The impact of detention on the social-emotional wellbeing of children seeking asylum: a comparison with community-based children

The impact of detention on the health of asylum seekers: An updated systematic review: A systematic review

Background

The number of people fleeing persecution and regional conflicts is rising. Western countries have applied increasingly stringent measures to discourage those seeking asylum from entering their country, amongst them, to confine asylum seekers in detention facilities. Clinicians have expressed concerns over the mental health impact of detention on asylum seekers, a population already burdened with trauma, advocating against such practices.

Objectives

The main objective of this review is to assess evidence about the effects of detention on the mental and physical health and social functioning of asylum seekers.

Search methods

Relevant literature was identified through electronic searches of bibliographic databases, internet search engines, hand searching of core journals and citation tracking of included studies and relevant reviews. Searches were performed up to November 2023.

Selection criteria

Studies comparing detained asylum-seekers with non-detained asylum seekers were included. Qualitative approaches were excluded.

Data collection and analysis

Of 22,226 potential studies, 14 met the inclusion criteria. These studies, from 4 countries, involving a total of 13 asylum-seeker populations. Six studies were used in the data synthesis, all of which reported only mental health outcomes. Eight studies had a critical risk of bias. Meta-analyses, inverse variance weighted using random effects statistical models, were conducted on post-traumatic stress disorder (PTSD), depression, and anxiety.

Main results

A total of 27,797 asylum seekers were analysed. Four studies provided data while the detained asylum seekers were still detained, and two studies after release. All outcomes are reported such that a positive effect size favours better outcomes for the non-detained asylum seekers. The weighted average SMD while detained is 0.45 [95% CI 0.19, 0.71] for PTSD and after release 0.91 [95% CI 0.24, 1.57]; for anxiety 0.42 [95% CI 0.18, 0.66] and for depression 0.68 [95% CI 0.10, 1.26] both while detained. Based on single-study data, the SMD was 0.60 [95% CI 0.02, 1.17] for depression and 0.76 [95% CI 0.17, 1.34] for anxiety, both after release. Three studies (one study each) reported outcomes related to psychological distress, self-harm and social well being. Psychological distress favoured the detained but was not significant; whereas both effect sizes on self-harm and social wellbeing indicated highly negative impacts of detention; in particular, the impact on self-harm was extremely high. The OR of self-harm was reported separately for asylum seekers detained in three types of detention: Manus Island, Nauru and onshore detention. The ORs were in the range 12.18 to 74.44; all were significant.

Authors' conclusions

Despite similar post-migration adversities amongst comparison groups, findings suggest an independent adverse impact of detention on asylum seekers' mental health, with the magnitude of the effect sizes lying in an important clinical range. These effects persisted beyond release into the community. While based on limited evidence, this review supports concerns regarding the detrimental impact of detention on the mental health of already traumatised asylum seekers. Further research is warranted to comprehensively explore these effects. Detention of asylum seekers, already grappling with significant trauma, appears to exacerbate mental health challenges. Policymakers and practitioners should consider these findings in shaping immigration and asylum policies, with a focus on minimising harm to vulnerable populations.

Resilience and Positive Wellbeing Experienced by 5-12-Year-Old Children with Refugee Backgrounds in Australia: The Childhood Resilience Study

Refugee research tends to be deficit based and focused on the risks threatening positive adaptation and wellbeing. High rates of mental (and physical) health issues have been reported for refugee adults and children, including intergenerational trauma. This study uses the new Child Resilience Questionnaire (CRQ), co-designed with refugee background communities, to describe resilience and positive wellbeing experienced by children of refugee-background. The Childhood Resilience Study (CRS) recruited 1132 families with children aged 5-12 years in Victoria and South Australia, Australia. This included the recruitment of 109 families from 4 refugee background communities: Assyrian Chaldean (Iraq, Syria), Hazara (Afghanistan), Karen (Burma, Thailand) and Sierra Leonean families. CRQ-parent/caregiver report (CRQ-P/C) scores were categorised into 'low', 'moderate' and 'high'. The child's emotional and behavioural wellbeing was assessed with the Strengths and Difficulties Questionnaire, with positive wellbeing defined as <17 on the total difficulties score. Tobit regression models adjusted for a child's age. The CRQ-P/C scores were not different for boys and girls of refugee background. Children of refugee-background (n = 109) had higher average CRQ-P/C scores than other CRS children (n = 1023) in the personal, school and community domains, but were lower in the family domain. Most children with 'high' resilience scores had positive wellbeing for both children of refugee-background (94.6%) and other CRS children (96.5%). Contrary to common stereotypes, children of refugee-background show specific individual, family, school and cultural strengths that can help them navigate cumulative and complex risks to sustain or develop their positive wellbeing. A better understanding as to how to build strengths at personal, family, peer, school and community levels where children are vulnerable is an important next step. Working in close collaboration with refugee communities, schools, policy makers and key service providers will ensure the optimal translation of these findings into sustainable practice and impactful public policy.

Young children's development after forced displacement: a systematic review

OBJECTIVES

To examine the impact of displacement experiences on 0- to 6-year-old children's social-emotional and cognitive development, as well as influencing factors on reported outcomes.

