[child-rights] Australian Inquiry into Children in Immigration Detention

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National Inquiry into Children in Immigration Detention
Psychological Well Being of Child and Adolescent Refugee and Asylum
Seekers:
Overview of Major Research Findings of the Past Ten Years
Australian Human Rights & Equal Opportunity Commission
http://www.humanrights.gov.au/human_rights/children_detention/psy_review.html
Prepared by Trang Thomas and Winnie Lau

Abstract

    Major Research Findings

      i. Post Traumatic Stress Disorder and Symptomology

      ii. Co-existence of several disorders and symptomology

      iii. Risk (Vulnerability) and Protective (resilience) factors

    Conclusions

    References and Suggested Readings

    About the Authors


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Abstract

This paper outlines major international research findings of the past
ten years reflecting knowledge gathered about the psychological health
of child and adolescent refugee/asylum seekers. In doing so, several key
areas of consistency are identified. First, with the majority of
research in this area centered on the prevalence of psychopathology, and
particularly post-traumatic stress symptoms, it has been clearly
demonstrated that refugee children and adolescents are vulnerable to the
effects of pre-migration, most notably exposure to trauma. Second,
particular groups in this population constitute higher psychological
risk than others, namely those with extended trauma experience,
unaccompanied or separated children and adolescents, and those engaged
in the uncertain process of sought asylum. Third, certain risk and
protective factors appear to exist that temper or aggravate poor
psychological health. These include family cohesion, parental
psychological health, individual dispositional factors such as
adaptability, temperament and positive self-esteem, and environmental
factors such as peer and community support.

The research is less clear however in a number of areas. These include
the mechanisms by which risk and protective factors exacerbate and
temper the effects of trauma and migration experience, as well as the
role of culture as a mediator in the experience of trauma and migration.

Despite being a perennial issue, circumstances of irregular migration
across the world have only recently impelled psychological interest into
the mental health of refugee and asylum seekers. The Office of the
United Nations High Commissioner for Refugees (UNHCR) estimates that
there are 22.3 million refugees worldwide. A refugee is someone who
"owing to well founded fear of being persecuted for reasons of race,
religion, nationality or membership of a particular social group or
political opinion, is outside the country of his nationality and is
unable or, owing to such fear is unwilling to avail himself of the
protection of that country; or who, not having a nationality and being
outside that country of his former habitual residence as a result of
such events, owing to such fear, is unwilling to return to it" (Article
1A(2), Convention relating to the Status of Refugees (1951)). This
definition is contrasted with that of an asylum seeker, whose status as
a refugee is yet to be formally determined by the host society (Human
Rights and Equal Opportunity Commission, 2001). More importantly, these
definitions are to be differentiated from that of an economic migrant
whose mobilisation is voluntary and primarily motivated by improved
material circumstances as opposed to human rights and safety (Morrow,
1994).

While there is considerable and growing literature in the mental health
of adult refugee/asylum seekers, current research acknowledges a lack of
understanding in the mental health of child and adolescent
refugee/asylum seekers (Dybdahl, 2001; Hicks, Lalonde & Pepler, 1993;
Hyman, Vu & Beiser, 2000). This is particularly the case regarding the
mental health of child and adolescent refugee/asylum seekers in
detention. This is surprising given that as many as half the world's
refugee population is comprised of children and adolescents (Cole,
1998). Such limited investigation however, may in part be due to the
difficulties associated with population access, systematic sampling,
cultural and language barriers, limited cross culturally validated
measurement techniques, and wariness of parents and participants to
trust researchers (Richman, 1993; Silove, Sinnerbrink, Field,
Manicavasagar & Steel, 1997).

Though not all refugee and asylum seeking children and adolescents are
subjected to these circumstances, experiences often claimed to be
encountered by them include the violent death of a parent,
injury/torture towards a family member(s), witness of murder/massacre,
terrorist attack(s), child-soldier activity, bombardments and shelling,
detention, beatings and/or physical injury, disability inflicted by
violence, sexual assault, disappearance of family members/friends,
witness of parental fear and panic, famine, forcible eviction,
separation and forced migration (Burnett & Peel, 2001; Davies & Webb,
2000).

