Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors

doi:10.1016/S0140-6736(11)60051-2

The Lancet

Volume 379, Issue 9812, 21–27 January 2012, Pages 266-282

https://doi.org/10.1016/S0140-6736(11)60051-2 Get rights and content

Summary

We undertook a systematic search and review of individual, family, community, and societal risk and protective factors for mental health in children and adolescents who are forcibly displaced to high-income countries. Exposure to violence has been shown to be a key risk factor, whereas stable settlement and social support in the host country have a positive effect on the child's psychological functioning. Further research is needed to identify the relevant processes, contexts, and interplay between the many predictor variables hitherto identified as affecting mental health vulnerability and resilience. Research designs are needed that enable longitudinal investigation of individual, community, and societal contexts, rather than designs restricted to investigation of the associations between adverse exposures and psychological symptoms. We emphasise the need to develop comprehensive policies to ensure a rapid resolution of asylum claims and the effective integration of internally displaced and refugee children.

Introduction

Children and adolescents who flee persecution and resettle in high-income countries often endure great physical and mental challenges during displacement, and suffer continuing hardships after arrival. Most of these refugees come from geographically distant, low-income settings.¹ The adverse events that necessitated their flight are often only the beginning of a long period of turbulence and uncertainty. Young people might travel for weeks or months in dangerous circumstances to seek asylum in a high-income country, and are sometimes temporarily or permanently separated from family and need to use professional traffickers to reach their destination.² The challenges typically encountered after arrival include, first, the complex legal immigration processes that asylum seekers must negotiate to gain refugee status or be repatriated,³ and second, the huge social, cultural, and linguistic differences between the place of origin and the new setting.

The process of sociocultural adaptation can be quite gradual, and refugees integrate to different extents with the host community.⁴ Children with disrupted or minimal school education are suddenly immersed in a new education system. Racial discrimination and bullying, exacerbated by policies to accommodate asylum seekers in already impoverished and disadvantaged areas, are widespread.⁵ Immigration policies for dispersal and detention can negatively affect refugees' attempts to settle in their host community.⁶ However, rapid resolution of asylum decisions eases access to social, health, education, and employment opportunities and infrastructures. Refugee children in high-income countries do not usually lack basic material necessities, yet certain factors nonetheless place their healthy development at risk. In this Review, we draw attention to the specific risk and protective factors that affect the psychological wellbeing of refugee children. Table 1 summarises all the studies included in this Review. Table 2 summarises the main findings according to individual factors, and table 3 according to family, community, and societal factors.

Section snippets

Effects of displacement

Although there are a reasonable number of reports about children exposed to conflict,⁵¹ the importance of displacement, as an additional variable to exposure to organised violence, has only been assessed in four Croatian studies.23, 29, 31, 50 In a study³¹ with a 30-month follow-up, post-traumatic stress disorder, depression, and somatic complaints decreased with time in internally displaced and non-displaced children, but psychosocial adaptation remained worse in displaced children and did not

Exposure to violence

Direct experience of adverse events is associated with an increased likelihood of psychological disturbance in refugee children. The degree of post-traumatic stress disorder was associated with personal experiences of traumatic events, especially those occurring when away from home.²² Internalising difficulties in the initial phase after displacement were associated with adverse events before migration,³⁵ whereas the rates of sleep disturbances and anxiety were increased in children with direct

Exposure to violence

Familial experiences of adverse events affect children's psychological functioning. Some types of parental exposures are more strongly associated with children's mental health problems than are children's own exposures,34, 44 particularly if parents have been tortured9, 15, 16, 34, 55 or are missing.³⁴ Familial adverse events before the child's birth were a major determinant of children's later psychological outcomes in Central American, but not in southeast Asian⁵⁶ or Middle Eastern refugees.³⁴

Social support and community integration

Perceptions of acceptance or discrimination within host countries are highly relevant. In a study of displaced Bosnian adolescents,⁴⁸ those internally displaced or displaced to Croatia reported more perceived discrimination than did those who had resettled in Austria. Low peer violence and discrimination were positively linked to self-esteem. Boys were more likely to report discrimination than were girls,35, 48 and this difference was predictive of poorer psychological functioning. Perceived

Ideological and religious contexts

The evidence for religious beliefs is mixed. Among Bosnian adolescents resettled in Austria and Croatia, religious commitment (assessed as a composite of frequency of participation in religious activities and degree of subjective personal belief) was associated with low anxiety and depressive symptoms.⁴⁸ Among Middle-Eastern groups in Denmark, Muslim and Christian refugee adolescents had lower scores for internalising behaviours than did those who belonged to a persecuted minority religion or