STUDY DESIGN

We systematically searched MEDline, Psyndex, Cochrane Library, Web of Science, Elsevier, TandF, Oxford Journal of Refugee Studies, Journal of Immigrant & Refugee Studies, and Canada's Journal on Refugees for existing literature regarding social-emotional and cognitive outcomes in children directly exposed to forced displacement due to political violence. Results were synthesized in the discussion and displayed using harvest plots.

RESULTS

Our search generated 9,791 articles of which 32 were selected for review and evaluation according to NICE criteria. Included studies provided results for 6,878 forcibly displaced children. Measured outcomes were diverse and included areas such as peer relations, prosocial behavior, family functioning, play, intelligence, learning performance, and language development. Repeated exposure to adverse experiences, separation from parents, parental distress, as well as duration and quality of resettlement in the host country were reported as influencing factors in the reviewed studies.

CONCLUSION

As protective factors like secure and stable living conditions help to promote children's development, we call for policies that enhance participation in the welcoming society for refugee families. Early integration with low-threshold access to health and educational facilities can help to mitigate the wide-ranging negative consequences of forced displacement on young children's development.

Refugee child health: a systematic review of health conditions in children aged 0-6 years living in high-income countries

This study describes the extent, quality and cultural appropriateness of current research on the health conditions of refugee children aged 0-6 years settled in high-income countries. A systematic review was conducted, including original articles published on the health conditions experienced by refugee children. A total of 71 papers were included. The studies varied considerably in their research design, population characteristics and health conditions. Studies included information on 37 different health conditions, with the majority non-communicable diseases, in particular growth, malnutrition and bone density. Although the studies identified a wide range of health issues, a coordinated effort to prioritise research on particular health topics was lacking, and health conditions studied do not align with the global burden of disease for this population. Additionally, despite being rated medium-high quality, most studies did not describe measures taken to ensure cultural competency and community involvement in their research. We suggest a coordinated research effort for this cohort, with greater emphasis on community engagement to improve the evidence-base of the health needs of refugee children after settlement.

Changing landscape of paediatric refugee health in South Western Sydney, Australia: a retrospective observational study

OBJECTIVES

To examine the changing health needs of refugee children and young people (CYP) entering Australia, in relation to key government policy changes.

STUDY DESIGN

Retrospective analysis of health service use data over 11 years.

SETTING

Paediatric refugee clinics in South Western Sydney (SWS), the Australian region with the largest annual resettlement of refugees.

PARTICIPANTS

Refugee CYP (≤25 years) attending the SWS paediatric refugee clinics for their first visit between 2009 and 2019.

MEASURES

Clinician defined health conditions categorised as communicable and non-communicable disease (NCD).

RESULTS

Data were analysed for 359 CYP, mean age 9.3 years; 212 male (59.1%). Most CYP (n=331, 92.2%) had health problems identified; 292 (81.3%) had ≥1 NCD and 24 (6.7%) had ≥1 communicable disease. The most frequent individual NCDs were dental disease (n=128, 35.7%) and vitamin D deficiency (n=72, 20.1%). Trend analysis showed increased odds of identifying an NCD from 2013 onwards (crude OR 1.77, 95% CI 1.06 to 2.96). Neurodevelopmental problems, especially Global Developmental Delay (n=31, 8.6%), emerged as more prevalent issues in the latter half of the decade. There were significantly increased odds of identifying a neurodevelopmental problem in 2016-2019, especially in 2016-2017 (adjusted OR 2.93, 95% CI 1.34 to 6.40). Key policy changes during this period included acceptance of refugees with disabilities from 2012, additional Australian Humanitarian Programme intake from the Eastern Mediterranean region and mandatory offshore processing for those seeking asylum by boat from 2013. In response to the changing needs, local health services adopted nurse-led primary healthcare screening, early childhood services, youth and disability clinics.

CONCLUSIONS

Refugee CYP in Australia are presenting with a growing burden of NCDs, with neurodevelopmental problems contributing. Government policy changes affect the sociodemographics of resettled populations, influencing health profiles. Paediatric refugee health services need to be responsive to the changing needs of these populations to optimise well-being.

Persistence of Emotional Distress in Unaccompanied Migrant Children and Adolescents Primarily From the Northern Triangle of Central America

Importance

In the US, unaccompanied migrant children and adolescents (hereinafter referred to as children) are predominantly from Central America's Northern Triangle. While unaccompanied migrant children are at high risk for psychiatric sequelae due to complex traumatic exposures, longitudinal investigations of psychiatric distress after resettlement are lacking.

Objective

To identify factors associated with emotional distress and longitudinal changes in emotional distress among unaccompanied migrant children in the US.

Design, Setting, and Participants

For this retrospective cohort study, the 15-item Refugee Health Screener (RHS-15) was administered between January 1, 2015, and December 31, 2019, to unaccompanied migrant children as part of their medical care to detect emotional distress. Follow-up RHS-15 results were included if they were completed before February 29, 2020. Median follow-up interval was 203 days (IQR, 113-375 days). The study was conducted in a federally qualified health center that provides medical, mental health, and legal services. Unaccompanied migrant children who completed the initial RHS-15 were eligible for analysis. Data were analyzed from April 18, 2022, to April 23, 2023.

