Long-term effects of organized violence on young Middle Eastern refugees' mental health

Coping with the long-term impact of civil strife: A grief-centered analysis of Tamil Sri Lankan communities affected by ethnopolitical conflict

Limited research has examined coping mechanisms in response to chronic war-related stressors, as opposed to war-exposure trauma. The current study sought to investigate the types of losses experienced by communities affected by the Sri Lankan conflict, how participants responded to their losses, and what coping mechanisms they employed. Data consisted of interviews from two independent investigations conducted following the end of the conflict in Northern Sri Lanka (total N = 103). Interview transcripts were analyzed using a directed content analysis approach. Participants most frequently described experiencing material loss and loss of loved ones. Relatedly, participants commonly reported experiencing ambiguous loss, that is, living with the uncertainty of their loved one's death. These losses were particularly pronounced by gender, with women experiencing higher rates of loss. Common coping strategies included support-seeking, including informal support from social networks and religion, and formal mental health services. Additionally, participants described a range of longer term coping strategies from establishing a future-oriented cognitive style to a sense of helplessness and resignation. The findings shed light on how conflict-affected groups cope with profound loss. We provide recommendations for how such findings can inform grief-related clinical interventions.

Influence of post-migration living difficulties on mental health among refugees and asylum seekers: A scoping-review on clinical tools

BACKGROUND

The literature indicates an increasing interest in the mental health of refugees (R) and asylum seekers (AS) - particularly how it could be affected by previous exposure to trauma and violence - but less has been written about the issues they are forced to face during the post-migration period and how these also can affect mental health. Research shows that the mental health of R/AS is highly influenced by their post-migration conditions and may deteriorate due to post-migration social health-related determinants; in addition, a lack of language skills, discrimination, separation from family, poverty, and other stressors can contribute to social isolation. The difficulty in asking for help in case of psychological distress and, consequently, in accessing care, contributes to the worsening of their clinical condition.

AIMS

The primary purpose of this study is to identify and provide a review of the clinical tools used to screen migrants (R/AS) at risk of developing psychological distress, identifying post-migration difficulties.

METHODS

We searched studies in PubMed, Embase, Scopus, Cochrane (Central), and Cinahl (ultimate) with the last search on 14 April 2023, using a combination of keywords and Medical Subject Headings (MeSH).

RESULTS

Our systematic search identified 1,878 records. After removing duplicates, we screened 1,238 records by title and abstract, retaining 97 for full text review. Of these, 68 met full eligibility criteria (1995-2023). A total of 30 social scales have been identified, as well as structured or semi-structured questionnaires and interviews. Translated into multiple languages, the tools can be self-administered or administered by trained professionals. PMLD is known for its effectiveness in evaluating the post-migration period and predicting mental health issues.

CONCLUSIONS

Considering the limited number of studies and, consequently, the limited number of tools found, it can be inferred that not enough attention is given to post-migration in the broader sense.

The Effect of Psychoeducation on Attitudes toward Violence and Risky Behaviors among Refugee Adolescents

This study was conducted to examine the effect of psychoeducation on attitudes toward violence and risky behaviors among refugee adolescents. This was a randomized controlled experimental study conducted with refugee adolescents (n = 101) studying in a high school in southern Turkey. After psychoeducation, it was determined that there was a significant decrease in the prevalence of antisocial behaviors, alcohol use, suicidal thoughts, unhealthy eating habits, and school dropout thoughts among adolescents according to the subdimensions of the risky behavior scale. Psychoeducation was found to be effective in reducing attitudes toward violence and preventing risky behaviors among refugee adolescents.

A systematic review of studies on resilience and risk and protective factors for health among refugee children in Nordic countries

The Nordic welfare model is often used as an example for the promotion of health and wellbeing, even in vulnerable groups of children, such as refugees. Nonetheless, there are no published reviews on resilience and/or risk and protective factors for physical and mental health among refugee children living in Nordic countries. In this systematic review, we identified 5181 studies on the topic, screened titles, and abstracts, viewed 632, and finally included 26 studies. These studies described 18 samples with a total of 34,080 individuals ranging in ages 0-18 years. Overall, the studies were of good quality. Nearly all studies assessed adversity. Six studies reported physical health outcomes and all studies mental health outcomes, most often post-traumatic stress disorder and anxiety. None explicitly studied resilience. While we found that age and sex are the most frequently studied  risk- and protective factors, findings are inconclusive, since the direction of the associations was different in the different studies. This systematic review indicates that there is still a need for well-designed and -powered studies using clear definitions of key study concepts to examine health outcomes and resilience among refugee children in Nordic countries.

Newcomers to Unwelcoming Lands: A Conceptual Review of the Dimensions of Discrimination Experienced by Refugee Youth and the Processes Imparting Risk and Resilience

In 2018, half of refugees worldwide were under the age of 18. Although often resilient, refugee youth experience chronic and pervasive traumatic events prior to and during migration, and are at risk for continued victimization and stressors while in their host country. In particular, refugee youth encounter ongoing discrimination during resettlement, a primary stressor that reduces their wellbeing and adaptation. Given the relevance of discrimination for refugee youth, the goal of the current review is to increase our understanding of the dimensions of discrimination faced by refugee youth and the risk and resilience processes that may be involved in these negative experiences. Thus, this review presents the existing theoretical and empirical research on this topic and creates a model that organizes these findings. The present review concludes with recommendations for prevention and intervention efforts and considerations for future research.

With a little help from my friends? Acculturation and mental health in Arabic-speaking refugee youth living with their families

Introduction

Refugee youth are often faced with the compounding challenges of heightened exposure to traumatic events and acculturating to a new country during a developmental period when their sense of self is still forming. This study investigated whether refugee youth’s acculturation orientation (separation, integration, marginalization, and assimilation) is associated with depressive and posttraumatic stress symptoms and aimed to identify additional indicators of acculturation that may contribute to mental health.

Methods

A total of 101 Arabic-speaking refugee youths (aged 14–20 years), who were living with their families and attending school in Germany, took part in the study. They answered questions concerning traumatic exposure and posttraumatic stress symptoms, depressive symptoms, and several indicators of acculturation, including cultural orientation, positive and negative intra- and intergroup contact, language skills and friendship networks. All participants were categorized into one of four acculturation orientations using median splits.

Results

Kruskal–Wallis rank sum tests revealed that acculturation orientation was not significantly associated with depressive symptoms [χ2 (3, 97) = 0.519, p = 0.915] or posttraumatic stress symptoms [χ2 (3, 97) = 0.263, p = 0.967]. Regression analysis revealed that German language skills were significantly associated with lower scores of depressive symptoms (p = 0.016) and number of friends in Germany was significantly associated with lower scores of depressive (p = 0.006) and posttraumatic stress symptoms (p = 0.002), respectively.

Discussion

Policies that provide refugee youth with access to language classes and social activities with peers do not only enable them to actively participate in a new society but may also have a positive effect on their mental health.

