Refugee children's mental health and development - A public health problem in Europe.

Knowledge about refugee children's mental health has developed considerably during the last 30 years. From believing that children's reactions largely depend on their parents, it has become clear that children are influ-enced both by their own experiences, by the reactions of their caregivers and by the social environment in which they live. While psy-chological problems are frequent in children close to arrival in exile, follow-up studies have shown that the magnitude of the problems is reduced over time. Aspects of social life as well as stressful events in exile seem to be of paramount importance for children's ability to recover from early traumatization. Pro-longed asylum procedures, temporary resi-dence permits, delayed family reunifications, many school-moves and xenophobic attitudes is counteracting healthy development. The results of research on refugee children and youth indicate the existence of a large public health problem which calls for policy change and political action.

Parental post-traumatic stress and psychiatric care utilisation among refugee adolescents.

Parental psychiatric morbidity related to experiences of war and trauma has been associated with adverse psychological outcomes for children. The aim of this study was to investigate parental post-traumatic stress in relation to psychiatric care utilization among children of refugees with particular attention on the child's own refugee status, sex of both child and parents, and specific psychiatric diagnoses. This was a register study in a population of 16 143 adolescents from refugee families in Stockholm County born 1995-2000 and followed between 2011 and 2017 (11-18 years old). Parental post-traumatic stress, identified in three levels of care, was analysed in relation to child and adolescent psychiatric care use. Cox regression analysis was used to estimate hazard ratios (HR) and 95% confidence intervals (CI), adjusted for duration of residence and demographic and socioeconomic variables. Having a mother with post-traumatic stress was associated with higher psychiatric care utilization, with adjusted HR 2.44 (95% CI 1.90-3.14) among foreign-born refugee children and HR 1.77 (1.33-2.36) among Swedish-born children with refugee parents, with particularly high risks for children with less than five years of residence (HR 4.03; 2.29-7.10) and for diagnoses of anxiety and depression (HR 2.71; 2.11-3.48). Having a father with post-traumatic stress was not associated with increased HRs of psychiatric care utilization. Similar results were seen for boys and girls. Treatment for post-traumatic stress should be made available in refugee reception programmes. These programmes should use a family approach that targets both parents and children.

Parental Posttraumatic Stress and School Performance in Refugee Children.

Refugee children in the Nordic countries have been reported to perform poorly in school and carry a high burden of familial posttraumatic stress. The present study aimed to investigate the impact of maternal and paternal posttraumatic stress on the school performance of refugee children. We used national register data on school grades at age 15-16 along with demographic and migration indicators during 2011-2017 in a population of 18,831 children in refugee families in Stockholm County, Sweden. Parental posttraumatic stress was identified in regional data from three levels of care, including a tertiary treatment center for victims of torture and war. Multivariable linear and logistic regression models were fitted to analyze (a) mean grade point averages as Z scores and (b) eligibility for upper secondary school. In fully adjusted models, children exposed to paternal posttraumatic stress had a lower mean grade point average, SD = -0.14, 95% CI [-0.22, -0.07], and higher odds of not being eligible for upper secondary education, OR = 1.37, 95% CI [1.14, 1.65]. Maternal posttraumatic stress had a similar crude effect on school performance, SD = -0.15, 95% CI [-0.22, -0.07], OR = 1.25, 95% CI [1.00, 1.55], which was attenuated after adjusting for single-parent households and the use of child psychiatric services. The effects were similar for boys and girls as well as for different levels of care. Parental posttraumatic stress had a small negative effect on school performance in refugee children, adding to the intergenerational consequences of psychological trauma.

Parental PTSD and school performance in 16-year-olds - a Swedish national cohort study.