Exposures

Traumatic events before migration, during migration, during detention, and after resettlement in the US.

Main Outcomes and Measures

Emotional distress, including symptoms of posttraumatic stress disorder, anxiety, and depressive symptoms, as indicated by the RHS-15 (ie, score ≥12 on items 1-14 or ≥5 on item 15).

Results

In total, 176 unaccompanied migrant children completed an initial RHS-15. They were primarily from Central America's Northern Triangle (153 [86.9%]), were mostly male (126 [71.6%]), and had a mean (SD) age of 16.9 (2.1) years. Of the 176 unaccompanied migrant children, 101 (57.4%) had screen results above the positive cutoff. Girls were more likely to have positive screen results than boys (odds ratio, 2.48 [95% CI, 1.15-5.34]; P = .02). Follow-up scores were available for 68 unaccompanied migrant children (38.6%). On the follow-up RHS-15, most scored above the positive cutoff (44 [64.7%]). Three-quarters of unaccompanied migrant children who scored above the positive cutoff initially continued to have positive scores at follow-up (30 of 40), and half of those with negative screen scores initially had positive scores at follow-up (14 of 28). Female vs male unaccompanied migrant children (unstandardized β = 5.14 [95% CI, 0.23-10.06]; P = .04) and initial total score (unstandardized β = 0.41 [95% CI, 0.18-0.64]; P = .001) were independently associated with increased follow-up RHS-15 total score.

Conclusions and Relevance

The findings suggest that unaccompanied migrant children are at high risk for emotional distress, including symptoms of depression, anxiety, and posttraumatic stress. The persistence of emotional distress suggests that unaccompanied migrant children would benefit from ongoing psychosocial and material support after resettlement.

Post-Traumatic Stress Disorder in Unaccompanied Refugee Minors: Prevalence, Contributing and Protective Factors, and Effective Interventions: A Scoping Review

In 2021, there were close to 37 million children displaced worldwide. There were 13.7 million refugees and an additional 22.8 million internally displaced. In Europe, this included 23,255 unaccompanied minors seeking asylum, up 72% compared with 2020 (13,550). The objective was to review the current literature regarding PTSD in unaccompanied refugee minors (URM). The authors searched Ovid Medline, Embase, and Cochrane Library from 1 January 2008 through 15 January 2019. Thirty full texts were chosen that specifically studied unaccompanied refugee minors (URM). The results showed that URM had a prevalence of post-traumatic stress disorder (PTSD of 17-85% across the studies reviewed. There were numerous factors that contributed to PTSD, including cumulative stress and trauma, guilt, shame, and uncertainty about legal status. Protective factors included resilience, a trusted mentor, belonging to a social network, religion, having an adult mentor, and having a family (even if far away). Immigrant youth can thrive most easily in multiculturally affirming countries. Five interventions demonstrated effectiveness, comprising trauma-focused cognitive behavioral therapy (TF-CBT); "Mein Weg", a TF-CBT combined with a group-processing mixed therapy approach; teaching recovery techniques (TRT), narrative exposure therapy for children (KIDNET), and expressive arts intervention (EXIT). The significant mental health conditions include depression, anxiety, internalizing and externalizing behaviors, and frequently PTSD. It is fair to conclude that the high levels of mental health problems experienced in URM are due to exposure to traumatic experiences, separation from parents, and lack of social support.

Offshore detention: cross-sectional analysis of the health of children and young people seeking asylum in Australia

OBJECTIVE

To describe the health and well-being of children and young people (CYP) seeking asylum subjected to Australia's immigration policy of indefinite mandatory detention on Nauru.

DESIGN

Cross-sectional analysis of a cohort of CYP seeking asylum.

SETTING

Australian paediatric clinicians from 10 health services completed detailed health assessments around the time of transfer from Nauru, mostly to Australia.

PARTICIPANTS

Sixty-two CYP who were ≤18 years on entry into offshore immigration detention on Nauru between 2013 and 2019. Mean age at health assessment was 9 years.

MAIN MEASURES

Health outcomes were categorised as physical, mental or neurodevelopmental concerns/conditions. Risk and protective factor data were collected using the adverse childhood experiences and refugee-specific adverse childhood experiences tools.

RESULTS

Over half of the CYP (n=32, 52%) were held on Nauru for ≥4 years. The vast majority of CYP had physical health (n=55, 89%) and mental health (n=49, 79%) concerns including self-harm or suicidal ideation/attempt (n=28, 45%). Mental health concerns were more likely in CYP who were school-aged (p=0.001), had been held on Nauru for ≥1 year (p=0.01); originated from the Eastern Mediterranean region (p<0.05); witnessed trauma (p<0.05) or had exposure to ≥4 refugee-specific adverse childhood experiences (p<0.05). Neurodevelopmental concerns were seen in eight children (13%).