Other forms of trauma might include the endurance of political
oppression, harassment and deprivation of human rights and education
(Burnett & Peel, 2001). Such experiences not only make refugee/asylum
seeking populations heterogeneous, they also create vulnerability in
children and adolescents due to their incomplete biopsychosocial
development, dependency, inability to understand certain life events
(Kocijan-Hercigonja, Rijavec & Hercigonja, 1998) and underdevelopment of
coping skills (Ajdukovic & Ajdukovic, 1993).

This summary outlines major international research findings of the past
ten years reflecting knowledge gathered about the psychological health
and well-being of child and adolescent refugee/asylum seekers. It
incorporates a search of literature from the psychINFO, Medline,
BioMedNet, Academic Research Library, EBSCO, Proquest, Science Direct
and Wiley-Interscience databases using criteria restricted to articles
from 1990 to date and in the English language. Search terms included
single and combined forms of the following descriptors: refugee camp,
refugee detention, imprisonment, child and/or adolescent refugee, asylum
seeker, displacement, Australia, development, long term effects, long
term stress, post-traumatic stress, stress, psychopathology, mental
health, psychiatric effects and psychological well being.

The review is divided into major sections of studied areas in the
literature, namely post-traumatic stress disorder (PTSD), co-existence
of several symptoms and disorders (a term that broadly means serious
problems), and risk (vulnerability) and protective (resilience) factors
at both pre- and post- migration phases. It should be noted that this
paper does not aim to provide an exhaustive discussion of theoretical
issues, methodological considerations (e.g., problems in retrospective
data collection) or treatment issues, but rather to highlight major
findings and conclusions of this research. It should also be noted that
the paucity of research in child and adolescent refugee/asylum seekers
necessitates at times reference to knowledge from adult populations.
Where such reference is made, caution should be taken to avoid
overgeneralisation of these findings to this new risk population of
children and adolescents.

Major Research Findings

i. Post Traumatic Stress Disorder and Symptomology
Given that war and political violence are major causes of forced
migration, many child and adolescent refugee and asylum seekers migrate
with a history of traumatic stress exposure (Almqvist &
Brandell-Forsberg, 1997). Investigations directed at the evaluation of
the impact of trauma on psychological well being in these groups have
predominantly focused on the prevalence of Post Traumatic Stress
Disorder (PTSD) and/or its symptomology (Richman, 1993; Weine, 2002).

Post Traumatic Stress Disorder (PTSD) refers to a configuration of
symptoms experienced after a traumatic event and is classified as an
anxiety disorder, which may in nature be acute or chronic, and of short
or long term duration (Cunningham & Cunningham, 1997)

Children and adolescents who present with PTSD may exhibit symptoms of
confused and disordered memory about events, repetitive play themes
related to trauma, personality change, imitation of violent behaviour
and pessimistic expectations regarding survival (Hicks et al., 1993).
Although symptoms vary across age groups, in preschoolers, they are
generally manifested in very high anxiety, social withdrawal and
regressive behaviours. In school-aged children, symptoms can include
flashbacks, exaggerated startle responses, poor concentration, sleep
disturbance, complaints of physical discomfort and conduct problems. In
adolescents, symptoms may include acting out, aggressive behaviours,
delinquency, nightmares, trauma and guilt over one's own survival (Hicks
et al., 1993).

Despite controversy surrounding the application of PTSD to
refugee/asylum seeking children and adolescents (e.g., the diagnostic
approach 'medicalises' and 'westernises' emotional disturbance and
'pathologises' perfectly normal reactions to abnormal situations),
investigations across various countries have shown that trauma
symptomology is common in refugee children and adolescents (Ajdukovic &
Ajdukovic, 1993; Hjern, Angel, & Hoejer, 1991; Kinzie, Sack, Angell,
Manson & Ben, 1986; Mollica, Poole, Son, Murray & Tor, 1997; Sack,
Clarke & Seeley, 1996; Sack, Seeley & Clarke, 1997).