Conclusions and recommendations

Many different factors affect the mental health of forcibly displaced children in the presence of substantial life challenges. Table 4 summarises the key protective and risk factors. In accord with Reed and colleagues' Review,⁵³ premigration exposure to violence was strongly predictive of psychological disturbance. Family factors and living arrangements have received much more attention in high-income settings than in the low-income and middle-income settings. Overall, the ability to integrate

Search strategy and selection criteria

The Medline, Scopus, PsycINFO, Embase, Web of Science citation, and Cochrane databases were systematically searched for studies about risk and protective factors that were reported from January, 1980, to July, 2010. Searches of similar terms were combined such as “asylum seeker”, “refugee”, “displaced person”, “migrant” with “child”, “adolescent”, “young”, “minor”, “youth” or “teenage”, and terms including “psychiatr*”, “psycholog*”, “psychosocial”, “mental”, “resilience”, “outcome”,

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ReviewMental health of displaced and refugee children resettled in high-income countries: risk and protective factors

Summary

Introduction

Section snippets

Effects of displacement

Exposure to violence

Exposure to violence

Social support and community integration

Ideological and religious contexts

Conclusions and recommendations

Search strategy and selection criteria

Child Abuse Neglect

Child Abuse Neglect

J Am Acad Child Psychiatry

Soc Sci Med

Lancet

J Adolesc Health

Child Abuse Neglect

Soc Sci Med

Child Abuse Neglect

Child Abuse Neglect

Child Abuse Neglect

J Am Acad Child Psychiatry

J Am Acad Child Psychiatry

Soc Sci Med

Soc Sci Med

J Am Acad Child Psychiatry

Child Adolesc Psychiatr Clin N Am

Soc Sci Med

Aust N Z J Public Health

Child Abuse Neglect

J Am Acad Child Psychiatry

J Am Acad Child Psychiatry

J Am Acad Child Adol Psychiatry

Biol Psychiatry

Soc Sci Med

J Am Acad Child Psychiatry

2008 global trends: refugees, asylum seekers, returnees, internally displaced and stateless persons

The challenges of ensuring protection to unaccompanied and separated children in composite flows in Europe

Refugee Surv Q

Theoretical perspectives on post-migration adaptation and psychological well-being among refugees: towards a resource-based model

J Refugee Stud

Comparative studies of acculturative stress

Int Migr Rev

Stories of pre-war, war and exile: Bosnian refugee children in Sweden

Med Confl Surviv

Policies of deterrence and the mental health of asylum seekers

JAMA

Effects of war and organized violence on children: a study of Bosnian refugees in Sweden

Am J Orthopsychiatry

Comparing psychological distress, traumatic stress reactions, and experiences of unaccompanied refugee minors with experiences of adolescents accompanied by parents

J Nerv Ment Dis

The effects of exposure to community violence on Khmer refugee adolescents

J Trauma Stress

War traumas and community violence: psychological, behavioral, and academic outcomes among Khmer refugee adolescents

J Multicult Soc Work

Resilience and vulnerability among refugee children of traumatized and non-traumatized parents

Child Adolesc Psychiatry Ment Health

Different perspectives on emotional and behavioural problems in unaccompanied refugee children and adolescents

Ethn Health

Psychosocial adaptation of children while housed in a Swedish refugee camp: aftermath of the collapse of Yugoslavia

Stress Med

Mental health of Somali adolescent refugees: the role of trauma, stress, and perceived discrimination

J Consult Clin Psychol

Southeast Asian refugee children: violence experience and depression

Int J Psychiatr Nurs Res

The “lost boys of Sudan”: functional and behavioral health of unaccompanied refugee minors re-settled in the United States

Arch Pediatr Adolesc Med

The mental health of children upon their return home after a long displacement period

Coll Antropol

Depression and perceived family functioning in Croatian displaced children

Drustvena Istrazivanja

Political violence, family stress and mental health of refugee children in exile

Scand J Soc Med

Risk and resilience for psychological distress amongst unaccompanied asylum seeking adolescents

J Child Psych Psychiatry

Belonging and connection to school in resettlement: young refugees, school belonging, and psychosocial adjustment

Clin Child Psychol Psychiatry

Coping strategies of refugee, displaced, and non-displaced children in a war area

Nord J Psychiat

Review
Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors