Mental health of refugee children

Mental health of refugee children is often affected by pre-migration and post-migration stressors.[1]:p.17 Compared to other immigrants, refugee children are more likely to have serious problems associated with malnutrition, disease, physical injuries, brain damage and sexual or physical abuse.[2]:p.5 These problems may affect the child's cognitive, social and emotional development, leading to serious mental deficiencies/illnesses including post-traumatic stress disorder (PTSD), anxiety and depression.[2]:p.5

Refugee definition

Bantu refugee children from Somalia at a farewell party in Florida before being relocated to other places in the United States.

According to the United Nations High Commissioner for Refugees (UNHCR), the term refugee refers to any individual who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion.[3]:p.5

Approximately 44% of the world’s refugees are children.[4] A child is anyone below the age of 18 according to the Convention on the Rights of a Child on the Involvement of Children in Armed Conflicts.[5] Since 1980, 1.8 million refugees have been invited to live in the United States, 40% of whom have been children. An estimated 95% of them resettle with their parents.[6] About 80% of the world’s refugees are hosted by developing countries.[6] Presently, the largest refugee producing countries include Afghanistan, Iraq, Somalia and Sudan.[6]

Pre-migration factors

Factors leading to mental health illness in refugee children that occur prior to resettlement are child labour (which includes recruitment as both soldiers and sex slaves), warfare and economic disparity.

Child labour

Children can suffer from mental health issues as a result of their utilization as “workers” within a given nation.

Sex industry

Many unaccompanied children fleeing from conflict zones in Moldova, Romania, Ukraine, Nigeria, Sierra Leone, China, Afghanistan or Sri Lanka are forced into sex trafficking.[7][8]:p.9 About 1.2 million children are trafficked for labour or sexual exploitation, representing about 50 percent of the 2.4 million people trafficked worldwide.[9] Refugee children choose to leave their homeland due to poverty, political crisis, violent conditions, persecution, or a lack of protection due to human rights violations.[8]:p.9 While fleeing their country of origin, many unaccompanied children are forced to travel with human smugglers who attempt to exploit these children as child sex workers.[10] Children living in volatile economic conditions are particularly vulnerable to traffickers, and young girls represent the primary target of sexual exploitation.[8]:p.9

Child soldiers

Former child soldiers in the eastern Democratic Republic of the Congo.

During times of war, children can be recruited as child soldiers and placed on the battlefield. Many children are abducted and forced to become soldiers whereas other children join voluntarily.[11]:p.1 Whether a child is abducted and forced into the army or joins voluntarily, war itself often become a part of the child’s identity. This phenomenon – combined with the effects of conflict on the physical welfare and mental stability of the child – demonstrates how difficult reintegration may be when they are removed from the unstable environment.[11]:p.3 Former child soldiers are more likely to attain severe mental health problems including symptoms of PTSD, anxiety and depression.[12]

Warfare

War can impair the mental faculties of children prior to their resettlement as refugees. Throughout the past century, the proportion of war victims who are civilians has increased from 5 per cent to over 90 per cent in certain conflict regions, and a majority of the affected civilians are children.[1]:p.9 Refugee children can suffer from physical trauma and mental trauma due to prolonged confrontation with violence.[13]:p.95 Children tend to feel the most helpless and vulnerable during times of conflict, and may experience feelings of shame and loss of self-confidence in their ability to control their own lives. Prolonged experiences with warfare also put children at risk to develop PTSD.[13]:p.95

Economic disparity

Poverty affects both the physical and mental health of children.[14] Poverty is an important pre-migration factor to consider when characterizing mental illnesses in refugee children because it is intrinsically alienating and distressing. Poverty affects the development and maintenance of emotional, behavioral, and psychiatric problems.[14] Economic disparity can be a determinant and a consequence of poor mental health.[14]

Post-migration factors

Following a child’s resettlement, the main issues are the adverse effects of a child’s potential separation from family members and the stigma that accompanies a refugee during the process of resettlement.