CONCLUSIONS

This study highlights the almost universal physical and mental health difficulties in a sample of CYP who experienced forced migration and were subjected to Australia's offshore immigration detention policy. Immigration detention in recipient countries, a known adverse childhood experience, may contribute to or exacerbate harmful outcomes in CYP seeking asylum.

Health of children who experienced Australian immigration detention

BACKGROUND

Australian immigration policy resulted in large numbers of children being held in locked detention. We examined the physical and mental health of children and families who experienced immigration detention.

METHODS

Retrospective audit of medical records of children exposed to immigration detention attending the Royal Children's Hospital Immigrant Health Service, Melbourne, Australia, from January 2012 -December 2021. We extracted data on demographics, detention duration and location, symptoms, physical and mental health diagnoses and care provided.

RESULTS

277 children had directly (n = 239) or indirectly via parents (n = 38) experienced locked detention, including 79 children in families detained on Nauru or Manus Island. Of 239 detained children, 31 were infants born in locked detention. Median duration of locked detention was 12 months (IQR 5-19 months). Children were detained on Nauru/Manus Island (n = 47/239) for a median of 51 (IQR 29-60) months compared to 7 (IQR 4-16) months for those held in Australia/Australian territories (n = 192/239). Overall, 60% (167/277) of children had a nutritional deficiency, and 75% (207/277) had a concern relating to development, including 10% (27/277) with autism spectrum disorder and 9% (26/277) with intellectual disability. 62% (171/277) children had mental health concerns, including anxiety, depression and behavioural disturbances and 54% (150/277) had parents with mental illness. Children and parents detained on Nauru had a significantly higher prevalence of all mental health concerns compared with those held in Australian detention centres.

CONCLUSION

This study provides clinical evidence of adverse impacts of held detention on children's physical and mental health and wellbeing. Policymakers must recognise the consequences of detention, and avoid detaining children and families.

Health of children in Australian immigration detention centres: An analysis of the quarterly health reports from 2014 to 2017

AIM

This study examines 3 years of child and adolescent health data from Australian onshore and offshore immigration detention centres from 2014 to 2017, quantifying the health presentation data of children and adolescents in Australian immigration detention and comparing rates between onshore and offshore detention.

METHODS

This study utilised the Quarterly Immigration Detention Health Reports over a period of 3 years. To compare onshore and offshore datasets, we calculated the rate of health events per quarter against the estimated quarterly onshore and offshore detention population of children. We ran a series of two-proportion z-tests for each matched quarter to calculate median z and P values for all quarters. These were used as an indicator as to whether the observed differences between onshore and offshore events were statistically significant.

RESULTS

The estimated number of children detained per quarter onshore ranged from 700 in 2014 (quarter 3) to 13 in 2016 (quarters 3 and 4); the estimated quarterly population of children in offshore detention ranged from 186 in 2014 (quarter 3) to 42 in 2017 (quarter 2). Children offshore had significantly higher rates of consultations with a mental health nurse (z = -1.96; P = 0.002), psychologist (z = -2.32; P = 0.01) and counsellor (z = -3.41; P < 0.001). As for reasons for presentation to general practitioners and psychiatrists, complaints related to skin (z = -1.97; P = 0.05), respiratory issues (z = -1.96; P = 0.05) and urological issues (z = -2.21; P = 0.03) were significantly higher amongst children detained offshore.

CONCLUSIONS

Compared to children in the Australian community, children detained both onshore and offshore had greater health needs. Children offshore also presented more frequently with a range of complaints and accessed health services at higher rates than children detained onshore; this adds to growing evidence about the harms of offshore detention and detention more generally.

Prevalence, methods and characteristics of self-harm among asylum seekers in Australia: protocol for a systematic review

INTRODUCTION

Asylum seekers are at increased risk of self-harm compared with the general population, and the experience of detention may further exacerbate this risk. Despite this, evidence regarding the prevalence, methods and characteristics of self-harm among asylum seekers in Australia (including those detained in onshore and offshore immigration detention) has not been synthesised. Such information is necessary to inform evidence-based prevention initiatives, and effective clinical and governmental responses to self-harm. This review will synthesise findings from the literature regarding the prevalence, methods and characteristics of self-harm among asylum seekers in both detained and community-based settings in Australia.

METHODS AND ANALYSIS

We searched key electronic health, psychology and medical databases (PsycINFO, Scopus, PubMed and MEDLINE) for studies published in English between 1 January 1992 and 31 December 2021. Our primary outcome is self-harm among asylum seekers held in onshore and/or offshore immigration detention, community detention and/or in community-based arrangements in Australia. We will include all study designs (except single case studies) that examine the prevalence of self-harm in asylum seekers. Studies published between 1992-the commencement of Australia's policy of mandatory immigration detention-and 2021 will be included. We will not apply any age restrictions. The Methodological Standard for Epidemiological Research scale will be used to assess the quality of included studies. If there are sufficient studies, and homogeneity between them, we will conduct meta-analyses to calculate pooled estimates of self-harm rates and compare relevant subgroups. If studies report insufficient data, or there is substantial heterogeneity, findings will be provided in narrative form.