Refugee mental health and the role of place in the Global North countries: A scoping review

Post-migration factors significantly influence refugee mental health. This scoping review looks at the role of place in refugee mental health. We included 34 studies in Global North high-income countries that elaborated on the place characteristics of facilities, neighbourhoods, urban and rural areas, and countries. While the role of place remains under-theorised, all studies reveal common characteristics that support a strong relationship between place of residence, refugee mental health and wellbeing outcomes in post-migration context. Given that refugees often have little or no choice of where they ultimately live, we suggest future research should focus on how characteristics of place co-constitute post-migration refugee mental health risks, protections, and outcomes.

Addressing Mental Health Concerns in Refugees and Displaced Populations: Is Enough Being Done?

There are over 82.4 million forcibly displaced people worldwide, about a quarter of whom are resettling as refugees. In the wake of the global refugee crisis spurred by conflict, religious and political persecution, human rights violations, and climate disasters, a mental health has crisis followed. Not only does trauma experienced in home countries and as part of forced migration affect mental health, so too do post-migration traumatic events, discrimination, lack of access to quality and affordable healthcare and housing, and acculturation. To address mental health concerns in refugees and displaced populations, collective action is needed not only from health care providers but also from mental health researchers, funders, journals, resettlement agencies, government entities, and humanitarian organizations. The present review highlights the work of numerous scholars and organizations with the goal of understanding the mental health concerns of forcibly displaced persons within and across ecological systems. The present review seeks to bring attention to the experiences of forcibly displaced persons, summarize the growing body of research understanding the acute and chronic effects of forced displacement and possible interventions, and give a call to action for all members of the global community at every level to engage in joint efforts to improve mental health in refugees and displaced persons. Notably, there is a need for more interventions at the familial and community level that serve not only as treatment but also as prevention. Smartphone-based interventions, mind-body modalities, and interventions delivered by lay and non-clinician community members hold promise. Numerous strides could be made in refugee mental health and treatment when funding agencies include these goals in their research priorities. Despite the challenges they have faced, persons who resettle as refugees are incredibly resilient and deserve to be afforded every right, opportunity, dignity, and respect.

Vulnerabilities of Syrian refugee children in Turkey and actions taken for prevention and management in terms of health and wellbeing

BACKGROUND

The Syrian crisis, which started in March 2011, has resulted in the displacement of 6.3 million refugees predominantly to neighboring countries in addition to the internal displacement of 6.2 million people. Turkey is the country hosting the largest number of refugees in the world with 3.6 million Syrian refugees 46 % of which are under 18 years old.

OBJECTIVE

The purpose of this article is to conduct a narrative review and analyze the vulnerabilities of refugee children in Turkey from the lens of the Sustainable Development Goals (SDG), more specifically SDG Goal 3: Good Health and Wellbeing, with a specific focus on Syrian refugee children. Moreover, this article explores the actions taken to prevent and mitigate issues that arise from these vulnerabilities.

METHOD

This narrative review article collected data from various primary and secondary sources on the Turkish refugee framework including national and international legislation, governmental and non-governmental data and reports, and scientific papers.

RESULTS

Syrian refugee children in Turkey are facing a variety of risks in terms of their health and wellbeing including communicable and non-communicable diseases, post-traumatic stress disorder, depression, family violence, child labor, and child marriage. The measures taken for prevention and response by governmental and non-governmental entities are multilateral and aim to address issues from multiple perspectives including medical, psychosocial, child protection, and legal.

CONCLUSIONS

The interventions and restructuring of the health system in Turkey contribute to the SDG number 3 for refugee children. The existence of a legal system which enables refugee access to health, protection, and other social services is key to achieve this goal. However, the existing system could be improved especially through solidifying the legal basis and centralizing the implementation for child and refugee protection. The engagement of all stakeholders to improve the health and wellbeing of refugee children remains vital.

Refugee Women with a History of Trauma: Gender Vulnerability in Relation to Post-Traumatic Stress Disorder

Refugees represent a population whose living conditions have a strong impact on their mental health. High rates of post-traumatic stress disorder (PTSD), more than other mental disorders, have been found in this group, with women having the highest incidence. The objective of the present systematic review was to identify and examine studies from the last fifteen years on the relationship between the impact of traumatic experiences and PTSD psychopathology in refugee women. Twelve studies were included, from which the overall results approved this relation. In addition, six of these studies show that exposure to sexual trauma in refugee women is associated with the high odds of being at risk for PTSD. These findings suggest that gender-related traumatic experiences can explain the high rate of PTSD in refugee women and highlight the unmet need for psychosocial health care in this population.

Children at risk: A nation-wide, cross-sectional study examining post-traumatic stress symptoms in refugee minors from Syria, Iraq and Afghanistan resettled in Sweden between 2014 and 2018

Background

The objective of the present study was to assess nation-wide, representative prevalence estimates for symptom-defined posttraumatic stress disorder (PTSD) within populations of refugee minors from Afghanistan, Syria and Iraq resettled in Sweden.

Methods

A nation-wide, cross-sectional, questionnaire study with a stratified sample of refugee minors, aged 16–18 years, from Afghanistan, Iraq and Syria, resettled in Sweden between 2014 and 2018 (N = 5071) was conducted. The response rate was 22.3%, leaving n = 1129 refugee minors (boys 53.1% / girls 46.9%) in the final sample. Symptom-defined prevalences of PTSD were measured using CRIES-8 with ≥17 as cut-off. Data were analyzed using frequency distributions, and strata-specific PTSD prevalences with 95% confidence intervals (95% CIs), were estimated. The association between migratory status on arrival (unaccompanied vs. accompanied) and PTSD was estimated using crude and adjusted odds ratios (OR) utilizing logistic regression analyses with 95% CIs.

Results

Overall, the weighted PTSD prevalence was 42% (95% CI 38.9–45.1), with minors from Afghanistan presenting the highest prevalence (56.9, 95% CI 51.5–62.2), compared to minors from Iraq (36.8, 95% CI 28.9–45.4) and Syria (33.4, 95% CI 29.4–37.6). Unaccompanied minors from Afghanistan had higher odds of PTSD compared to accompanied minors from Afghanistan (OR = 1.92, 95% CI 1.08–3.40). Gender differences were non-significant.

Conclusions

High prevalences of symptom-defined PTSD among refugee minors in general and in unaccompanied minors from Afghanistan in particular, were revealed. Findings calls for continued efforts to support this especially vulnerable group.

Prevalence of psychiatric symptoms among refugee adolescents in Turkey: a controlled study

Objective:

To investigate prevalence of internalized and externalized psychological symptoms and war-related adverse events among a representative secondary-school sample of Syrian refugee adolescents, and to compare levels of depression, anxiety, and stress between Syrian refugee adolescents and Turkish adolescents.

Methods:

Syrian refugee adolescents (n=70) and Turkish adolescents (n=70) were asked to complete the Depression, Anxiety, and Stress Scales (DASS-42) and Strengths and Difficulties Questionnaire (SDQ).

Results:

DASS and SDQ scores were significantly different between the two groups; scores in all problem areas were higher in refugees. Loss of a family member increased depression, stress, and total difficulty scored, whereas witnessing death increased anxiety and stress and experiencing multiple events increased depression, anxiety, and total difficulty scores. Maternal years of schooling correlated inversely with SDQ emotional symptoms, conduct problems, and hyperactivity/inattention problem scores. Both parents’ years of schooling correlated inversely with SDQ total difficulties scores.

