REVIEW
The mental health of refugee children
M Fazel, A Stein
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Arch Dis Child 2002;87:366–370
The UK is facing a major increase in the number of
people seeking asylum each year, of whom
approximately a quarter are children. The stressors to
which refugees are exposed are described in three
stages: (1) while in their country of origin; (2) during
their flight to safety; and (3) when having to settle in a
country of refuge. The evidence concerning the impact
of displacement on children’s mental health is reviewed
and a framework for conceptualising the risk factors is
proposed. The available literature shows consistently
increased levels of psychological morbidity among
refugee children, especially post-traumatic stress
disorder, depression, and anxiety disorders. The
principles underlying the delivery of mental health care
for these children are also considered. It is argued that
much primary prevention can be undertaken in the
school context. Some key aspects of British immigration
law are examined and the tension between the law and
the best interests of the child principle is discussed.
There is particular concern for the plight of
unaccompanied children. Attention to the mental health
needs of this vulnerable group is urgently required.
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One per cent of the world’s population, 50million people, are currentlyuprooted—23 million are refugees who
have sought safety in another country, and 27
million are displaced within their own country.1
In the past decade the worldwide refugee popula-
tion has increased tenfold and all indicators show
that this number will continue to rise.2 (A refugee
is defined as: a person who, “owing to a
well-founded fear of being persecuted for reasons
of race, religion, nationality, membership of a
particular social group or political opinion, is out-
side 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 hav-
ing a nationality and being outside the country of
his former habitual residence as a result of such
events, is unable or, owing to such fear is unwill-
ing to return to it”.3) The UK is facing a major
increase in the number of people seeking asylum,
with 100 000 applications made in the year 2000,
representing a 250% increase in just four years.4
However, other countries are facing more formi-
dable challenges; for example, Tanzania in 1999
received more refugees than the whole of Western
Europe combined.1
Over half of the world’s displaced population
are children. In the past 10 years it is estimated
that more than two million children have been
killed in conflict, with a further six million
wounded and one million orphaned.5 The 1989
UN Convention on the Rights of the Child offers
an important theoretical and legal framework for
the protection of children; however, national
immigration law is often the arena where human
rights and national self interests clash and the
principle of promoting the best interests of
refugee children can be overlooked. Refugee chil-
dren are at significant risk of developing psycho-
logical problems, and although in the UK they
will have arrived in one of the richest countries in
the world, the services potentially available to
help them are often ill equipped to address their
needs, and imminent legislation might even
exacerbate their problems.
THREE STAGES OF TRAUMATIC
EXPERIENCES
The stresses to which most refugees are exposed
can be understood as occurring at three different
stages: (1) while in their country of origin; (2)
during the flight to safety; and (3) when having
to settle in a country of refuge.6
(1) In their native countries many refugees have
experienced considerable trauma. They have
often been forced to flee their homes because
of exposure war or combat and hence
witnessed violence, torture, and losses of
close family and friends. Refugee children
might have no memory of a period of stabil-
ity; their school education, if any, is likely to
have been disrupted; and parental distress
and general insecurity are common
experiences.7
(2) The journey to a country of refuge can also be
a time of further stress. It can take many
months and expose the refugees to more life
threatening dangers. Refugee children at
these times can experience separation from
parents, either by accident or as a strategy to
ensure their safety. As international immi-
gration controls tighten, more children are
being placed in the hands of smugglers to
ensure their escape, either as the only
representative their family can afford to send
away or in the hope that the child alone
would have better chances of gaining refugee
status.8
(3) The final stage of finding respite in another
country can be a time of additional difficulty
as many have to prove their asylum claims
and also try to integrate in a new society.9
This period is being increasingly referred to
as a period of “secondary trauma” to high-
light the problems encountered. On arriving,
a refugee child will need to settle into a new
See end of article for
authors’ affiliations
. . . . . . . . . . . . . . . . . . . . . . .
Dr M Fazel, University
Department of Psychiatry,
Warneford Hospital,
Oxford OX3 7JX, UK;
mina.fazel@psych.ox.ac.uk
Accepted 25 July 2002
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366
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school and find a peer group. Children might have to pre-
maturely assume adult roles; for example, as a vital
language link with the outside world.
PSYCHOLOGICAL IMPLICATIONS OF
DISPLACEMENT FOR CHILDREN
There is considerable evidence that refugee children are at sig-
nificant risk of developing psychological disturbance as they
are subject to a number of risk factors. Table 1 provides a
framework for conceptualising these risk factors. Refugee
children suffer both from the effects of coming from a war
zone and of adjusting to an unfamiliar culture. These stressors
also affect their families.10 11 Moreover, consistent research
findings show that as the number of risk factors accumulates
for children, the likelihood that they will develop psychologi-
cal disturbance dramatically increases.12 In particular, Rutter
has shown the synergistic effects of multiple risk factors on
adverse child outcome.11
Studies of children in exile show that the prevalence of
emotional and behavioural disorders is high, with the most
frequent diagnostic categories being post-traumatic stress
disorder (PTSD), anxiety with sleep disorders, and depression.