ETHICS AND DISSEMINATION

This review is exempt from ethics approval as it will synthesise findings from published studies with pre-existing ethics approval. Our findings will be disseminated through a peer-reviewed journal article and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020203444.

Mental Health Care of Detained Youth Within Juvenile Detention Facilities

Mental health treatment of juvenile offenders and undocumented immigrant youth in detention provides a unique opportunity for treatment providers. Although the work may be challenging, the clinical needs and opportunities for early and meaningful interventions are significant. One of the best clinical experiences a psychiatrist can have is working with extremely high-risk youth to help them find safer and better developmental pathways. Few settings can offer such an opportunity to leverage clinical skills to improve the lives and futures of children and adolescents as are afforded to those professionals lucky enough to work in juvenile justice settings.

Mental health of unaccompanied children: effects of U.S. immigration policies

BACKGROUND

There is an unprecedented surge of forcibly displaced people globally, with a crisis of unaccompanied minors seeking haven across the US border.

AIMS

This paper aims to provide an understanding of the intersection between mental health and immigration policies.

METHOD

Examples of contemporary policies that focus on the deterrence, detention and deportation of unaccompanied minors in the USA, will be discussed, as well as the mental health effects of such 'iron triangle' immigration policies.

RESULTS

In the ideal circumstances, systems and policies for migrant children would uphold international humanitarian law, hasten the shift from enforcement to protection, adhere to a 'do no (further) harm' model that uses a trauma-informed, culturally responsive approach to engaging with migrant children, engage the community as stakeholders to end detention and advocate to share the burden of responsibility.

CONCLUSIONS

Building a humanitarian response that protects both country and migrant interest is possible through commitment and policy change that addresses mental, physical and legal protection needs.

Mental health consequences of detaining children and families who seek asylum: a scoping review

Almost 80 million people globally are forcibly displaced. A small number reach wealthy western countries and seek asylum. Over half are children. Wealthy reception countries have increasingly adopted restrictive reception practices including immigration detention. There is an expanding literature on the mental health impacts of immigration detention for adults, but less about children. This scoping review identified 22 studies of children detained by 6 countries (Australia, Canada, Hong Kong, Netherlands, the UK and the US) through searches of Medline, PsychINFO, Emcare, CINAHL and Scopus data bases for the period January 1992-May 2019. The results are presented thematically. There is quantitative data about the mental health of children and parents who are detained and qualitative evidence includes the words and drawings of detained children. The papers are predominantly small cross-sectional studies using mixed methodologies with convenience samples. Despite weaknesses in individual studies the review provides a rich and consistent picture of the experience and impact of immigration detention on children's wellbeing, parental mental health and parenting. Displaced children are exposed to peri-migration trauma and loss compounded by further adversity while held detained. There are high rates of distress, mental disorder, physical health and developmental problems in children aged from infancy to adolescence which persist after resettlement. Restrictive detention is a particularly adverse reception experience and children and parents should not be detained or separated for immigration purposes. The findings have implications for policy and practice. Clinicians and researchers have a role in advocacy for reception polices that support the wellbeing of accompanied and unaccompanied children who seek asylum.

Systematic review of depression and suicidality in child and adolescent (CAP) refugees

Child adversity and trauma has been shown to have incredible detrimental effects physically and mentally in the subsequent adult life. Importantly, refugee minors are especially vulnerable to trauma. Thus far there are numerous studies examining cohorts of child and adolescent refugees and their impact on mental health in general and post-traumatic stress disorder (PTSD), but none have focused specifically on depression and suicide.  The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for the current systematic review. 25 articles out of 2660 queried were identified to be included in the review. Overall, CAP refugees have increased risk for major depressive disorder and suicidality compared to the general population to which they have immigrated, regardless of origin. Due to the differences in the assessment tools used, it is hard to parse out if mood disturbance was secondary to major depressive disorder (MDD) or PTSD, or that suicidality is independent or a sequela of MDD/PTSD. Given the vulnerability of CAP refugees after trauma future studies are needed to further elucidate their risk of concurrent depression and suicidality, so as to facilitate appropriate treatment.

Racism, healthcare access and health equity for people seeking asylum

People seeking asylum are at risk of receiving poorer quality healthcare due, in part, to racist and discriminatory attitudes, behaviours and policies in the health system. Despite fleeing war and conflict; exposure to torture and traumatic events and living with uncertainty; people seeking asylum are at high-risk of experiencing long-term poor physical and mental health outcomes in their host country. This article aims to raise awareness and bring attention to some common issues people seeking asylum face when seeking healthcare in high-income countries where the health system is dominated by a Western biomedical view of health. Clinical case scenarios are used to highlight instances of racist healthcare policies and practices that create and maintain ongoing health disparities; limited access to culturally and linguistically appropriate health services, and lack of trauma-informed approaches to care. Nurses and midwives can play an important role in countering racism in healthcare settings; by identifying and calling out discriminatory practice and modelling tolerance, respect and empathy in daily practice. We present recommendations for individuals, organisations and governments that can inform changes to policies and practices that will reduce racism and improve health equity for people seeking asylum.