While the nature and extent of trauma exposure varies cross culturally,
and from direct to indirect and single to repeated events, studies
particularly document the prevalence of post-traumatic stress
symptomology. Though not conducted within the last ten years, the
pioneering work of Kinzie et al. (1986) is cited frequently throughout
the recent literature. In this classical study, these authors
interviewed 46 Cambodian refugees aged between 14-20, all of who were
exposed between the ages of 8-12 to starvation, separation, beatings and
executions. Almost half of these subjects having been exposed to trauma,
exhibited PTSD symptoms alongside less effective adaptation, which was
considered to be within clinical range.

In a larger study with 209 Cambodians aged between 13-25 resettled in
the United States, Sack and colleagues (1994) found an 18% prevalence
rate of PTSD and an 11% rate of depressive disorder in their
participants. High rates of psychiatric disorder were also observed in
participants' parents, with 53% of mothers reporting symptoms consistent
with a PTSD diagnosis, and 23% with a diagnosis of depression. Amongst
fathers of this sample, 29% indicated PTSD symptomology and 14%
indicated depression.

Examining the case records of 191 clients presenting for service and
treatment at a torture and trauma rehabilitation centre in Australia,
Cunningham and Cunningham (1997) identified patterns of torture and
trauma experience and symptomology. Of the six core patterns of
symptomology revealed in the analysis, PTSD symptoms featured most
dominantly. Saigh (1991) similarly administered the children's PTSD
inventory to 840 Lebanese children aged between 9-12 living in Beirut.
While violent traumatic exposure varied from direct to indirect among
children, no comparable differences were observed in PTSD scores. In
all, 27% of these children met PTSD criteria, supporting the view that
children can be traumatised in numerous ways (Berman, 2001).

The relationship between trauma exposure and PTSD symptomology however
is not confined to South East Asian and Lebanese children (Kinzie et
al., 1986; 1989; Macksoud & Aber, 1996; Sack et al., 1994). Over recent
years, such findings have been established cross culturally among
children and youth from regions such as:

    a.. Afghanistan (Mghir, Freed, Raskin & Katon, 1995);
    b.. Bosnia (Geltman, et al, 2000; Papageorgiou, et al, 2000; Weine, et
al, 1995);
    c.. Chile (Hjern, Angel & Hojer, 1991);
    d.. Croatia (Ajdukovic & Ajdukovic, 1993);
    e.. Central America (Arroyo & Eth, 1996; Espino, 1991; Rousseau,
Drapeau & Corin, 1997);
    f.. El Salvador and Nicaragua (Arroyo & Eth, 1996);
    g.. The Gaza Strip (Thabet & Vostanis, 2000);
    h.. Iraqi-Kurdistan (Ahmad, Mohamed & Ameen, 1997);
    i.. Israel (Laor, et al, 1996);
    j.. Iran (Almqvist & Brandell-Forsberg, 1997; Almqvist & Broberg,
1999);
    k.. Sudan (Paardekooper, de Jong & Hermanns, 1999); and
    l.. Tibet (Servan-Schreiber, Le Lin & Birmaher, 1998).
Although studies have consistently linked trauma symptomology with the
experience of trauma related events, which are usually attributed to
organised violence and war, fewer investigators have attempted to relate
exposure to a diagnosis for PTSD. Hence, the focus on symptomology
renders it unclear as to whether a complete diagnosis can be applied to
trauma experience (Green, et al., 1991). The implications of such issues
are important to consider given the position of those seeking formal
refugee status. Notwithstanding, Almqvist and Brandell-Forsberg (1997)
are among few researchers to demonstrate effectively the applicability
of PTSD criteria to symptomology expressed in children. Similar
diagnoses have been demonstrated by Schwarz and Kowalski (1991a).