Separation

Refugee children without caretakers have a greater risk of exhibiting psychiatric symptoms of mental illnesses following traumatic stress.[15]:p.9 Unaccompanied refugee children display more behaviour problems and emotional distress than refugee children with caretakers.[15]:p.9 Parental well-being plays a crucial role in enabling resettled refugees to transition into a new society. If a child is separated from his/her caretakers during the process of resettlement, the likelihood that he/she will develop a mental illness increases.[15]:p.17

Stigma

Refugees are at risk of stigmatization due to their race, ethnicity, and/or religion. Refugees can also be stigmatized if they encounter mental health deficiencies prior to and during their resettlement into a new society.[15]:p.14 Differences between parental and host country values can create a rift between the refugee child and his/her new society.[2]:p. 5 Less exposure to stigmatization lowers the risk of refugee children developing PTSD.[15]:p.14

Access to healthcare

Cognitive and structural barriers make it difficult to determine the medical service utilization rates and patterns of refugee children. A better understanding of these barriers will help improve mental health care access for refugee children and their families in North America.[16]

Cognitive and emotional barriers

Many refugees develop a mistrust of authority figures due to repressive governments in their country of origin. Fear of authority and a lack of awareness regarding mental health issues prevent refugee children and their families from seeking medical help.[17]:p.76 Certain cultures use informal support systems and self-care strategies to cope with their mental illnesses, rather than rely upon biomedicine.[18]:p.279 Language and cultural differences also complicate a refugee’s understanding of mental illness and available health care.[18]:p.280

Other factors that delay refugees from seeking medical help are:[18]:p.284

Structural barriers

Upon arrival to their host country, refugees encounter language barriers, a lack of culturally-competent care, cost complications, a lack of public awareness and access to information about available resources, and administrative deterrents for health care providers to take on refugee patients that prevent access to adequate mental health care services.

Language barriers

A broad spectrum of translation services are available to all refugees, but only a small number of those services are government-sponsored. Community health organizations provide a majority of translation services, but there is a shortage of funds and available programs.[19] Since children and adolescents have a greater capacity to adopt their host country's language and cultural practices, they are often used as linguistic intermediaries between service providers and their parents.[2] This may result in increased tension in family dynamics where culturally sensitive roles are reversed. Traditional family dynamics in refugee families disturbed by cultural adaptation tend to destabilize important cultural norms, which can create a rift between parent and child. These difficulties cause an increase of depression, anxiety and other mental health concerns in culturally-adapted adolescent refugees.[2]

Relying on other family members or community members has equally problematic results where relatives and community members unintentionally exclude or include details relevant to comprehensive care.[19] Health care practitioners are also hesitant to rely on members of the community because it is breaches confidentiality.[20]:p.174 A third party present also reduces the willingness of refugees to trust their health care practitioners and disclose information.[20] Patients may receive a different translator for each of their follow-up appointments with their mental health care providers, which means that refugees need to re-tell their story via multiple interpreters, further compromising confidentiality.[19]

Culturally competent care

Culturally competent care exists when health care providers have received specialized training that helps them to identify the actual and potential cultural factors informing their interactions with refugee patients.[19]:p.524 Culturally competent care tends to prioritize the social and cultural determinants contributing to health, but the traditional Western biomedical model of care often fails to acknowledge these determinants.[19]:p.527

To provide culturally competent care to refugees, mental health care providers should demonstrate some understanding of the patient’s background, and a sensitive commitment to relevant cultural manners (for example: privacy, gender dynamics, religious customs, and lack of language skills).[19]:p.527 The willingness of refugees to access mental health care services rests on the degree of cultural sensitivity within the structure of their service provider.[19]:p.528

The protective influence exercised by adult refugees on their child and adolescent dependents makes it unlikely that young adult-accompanied refugees will access mental healthcare services. Only 10-30% of youth in the general population, with a need for mental healthcare services, are currently accessing care.[21]:p.342 Adolescent ethnic minorities are less likely to access mental healthcare services than youth in the dominant cultural group.

Parents, caretakers and teachers are more likely to report an adolescent’s need for help, and seek help resources, than the adolescent.[21]:p.348 Unaccompanied refugee minors are less likely to access mental health care services than their accompanied counterparts. Internalizing complaints (such as depression and anxiety) are prevalent forms of psychological distress among refugee children and adolescents.[21]:p.347

Other obstacles

Additional structural deterrents for refugees:

Structural deterrents for healthcare professionals:

Access to education

Adapting to a new school environment is one of the major tasks facing refugee children when they arrive in a new country or refugee camp.[29] Education is crucial in the psychosocial adjustment and cognitive growth of refugee children. Due to these circumstances, it is important for educators consider the needs, obstacles, and successful educational pathways for children refugees.[6]

Issues faced

Structure of the education system

Schools in North America lack the resources necessary to support refugee children in negotiating their academic experience and the diverse learning needs of refugee children often go unnoticed.[30] Complex schooling policies that vary by classroom, building and district, and procedures that require written communication or parent involvement intimidate the parents of refugee children.[30] Educators in North America typically guess the grade in which refugee children should be placed because there is not a standard test or formal interview process required of refugee children.[31]:p.189

Sahrawi refugee children learning Arabic and Spanish, math, reading and writing, and science subjects.