Conclusion:

Syrian refugee adolescents had higher depression, anxiety, behavioral problems, peer relationship problems, and general difficulties than their Turkish peers. Facilitating refugees’ access to mental health services, educating their parents, consulting, and monitoring at-risk children may contribute to reducing psychosocial problems in refugee children.

A System Model of Post-Migration Risk Factors Affecting the Mental Health of Unaccompanied Minor Refugees in Austria-A Multi-Step Modeling Process Involving Expert Knowledge from Science and Practice

Various studies have indicated that unaccompanied minor refugees (UMRs) have a higher risk of suffering from mental health problems than do accompanied minor refugees and general population norm. However, only a few studies provide data on UMRs regarding post-migration risk factors, their interrelations, and their influence on mental health. In this study, system models of post-migration risk factors for mental health and their interactions were developed in the case of Austria. In three consecutive interactive workshops with scientists and practitioners, fuzzy-logic cognitive mapping techniques were used to integrate the experts’ knowledge. The resulting final system model consists of 11 risk factors (e.g., social contacts in the host country, housing situation, or professional health care services). The model provides a deeper insight into the complexity of interrelated direct, indirect, and reciprocal relations, as well as self-reinforcing triads. This systemic approach provides a sound basis for further investigations, taking into account the inherent complex multifactorial dependencies in this topic.

Adolescents’ Peer Friendship and Anxiety and Depression among First-Generation Immigrant BAME Families in the UK

There is equivocal evidence on how being a child in a Black, Asian and Minority Ethnic (BAME) immigrant family affects internalizing symptoms such as anxiety. This cross-sectional study examined the relationships between peer friendships and anxiety/depression symptoms in BAME immigrant adolescents (IA) and white native adolescents (WNA). Method: Sixty-two adolescents from the UK (IA = 26, WNA = 36, mean age = 14 years) were assessed on close friendship, social competence, social anxiety, and depression. Immigrant family parents (n = 23) were also assessed on cultural orientation. There were no significant differences in anxiety and depression between groups. Bayes factors supported the conclusion that the groups did not differ. However, IA and WNA groups had different patterns of associations between close friendship/social competence and anxiety and depression symptoms. Close friendships were more strongly associated with lower anxiety/depression in IAs than WNAs, and social competence was more strongly associated with lower anxiety/depression in WNAs than IAs. Moderation analyses indicated that the relationship between close friendship and social and separation anxiety was significantly moderated by ethnic group, as was the relationship between social competence and generalized anxiety. The findings suggest that social and separation anxiety are more strongly associated with close friendships for BAME immigrant children than for non-immigrant adolescents. As such, activities that help BAME immigrant children to foster close relationships may have positive effects on their well-being.

They ask for protection: An exploratory study into experiences with violence among unaccompanied refugee children in Dutch reception facilities

BACKGROUND

Children placed under governmental supervision and staying in residential or foster care are more vulnerable to violence than children who live with their own families. One specific group of children staying in reception facilities under governmental supervision comprises unaccompanied refugee children who have fled to a host country without their parents.

OBJECTIVE

This qualitative study explores the experiences of unaccompanied children with regard to violence in reception facilities in the Netherlands from the perspective of the children.

PARTICIPANTS AND SETTING

183 unaccompanied children (N = 183) sheltered in a variety of reception facilities in the Netherlands.

METHOD

Semi-structured interviews were conducted focusing on several topics related to their perceived quality of life. The transcripts of the interviews were analyzed for experiences with violence occurring inside the reception facilities. The codebook that was used was based on the categorization of maltreatment in the fourth United States National Incidence Study (NIS-4) and the interpretation of violence by the Committee on the Rights of the Child in General Comment No. 13 (GC 13).

RESULTS

A large share (66 %) of the unaccompanied children had experienced violence in various reception facilities. Most of the experiences reported had to do with either physical and emotional abuse and neglect or institutional violence.

CONCLUSION

The breadth of experiences of violence underlines the responsibility of the Dutch state to invest in the safe reception of unaccompanied children in order to protect their development, while also investing in further research on the prevalence of violence in the reception of unaccompanied children.

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 Real Emergency at Our Southern Border Is Mental Health

On February 15, 2019, President Trump declared a national emergency at the border of the United States and Mexico stating that "We're talking about an invasion of our country with drugs, with human traffickers, with all types of criminals and gangs."¹ As clinical scientists, we are able to unpack data from the federal government and other sources to evaluate this statement. In contrast to the declaration, available data fail to support an invasion of drugs and criminals and instead point to a real humanitarian emergency regarding the mental health of children and families migrating to the United States from Central America.

Anger and Sadness Regulation in Refugee Children: The Roles of Pre- and Post-migratory Factors

Pre- and post-migratory factors have been implicated in refugee children's mental health. However, findings regarding their unique and joint roles are inconsistent or nonexistent. We examined the main and interactive relations of pre-migratory life stressors and post-migratory daily hassles and routines to emotion regulation-a key marker of mental health-in 5- to 13-year-old Syrian refugee children (N = 103) resettling in Canada. Mothers and children completed questionnaires assessing pre-migratory life stressors and post-migratory daily hassles. Mothers also reported their children's adherence to family routines and emotion regulation abilities (i.e., anger and sadness regulation) via questionnaire. Overall, children who more frequently engaged in family routines showed better anger regulation. Pre- and post-migratory factors also interacted, such that greater post-migratory daily hassles were associated with worse sadness regulation for children with lower levels of pre-migratory life stressors, but were unassociated with the sadness regulation of children who experienced higher levels of pre-migratory life stressors. Results suggest that pre- and post-migratory factors play unique and joint roles in refugee children's emotion regulation during resettlement.

Gewalterfahrungen und psychische Gesundheit im Verlauf bei unbegleiteten minderjährigen Flüchtlingen in Deutschland

Zusammenfassung. Hintergrund: Über die seelische Gesundheit von minderjährigen Flüchtlingen, die ohne sorgeberechtigte Person nach Deutschland gereist sind, liegen bisher kaum Daten und keinerlei längsschnittliche Untersuchungen vor. Fragestellung: Ziel ist es daher, die psychische Gesundheit im Zusammenhang mit stressvollen Erfahrungen (insbesondere familiäre und organisierte Gewalterfahrungen) sowie deren Entwicklung nach etwa zwei Jahren bei unbegleiteten minderjährig Geflüchteten in Deutschland zu untersuchen. Methode: In einer Querschnittsstudie wurden belastende Erlebnisse sowie posttraumatische, depressive und psychosomatische Symptome bei 57 unbegleiteten und 22 begleiteten minderjährig eingereisten Flüchtlingen mittels strukturierter klinischer Interviews untersucht. Nach durchschnittlich 20 Monaten wurde eine Subgruppe der unbegleiteten Minderjährigen erneut untersucht. Ergebnisse: Ein Drittel der Teilnehmer erfüllte die Kriterien einer PTBS-Diagnose nach DSM-IV. Nach Einbezug einer Gruppe begleiteter minderjähriger Flüchtlinge zeigte sich, dass vor allem organisierte und familiäre Gewalterfahrungen sowie die Dauer der Flucht bedeutsame Prädiktoren hinsichtlich der PTBS-Symptomschwere waren. Für das psychische Wohlbefinden insgesamt waren die erfahrene Gewalt in der Herkunftsfamilie, bestehende Freundschaften und das Vorhandensein von Privatsphäre relevant. Ergebnisse einer Folgeuntersuchung mit einer Teilgruppe der UMF etwa 20 Monate später zeigten, dass die psychische Beeinträchtigung im Durchschnitt unverändert hoch geblieben war. Fazit: Die Möglichkeit einer frühzeitigen psychischen Untersuchung mit Erfassung kindlicher Gewalterlebnisse sowie ein verbesserter Zugang zu einer traumafokussierten Behandlung mit Sprachmittlern sind wichtig, um Leid zu reduzieren und Integration zu ermöglichen.