One controversy noted throughout the literature relating to refugee
children and adolescents and PTSD is whether it is the totality of
exposure to war related stress that is harmful, or whether in fact
trauma responses are dependent on the nature, type, amount and duration
of exposure to stress (Athey & Ahearn 1991; Jensen & Shaw, 1993, cited
in Berman, 2001; Mghir et al., 1995). Reviews of such studies indicate
evidence for the suggestion that the greater the nature and extent of
exposure, the poorer one's psychological outcome in terms of onset and
severity of PTSD symptoms (Espino, 1991; Papageorgiou et al., 2000).

Extending their diagnostic approach to trauma symptomology, Almqvist and
Brandell-Forsberg (1997) also investigated whether the amount of trauma
exposure is related to the prevalence and stability of PTSD over time.
Whilst finding it is possible to diagnose PTSD during initial stages of
assessment and one year later, these authors also found that one fifth
of children directly exposed to organised violence and persecution
(e.g., through assault on parents or bomb attacks within 50 metres) were
at risk for developing chronic states of PTSD.

Similarly, though not drawing directly from a refugee but rather
displaced and war exposed population, Macksoud and Aber (1996) examined
the relationship between the number and type of war traumas and
psychosocial development among 224 Lebanese children aged between 10-16.
Using measures of war exposure, war trauma, mental health, PTSD and
adaptation, these investigators assessed ten categories of war exposure.
As predicted, the number and type of traumatic exposure were positively
related to PTSD symptoms. Children exposed to multiple traumas (e.g.,
shelling, combat) and those who were bereaved, victimised by or had
witnessed violent acts, showed more PTSD symptoms than those who had not
witnessed such acts. Moreover, depressive symptoms were more evident in
children who had experienced separation from their parents and
displacement than those who remained with their parents.

Finding that 34% of adolescent and young adult refugees from Afghanistan
met criteria for PTSD, major depression or both, Mghir et al. (1995)
similarly demonstrated an association between the presence of these
disorders and the total number of events experienced. In her
investigation of Khmer adolescent refugees exposed to community
violence, Berthold (1995) also noted the impact of multiple traumas
before and following resettlement in the US on PTSD.

Sinnerbrink and colleagues (1997) also examined the relationship between
exposure to violence and mental health outcome in Khmer adolescents in
the USA. A quarter of these subjects partially or fully met criteria for
PTSD with the number of violent events experienced predicting PTSD and
level of functioning. Not only was pre-migration exposure predictive of
PTSD, the number of violent events exposed to across subjects' lifetime
(i.e., time in Cambodia and US) also and more strongly predicted PTSD
and level of functioning. This finding is noteworthy as it demonstrates
the cumulative effect of trauma and its predisposing features to future
distress and function (Sinnerbrink et al., 1997).

Lonigan and colleagues (1991, cited in Almqvist & Brandell-Forsberg,
1997) and Pynoos, Steinberg and Wraith (1995) in their investigations of
school-aged children have also shown a correlation between the amount of
traumatic exposure and PTSD prevalence. The association between severity
of exposure in terms of number and proximity of experienced events and
the presence of PTSD in children and adolescents has been supported in
different cultures including Bosnian (Papageorgiou et al., 2000);
Vietnamese (Mollica et al., 1997); Cambodian (Sack, Clarke & Seeley,
1996); Palestinian (Garbarino & Kostelny, 1996; Thalbet & Vostanis,
1999), Middle Eastern (Montgomery, 1998) and Central American (Espino,
1991).

So far, the studies reviewed have clearly outlined the shorter-term
consequences of organised violence and war and their resultant traumatic
outcomes for children and adolescents from a cross sectional
perspective. Little research however, has been conducted into the
evolution of PTSD symptoms and its long-term development and persistence
in refugee/asylum seeking children and adolescents (Punamaki, 2001). The
preliminary nature of longitudinal research in this area therefore, has
produced equivocal findings. Nevertheless, there are some studies that
demonstrate the persistence of PTSD symptoms across time.