The incidence of these disorders is difficult to estimate but
most studies have found significantly raised levels of
disturbance compared to control populations. For example,
studies of newly arrived refugee children show rates of anxi-
ety from 49% to 69%,13–17 with prevalence dramatically
increasing if at least one parent had been tortured or if fami-
lies have been separated. Table 2 lists common presenting
symptoms of the different disorders.18 Children, however,
often present with a mixture of the symptoms listed and not
necessarily fulfilling a single diagnostic category, for example
with a mixture of post-traumatic and depressive symptoma-
tology.
Cambodian refugees are the most widely studied group; in
a study of 46 children followed up over a number of years, 47%
had an Axis 1 diagnosis and comorbidity was common. In
particular this study found rates of PTSD at 40%, depression at
21%, and anxiety at 10%. Three years later, levels were still
high, with 48% manifesting PTSD and 41% depression. After
six years, PTSD was still prominent and a strong relation was
found between PTSD and later stressful events, suggesting
that the child is left more vulnerable to later traumatic
experiences.16 19–21
Some studies have attempted to identify protective factors
that enable children at high risk to be more resilient. These
include: (1) a supportive family milieu; (2) an external
societal agency that reinforces a child’s coping efforts; and (3)
a positive personality disposition.12 The response and function-
ing of a parent during and after stress can also have a
profound effect on child behaviour.22 Brown and Harris found
a greater vulnerability to depression in adults who lost a par-
ent in childhood, and that the key predictor of this vulnerabil-
ity was the quality of care giving the child received after the
loss itself.22a
In addition to the mental health needs of refugee children,
there have been studies that have highlighted considerable
physical health problems. A study of newly arrived refugee
children in New York showed that 30% had conditions that
required further medical attention.23 Anaemia, parasitic infec-
tions, and dental caries were the most frequently presenting
problems; in addition, 43% were positive for hepatitis B
surface antigen and 20% were found to be latently infected
with the tuberculosis bacterium. Another study in Sweden
found 15% of refugee children had iron deficiency anaemia.13
PRINCIPLES OF MENTAL HEALTH CARE
When planning for the mental health needs of refugee
children, two main areas need targeting: firstly, the provision
of appropriate help for those experiencing psychological diffi-
culties; and secondly, to pay attention to develop primary pre-
vention strategies to this high risk group.
Traumatic events can have an effect on a child’s emotional,
cognitive, and moral development because they influence the
child’s self perceptions and expectations of others. However,
finding appropriate ways to treat these problems is hampered
by the lack of reliable evidence for the effectiveness of clinical
therepeutic interventions with refugee children as most of the
research has been conducted following single traumatic
events (such as floods, single school shootings). Many refugee
children, however, have experienced prolonged and repeated
trauma.
The general consensus is that there is a need for a variety of
different treatments, including individual, family, group, and
school based interventions.24 25 Cognitive behavioural treat-
ment for single traumatic events has been used,26 27 and a
number of case series and single case studies have reported
good results for treatments including play, art, music therapy,
and story telling.6 24 27–29 Of added significance are the
post-traumatic symptoms of parents and the impact of these
on their capacity to parent.30
Table 1 Risk factors for mental health problems in
refugee children
Parental factors
Post-traumatic stress disorder (PTSD) in either parent49
Maternal depression24
Torture, especially in mother14
Death of or separation from parents24 50
Direct observation of the helplessness of parents12 14
Underestimation of stress levels in children by parents51
Unemployment of parents12
Child factors
Number of traumatic events—either experienced or witnessed52
Expressive language difficulties14
PTSD leading to long term vulnerability in stressful situations53
Physical health problems from either trauma or malnutrition54
Older age12
Environmental factors
Number of transitions36
Poverty6
Time taken for immigration status to be determined55
Cultural isolation24
Period of time in a refugee camp14
Time in host country (risk possibly increases with time)21
Table 2 Summary of common presenting symptoms
of psychological disorders in refugee children
Post-traumatic stress disorder
Persistent avoidance of stimuli: specific fears; fear of being alone;
withdrawal
Re-experiencing aspects of the trauma: nightmares; visual images;
feelings of fear and helplessness
Persistent symptoms of increased arousal: easily aroused;
disorganised and agitated behaviour; lack of concentration
Other anxiety symptoms
Marked anxiety and worry: irritability, restlessness
Other sleep disorders
Somatic symptoms including headaches and abdominal pain
Depression
Low mood
Loss of interest or pleasure
Declining school performance
Conduct disorders
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No studies have evaluated the benefit of group treatments,
however, based on evidence for groups in other circumstances,
it would appear that this may be a good way to help children
develop a sense of coping and mastery and sharing ways of
solving common problems.26 A number of children’s disorders
could be addressed directly; for example, many suffer from
depression and common sleep problems for which psycho-
therapeutic treatments and medication are available.31 32
Addressing the treatment needs of refugee children can
often seem overwhelming to those involved as they do not
easily fit with prescribed care packages28 and often require
working with many different professionals and agencies such
as interpreters, legal/immigration teams, voluntary organisa-
tions, ethnic support groups, social services, and schools. This
unavoidably requires more time and resources.27 33 Successful
programmes emphasise the role of cross-cultural teams who
can work in an extended outreach manner.27 Some pro-
grammes have also tried to integrate traditional healing
methods to try and enhance the effectiveness of treatment.29
Home based or school based work has advantages with fami-
lies who might have a lingering distrust of authority.