The antecedents of well-being in first-generation migrant children: A systematic review

Migrant children's well‐being has emerged into the spotlight of academic literature and policy‐makers in recent times. This systematic review is aimed at analysing the publication trends on the topic and at synthesising the available evidence on the antecedents of well‐being of first‐generation international migrant children. Systematic searches of primary studies were conducted in 18 databases using search terms related to migration, childhood and well‐being. Three rounds of screening and data extraction, researchers' full agreement and the inclusion criteria produced 39 eligible studies. Critical appraisal of results revealed a fragmentation in the literature, the evidence available being mostly descriptive and focused on involuntary migrants settled in Western countries. A bias across publications overlooking younger migrant children was unveiled. The compartmentalisation of the evidence hindered an understanding of the magnitude of the different effects of migration on well‐being. Antecedents of well‐being have been documented as factors fostering and hindering well‐being. Important gaps in literature and key antecedents of well‐being have been uncovered for voluntary and involuntary migrant children. These findings show limitations in the available evidence pointing to specific suggestions for future research that should help improve interventions at the social and individual levels.

A systematic review of socio-ecological factors contributing to risk and protection of the mental health of refugee children and adolescents

In the past decade, millions of children and adolescents have been forced to flee from protracted or newly erupted violent conflicts. Forcibly displaced children are particularly vulnerable for developing mental health problems. However, a timely and systematic review of the current evidence is lacking. We conducted a systematic review of factors contributing to the mental health of refugee children across different socio-ecological levels (individual, family, community, sociocultural). We systematically searched the databases Medline, PsycINFO, Web of Science, and Cochrane for English studies published in peer-reviewed journals between August 2010 and May 2020. Of the 2413 identified studies, 63 were included in the analyses. Only 24 studies were considered to be of high quality. Pre-migration individual (risk: exposure to war-related trauma, female gender) and post-migration family factors (risk: parental mental health problems and impaired parenting, protective: family cohesion) currently have the best evidence base. Post-migration community (protective: school connectedness, support by peers) and sociocultural factors (risk: discrimination and acculturative stress, protective: integrative acculturation) have gained some support in high-income settings. Prevention and intervention approaches should integrate factors across different socio-ecological levels. More longitudinal studies and research in low- and middle-income countries are needed to advance our knowledge on causal mechanisms behind factors contributing to refugee youth's mental health.

Psychological morbidity among forcibly displaced children-a literature review

In 2018, nearly 75 million people were displaced from their place of origin of which 20.4 million are considered as refugees. Children constitute over half of this population. A review of the currently available literature regarding the psychological impact of forced displacement on children was performed with the concept examined under three stages of flight: pre-migration, intra-migration and post-migration. The resilience of children despite adversities is explored. Post-traumatic stress disorder (PTSD), depression and anxiety are the most commonly studied effects of forced migration on children. Rates range from 20 to 52.7%, 23 to 44.1% and 38.3 to 69% respectively. PTSD is associated with pre-migration disturbances such as witnessing death or torture of relatives, assaults and separation from family. Intra-migration difficulties relate to the hazardous journey, length of detention, type of facility and failed asylum application. Post-migration difficulties highlighted are insecure asylum status, housing worries, multiple relocations and poor acculturation technique and are more related to depression and anxiety. Despite these challenges and the tremendous horror witnessed, the majority of children report good functionality in their host countries in the long-term. The purpose of this report is to provide an overview of the factors contributing to the manifestation of mental health issues in child refugees as well as to examine mechanisms which enhance successful resettling in the host society. Health and social care providers must understand the complex interplay between the damaging effects of displacement, and the innate protective factors that persecuted children possess. Management should involve a holistic approach that considers children, families and native communities.

Asylum seeking children and adolescents in Australian immigration detention on Nauru: a longitudinal cohort study

INTRODUCTION

Immigration detention has a profound and negative impact on the physical health, mental health, development and social-emotional well-being of children, adolescents and their families. Australian clinicians will report results from detailed health and well-being assessments of asylum seeking children and adolescents who have experienced prolonged immigration detention.

METHODS AND ANALYSIS

This is a national, multicentre study with a longitudinal cohort design that will document health and well-being outcomes of the children and adolescents who have been detained in offshore detention on the remote island of Nauru. Outcome measures will be reported from the time arrival in Australia and repeated over a 5-year follow-up period. Measures include demographics, residency history and refugee status, physical health and well-being outcomes (including mental health, development and social-emotional well-being), clinical service utilisation and psychosocial risk and protective factors for health and well-being (eg, adverse childhood experiences). Longitudinal follow-up will capture outcomes over a 5-year period after arrival in Australia. Analysis will be undertaken to explore baseline risk and protective factors, with regression analyses to assess their impact on health and well-being outcomes. To understand how children's outcomes change over time, multilevel regression analysis will be utilised. Structural equation modelling will be conducted to explore the correlation between baseline factors, mediational factors and outcomes to assess trajectories over time.