Violation and hope: Refugee survival in childhood and beyond

BACKGROUND

The psychological complexity of refugee status for children is poorly understood. Alone or with family members, child refugees are exposed to multiple and potentially traumatic events, including conflict and human rights deprivation in their country of origin, perilous and life-threatening escape journeys, years of statelessness, and isolation and discrimination in their new host country.

AIMS

This phenomenological study explored the positive and negative interpretations of four adults as they sought to make sense of their experiences of refugee status as children.

METHOD

Interpretative Phenomenological Analysis (IPA) guided the development of semi-structured interview for data collection and analysis.

RESULTS

One superordinate theme, Violation and Hope, overarched three subordinate themes, Violent detachment, Refugee identity, and Resourcefulness and reciprocity. One divergent theme also emerged: Clashing identities. These themes provide unique insight into the interpreted experiences of escaping oppression and persecution in each participant's country of origin as children, and the ensuing bleak interval as refugees, belonging nowhere. They identify the risk of becoming pawns of opportunism without human rights protection. Once stateless, survival was not guaranteed, producing a stark merging of acceptance of mortality and determined resourcefulness as children. Avoidant coping became a positive tool for surviving ever present threat, and was crucial in defining a life philosophy that was future oriented as they entered adulthood.

CONCLUSION

These participants rejected a 'refugee victim' identity, emphasising a legacy of resourcefulness, hope, gratitude and reciprocity, domains of post-traumatic growth which are unreported aspects of refugee well-being that can provide future therapeutic and research direction.

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.

Prevalence of mental disorders in young refugees and asylum seekers in European Countries: a systematic review

The European Union member states received about 385,000 asylum applications from children and adolescents below 18 years in 2015, and 398,000 in 2016. The latest political crises and war have led to an upsurge in refugee movements into European countries, giving rise to a re-evaluation of the epidemiology of psychiatric disorders and mental health problems among young refugees and asylum seekers. We systematically searched five electronic databases and reference lists of pertinent review articles. We then screened the results of forward citation tracking of key articles for relevant studies in the field for the period from January 1990 to October 2017. We dually reviewed citations and assessed risk of bias. We reported the results narratively, as meta-analyses were impeded due to high heterogeneity. We included 47 studies covered in 53 articles. Overall, the point prevalence of the investigated psychiatric disorders and mental health problems varied widely among studies (presenting interquartile ranges): for posttraumatic stress disorder between 19.0 and 52.7%, for depression between 10.3 and 32.8%, for anxiety disorders between 8.7 and 31.6%, and for emotional and behavioural problems between 19.8 and 35.0%. The highly heterogeneous evidence base could be improved by international, methodologically comparable studies with sufficiently large sample sizes drawn randomly among specific refugee populations. The prevalence estimates suggest, nevertheless, that specialized mental health care services for the most vulnerable refugee and asylum-seeking populations are needed. REGISTRATION: The systematic review protocol was registered in PROSPERO on October 19th, 2017 with the number: CRD42017080039 and is available from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=80039.

Feasibility of a trauma-informed parent-teacher cooperative training program for Syrian refugee children with autism

Although the number of Syrians affected by the civil war rises, little work has been done to address the needs of Syrian refugee children with autism spectrum disorder. This research aimed to test the feasibility and acceptability of a culturally sensitive intervention developed specifically for children with autism spectrum disorder affected by trauma. Local partners advised the program team on cultural norms. Nine parents and 11 teachers were recruited to participate in 12-week parent-teacher cooperatives in a large Turkish city. We used qualitative methods to analyze interviews with each participant after intervention completion. A total of 14 participants completed the program (70%). All interviewees were women and Syrian refugees. Local political events, transportation costs and safety, and illnesses impacted attrition and attendance. All participants were satisfied with program content, including gains in autism knowledge, behavior management skills, and social support. Program-related challenges included applying skills to nonverbal children. The majority of participants made recommendations for program improvement, including a need for services outside urban areas. Flexible program delivery methods, including online options, might better accommodate participants unable to travel due to distance, political unrest, or safety. More research is needed to rigorously test program outcomes and to evaluate efforts to train local program leaders.

Review: How should child mental health services respond to the refugee crisis?

BACKGROUND

Child mental health services and related agencies are faced with an increasing challenge in responding to the influx of refugee children around the world. There is strong evidence on the prevalence and complexity of these children's mental health problems and broader needs.

AIMS

To review the research literature on risk and protective factors, and associated mental health interventions for refugee children.

METHODS

Peer-reviewed studies were included for the period 2004-2017; if they included refugee, asylum-seeking or internally displaced children under 18 years; and adopted a quantitative design. Vulnerability and protective factors for refugee children were considered in this context, followed by the respective types of interventions at pre-, peri- and postmigration stage, and across high- and low-/middle-income countries. Eighty-two peer-reviewed studies fulfilled the selection criteria.

RESULTS

The existing body of literature is largely based on identifying risk factors among children with mental health problems and predominantly designing trauma-focused interventions to reduce their symptomatic distress. Recent research and services have gradually shifted to a broader and dynamic resilience-building approach based on ecological theory, that is at child, family, school, community and societal level. There is increasing evidence for the implementation and effectiveness of multimodal interventions targeting all these levels, despite the methodological constraints in their evaluation.

CONCLUSIONS

In high-income countries, child mental health services need to collaborate with all agencies in contact with refugee children, establish joint care pathways, and integrate trauma-focused interventions with family and community approaches. In low- and middle-income countries, where specialist resources are sparse, resilience-building should aim at maximising and upskilling existing capacity. A six-dimensional psychosocial model that applies to other children who experience complex trauma is proposed.

Adjustment of refugee children and adolescents in Australia: outcomes from wave three of the Building a New Life in Australia study

BACKGROUND

High-income countries like Australia play a vital role in resettling refugees from around the world, half of whom are children and adolescents. Informed by an ecological framework, this study examined the post-migration adjustment of refugee children and adolescents 2-3 years after arrival to Australia. We aimed to estimate the overall rate of adjustment among young refugees and explore associations with adjustment and factors across individual, family, school, and community domains, using a large and broadly representative sample.

METHODS

Data were drawn from Wave 3 of the Building a New Life in Australia (BNLA) study, a nationally representative, longitudinal study of settlement among humanitarian migrants in Australia. Caregivers of refugee children aged 5-17 (N = 694 children and adolescents) were interviewed about their children's physical health and activity, school absenteeism and achievement, family structure and parenting style, and community and neighbourhood environment. Parent and child forms of the Strengths and Difficulties Questionnaire (SDQ) were completed by caregivers and older children to assess social and emotional adjustment.