The work of Kinzie et al. (1986; 1989) represents one of the few
attempts to evaluate the persistence of PTSD over several years. As
discussed earlier, these researchers examined the effects of massive
trauma on 40 Cambodian refugees who had been imprisoned for up to two
years in concentration camps during the Pol Pot regime. All subjects had
endured separation from family, forced labour and starvation and many
had witnessed killings and other forms of torture. Four years after
leaving Cambodia, up to 50% of subjects developed PTSD. Mild but
prolonged, depressive symptoms were evident in 38% of subjects. Results
of a 3-year follow up with 30 of the 40 original subjects revealed that
although depressive symptoms had diminished, 48% of subjects still
exhibited symptoms meeting the criteria for PTSD, supporting the notion
that traumatic symptoms endure over time. Subjects with poorer PTSD
outcomes also showed poorer social adjustment. Six years following the
initial study, 38% of subjects still exhibited PTSD criteria, though
there was a reduction in the rate of depression (Sack, Clarke, Him,
Dickason, Goff, Lanham & Kinzie, 1993). Twelve years after the initial
study, 35% of subjects still exhibited criteria for PTSD and 14% had
depression (Sack, Him & Dickason, 1999).

These authors add increasing empirical weight to the idea that PTSD in
children and adolescents can persist from several up to twelve years.
These authors also note however, along with the prevalence of
depression, the intensity of PTSD symptoms tend to diminish over time.
Where depression was initially shown to co exist with PTSD symptoms,
depressive symptoms were no longer evident after six years. Such
findings are important as they sustain the theoretical argument that
PTSD symptoms are distinct from symptoms of depression and are indeed a
manifestation of massive trauma, contrary to the result of resettlement
stress (Sack et al., 1993; Sack et al., 1995). Despite the persistence
of PTSD, participants in Sack et al's. (1993) study were generally
adaptive. Most, for instance, were able to pursue some forms of college
education. As Kinzie et al. (1990) and Sack (1998) state though, the
impact of trauma is likely to affect child development over time
resulting in fluctuating symptom profiles of both PTSD and depression.
Of the more recent studies investigating the long-term consequences of
trauma, Almqvist and Broberg (1999) assessed the prevalence of PTSD in
Iranian preschoolers following two and a half years of resettlement in
Sweden. For a fifth of children previously exposed to trauma, PTSD
diagnoses remained stable. Supporting the argument that PTSD can be
enduring, these authors also remarked on the problem of much research,
which relies heavily on parental interviews for data (Almqvist &
Broberg, 1999; Geltman et al., 2000). In their interviews with both
children and parents, a significant difference was observed in the
initial investigation, where according to parents, only 2% of children
met criteria for PTSD. When the children were interviewed however, 21%
met PTSD criteria. That is, parents were found to underestimate and/or
deny symptoms of trauma re-experience in their children, a major
criterion for PTSD.

Though these findings might be attributable to parents' desires to
protect their children, they demonstrate that parents may also down play
the presentation of symptoms in children. This is supported by arguments
that PTSD is difficult to observe in young children due to problems in
identifying avoidance symptoms, a further criterion of PTSD. Lastly,
Macksoud and Aber (1996) and Ahmad et al. (1998) have also observed
chronic/continuous PTSD in samples of Lebanese children exposed to
single events in civil war and Iraqi Kurdish children respectively. The
high level of PTSD persistence in the above studies is consistent with
general studies regarding children who develop PTSD following exposure
to other trauma (McFarlane, 1987, cited in Hodes, 2000). Regarding the
long-term effects of trauma, age at the time of traumatic experience
does not appear to influence its persistence (Dreman & Cohen, 1990).

It should be noted that disagreement and inconsistencies regarding
mental health in refugee populations does exist despite evidence for
poor psychological adaptation (Dybdahl, 2001; Beiser, Dion, Gotowiec,
Hyman & Vu, 1995). Of studies which have produced equivocal findings,
Becker, Weine, Vojvoda and McGlashan (1999) investigated the psychiatric
sequelae of Bosnian adolescents after a year of resettlement to assess
delayed PTSD onset. Of those initially diagnosed with PTSD, none met
criteria for diagnosis a year later and only one subject not previously
diagnosed, displayed PTSD symptomology. Becker et al. (1999) concluded
that the diminution of PTSD over time might reflect the fact that
symptoms are transient and not representative of enduring
psychopathology. Hence, while there is evidence to support the chronic
nature of PTSD in refugee children and adolescents, there is also
evidence to suggest that such long-term effects may be mediated by other
factors. Becker et al. (1999) did nevertheless observe that the symptoms
shown at one year follow up remained similar to the clusters of symptoms
observed in their initial investigation and that Bosnian adolescents had
also remained with their parents, potentially offsetting PTSD
symptomology. Indeed, Ajdukovic and Ajdukovic (1998) cautioned that the
child's exposure to extreme intense trauma can have delayed effects and
can cause difficulties in psychological functioning in adulthood.