Aim: Posttraumatic stress disorder (PTSD) in parents can have severe consequences also for their children. Prevalence of PTSD is high among refugees. Refugee children have been reported to perform poorly in school. The aim of this study was to investigate the impact of PTSD in refugee and native Swedish parents on children's school performance and to compare the impact of PTSD with that of other major psychiatric disorders. Methods: Register study where multiple regression models were used to analyse school performance in 15-16-year-olds in a national cohort (n = 703,813). PTSD and other major psychiatric disorders (bipolar, depression and/or psychotic disorders) were identified from out- and in-patient hospital care. Results: Maternal and paternal PTSD were associated with lower grades, with adjusted effects of 0.30-0.37 SD in refugee and 0.46-0.50 SD in native Swedish families. Impact of PTSD was greater than that of other psychiatric disorders and comorbidity to PTSD did not increase this impact. Although the impact of PTSD on grades was greater in children in native Swedish families, consequences with regard to eligibility to secondary education were greater for children in refugee families, where 35% of these children were ineligible. Conclusions: Parental PTSD has major consequences for children's school performance and contributes to the lower school performance in children in refugee families in Sweden. Identification and treatment of PTSD in refugee parents is important for offspring educational achievement. Psychiatric clinics and treatment centres need to have a strategy for support, including educational support, to the offspring of their patients with PTSD.

Is silence about trauma harmful for children? Transgenerational communication in Palestinian families.

Style of family communication is considered important in the transgenerational transmission of trauma. This study had three aims: first, to identify the contents of family communication about past national trauma; second, to examine how parents' current war trauma is associated with transgenerational communication; and third, to analyze the associations between transgenerational communication and children's mental health, measured as posttraumatic stress disorder (PTSD), depression and psychological distress. The study sample consisted of 170 Palestinian families in Gaza Strip, in which both mothers (n = 170) and fathers (n = 170) participated, each with their 11-13-year-old child. Mothers and fathers responded separately to three questions: 1) what did their own parents tell them about the War of 1948, Nakba?; 2) what did they tell their own children about the Nakba?; and 3) What did they tell their own children about the 1967 Arab-Israeli War and military occupation? Current war trauma, as reported separately by mothers, fathers and their children, refers to the Gaza War 2008/09. Children reported their symptoms of PTSD, depression, and psychological distress. Results revealed seven communication content categories and one category indicating maintaining silence about the traumas. Fathers' high exposure to current war trauma was associated with a higher level of communicating facts, reasons, and meanings regarding the1948 and 1967 wars, and mothers' high exposure to current war trauma was associated with a lower level of maintaining silence. Family communication about facts, reasons, and meanings was significantly associated with children not showing PTSD and marginally with not showing psychological distress, while maintaining silence was not associated with children's mental health.

Transmitting trauma: a systematic review of the risk of child abuse perpetrated by parents exposed to traumatic events.

OBJECTIVES: To review the empirical evidence of a potential association between parental trauma and parental child abuse. METHODS: Following PRISMA guidelines, 4645 publications were identified through a systematic search in PubMed, PsycINFO and Cochrane. The final number of publications included was 15. RESULTS: The prevalence of child abuse was found to be consistently higher in populations exposed to traumatic events (prevalence range 36.0-97.5%) compared with non-exposed groups. Parents exposed to trauma were more likely to abuse their children in all studies, and trauma severity, including a PTSD diagnosis in parents, was associated with perpetration of child abuse in most studies. Such associations appeared to be independent of the type of traumatic event. The findings underscore that trauma does not only affect the individual, but also the family. CONCLUSIONS: Parental trauma seems to be associated with perpetration of child abuse within the family. Abusive behavior against children could be a potential trauma reaction, which should be considered in preventive strategies aimed at reducing harm in traumatized families.

"What kept me going": A qualitative study of avoidant responses to war-related adversity and perpetration of violence by former forcibly recruited children and youth in the Acholi region of northern Uganda.

