children and adolescents include low soci
onomic status (Howard & Hodes, 2000); long-term unemployment in parents, particularly fathers; school problems
guage problems; and discrimination and bullying (Hyman et al, 2000).
th regard to individual characteristics, those found to enhance resilience in children and adolescents at a post-
gration level have included a realistic expectation of adjustment (McKelvey & Webb, 1996, cited in Hodes, 2000).
onsistent findings regarding individual characteristics however are more common throughout the literature. For
ample, contradictory findings have been obtained for the protective nature of age and gender. While some sugges
cognitive immaturity of younger children is protective at migration (Dybdahl, 2001; Elbedour, ten-Bensel & Bastie
93; Garbarino & Kostelny, 1996; Papageorgiou et al., 2000), others suggest it is the inability to articulate and
press distress or the attribution of egocentric explanations in younger children, which constitute risk (Berman, 200
milarly regarding gender, it has been found that boys are more vulnerable than girls (Elbedour et al., 1993; El Hab
al., 1994) and where under conditions of accumulative risk factors such as injury through political violence and
ysical violence or maternal depression in the family unit, boys are particularly vulnerable to emotional and
havioural problems (Garbarino & Kostelny, 1996). Contrarily, the results of studies on children exposed to the Gul
r have found that females show higher frequencies of stress reactions than males (Greenbaum, Erlich & Toubiana
93; Klingman, 1994) and greater decreases over time in boys relative to girls in post-traumatic stress, anxiety and
pression (Stein, Gardner & Kelleher, 1999). Differences in gender may reflect cultural expectations for the display
otion or females being more adept to openly report symptoms. Importantly, they also reflect the complex and
namic interplay between risk and protective factors yet to be understood by the research.
e availability of support systems facilitates successful adaptation even when children and adolescents have
vived extreme trauma (Fox, Cowell & Montgomery, 1994). Almqvist and Broberg (1999) for example, investigated
relevance of peer relationships, exposure to bullying or harassment, marital discord/harmony and parental menta
alth in the mental health and social adjustment of refugee children and adolescents in Sweden. They noted the
otective nature of good paternal and maternal mental health, marital harmony and positive peer relationships.
nversely, isolation from support has been found to be a major predictor of poor psychological adaptation (Jupp &
ckey, 1990).
ine with the positive influence of social support, the maintenance of close ethnic community ties has also been
own to be a protective factor to mental health in children and adolescents, alongside cultural and religious traditio
ich assist to restore continuity in the past and present (Punamaki, 1996; Rousseau, 1995; Sack, 1995).
ough discussion of treatment issues is beyond the scope of this paper, early intervention and psychosocial
sistance have frequently been reported as crucial protective factors PUNAMAKI (2001) despite low rates of help
eking behaviour in refugee populations (Howard & Hodes, 2000). Indeed, in her assessment of young Chilean
ults who experienced childhood war related traumas of parental loss, Punamaki (2001) concluded that both the
ure of trauma and the timing and duration of assistance were critical to wellbeing in adulthood.
nclusions
hough preliminary in nature, the research in the psychological well-being of children and adolescent refugee and
ylum seekers has identified key areas of consistency. It is apparent that most research in this area is directed at th
evalence of psychopathology, with particular emphasis on post-traumatic stress symptomology. This research
arly demonstrates that refugee children and adolescents are vulnerable to the effects of pre-migration, most nota
posure to trauma. It is also apparent that particular groups in this population constitute higher psychological risk
n others, namely those with extended trauma experience, unaccompanied or separated children and adolescents
d those still in the process of seeking asylum. Finally, it is apparent that certain risk and protective factors exist to
mper or aggravate poor psychological health. Such factors include family cohesion, family support and parental
ychological health; individual dispositional factors such as adaptability, temperament and positive esteem; and
vironmental factors such as peer and community support.
e psychological research however is less clear in a number of areas. These include the mechanisms by which risk
d protective factors exacerbate and temper the effects of trauma and migration experience and the role of culture
mediator in the experience of trauma and migration experience.
ough not presently discussed, future research needs to be directed at the improvement of methodologies (e.g.,
ss cultural validation of measurement techniques); the extension of knowledge and outcomes beyond PTSD and
ychopathology (e.g., the development of theoretical models incorporating systematic effects of risk and protective
tors), the influence and comparison of cultural context; the investigation of long term effects and impact of
culturation and the investigation of treatment issues centered around individual and family systems (Weine, 2002)
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out the authors
ang Thomas, Ph.D is Professor of Psychology at the Royal Melbourne Institute of Technology
nnie Lau, BBSc (Hon) is a Clinical Psychology Researcher at the Royal Melbourne Institute of Technology
The Child Behaviour Checklist is a commonly used test for children from 2 to 16 years of age to monitor their well
ng, such as whether they are anxious, uncommunicative, depressed, aggressive, delinquent, withdrawn or
peractive.
The Diagnostic Interview Assessment Scale are structured interview schedules employed to yield information abo
presence, absence, severity of symptoms or give a global indication of psychopathology.