RESULTS

Sound adjustment according to the SDQ was observed regularly among young refugees, with 76-94% (across gender and age) falling within normative ranges. Comparison with community data for young people showed that young refugees had comparable or higher adjustment levels than generally seen in the community. However, young refugees as a group did report greater peer difficulties. Bivariate and multivariate linear regression analyses showed that better reported physical health and school achievement were associated with higher adjustment. Furthermore, higher school absenteeism and endorsement of a hostile parenting style were associated with lower adjustment.

CONCLUSIONS

This is the first study to report on child psychosocial outcomes from the large, representative longitudinal BNLA study. Our findings indicate sound adjustment for the majority of young refugees resettled in Australia. Further research should examine the nature of associations between variables identified in this study. Overall, treating mental health problems early remains a priority in resettlement. Initiatives to enhance parental capability, physical health, school achievement and participation could assist to improve settlement outcomes for young refugees.

Health, Education and Employment Outcomes in Young Refugees in the Nordic Countries: A Systematic Review

Objectives: Since 2000, approximately 500,000 refugees have settled in the Nordic countries, about a third of them being children and young people. To identify general trends, and to detect gaps in the existing knowledge about the socioeconomic and health status of these young refugees, this review discusses the literature regarding three key areas related to welfare policy: health, education and employment. Methods: A systematic search in PubMed, Scopus, SocINDEX, Sociological Abstracts, Embase and Cochrane, and a search for publications from relevant institutions were undertaken. All publications had to be original quantitative studies published since 1980. The total number of studies identified was 1353, 25 publications were included. Results: Young refugees had poorer mental health than ethnic minority and native-born peers. Mental health problems were related to pre-migration experiences but also to post-migration factors, such as discrimination and poor social support. Refugees performed worse in school than native-born and few progressed to higher education. Experiencing less discrimination and having better Nordic language proficiency was associated with higher educational attainment. A higher proportion of refugees were unemployed or outside the labour force compared with other immigrants and native-born. Assessment instruments varied between studies, making comparisons difficult. Conclusions: The study suggests pre-migration factors but also post-migration conditions such as perceived discrimination, social support and Nordic language proficiency as important factors for the mental health, education and employment outcomes of young refugees in the Nordic countries. Further Nordic comparative research and studies focusing on the relationship between health, education and employment outcomes are needed.

Mental Health of Refugees and Asylum Seekers: Assessment and Intervention

With unprecedented numbers of displaced persons worldwide, mental health clinicians in high-income countries will increasingly encounter refugee and asylum-seeking patients, many of whom have experienced significant adversity before and after their migration. This paper presents a summary of the recent evidence on the assessment and treatment of refugees across the lifespan to inform clinicians' approaches to care of refugee patients in mental health care settings. Assessment and interventions for refugees are grounded in an ecosystemic approach which considers not only pre-migratory trauma, but social, familial, and cultural determinants of mental health in the host country. Evidence for psychotherapy and pharmacological treatments are reviewed, highlighting promising interventions while acknowledging that further research is needed. Ultimately, serving refugees necessitates a biopsychosocial approach that engages clinicians as medical experts, therapists, and advocates.

Islamophobia, Health, and Public Health: A Systematic Literature Review

BACKGROUND

In 2017, a "Muslim ban" on immigrants to the United States was coupled with a continued rise in Islamophobia and hate crimes toward Muslims. Islamophobia undermines health equity, yet delineating the effects of Islamophobia globally is challenging as it affects a myriad of groups (geographically, racially, and socially). Additionally, stereotypes equate all Muslims with populations from the Middle East and South Asia. To date, health research pays insufficient attention to Islamophobia, Muslims, and those racialized to be Muslim.

OBJECTIVES

This literature review advances our understanding of racism and health by examining the racialization of religion, by specifically examining Islamophobia as a form of discrimination.

SEARCH METHODS

Per PRISMA guidelines, we conducted a search in October 2017 using PubMed-MEDLINE and a combination of terms. We identified additional articles using other search engines. For inclusion, articles needed to include a descriptor of discrimination, contain an identifier of Muslim or Muslim-like identity (i.e., groups commonly perceived as Muslim, including Arabs, Middle Easterners, North Africans, and South Asians), include a health outcome, be in English, and be published between 1990 and 2017.

SELECTION CRITERIA

We identified 111 unique peer-reviewed articles. We excluded articles that did not meet the following criteria: (1) examined Islamophobia, discrimination, or racism among a Muslim or Muslim-like population; (2) included a health outcome or discussion of health disparities; and (3) was conducted in North America, Europe, Australia, or New Zealand. This yielded 53 articles.

RESULTS

The majority of studies (n = 34; 64%) were quantitative. The remaining studies were qualitative (n = 7; 13%), mixed methods (n = 2; 4%), or reviews (n = 10; 19%). Most studies were based in the United States (n = 31; 58%). Nearly half of the reviewed studies examined mental health (n = 24; 45%), and one fourth examined physical health or health behaviors (n = 13; 25%). Others focused on both physical and mental health (n = 10; 19%) or health care seeking (n = 7; 13%). Studies showed associations between Islamophobia and poor mental health, suboptimal health behaviors, and unfavorable health care-seeking behaviors.

CONCLUSIONS

This study elucidates the associations between Islamophobia, health, and socioecological determinants of health. Future studies should examine the intersectional nature of Islamophobia and include validated measures, representative samples, subgroup analyses, and comparison groups. More methodologically rigorous studies of Islamophobia and health are needed. Public Health Implications. Addressing the discrimination-related poor health that Muslims and racialized Muslim-like subgroups experience is central to the goals of health equity and assurance of the fundamental right to health.

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

Accumulating literature demonstrates that immigration detention is harmful to children. However, there is a scarcity of scientifically rigorous and reliable data about the health of children held in detention facilities. The aim of the study was to compare a community-based population of recently arrived refugee children flown into Australia, not detained, resettled in a non-urban area, with a population of children who arrived by boat seeking asylum, detained since arrival. The parent-version of the strength and difficulties questionnaire (SDQ) of children aged 4-15 years was compared in children living in the community with those held in detention. We compared 86 children who had a parent-completed SDQ performed, 38 (44%) in the community group and 48 (56%) in the detention group. The community sample had been living in Australia for 325 days, with no time in detention. The detention sample had been living in detention for a mean of 221 days. The mean age was similar for the community and detention sample at 8.4 years (P = 0.18). In the total sample, children in the detention group had significantly higher SDQ total difficulties scores than children in the community group (P < 0.0001). There was no difference between age groups (P = 0.82). The children in the detention group had, on average, an SDQ total difficulties score that was 12 points higher than children in the community group. Four of the five SDQ subscale scores indicated greater disturbance amongst children in detention (< 0.0001) compared to children living in the community. The detention group had significantly higher scores (P < 0.001) for all except Pro-social scores as compared to Australian norms for the 4-6 and 7-15 years age group. This study presents a rare opportunity to compare the wellbeing of displaced children who were detained following arrival in Australia with those settled in the Australian community since arrival. The community children's scores approximated data from the general Australian childhood population. Children held in detention had significantly more social, emotional and behavioural difficulties than children living in the community, and at levels resembling a clinical cohort. Despite the small sample size, data restrictions and other limitations of the data, statistical significance in differences between the community and detention children is marked and arguably demonstrates the negative impact of post-arrival detention in children who are presumed to have similar levels of pre-arrival adversity. If the objective is to optimise the health and wellbeing of children seeking asylum, removal of post-arrival detention is one of the most powerful interventions available to host countries.