This qualitative study investigates what, according to 36 former forcibly recruited women and men, enabled them to "keep on going" during and after their forced recruitment in the twenty-year-long civil war in northern Uganda. Furthermore, the study conveys the ways most of the former forcibly recruited kept on going and today cope with ongoing war-related adversity and difficult reintegration processes without relying on psycho-social intervention. Thirty-five of the 36 women and men were forcibly recruited when they were children by the Lord's Resistance Army (LRA) from the Acholi region of northern Uganda. Over the course of five visits to the Acholi region from 2012 to 2016, 10 months of ethnographic fieldwork was carried out involving interviews and participant observation. The 36 Acholi women and men shared how they experienced and responded to suffering from brutal torture and being forced to perpetrate often lethal violence against fellow Acholi who had tried to escape the LRA. The article provides an overview of the responses to this war-related adversity and the results document how avoidant coping is the preferred and most common coping response among the 36 former forcibly recruited women and men in this study. We take an interdisciplinary approach to discussing how these avoidant coping responses resonate with psycho-traumatology research on responses to war-related trauma and with conceptualizations of resilience. We end with the argument that avoidant responses to war-related adversity, when faced in clinical and diagnostic settings, should not be understood exclusively from a biomedical perspective: Responses to war-related adversity must be carefully investigated in collaboration with the human beings who have experienced the war-related adversity and based on integrative and emic approaches that consider the locally situated notions of how to cope with adversity and "keep on going" in their own right.

A systematic review of risk and protective factors associated with family related violence in refugee families.

The current systematic review summarizes the evidence from studies examining the risk and protective factors associated with family related violence in refugee families. Data included 15 peer-reviewed qualitative and quantitative studies. In order to gain an overview of the identified risk and protective factors an ecological model was used to structure the findings. At the individual level, parental trauma experiences/mental illness, substance abuse and history of child abuse were found to be risk factors. Family level risk factors included parent-child interaction, family structure and family acculturation stress. At the societal level low socioeconomic status was identified as a risk factor. Cultural level risk factors included patriarchal beliefs. Positive parental coping strategies were a protective factor. An ecological analysis of the results suggests that family related violence in refugee families is a result of accumulating, multiple risk factors on the individual, familial, societal and cultural level. The findings suggest that individual trauma and exile related stress do not only affect the individual but have consequences at a family level. Thus, interventions targeting family related violence should not only include the individual, but the family.

Refugee children have fewer contacts to psychiatric healthcare services: an analysis of a subset of refugee children compared to Danish-born peers.

PURPOSE: Studies show a high level of mental health problems among refugee children. This study examined whether a subset of refugee children living in Denmark accessed psychiatric healthcare services more than those born in the country. METHODS: This study compared 24,427 refugee children from Asia, The Middle East, Sub-Saharan Africa and former Yugoslavia, who obtained residency in Denmark between 1 January 1993 and 31 December 2010 with 146,562 Danish-born children, matched 1:6 on age and sex. The study looked at contacts with psychiatric hospitals as well as psychologists and psychiatrists in private practice. RESULTS: Between 1 January 1996 and 30 June 2012, 3.5 % of the refugee children accessed psychiatric healthcare services compared to 7.7 % of the Danish-born children. The rate ratio of having any first-time psychiatric contact was 0.42 (95 % CI 0.40-0.45) among refugee boys and 0.35 (95 % CI 0.33-0.37) among refugee girls, compared to Danish-born children. Figures were similar for those accessing private psychologists or psychiatrists, emergency room, inpatient and outpatient services. CONCLUSIONS: Refugee children used fewer psychiatric healthcare services than Danish-born children. This may indicate that refugee children experience barriers in accessing psychiatric healthcare systems and do not receive adequate assessment of their mental health and subsequent referral to specialist services.

A novel bio-psycho-social approach for rehabilitation of traumatized victims of torture and war in the post-conflict context: a pilot randomized controlled trial in Kosovo.