ETHICS AND DISSEMINATION

This research project was approved by the Sydney Children's Hospitals Network Human Research Ethics Committee. Subsequent site-specific approvals have been approved in 5 of the 11 governing bodies where the clinical consultations took place. In order to ensure this research is relevant and sensitive to the needs of the cohort, our research team includes an asylum seeker who has spent time in Australian immigration detention. Results will be presented at conferences and published in peer-reviewed Medline-indexed journals.

The psychobiological consequences of child separation at the border: lessons from research on attachment and emotion regulation

In the spring of 2018, the Attorney General of the United States issued a memorandum declaring a "zero tolerance policy" under which all adults entering the United States illegally would be criminally prosecuted, and, if traveling with minor children, forcibly separated from their children. Although the government was ordered to reunite the children with their parents it is still unclear how many children have been or remain separated. Given the high risk of permanent harm to a vulnerable population, and the fact that this risk may continue into the near future, we present a review of what nearly eight decades of scholarly research has taught us about the damaging impact of deprivation and separation from parents. The article briefly reviews the origins of attachment theory as well as empirical studies that examine the psychobiological impact on children who experienced parental deprivation or separation. The paper concludes with recommendations, for future research.

Paediatric asylum seekers in Western Australia: Identification of adversity and complex needs through comprehensive refugee health assessment

AIM

Asylum seekers (ASs) report high rates of trauma and difficulty accessing health and educational services. This study aims to ascertain the needs of paediatric ASs managed by the tertiary Western Australian paediatric Refugee Health Service (RHS), including demographic features, the range of health and psychosocial issues and ongoing management challenges.

METHODS

An audit of multidisciplinary RHS assessments, health records and hospital admissions for new AS patients (<16 years) between July 2012 and June 2016 was undertaken.

RESULTS

Records for 110 ASs were reviewed (mean age 6 years, standard deviation 4.72 years). Multiple issues (medical, psychological, developmental, educational) were identified after the first tertiary assessment (median 4, interquartile range (IQR) 3-6) compared to referral sources (median 1, IQR 0-2, P < 0.001). The median number of issues per child at audit completion was 6 (IQR 4-7, P < 0.001). Multiple refugee adverse childhood experiences were identified, with all experiencing >3 (median 4, IQR 4-5). Most had detention experience (107/110, 97.2%), family separation (91/108, 84%) and interrupted education (41/46, 89.2%). The median duration of detention was 7 months (IQR 3-12.5 months) at time of initial review across multiple sites (median 2, IQR 1-3 locations). High rates of hospital interaction were evident, with 45.4% requiring hospital admission and 36% presenting to the emergency department. The median number of outpatient appointments attended per child was 5 (IQR 2-8). Parental and child mental health concerns were identified in 53.6 and 46.3%, respectively.

CONCLUSIONS

Paediatric ASs have complex trauma backgrounds with exposure to multiple adverse events within disrupted family units. The majority of Western Australian ASs assessed demonstrated negative health or education sequelae compounded by detention not previously identified prior to comprehensive paediatric review. Our data support the urgent removal of ASs from held detention. Ongoing holistic assessment and management engaging multidisciplinary trauma-informed paediatric refugee services to optimise health and well-being is recommended.

New developments in the mental health of refugee children and adolescents

The increase in refugees globally since 2010 and the arrival of many into Europe since 2015, around 50% of whom are under 18 years, have been the stimulus to greater investigation and publications regarding their mental health. This clinical review summarises selected themes in the field as described in the published literature since 2016. The themes include refugee statistics, premigration and postmigration experiences, psychopathology focusing on parent-child relationships, unaccompanied refugee minors and associations between resettlement, acculturation and mental health. Some important reviews and studies are discussed that address service and treatment provision. While there has been a recent increase in research in this field, more is needed into the course of psychopathology, protective factors and the promotion of integration into resettlement countries, as well as models of service delivery and treatment effectiveness.

Prevention of psychological distress and promotion of resilience amongst unaccompanied refugee minors in resettlement countries

AIM

As increasing numbers of unaccompanied refugee minors (URMs) are arriving in Europe, there is a need to investigate which factors promote psychological resilience and improve their mental health. This review aims to identify preventive post settlement influences, including living arrangements, access to mental health services, and effective treatments that may improve mental health outcomes.

METHODS

A systematic literature review was conducted of published papers in any language for children (<18 years) entering a host country, unaccompanied and seeking asylum. Specific studies were eligible if they examined any treatment or nontreatment influences on mental health or psychological resilience for the URM. Thirteen published quantitative studies were identified.

RESULTS

URMs in more supportive living arrangements including foster care had lower risk of PTSD and lower depressive symptoms compared with those in semi-independent care arrangements. URMs living in reception settings that restricted freedom had more anxiety symptoms. Regarding help seeking, one study found only 30% of URMs had foster parents or guardians who could detect a mental health need. Two papers found the URMs had low levels of contact with mental health services despite the high prevalence of psychiatric symptoms. URMs were less likely than accompanied children to receive trauma-focused interventions, cognitive therapy, or even practical assistance with basic social needs. With regard to treatment evaluation, only case series were identified. Three studies found cognitive behavioural therapy improved PTSD symptoms and mental health outcomes. A less structured approach (mental health counselling alone) did not improve functional health outcomes.