Protective factors for social-emotional well-being of refugee children in the first three years of settlement in Australia

AIM

This longitudinal study investigated protective factors for social-emotional well-being in refugee children in Australia.

METHODS

Newly arrived refugee children aged 4-15 years were recruited between 2009 and 2013 and assessments were conducted at two points, at years 2 and 3 postarrival. Social-emotional well-being was assessed using the Strengths and Difficulties Questionnaire (SDQ). Protective factors were assessed by structured interview and the Social Readjustment Rating Scale (SRRS); scores <150 reflect fewer stressful life events in the previous year.

RESULTS

Forty-three eligible refugee children were recruited. The SDQ was completed by parents in 90% and protective factor data in 80% at years 2 and 3 of follow-up. Protective factors for normal SDQ scores were: originating from Africa (p=0.01), father present on arrival (p=0.019) and family SRRS scores <150 at year 2 (p=0.045). The median number of protective factors was 4 (range 1-8). Better SDQ scores were associated with ≥4 protective factors (p<0.006). Furthermore, more protective factors increased the child's likelihood of a stable or improved SDQ score over time (p<0.04). Modifiable protective factors likely to promote social-emotional well-being include stability in the child's school and residence, parental employment, financial and marital stability, proximity to one's own ethnic community and external community support.

CONCLUSIONS

Cumulative protective factors, some of which are potentially modifiable, can predict social-emotional well-being in newly arrived refugee children. Children with four or more protective factors are at low risk of poor social-emotional well-being.

Syrian Adolescent Refugees: How Do They Cope During Their Stay in Refugee Camps?

To date, more than 11 million Syrians have been forced from their homes due to the civil war in that country. However, little research has been done on adolescent Syrian refugees. This study aimed to fill that gap in the research literature by examining how adolescent Syrian refugees cope with the harsh situation of having fled from their homes. We explored how personal capital factors, sense of coherence (SOC), wishes, and expectations, as well as socio-demographic and situational factors, contribute to a variety of mental health and psychological problems, namely, internalizing and externalizing problems and post-traumatic stress symptoms. Data were gathered from 110 adolescents aged 13-18 of whom 50.9% were boys. Participants filled out self-report questionnaires that asked about demographics, exposure to war, appraisal of danger, receiving aid, SOC, wishes, and expectations. They also completed the Achenbach Youth Form. The results show that girls appraised their situation as more dangerous and reported more internalizing, externalizing, and post-traumatic stress symptoms. By contrast, boys reported more exposure to war experiences and stronger SOC. Younger adolescents reported stronger SOC, while older adolescents reported more psychological problems. The adolescents who had more recently arrived in the refugee camp were in better condition, thereby reporting stronger SOC, higher expectations, and fewer psychological problems. The amount of time spent in the refugee camp, gender, exposure to war situations, and appraisal of danger all contributed to the explained variance in the different psychological problems. However, once the personal resource SOC was entered into the model, it mediated the relationships between all of the socio-demographic and situational variables, on the one hand, and the examined psychological problems, on the other. The results are discussed based on the personal-capital model of salutogenesis and its relations with traumatic stress.

A Systematic Review of Longitudinal Risk and Protective Factors and Correlates for Posttraumatic Stress and Its Natural History in Forcibly Displaced Children

BACKGROUND

Posttraumatic stress (PTS) results in significant distress or functional impairment. Prevalence studies report higher rates of PTS in forcibly displaced children (FDC). Current evidence deriving mainly from cross-sectional studies is unable to make causal attributions. Given rising rates of forcible displacement reported by the United Nations High Commissioner for Refugees (UNHCR) in 2014, there is increasing need to determine the best policies and practice for engaging mental health needs of FDC.

METHODS

This systematic review identifies (1) longitudinal risk and protective factors and correlates for PTS and (2) its natural history in FDC, contributing to research identifying vulnerable subgroups and malleable factors for PTS and understanding its natural history. No meta-analysis was conducted due to heterogeneity; results were analyzed through narrative synthesis.

RESULTS

Eleven longitudinal studies were identified. All but one were prospective cohort designs. They identified prevalence rates between 20% and 48.7% at baseline, 10% and 48.3% at 1 year ( k = 7), 18% and 48% at 2-3 years ( k = 2), 8% and 38% at 6 years ( k = 2), and 35% at 12 years using nine measurement methods in seven independent samples. Evidence from multiple associations supported the following risk factors: exposure to traumatic stressors or other stress, older age, and prior psychopathology. Evidence predominantly supported the stability of PTS with some decline.

CONCLUSION

While results should be interpreted with caution given small or unrepresentative samples, they suggest regular mental health screenings should be conducted for FDC, who are a vulnerable subgroup with variable onset and remission. Risk associations with prior psychopathology also suggest that screening upon arrival may be advisable for early intervention and prevention.

Refugee children and their health, development and well-being over the first year of settlement: A longitudinal study

AIM

This study aimed to describe refugee children, their families and settlement characteristics, and how their development and social-emotional well-being change over time.

METHODS

We conducted a longitudinal study of 61 refugee children (6 months to 15 years) in an Australian setting, over 2009-2013 and measured child, family and settlement factors as well as physical health, development and social-emotional well-being (Strengths and Difficulties Questionnaire, SDQ).

RESULTS

Questionnaires were completed with parents of 54 (89%) children at year 2 and 52 (100%) at year 3. Forty percent of parents had low levels of education, 30% of fathers were absent on arrival, 13% of children were born in refugee camps and 11% of parents self-disclosed previous trauma. Over time, there was increased parental employment (P = 0.001), improved English proficiency for partners (P = 0.02) and reduced stressful life events in the last 12 months (P = 0.003). At years 2 and 3, parents were studying English (96%; 76%), accessing government financial support (96%; 100%) and primary health care (98%; 87%), and feeling supported by their own (78%; 73%) or the general (69%; 63%) community. Fifteen percent of children had a chronic disease, and 13% were obese and overweight. In pre-school children, 27% had mild developmental problems in year 2; all were normal by year 3. Abnormal SDQ total difficulties scores reduced over time from 13 to 6% of children but this did not reach significance.

CONCLUSION

Most refugee children have developmental and well-being outcomes within the normal range by year 3. However, a minority of children have persistently poor social-emotional outcomes.

Immigration-related mental health disorders in refugees 5-18 years old living in Turkey

PURPOSE

This study assessed early-onset psychiatric disorders and factors related to these disorders in a group of refugee children after immigration due to war.