BACKGROUND: Some evidence showed that multidisciplinary rehabilitation in Western countries is effective for treating war-related trauma, but it remains unclear whether this approach is applicable to civilians living in resource-poor countries affected by war. In 2012-14, Danish Institute against Torture (DIGNITY) conducted a randomized controlled trial (RCT), in partnership with Kosova Rehabilitation Centre for Torture Victims (KRCT), to examine the effects of multidisciplinary intervention among victims of torture and war in Kosovo. METHODS: A single-center, randomized, parallel-arm, single-masked, waiting-list controlled trial was implemented in northern Kosovo. Thirty-four participants meeting the recruiting criteria were randomized to either intervention group, which received integrated treatments plus a once-daily multivitamin, or the waiting list group, which received multivitamin alone. The integrated treatments consisted of 10 weekly individual 60-min sessions of cognitive behavioral therapy (CBT), based on an adapted prolonged exposure therapy manual, an individual 20-min breathing exercise with an emWave biofeedback device, and 90-min group physiotherapy. The waiting list group also received the same treatment after the intervention group had completed their sessions. Outcome assessments were conducted at 3, 6 and 9 months after baseline assessment. Outcomes measures consisted of 4 subtypes: mental, emotional, physical health, functioning and social outcomes, i.e. PTSD, depression, anxiety, chronic pain, anger and hatred expression, body mass index, handgrip strength, standing balance, income, employment rate and disability score. RESULTS: Over 1/3 of PTSD cases were successfully treated. Inconsistent patterns with mental health and chronic pain outcomes were observed while there was a definite impact of intervention on functioning and social outcomes, i.e. the employment rate, which increased nearly 15 %, and the monthly wage, which rose 45-137 %. There was also a noticeable improvement in handgrip strength and disability score; the feelings of anger and hatred diminished. However, most of these changes did not reach statistical significance. CONCLUSIONS: The impact of bio-psycho-social intervention is likely sensitive to the context of post-war economy in Kosovo and the treatment goals. The potential for improving the emotional well-being and employment outcome in victims was demonstrated. A larger scale RCT in a similar setting is needed, with close monitoring of treatment integrity and data reliability. TRIAL REGISTRATION: Clinicaltrials.gov (NCT01696578).

The transmission of trauma in refugee families: associations between intra-family trauma communication style, children's attachment security and psychosocial adjustment.

This study explores the transmission of trauma in 30 Middle Eastern refugee families in Denmark, where one or both parents were referred for treatment of PTSD symptoms and had non-traumatized children aged 4-9 years. The aim of the study was to explore potential risk and protective factors by examining the association between intra-family communication style regarding the parents' traumatic experiences from the past, children's psychosocial adjustment and attachment security. A negative impact of parental trauma on children might be indicated, as children's Total Difficulties Scores on the Strengths and Difficulties Questionnaire (SDQ) were significantly higher than the Danish norms. A negative association between children's attachment security as measured by the Attachment and Traumatization Story Task and higher scores on the SDQ Total Difficulties Scale approached significance, suggesting that the transmission of trauma may be associated with disruptions in children's attachment representations. Furthermore a significant association between parental trauma communication and children's attachment style was found.

Disclosure and silencing: A systematic review of the literature on patterns of trauma communication in refugee families.

This systematic review aimed to explore the effects of different degrees of parental disclosure of traumatic material from the past on the psychological well-being of children in refugee families. A majority of studies emphasize the importance of the timing of disclosure and the manner in which it takes place, rather than the effects of open communication or silencing strategies per se. A pattern emerged in which the level of parental disclosure that promotes psychological adjustment in refugee children depends on whether the children themselves have been directly exposed to traumatic experiences, and whether the children are prepubescent or older. The process of trauma disclosure is highly culturally embedded. Future research needs to address the culturally shaped variations in modulated disclosure and further explore how modulated disclosure can be facilitated in family therapy with traumatized refugee families.

Attachment narratives in refugee children: interrater reliability and qualitative analysis in pilot findings from a two-site study.

Although forced migration research on refugee family functioning clearly points to the potential breakdown of parental availability and responsiveness in the context of cumulative migration stressors, studies exploring attachment security in refugee children are surprisingly lacking so far. The authors report their findings from a 2-site, small-scale administration of an attachment measure, adapted for use with refugee children aged between 4 and 9 years from a reliable and validated doll-play procedure. We evaluated interrater reliability and conducted a qualitative analysis of refugee children's narrative response to identify migration-specific representational markers of attachment quality. The level of agreement among 3 independent coders ranged between .54 to 1.00 for both study samples, providing initial psychometric evidence of the measure's value in assessing child attachment security in this population. The exploratory analysis of migration-related narrative markers pointed to specific parameters to be used in parent-child observational assessments in future validation of the attachment measure, such as parental withdrawal or trauma-communication within the parent-child dyad.