CONCLUSION

Higher support living arrangements with low restrictions are associated with lower psychological distress. Most URMs are not receiving psychological interventions, and there is a dearth of studies evaluating treatment effectiveness for this group. There is an urgent need for more research to investigate pathways to mental health services and treatment efficacy in this vulnerable group.

Mental health needs and services for migrants: an overview for primary care providers

BACKGROUND

The objective of this article is to present an overview of the burden, spectrum of diseases and risk factors for mental illness among subgroups of migrants, namely, immigrants, refugees and individuals with precarious legal status. This expert review summarises some of the implications for primary care services in migrant receiving countries in the global North.

METHODS

A broad literature review was conducted on the epidemiology of mental health disorders in migrants and the available evidence on mental health services for this population focusing on key issues for primary care practitioners in high-income countries.

RESULTS

Although most migrants are resilient, migration is associated with an over-representation of mental disorder in specific subpopulations. There is a general consensus that stress-related disorders are more prevalent among refugee populations of all ages compared to the general population. Relative to refugees, migrants with precarious legal status may be at even higher risk of depression and anxiety disorders. Persistence and severity of psychiatric disorders among migrant populations can be attributed to a combination of factors including severity of trauma exposures during the migration process. Exposure to stressors after resettlement, such as poverty and limited social support, also impacts mental illness. Services for migrants are affected by restricted accessibility and should address cultural and linguistic barriers to and issues in the larger social environment that impact psychosocial functioning.

CONCLUSION

There is substantial burden of mental illness among some migrant populations. Primary care providers seeking to assist individuals need to be cognizant of language barriers to and challenges of working with interpreters as well as sensitive to cultural and social contexts within the diagnosis and service delivery process. In addition, best practices in screening migrants and providing intervention services for mental disorders need to be sensitive to where individuals and families are in the resettlement trajectory.

Children on the move in Europe: a narrative review of the evidence on the health risks, health needs and health policy for asylum seeking, refugee and undocumented children

BACKGROUND

Europe has experienced a marked increase in the number of children on the move. The evidence on the health risks and needs of migrant children is primarily from North America and Australia.

OBJECTIVE

To summarise the literature and identify the major knowledge gaps on the health risks and needs of asylum seeking, refugee and undocumented children in Europe in the early period after arrival, and the ways in which European health policies respond to these risks and needs.

DESIGN

Literature searches were undertaken in PubMed and EMBASE for studies on migrant child health in Europe from 1 January 2007 to 8 August 2017. The database searches were complemented by hand searches for peer-reviewed papers and grey literature reports.

RESULTS

The health needs of children on the move in Europe are highly heterogeneous and depend on the conditions before travel, during the journey and after arrival in the country of destination. Although the bulk of the recent evidence from Europe is on communicable diseases, the major health risks for this group are in the domain of mental health, where evidence regarding effective interventions is scarce. Health policies across EU and EES member states vary widely, and children on the move in Europe continue to face structural, financial, language and cultural barriers in access to care that affect child healthcare and outcomes.

CONCLUSIONS

Asylum seeking, refugee and undocumented children in Europe have significant health risks and needs that differ from children in the local population. Major knowledge gaps were identified regarding interventions and policies to treat and to promote the health and well-being of children on the move.

The impact of immigration detention on mental health: a systematic review

BACKGROUND

The number of asylum seekers, refugees and internally displaced people worldwide has increased dramatically over the past 5 years. Many countries are continuing to resort to detaining asylum seekers and other migrants, despite concerns that this may be harmful. In light of the considerable body of recent research, this review aims to update and expand on a 2009 systematic review on the mental health consequences of detention on adult, adolescent and child immigration detainees, which found (on the basis on 9 studies) that there was consistent evidence that immigration detention had adverse effects on mental health.

METHODS

Three databases were searched using key terms relating to immigration detention and mental health. Electronic searches were supplemented by reference screening. Studies were included if they were quantitative, included individuals detained for immigration purposes, reported on mental health problems and were published in peer-reviewed journals. Two reviewers independently screened papers for eligibility, and a further two reviewers completed quality appraisals for included studies.

RESULTS

Twenty- six studies (21 of which were not included in the 2009 review) reporting on a total of 2099 participants were included in the review. Overall, these studies indicated that adults, adolescents and children experienced high levels of mental health problems. Anxiety, depression and post-traumatic stress disorder were most commonly reported both during and following detention. Higher symptom scores were found in detained compared to non-detained refugees. In addition (and more clearly than was evident in 2009), detention duration was positively associated with severity of mental symptoms. Greater trauma exposure prior to detention was also associated with symptom severity.

CONCLUSIONS

The literature base reviewed in this paper consistently demonstrated severe mental health consequences amongst detainees across a wide range of settings and jurisdictions. There is a pressing need for the proper consideration of mental health and consequent risk of detention-related harm in decisions surrounding detention as well as for improved care for individuals within detention facilities. Recommendations based on these findings are presented, including increased focus on the identification of vulnerability and on minimising the duration of detention.