The ability to enroll in school and continue one's studies in developing countries is limited and uneven across regions and settings of displacement, particularly for young girls and at the secondary levels.[32] The availability of sufficient classrooms and teachers is low and many discriminatory policies and practices prohibit refugee children from attending school.[32] Educational policies promoting age-caps can also be harmful to refugee children.[31]:p.176

Residence

Refugee children who live in large urban centers in North America have a higher rate of success at school given that their families have access to additional social services that can help address their specific needs.[31]:p.190 Families who are unable to move to urban centers are at a disadvantage.

Language barriers and ethnicity

Acculturation stress occurs in North America when families expect refugee youth to remain loyal to ethnic values while mastering the host culture in school and social activities. In response to this demand, children may over-identify with their host culture, their culture of origin, or become marginalized from both.[33] Insufficient communication due to language and cultural barriers may evoke a sense of alienation or "being the other" in a new society. The clash between cultural values of the family and popular culture in mainstream Western society leads to the alienation of refugee children from their home culture.[30]

Many Western schools do not address diversity among ethnic groups from the same nation or provide resources for specific needs of different cultures (such as including halal food in the school menu). Without successfully negotiating cultural differences in the classroom, refugee children experience social exclusion in their new host culture.[30] The presence of racial and ethnic discrimination can have an adverse effect on the well-being of certain groups of children and lead to a reduction in their overall school performance.[31]:p.189

Other obstacles

Even though refugee students value education as an agent for change, they may not find success in school.[34]:p.67 Other obstacles may include:[17]

Developments

Role of teachers

North American schools are agents of acculturation and help refugee children to become “absorbed” into Western society.[35]:p.291 Successful educators help children process trauma they may have experienced in their country of origin while supporting their academic adjustment.[36] Refugee children benefit from established and encouraged communication between student and teacher, and also between different students in the classroom.[36] Familiarity with sign language and basic ESL strategies improves communication between teachers and refugee children.[29] Also, non-refugee peers need access to literature that helps educate them on their refugee classmates experiences.[36] Course materials should be appropriate for the specific learning needs of refugee children and provide for a wide range of skills in order to give refugee children strong academic support.[29]

Classroom environment

Refugee children thrive in classroom environments of social inclusion where all students are valued. A sense of belonging and ability to flourish and become part of the new host society are all factors that predict the well-being of refugee children in academics.[33] Increased school involvement and social interaction between students help refugee children combat depression and/or other underlying mental health concerns that emerge during the post-migration period.[37]

Parent - teacher relationship

Educators should spend time with refugee families discussing previous experiences of the child in order to place the refugee child in the correct grade level and to provide any necessary accommodations[31]:p.189 School policies, expectations, and parent's rights should be translated into the parent's native language since many parents do not speak English proficiently. Educators need to understand the multiple demands placed on parents (such as work and family care) and be prepared to offer flexibility in meeting times with these families.[29][30]

Supporting the academic adjustment of refugee children

Vietnamese refugee mother and children at a kindergarten in upper Afula, 1979.

Teachers can make the transition to a new school easier for refugee children by providing interpreters.[36] Schools meet the psychosocial needs of children affected by war or displacement through programs that provide avenues for emotional expression, personal support, and opportunities to enhance their understanding of their past experience.[38]:p.536 Refugee children benefit from a case-by-case approach to learning, because every child has had a different experience during their resettlement. Communities where refugee populations are higher should work with the schools to initiate after school, summer school, or weekend clubs that give the children more opportunities to adjust to their new educational setting.[36]

Bicultural integration is the most effective mode of acculturation for refugee adolescents in North America. The staff of the school must understand students in a community context and respect cultural differences.[17]:p.331 Parental support, refugee peer support, and welcoming refugee youth centers are successful in keeping refugee children in school for longer periods of time.[17]:p.334 Education about the refugee experience in North America also helps teachers relate better with refugee children and understand the traumas and issues a refugee child may have experienced.[17]:p.333

Case study

Vietnamese refugees

Most of these refugees have minimal formal education and little English proficiency. Upon arrival in the US, Vietnamese households are usually large including minor children, married children, grandchildren, other relatives and non-relatives.[39]:p.5

Vietnamese children face many problems within their schools and are affected by the backgrounds of schoolmates alongside their own backgrounds. These differentiations in backgrounds and cultures place them at a higher risk of pursuing disruptive behaviour.[39]:p.7 Contemporary Vietnamese American adolescents are prone to greater uncertainties, self-doubts and emotional difficulties than other American adolescents. Vietnamese children are less likely to say they have much to be proud of, that they like themselves as they are, that they have many good qualities, and that they feel socially accepted.[39]:p.11