Trauma and resilience in young refugees: a 9-year follow-up study.

The aim of the present study was to assess and understand the long-term trajectory of psychological problems among young Middle Eastern refugees in Denmark. Participants were 131 young refugees from the Middle East (76 girls, 55 boys; mean age = 15.3 years) from 67 families. They were assessed first on arrival in Denmark in 1992-1993 and again 8-9 years later. The high prevalence of psychological problems at arrival was considerably reduced by the time of follow-up, but it was still somewhat higher than what has been found in most community studies using the same assessment tools. Groups of children differed in showing low levels of symptoms at arrival that were stable (spared) or increased (reacting) and high levels at arrival that persisted (traumatized) or decreased (adapted). The number of types of traumatic experiences before arrival distinguished the spared and the traumatized young refugees and the number of types of stressful events after arrival the adapted and the traumatized, also after corrections for age, sex, specific traumatic events, parents' education and health, and the social situation of the young refugees. The study emphasizes the importance of environmental factors for healthy long-term adaptation after traumatic experiences related to war and other organized violence.

Household exposure to violence and human rights violations in western Bangladesh (I): prevalence, risk factors and consequences.

BACKGROUND: The ruling parties in Bangladesh have systematically used violence against political opponents and criminals. It is essential to 1) determine the magnitude and burden of organised crime and political violence (OPV) and human rights violations in the affected community, and to 2) identify the risk factors and key indicators for developing effective health intervention and prevention measures. METHODS: The population-based study consisted of two parts: a household survey and OPV screening at mobile clinics (presented in Part II). A cross-sectional, multistage cluster household survey was conducted in the Meherpur district in February-March 2008; 22 clusters with a sample size of 1,101 households (population of 4,870) were selected. RESULTS: Around 83% of households reported being exposed to at least two categories of OPV or human rights violations: 29% reported that the family members had been arrested or detained; 31% reported torture or other cruel, inhuman or degrading treatment or punishment. Crude mortality rate was 17.9/1,000 and under 5 mortality rate was 75/1,000. The annual injury rate was 36%, lifetime experience of violence-related injury was 50%, and pain experience within 2 weeks was reported by 57%. Over 80% of the population over 35 years old complained of pain. High prevalence of injury, lifetime experience of OPV-related injury and pain complaints are related to the level of exposure to OPV and human rights violations. A financial burden was imposed on families with an injured person. A geographical variation was revealed regarding reports of torture and lifetime experience of violence-related injury. A combination of individual, relational, community and societal factors, including variables such as political party affiliation, conflict with other families, household income and residential area, affected the risk of victimisation in the household. The odds ratio for reporting extrajudicial execution of a family member was 9.22 for Awami League supporters, 9.15 for Bangladesh Nationalist Party supporters; and 3.97 for Jamaat-e-Islami Party supporters compared with families with no political involvement. CONCLUSION: The level of violence and human rights violations is high. The affected population suffers from violence-related injuries and traumas, which could be a factor contributing to poverty. Victimisation is not random.

Rehabilitating torture survivors.

Refugees have often been exposed to torture in their countries of origin. A core issue is the resulting multifaceted presentation of somatic, psychological and social problems in the same individual, leading to severe activity limitations and participation restrictions. An international conference, "Rehabilitating Torture Survivors", was organized by the Rehabilitation and Research Centre for Torture Victims (a rehabilitation clinic and global knowledge and research centre with government support) in collaboration with the Centre for Transcultural Psychiatry at Rigshospitalet in Copenhagen, Denmark, in December 2008. The main topics were: the context of torture; mental problems including psychotherapy; internet-based therapy and pharmaco-therapy; chronic pain; social integration and family; and functioning and rehabilitation. Available evidence highlights the importance of an interdisciplinary approach to rehabilitation, but scientifically rigorous studies of comprehensive rehabilitation programmes for torture survivors are lacking. Therefore, effect studies are urgently warranted. Nevertheless, by combining expertise from different scientific and professional areas, important elements in the problems of torture survivors can be addressed from an evidence base generated both from traumatized and non-traumatized patient populations. Thus, trauma-focused cognitive behavioural therapy and/or eye movement desensitization and reprocessing, as well as interdisciplinary pain rehabilitation, should be components of a successful rehabilitation process, and great attention should be paid to contextual components.

