What is the Impact of Placement Type on Educational and Health Outcomes of Unaccompanied Refugee Minors? A Systematic Review of the Evidence

Unaccompanied refugee minors (hereafter URMs) are defined here as young people under the age of 18 who are outside of their country of origin, unaccompanied by a parent or customary caregiver and subject to immigration control because of forced migration. This includes those fleeing violence and those who have been trafficked.

Precise data about URM in the world are lacking. Figures on asylum applications provide some indication of the numbers: 95,205 asylum applications were recorded for unaccompanied or separated children in European countries in 2015 (Eurostat 2017). Sweden received 34,295 asylum applications from unaccompanied or separated children, while Germany recorded 22,255 (Eurostat 2017). The main countries of origin of URM in Europe were Syria, Afghanistan, Eritrea, Iraq and Somalia (Eurostat 2016). Smaller numbers of children migrate without a primary caregiver through government-sponsored resettlement programmes, mainly to the USA and Australia (UNHCR 2011). Available data from the USA and Europe suggest that the majority of URM are between the ages of 14 and 18, with less than 20% under 14 (European Commission 2013; Office of Refugee Resettlement 2013a).

URM experiences significant adversity in their country of origin, in transit to and on arrival in the host country. As a result, URM suffers from disproportionately higher levels of mental health problems, including post-traumatic stress disorder, depression and anxiety, than children who migrate with their parents or peers who are not migrants (Bronstein and Montgomery 2011; Fazel and Stein 2002; Fazel et al. 2012; Huemer et al. 2009; Lustig et al. 2004). Recent longitudinal analyses also show that mental health problems in URM persist throughout adolescence (Vervliet et al. 2013). While the bulk of current research evidence is on mental health, there is also evidence showing that some unaccompanied refugee minors have complex physical health needs, including incomplete immunisations, for example (Geltman et al. 2008; Levenson and Sharma 1999). It is not clear how these health needs are being met by the services responsible for their care, but one study suggests that children benefit from being placed in foster care (Wade et al. 2005). Research has also shown that education plays an important role in the resettlement of URM, with many eager to learn English and gain qualifications (Chase et al. 2008; Wade et al. 2012). However, their enthusiasm for education is often hampered by difficulties accessing the right provision, confusion about entitlements and language barriers (O’Higgins and Evans 2013).

In high-income countries, the welfare and provision of services to URM are usually the responsibility of regional or national child welfare agencies or immigration authorities; these are tasked with providing accommodation as well as other services, including access to education and health services. In some cases, these duties are devolved in part or completely to non-governmental, private or voluntary, organisations (de Ruijter de Wildt et al. 2015).

In this study, we refer to the provision of accommodation for children in care as placements. Depending on local and national policies, placements may include foster care (accommodation with a family other than their own), kinship care (with a member of the child’s extended family), semi-independent accommodation (usually shared housing), independent accommodation, or residential or group home. In some countries, URM is also placed in small or large detention centres dedicated to URM (de Ruijter de Wildt et al. 2015).

In the UK and USA, foster care is generally the preferred option, particularly for younger children (Brownlees and Finch 2010; Chase et al. 2008; de Ruijter de Wildt et al. 2015; Dorling et al. 2017; Office of Refugee Resettlement 2013b; Wade et al. 2005, 2012). Aside from the provision of accommodation, children looked after by the state receive additional social services and targeted assistance, for example access to education and health services, including psychological treatment (Pecora et al. 2010).

This review examines how different placement types are associated with the outcomes for unaccompanied refugee minors, in particular mental and physical health and educational outcomes. The proposed hypothesis is that stable housing provision and a supportive living environment are key elements contributing to good outcomes for URM. Foster care is thought to provide both these elements to a greater degree than other placement types (Hek 2007).

Porter and Haslam (2005) demonstrated, in a meta-analysis of pre- and post-displacement factors associated with (adult and youth) refugee mental health, that stable housing provision was a significant predictor of psychological well-being. A systematic review of risk and protective factors for (accompanied and unaccompanied) refugee children’s mental health concluded that a sense of safety and well-being at home was likely to be an important factor (Fazel et al. 2012). Little research has been conducted on the outcomes for URM in different placement types, and these are therefore not well understood (de Ruijter de Wildt et al. 2015; Fernandez and Barth 2010; Wade et al. 2012). This review addresses this gap in the literature and aims to inform policy and practice. Given the complex needs of URM, responding with adequate and effective social services is crucial. Understanding the impact of different placement types on outcomes is therefore paramount and urgent. Moreover, children’s services and voluntary agencies invest heavily in the provision of quality accommodation for children in their care.

To assess the state of the evidence, a systematic search of the literature was performed. Any quantitative empirical study carried out in a high-income country that analysed the relationship between placement type and mental or physical health or educational outcomes of URM was included. Comparison groups were important to establish the impact of different placement types, so studies in one placement type only were excluded. We anticipated that the research would be limited, so we accepted studies using any quantitative methodology, but we recognise that only well-designed randomised controlled trials and quasi-experimental studies can determine causality between placement type and outcomes.