Despite these issues and the fact that Vietnamese children attend urban public schools that many middle-class families have abandoned, they are making significant progress in education. Vietnamese adolescents are less likely than their American peers to drop out of high school, and Vietnamese young adults were more likely than their American peers to attend college.[39]:p.10

See also

References

  1. 1 2 United Nations. (1996). Promotion and Protection of the Rights of Children: Impact of Armed Conflict (PDF).
  2. 1 2 3 4 5 Hyman, Ilene; Beiser, Morton; Vu, Nhi (1996). "The Mental Health of Refugee Children in Canada". Refuge. 15 (5): 4–8.
  3. ↑ UNHCR. Convention and Protocol Relating to the Status of Refugees.
  4. ↑ UNHCR. (2006). “Measuring Protection by Numbers.” http://www.unhcr.org/publ/PUBL/4579701b2.pdf. P. 1.
  5. ↑ “Child Soldiers Global Report 2008.” Human Rights Watch: Coalition to Stop the Use of Child Soldiers. http://www.childsoldiersglobalreport.org/content/rwanda.[]
  6. 1 2 3 4 Bridging Refugee Youth and Children's Services. (2006). Educational Handbook for Refugee Parents. International Rescue Committee: New York.
  7. ↑ Batstone, David (2010). Not for Sale: The Return of the Global Slave Trade—and How We Can Fight It. ISBN 978-0-06-202372-8.
  8. 1 2 3 Ali, Mehrunnisa; Gill, Jagjeet Kaur; Taraban, Svitlana (2003). Unaccompanied / separated children seeking refugee status in Ontario : a review of documented policies and practices. OCLC 246931353.
  9. ↑ "Child Trafficking". World Vision Canada. 2002.
  10. ↑ Kielburger, C. (2009). "Refugee Children can Feel Abandoned in New Land". The Star Online.
  11. 1 2 United Nations Office for Disarmament Affairs: Panel Discussion at the United Nations. (February 2009). Conflict of Interests: Children and Guns in Zones of Instability (PDF). UNODA Occasional Papers No. 14: New York.
  12. ↑ Crosta, Peter M. (August 15, 2008). Mental Health Issues Prominent in Child Soldiers. Medical News Today: MediLexicon, Intl.
  13. 1 2 Schaal S, Elbert T (February 2006). "Ten years after the genocide: trauma confrontation and posttraumatic stress in Rwandan adolescents". J Trauma Stress. 19 (1): 95–105. doi:10.1002/jts.20104. PMID 16568463.
  14. 1 2 3 Murali, V. (2004). "Poverty, social inequality and mental health". Advances in Psychiatric Treatment. 10 (3): 216–24. doi:10.1192/apt.10.3.216.
  15. 1 2 3 4 5 Lustig, Stuart L. (2003). Review of Child and Adolescent Refugee Health (PDF). National Child Traumatic Stress Network: USA.
  16. ↑ de Anstiss H, Ziaian T, Procter N, Warland J, Baghurst P (December 2009). "Help-seeking for mental health problems in young refugees: a review of the literature with implications for policy, practice, and research". Transcult Psychiatry. 46 (4): 584–607. doi:10.1177/1363461509351363. PMID 20028678.
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  18. 1 2 3 Donnelly, Tam Truong; Hwang, Jihye Jasmine; Este, Dave; Ewashen, Carol; Adair, Carol; Clinton, Michael (2011). "If I Was Going to Kill Myself, I Wouldn't Be Calling You. I am Asking for Help: Challenges Influencing Immigrant and Refugee Women's Mental Health". Issues in Mental Health Nursing. 32 (5): 279–90. doi:10.3109/01612840.2010.550383. PMID 21574842.
  19. 1 2 3 4 5 6 7 McKeary, Marie; Newbold, Bruce (2010). "Barriers to Care: The Challenges for Canadian Refugees and their Health Care Providers". Journal of Refugee Studies. 23 (4): 523–45. doi:10.1093/jrs/feq038.
  20. 1 2 Fowler N (August 1998). "Providing primary health care to immigrants and refugees: the North Hamilton experience". CMAJ. 159 (4): 388–91. PMC 1229607Freely accessible. PMID 9732723.
  21. 1 2 3 Bean T, Eurelings-Bontekoe E, Mooijaart A, Spinhoven P (May 2006). "Factors associated with mental health service need and utilization among unaccompanied refugee adolescents". Adm Policy Ment Health. 33 (3): 342–55. doi:10.1007/s10488-006-0046-2. PMID 16755395.