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

The pre- and post-displacement factors associated with psychological problems among young refugees are not clear. From the existing research it appears that refugee children and adolescents are vulnerable to the effects of pre-migration exposure to trauma, but the long-term effects of such exposure are mediated by certain risk and protective factors at the individual, family and community level. The aim of the present study was to assess the influence of traumatic experiences before emigration, as well as social life after immigration, on the mental health of young Middle Eastern refugees 8-9 years after immigration into Denmark. The study group comprises 131 young refugees (76 girls and 55 boys; mean age 15.3 years) from 67 families. They were assessed in 2000-2001 as part of a follow-up study of 311 children, who in 1992-1993 were consecutively registered in Denmark as asylum seekers with at least one parent. Predictors of more externalizing behaviour were: witnessing attack on others after arrival, more schools attended, less attending school or work, lower mother's education in the home country and lower age. Predictors of more internalizing behaviour were: numbers of types of traumatic events before arrival, numbers of types of stressful events after arrival, and numbers of types of experiences of discrimination, lower mother's education in the home country, fewer Danish friends, not Muslim or Christian religion, less Danish proficiency and female gender. It is concluded that aspects of social life in Denmark, including mother's education and indicators of adaptation, as well as a stressful life context in exile, including discrimination, predicted psychological problems 8-9 years after arrival, more than traumatic experiences before arrival. Thus, the prevention of psychopathology in young refugees depends to a large extent on the political will to make provision for the necessary changes regarding reception and treatment of refugees.

Self- and parent assessment of mental health: disagreement on externalizing and internalizing behaviour in young refugees from the Middle East.

Self- and parent assessment of mental health problems yield a limited degree of cross-informant agreement in adolescent populations. Working with data from 122 refugee children, adolescents and young adults from the Middle East, the aims of this study were to analyse levels of agreement and disagreement between self- and parent ratings of externalizing and internalizing behaviour and to identify predictors for the differences between the two sets of ratings. Parents and children were interviewed separately using structured questionnaires. Mental health was assessed using the Achenbach System of Empirically-based Assessment. Self- and parent-rated scale scores correlated moderately. The mean score differences between self- and parent-rated internalizing and externalizing behaviour were 2.0 and 2.7, p < 0.005, respectively. A larger mean difference was found among boys concerning externalizing behaviour and among girls concerning internalizing behaviour. Individual (age, and sex) family (father's health situation) and ethnic background predicted this difference. This could indicate that parent ratings and children's self-ratings are two, qualitatively different constructs and not just a result of expected inter-observer disagreement. When assessing young refugees for possible treatment, this difference needs to be understood and taken into consideration.

Discrimination, mental problems and social adaptation in young refugees.

BACKGROUND: Mental problems have been hypothesized to impede social adaptation and vice versa, and discrimination is assumed to interact with both. The available empirical documentation is, however, limited. The objective of this study is to contribute to a more comprehensive understanding of associations and pathways between discrimination, mental problems and social adaptation in young refugees. METHODS: Structural Equation Modelling (SEM) was used for the analysis of cross-sectional data from interviews with 131 young Middle Eastern refugees residing in Denmark. RESULTS: Participants reported a mean of 1.8 experiences of discrimination, and the prevalence of five indicators of positive social adaptation was 47-92%. Discrimination, mental problems and social adaptation were strongly mutually associated, without gender difference. Discrimination predicted internalizing behaviour. Improved social adaptation correlated negatively with discrimination and with externalizing and internalizing behaviour. CONCLUSION: Perceived discrimination among young refugees from the Middle East is associated with mental problems and social adaptation. Discrimination seems to provoke internalizing but not externalizing behaviour. The direction of other pathways is ambiguous, suggesting a certain amount of recursive interaction between mental health, discrimination and social adaptation.