Ten databases were searched (MEDLINE, PsycINFO, Applied Social Science Index and Abstracts (ASSIA), CINAHL, Cochrane Library, Campbell Collaboration Library, Education Resources (ERIC), Social Service Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences) in April 2017. References lists and table of contents of relevant journals were searched by hand. A number of sources were also searched on the Internet, including government, charity and research (e.g. Chapin Hall) or policy (e.g. Australian Policy Online) websites. Several key experts were contacted by email. Searches were conducted in English only.

The following string of search terms was used: (“foster care*” or “foster home*” or “foster famil*” or “foster parent*” or “foster placement*” or “children* home” or “group home” or “residential unit” or “residential care” or “looked after child*” or “looked-after child*” or “child* in care” or “alternative care” or “out-of-home care” or “out of home care” or accommodation or “semi-independent” or “kinship care*”) AND (refugee* or (asylum adj1 seek*) or asylum-seek* or (forced adj1 migra*) or migrant* or separated or unaccompanied) AND (child* or kid* or youth* or young* or adolescen* or teen* or boy* or girl* or minor*). The three authors conducted the search and screened titles and abstracts. Studies for inclusion were agreed by all authors.

The results are first described narratively and then numerically through meta-analysis. A meta-analysis was only conducted for the studies including mental health outcomes, because only two studies with educational outcomes and none with physical health outcomes were identified (see description of included studies).

For this meta-analysis, data were extracted from the included studies if it included sufficient information for an effect size to be calculated. Extracted data are listed in Table 1. For the purpose of the meta-analysis, accommodation type was separated into two groups based on the inclusion of foster care. Group A includes foster care (and in certain studies also includes other types of accommodation that have been grouped with foster care), and Group B does not include foster care.

Data were extracted for meta-analysis from seven of the eight included studies that had a mental health outcome (see Table 1). In three of these studies, more than one mental health outcome was included for the same sample population. (The second mental health outcome is shown in italics in Table 1.) To avoid giving undue weight to these studies, only one outcome measure was chosen for each population. Bean et al. (2007) and Derluyn and Broekaert (2007) both present data for two mental health outcomes from a single population. PTSD was selected as the primary outcome for Bean et al. (2007), and depression as the primary outcome for Derluyn and Broekaert (2007). Meta-analysis was also computed with the other outcome in these two studies; this did not substantially change the findings. Porte and Torney-Purta (1987) on the other hand present data for a single mental health outcome from two overlapping sample populations. Data from this study are presented for the groups with larger sample sizes. A forest plot comparing the included and excluded data for Bean et al. (2007), Derluyn and Broekaert (2007), and Porte and Torney-Purta (1987) is shown in Fig. 3.

Meta-analysis was performed using the Comprehensive Meta-Analysis (CMA) software. Standard mean differences (SMD) were calculated for each study within CMA; SMD was used as the studies report different scales. Meta-analysis was performed using a random-effects model because of heterogeneity in the included studies (Higgins and Green 2011). Results are presented as forest plots.

The CASP checklists and consort statement were used as guidelines for critical appraisal (CASP 2017; von Elm et al. 2007).

Bean et al. (2007) was the only study to use a random sample, while others analysed convenience samples. Only three included studies report differences between participants and non-participants (Bean et al. 2007; Bronstein et al. 2012; Seglem et al. 2011). Sample sizes varied from 78 (Hodes et al. 2008) to 582; no author presented power calculations (Bean et al. 2007). In terms of study design, all included studies were observational, and none used randomisation or other quasi-experimental methods. This is not surprising as randomisation is challenging in practice in social care (Dixon et al. 2014; Mezey et al. 2015). Not all studies provided detailed demographic data on participants, and none outlined whether baseline differences between children in different types of placements were compared. Therefore, observed and unobserved differences may confound the relationship between placement type and outcomes. All but one study (Bean et al. 2007) was cross-sectional; therefore, alternative explanations for the findings cannot be ruled out. Most studies controlled for age, gender and time in country, however, important factors about young people’s experiences are omitted, for example age at which past event(s) in country of origin occurred, number and type of previous placements and other sources of support (Vervliet et al. 2013). Information about children’s care histories is also omitted; therefore, it is not known whether children may have spent time in other placement types prior to the current one. Seven studies used child self-report measures only, and two studies supplemented information from children’s self-reports with teacher and guardian (Bean et al. 2007) and social worker (Derluyn and Broekaert 2007) questionnaires. One study included clinical interviews with mental health professionals (Hollins et al. 2007), and one study examined the child’s environmental setting from the point of view of professionals with the standardised BIC-Q (Kalverboer et al. 2017). Not all measures may be valid for unaccompanied refugee minors, and self-report measures may be biased by recall and social desirability bias (Bean et al. 2006; Bowling 2009; Crawley 2010; Nederhof 1985). Reporting of symptoms may also vary according to age, gender, cultural background, literacy level, etc. (Jakobsen et al. 2011). Studies that use a mixture of self-report and professional reports and analyse concordance of data, for example, Bean et al. (2007) may provide a more accurate picture of mental health symptoms.