  22. ↑ Spitzer, Denise L. (2006). "The Impact of Policy on Somali Refugee Women in Canada". Refuge. 23 (2): 47–54.
  23. ↑ Walsh, Christina A.; Este, David; Krieg, Brigette; Giurgiu, Bianca (2011). "Needs of Refugee Children in Canada: What Can Roma Refugees Tell Us?". Journal of Comparative Family Studies. 42 (4): 599–613. JSTOR 41604470.
  24. ↑ Newbold B (April 2005). "Health status and health care of immigrants in Canada: a longitudinal analysis". J Health Serv Res Policy. 10 (2): 77–83. doi:10.1258/1355819053559074. PMID 15831190.
  25. ↑ O'Heir J (2004). "Pregnancy and childbirth care following conflict and displacement: care for refugee women in low-resource settings". J Midwifery Womens Health. 49 (4 Suppl 1): 14–8. doi:10.1016/j.jmwh.2004.04.031. PMID 15236699.
  26. 1 2 Nadeau L, Measham T (April 2006). "Caring for migrant and refugee children: challenges associated with mental health care in pediatrics". J Dev Behav Pediatr. 27 (2): 145–54. doi:10.1097/00004703-200604000-00013. PMID 16682882.
  27. ↑ Teng L, Robertson Blackmore E, Stewart DE (2007). "Healthcare worker's perceptions of barriers to care by immigrant women with postpartum depression: an exploratory qualitative study". Arch Womens Ment Health. 10 (3): 93–101. doi:10.1007/s00737-007-0176-x. PMID 17497307.
  28. ↑ Caulford P, Vali Y (April 2006). "Providing health care to medically uninsured immigrants and refugees". CMAJ. 174 (9): 1253–4. doi:10.1503/cmaj.051206. PMC 1435973Freely accessible. PMID 16636321.
  29. 1 2 3 4 Hoot, James L. (2011). "Working with very young refugee children in our schools: Implications for the world's teachers". Procedia - Social and Behavioral Sciences. 15: 1751–5. doi:10.1016/j.sbspro.2011.03.363.
  30. 1 2 3 4 5 Isik-Ercan, Zeynep (Autumn 2012). "In Pursuit of a New Perspective in the Education of Children of the Refugees: Advocacy for the Family". Educational Sciences: Theory & Practice (Special Issue): 3025–8. Retrieved 15 May 2013.
  31. 1 2 3 4 5 Wilkinson, Lori (2002). "Factors Influencing the Academic Success of Refugee Youth in Canada". Journal of Youth Studies. 5 (2): 173–93. doi:10.1080/13676260220134430.
  32. 1 2 Dryden-Peterson, Sarah (2011). Refugee Education: A Global Review (PDF). University of Toronto: UNHCR.
  33. 1 2 Correa-Velez I, Gifford SM, Barnett AG (October 2010). "Longing to belong: social inclusion and wellbeing among youth with refugee backgrounds in the first three years in Melbourne, Australia". Soc Sci Med. 71 (8): 1399–408. doi:10.1016/j.socscimed.2010.07.018. PMID 20822841.
  34. 1 2 Stewart, Jan (2011). Supporting Refugee Children: Strategies for Educators. University of Toronto Press: Toronto.
  35. ↑ Eisenbruch, Maurice (1988). "The Mental Health of Refugee Children and Their Cultural Development". International Migration Review. 22 (2): 282–300. doi:10.2307/2546651. JSTOR 2546651.
  36. 1 2 3 4 5 Szente, Judit; Hoot, James; Taylor, Dorothy (2006). "Responding to the Special Needs of Refugee Children: Practical Ideas for Teachers". Early Childhood Education Journal. 34: 15–20. doi:10.1007/s10643-006-0082-2.
  37. ↑ Kia-Keating M, Ellis BH (January 2007). "Belonging and connection to school in resettlement: young refugees, school belonging, and psychosocial adjustment". Clin Child Psychol Psychiatry. 12 (1): 29–43. doi:10.1177/1359104507071052. PMID 17375808.
  38. ↑ Rousseau C, Guzder J (July 2008). "School-based prevention programs for refugee children". Child Adolesc Psychiatr Clin N Am. 17 (3): 533–49, viii. doi:10.1016/j.chc.2008.02.002. PMID 18558311.
  39. 1 2 3 4 Zhou, M & Bankston, Carl. (2000). Straddling Two Social Worlds: The Experience of Vietnamese Refugee Children in the U.S. Education Resources Information Center, 111, pp. 1-84.

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