MATERIALS AND METHODS

This study was conducted between January 2016 and June 2016. Clinical interviews were conducted with 89 children and their families, and were performed by native speakers of Arabic and Persian who had been primarily educated in these languages and were living in Turkey. A strengths and difficulties questionnaire (SDQ) that had Arabic and Persian validity and reliability was applied to both children and their families. Independent variables for cases with and without a psychiatric disorder were analyzed using the χ² test for categorical variables, Student's t-test for those that were normally distributed, and Mann-Whitney U-test for data that were not normally distributed. Data that showed significant differences between groups who had a psychiatric disorder and on common effects in emerging psychiatric disorders were analyzed through binary logistic regression analysis.

RESULTS

A total of 89 children and adolescents were interviewed within the scope of the study. The mean age of cases was 9.96±3.98 years, and 56.2% (n=50) were girls, while 43.8% (n=39) were boys. Among these children, 47 (52.8%) had come from Syria, 27 (30.3%) from Iraq, 14 (15.7%) from Afghanistan, and 1 (1.1%) from Iran. A psychiatric disorder was found in 44 (49.4%) of the children. A total of 26 children were diagnosed with anxiety disorders, 12 with depressive disorders, 8 with trauma and related disorders, 5 with elimination disorders, 4 with attention deficit/hyperactivity disorder, and 3 with intellectual disabilities. It was determined that seeing a dead or injured person during war/emigration and the father's unemployment increased the risk of psychopathology. The OR was 7.077 (95% CI 1.722-29.087) for having seen a dead or injured individual and 4.51 (95% GA 1.668-12.199) for father's employment status.

CONCLUSION

Within the context of war and emigration, these children try to cope with the negative circumstances they experience prior to migration, as well as the despair they see their parents experience.

Posttraumatic stress and depression in Yazidi refugees

AIM

The aim of this investigation was to determine the frequency of mental pathologies in children and adolescents of the Yazidi minority group who immigrated to Turkey from Iraq. The refugees were asked about preventive and risk factors that occurred before and after their immigration.

SUBJECTS AND METHODS

The sample comprised 55 children and adolescents (30 males and 25 females) who were Yazidi refugees and had settled in the Uçkuyular, Oğuz, Onbaşı, and Uğurca villages of Batman, Turkey. The study was conducted 9 months after the refugees had immigrated. The participants were evaluated in their native language through a semistructured interview titled "Reliability and Validity of Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version - Turkish Version". A sociodemographic form was prepared so that investigators could understand their traumatic experiences before and after the migration and their current social conditions. All the interviews were conducted in the participants' native language without the help of translators. The investigators filled out the sociodemographic forms.

RESULTS

Posttraumatic stress disorder (PTSD) was detected in 20 children (36.4%), depression in 18 (32.7%), nocturnal enuresis in six (10.9%), and anxiety in four (7.3%). The following factors were found to be associated with depression: witnessing violence and/or death, being a girl, having older parents, being the elder child, and having multiple siblings (P<0.05). Risk factors for PTSD, depression, and comorbid conditions included witnessing violence and/or death (P<0.05). Four participants were observed to have both PTSD and depression (7.3%).

CONCLUSION

Most of the refugee children had experienced serious traumatic events in their home country. PTSD, depression, and comorbid mental problems are frequently seen in refugee children.

Psychische Auffälligkeiten von Flüchtlingskindern

Zusammenfassung. Die gestiegenen Flüchtlingszahlen in den letzten Jahren werden von einer erhöhten Forschungstätigkeit begleitet. Viele dieser Studien in der Klinischen Kinderpsychologie und Kinder-/Jugendpsychiatrie beschäftigen sich dabei mit psychischen Auffälligkeiten bei Flüchtlingskindern, insbesondere der Posttraumatischen Belastungsstörung und depressiven Symptomen. Als Ursache dieser Auffälligkeiten werden dabei vor allem traumatisierende Erlebnisse vor oder während der Flucht angenommen. Diese traumafokussierte Sichtweise greift jedoch zu kurz, da sie (a) Prozesse von Resilienz (b) den Einfluss von Akkulturation auf das psychische Befinden und (c) die unmittelbare Erfüllung von primären Grundbedürfnissen nach einer Flucht vernachlässigt.

The epidemiology of PTSD and depression in refugee minors who have resettled in developed countries

BACKGROUND

With an increasing number of refugees migrating across continents, the crisis is very apparent.

AIM

A literature review of patterns, risk factors and effects of post-traumatic stress disorder (PTSD) and depression in refugee minors was carried out involving those who have resettled in different developed countries.

METHODS

Papers were narrowed down by reading the abstracts and methods to ascertain whether the refugee children had resettled in developed countries and to ensure that they had not just been internally displaced.

RESULTS

High incidences of PTSD and depression were found in refugee minors and poorer mental health was correlated with increased exposure to violence. Factors such as social support and family security were important in reducing the rates of PTSD and depression, whereas the implications of age and gender were unclear. Long-term effects from these mental illnesses indicated scholastic issues, but no further worsening of symptoms.

CONCLUSIONS

Further research is needed regarding the follow-up of refugee minors with PTSD and depression to allow the establishment of more effective support systems, as long-term outcomes become more clearly understood. Few papers discuss the influence of religion, which may be an interesting line of future research as refugees move to more secular societies.

Posttraumatic Stress Disorder as a Mediator Between Trauma Exposure and Comorbid Mental Health Conditions in North Korean Refugee Youth Resettled in South Korea

A structural equation model was used to investigate the relationship between trauma exposure and comorbid mental health problems and the mediation effect of posttraumatic stress disorder (PTSD) between trauma and mental health variables. The research model is based on the stress-vulnerability conceptual framework in which PTSD as a comorbid disorder mediates the relationship between trauma exposure and mental health problems. A self-administered survey was administered to 144 North Korean refugee youth residing in South Korea. Trauma exposure, both interpersonal and noninterpersonal, had no direct relationship with comorbid mental health problems. However, interpersonal trauma contributed to comorbid mental health problems through PTSD, demonstrating the mediation effect of PTSD and supporting the stress-vulnerability hypothesis of the current research model. Clinical implications of the study and future direction for research are discussed.

Health, growth and psychosocial adaptation of immigrant children

The increasing population diversity in Europe demands clarification of possible ethnic influences on the growth and health of immigrant children and their psychosocial adaptation to the host countries. This article assesses recent data on immigrant children in Europe in comparison to European natives by means of a systematic review of the literature on growth patterns and data on children's health and adaptation. There were wide variations across countries in growth patterns and development of immigrant children and natives, with different trends in Central and Northern Europe with respect to Southern Europe. In general, age at menarche was lower in immigrant girls, while male pubertal progression seemed faster in immigrants than in European natives, even when puberty began after. Owing to the significant differences in anthropometric traits (mainly stature and weight), new reference growth curves for immigrant children were constructed for the largest minority groups in Central Europe. Possible negative effects on growth, health and psychosocial adaptation were pointed out for immigrant children living in low income, disadvantaged communities with a high prevalence of poor lifestyle habits. In conclusion, this review provides a framework for the health and growth of immigrant children in Europe in comparison to native-born children: the differences among European countries in growth and development of migrants and non-migrants are closely related to the clear anthropological differences among the ethnic groups due to genetic influences. Higher morbidity and mortality was frequently associated with the minority status of these children and their low socio-economic status. The observed ethnic differences in health reveal the need for adequate health care in all groups. Therefore, we provide suggestions for the development of health care strategies in Europe.