As indicated above, parental psychological well-being is a key factor in
the mental health of child/adolescent refugee and asylum seekers
(Papageorgiou et al., 2000; Sack et al., 1994). Research directed at
parental and familial influences has demonstrated that disorders
associated with child and adolescent refugee experiences cluster in
families. Sack, Clarke and Seeley (1995) for example, interviewed 118
Khmer adolescent refugees and one of their parents (usually mother).
These authors found that the risk for PTSD increased for adolescents
when one parent exhibited PTSD. When environmental influences to this
relationship such as separation/divorce of parents, therapeutic
intervention and socio-economic status were examined, no significant
impact was found.

While such findings may underscore a genetic susceptibility to PTSD
(Sack et al., 1995; Hodes, 2000), they also implicate the role of
learning factors in the concurrence of PTSD in children and their
parents. Lukman and Bach-Mortensen (1995, cited in Hodes, 2000) provide
support to the role of learning factors in PTSD and argue that such is
the established link between parent and childhood disorder that children
of torture victims, who seek asylum in resettlement countries, may have
high levels of emotional and physical symptoms such as stomachache or
headache, even when not exposed to the traumatic events themselves.
Moreover, parents' own experience of persecution, war violence,
terrorism, powerlessness and exhaustion can compromise their ability to
care for their children, increasing child/adolescent susceptibility to
PTSD and other psychopathology (Sack et al., 1986). Garbarino, Kostelny
and Dubrow (1991) and Richman (1993) further maintain that PTSD can be
evident in multiple family members, particularly when marital relations
are strained.

The findings observed above are consistent with Green et al. (1991) and
Punamaki (2001) who argue that parental capacity and family cohesion
after traumatic exposure are of equal or greater importance in the
post-traumatic stress reactions of young children. These authors provide
evidence that family dysfunction before exposure may predispose PTSD in
children and adolescents. Drawing similar conclusions, Arroyo and Eth
(1996) found that those children and adolescents in nuclear families
were less likely to receive psychiatric diagnoses than those who lived
alone or were fostered.

While psychological problems in the family are significantly related to
child psychopathology in refugee children and adolescents, the role of
mothers appears to be particularly important as shown by Ajdukovic and
Ajdukovic (1993) who found that mothers' emotional well-being best
predicted emotional well being and adaptation in children.

So far, consistent psychological outcomes have been reported in the
literature for children and adolescents regardless of their different
experiences, backgrounds and cultures. While these consistencies in the
literature are important to identify, the specific effects of culture
have been largely unexamined across studies. The complex role that
culture plays in the psychological health of child and adolescent
refugee and asylum seekers is highlighted by Rousseau, Drapeau and Corin
(1997). Comparing Central American and South East Asian refugee
children, Rousseau et al. (1997) showed that the impact of family
factors on post-traumatic symptomology is mediated by contextual as well
as cultural factors. In Central Americans, greater trauma exposure in
families was found to be more related to family conflict and depression,
whereas in South East Asians, increased trauma exposure was found to be
associated with less parental depression.

Arroyo and Eth (1996) have similarly observed contrasting symptom
profiles between Latin American and South East Asian refugee children,
where the former display more prevalent academic and conduct problems.
While not replicated, these differential findings across cultures
reflect the need to investigate systematically cultural influences on
child and adolescent mental health among the refugee and asylum seeking
populations.

remainder of report at
http://www.humanrights.gov.au/human_rights/children_detention/psy_review.html




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