Psychological distress in torture survivors: pre- and post-migration risk factors in a US sample

PURPOSE

To investigate the relationships between sociodemographic, pre- and post-migration variables with prevalence of psychological distress and global functioning in a heterogeneous sample of torture survivors.

METHODS

Clients referred from resettlement agencies via the Office of Refugee Resettlement (ORR) to a community clinic in the United States (N = 278) were interviewed with structured, translated questionnaires. Univariate and multivariate logistic regression analyses determined the associations of sociodemographic, pre-, and post-migration risk factors with posttraumatic stress disorder (PTSD), depression, anxiety, and global functioning.

RESULTS

Regression data indicate that length of time between arrival in US and clinical services was significantly associated with PTSD and depression; participants receiving services after 1 year of resettlement were more likely to experience PTSD (adjusted OR = 3.29) and depression (adjusted OR = 4.50) than participants receiving services within 1 year. Anxiety was predicted by female gender (adjusted OR = 3.43), age over 40 years (adjusted OR = 3.12), Muslim religion (adjusted OR = 2.64), and receiving medical services (AOR 3.1). Severely impaired global functioning was associated with female gender (adjusted OR = 2.75) and unstable housing status (adjusted OR = 2.21).

CONCLUSION

Findings highlight the importance of examining post-migration variables such as length of time in country prior to receiving services in addition to pre-migration torture history upon relocated torture survivors. Clinicians and policy-makers should be aware of the importance of early mental health screening and intervention on reducing the psychiatric burden associated with torture and forced relocation.

Fostering Resilience: Protective Agents, Resources, and Mechanisms for Adolescent Refugees' Psychosocial Well-Being

BACKGROUND

Adolescent refugees face many challenges but also have the potential to become resilient. The purpose of this study was to identify and characterize the protective agents, resources, and mechanisms that promote their psychosocial well-being.

METHODS

Participants included a purposively sampled group of 73 Burundian and Liberian refugee adolescents and their families who had recently resettled in Boston and Chicago. The adolescents, families, and their service providers participated in a two-year longitudinal study using ethnographic methods and grounded theory analysis with Atlas/ti software. A grounded theory model was developed which describes those persons or entities who act to protect adolescents (Protective Agents), their capacities for doing so (Protective Resources), and how they do it (Protective Mechanisms). Protective agents are the individuals, groups, organizations, and systems that can contribute either directly or indirectly to promoting adolescent refugees' psychosocial well-being. Protective resources are the family and community capacities that can promote psychosocial well-being in adolescent refugees. Protective mechanisms are the processes fostering adolescent refugees' competencies and behaviors that can promote their psychosocial well-being.

RESULTS

Eight family and community capacities were identified that appeared to promote psychosocial well-being in the adolescent refugees. These included 1) finances for necessities; 2) English proficiency; 3) social support networks; 4) engaged parenting; 5) family cohesion; 6) cultural adherence and guidance; 7) educational support; and 8) faith and religious involvement. Nine protective mechanisms identified were identified and grouped into three categories: 1) Relational (supporting, connecting, belonging); 2) Informational (informing, preparing), and; 3) Developmental (defending, promoting, adapting).

CONCLUSIONS

To further promote the psychosocial well-being of adolescent refugees, targeted prevention focused policies and programs are needed to enhance the identified protective agents, resources, and mechanisms. Because resilience works through protective mechanisms, greater attention should be paid to understanding how to enhance them through new programs and practices, especially informational and developmental protective mechanisms.

Refugee children and their families: supporting psychological well-being and positive adaptation following migration

The support of refugee children and their families is a worldwide concern. This article will highlight models of mental health care for refugee children and their families, focusing on collaborative care with primary care providers. Case vignettes are provided to illustrate how collaborative care can support refugee children׳s psychological well-being and positive adaptation following migration.

Understanding psychopathology in migrants: a mixed categorical-dimensional approach

BACKGROUND

Literature on mental disorders in migrants is constantly increasing. Only a few studies describe psychopathological dimensions in migrants over their nosographic diagnoses; however, there is a growing literature about the greater utility of a categorical-dimensional approach, rather than a solely categorical approach, in the understanding of mental disorders. The aim of this paper is to describe the phenomenology of mental disorders in migrants referred to the Transcultural Psychiatric Team of Bologna (BoTPT), by analysing the psychopathological dimensions that underlie their clinical diagnoses.

METHODS

We recruited all migrants who attended the BoTPT between May 1999 and July 2009. The psychopathological assessment was conducted with the Association for Methodology and Documentation in Psychiatry (AMDP) and clinical diagnoses were formulated according to ICD-10. We proceeded through a two-step analysis: (1) comparing the prevalence rates of psychopathological symptoms across diagnoses; then (2) conducting a factor analysis to assess how those symptoms configure psychopathological dimensions and how these dimensions underlie clinical diagnoses.

RESULTS

As expected, we found significant associations between diagnoses and the prevalence of their core psychopathological symptoms. Factor analysis revealed a strong polymorphism of the psychopathological presentation of mental disorders and unexpectedly showed that in each diagnostic cluster, the first extracted factor was not composed of core symptoms.

CONCLUSIONS

A mixed categorical-dimensional approach seems to improve the description of the psychopathology among migrants, as it adds relevant information regarding psychopathological dimensions useful to the understanding of the peculiar clinical expressivity of our patients.

[Children and adolescents from elsewhere: the violence experienced in their host society and the effects on their health, a literature]

OBJECTIVE

This integrative literature review aims to present a comprehensive portrayal of social violence experienced by first-generation immigrant children and adolescents, and its effects on their health and well-being.

METHOD

A French and English languages literature search was conducted in eight databases, without restrictions on dates of publication. Thirty studies were selected. Results were summarized according to three aspects: 1) types of violence experienced by young immigrants; 2) conditions under which this violence occurs; 3) effects of such violence on the health and well-being of young immigrants.

SYNTHESIS

Immigrant children and adolescents can experience various forms of physical, verbal, and relational violence. This violence seems to be mostly instigated by their peers and it has mainly been studied in terms of discrimination. Victimization may vary depending on factors such as ethnic composition of schools or time of residence in the host society. Violence may have many effects on mental health of immigrant youth: it is associated with both increased psychopathological symptoms and poorer mental health. Finally, the experience of violence is related to a more negative attitude of young immigrants toward their host society and a more positive attitude toward their own cultural community.

CONCLUSION

In addition to its having numerous adverse effects on their mental and social health and well-being, violence may prove to be a key factor in the experience of marginalization of immigrant youth. We propose certain research avenues to explore.

Refugee children: mental health and effective interventions

The mental health consequences of war and other forms of organized violence for children represent a serious global public health issue. Much of the research on the mental health of war-affected civilians has focused on refugees who have sought asylum in high-income countries and face the dual stress of a traumatic past and resettlement. This review will focus on the mental health of refugee children who have fled war as well as interventions to both prevent and treat adverse mental health outcomes. While war can have devastating mental health consequences, children raised in the midst of armed conflict also display resilience. Effective interventions for refugee children will be discussed both in terms of prevention and treatment of psychopathology, with a focus on recent developments in the field.