Importance of schools
A vital aspect of care for refugee children is in primary
prevention; schools are uniquely placed to undertake such
work. The goals of primary prevention can include enhancing
resilient behaviours in children; schools offer an excellent
framework for this, as well as monitoring of academic
progress, and behavioural and social adaptation.31 33 34 Schools
provide a place to learn, facilitate the development of peer
relationships, and help provide a sense of identity.35 36 In
particular, for refugee children, schools can play a vital part in
their integration by becoming an anchor, not only for
educational but also for social and emotional development,
and as an essential link with the local community for children
and parents. There is good evidence that a proportion of chil-
dren at high risk of developing long term psychological seque-
lae do however become competent young adults. One of the
key protective factors in influencing this outcome is the school
that acts as a stable social support.37 This support helps to
develop children’s resilience by enhancing their individual
competencies, in turn adding to their self worth and sense of
control over their environment.38
TENSIONS BETWEEN BRITISH IMMIGRATION LAW
AND THE BEST INTERESTS PRINCIPLE
The rights of asylum seeking children in the UK are limited.
When the UK government ratified the UN Convention on the
Rights of the Child in 1991, it entered a reservation in apply-
ing this legislation to refugee children “in so far as it relates to
the entry into, stay in, and departure from the UK on those
who do not have the right under the law of the UK to enter
and remain in the UK”.7 This reservation is one of the rare
areas of UK law concerning children where the best interests
principle does not play a part or where the protection of the
child is not the paramount concern.
The UK ranks ninth among European countries in terms of
asylum seekers per head of population.4 Statistics from the
year 2000 show that the largest numbers arriving in the UK
were from Iraq, Sri Lanka, the Federal Republic of Yugoslavia,
Iran, and Afghanistan. Less than one third of asylum applica-
tions were allowed to stay (for example, 11% were granted full
refugee status and 23% Exceptional Leave to Remain—a
status which is reviewed after five years).4 39
Since the influx of refugees into Britain significantly
increased following the Balkan conflict there have been four
major changes in UK National Immigration law in eight years.
The most recent change in the 2001–02 parliamentary session
has placed new emphasis on induction centres, accommoda-
tion centres, reporting centres, and rapid removals. The policy
of dispersing asylum seekers around the country will continue
and the number of places in detention centres will increase
fourfold.40
The thrust of these changes has been to deter non-political
refugees from entering Britain. Whether it has achieved this
Table 3 Possible impact of aspects of existing and imminent immigration law on the
mental health of refugee children
Policy aspects Description and background
Example of possible impact on
children
Dispersal Refers to a forced resettlement of
asylum seekers
If a refugee decides not to move they
then lose entitlement to benefits and
accommodation
Yet one more forced relocation for
children and moves children away
from a school they might have settled
in
Can be moved to an area without
important statutory and non-statutory
services
Accommodation centres New pilot policy to build three
accommodation centres for up to 750
asylum seekers to live until their status
is determined
Children for first six months to be
educated on these sites and away
from mainstream education
Reporting centres Centres to be set up throughout the
country, where refugees will have to
report in person at regular intervals
Adds to the uncertainty of the refugee
determination process and inability of
families to settle, as each reporting
time might imply sudden departure to
an unknown destination
Detention centres The government goal is to be able to
detain up to 4000 asylum seekers. In
2001, four new detention centres
were built, increasing the total in the
UK to eight
Detention of children under the age of
16 is against British law; however,
this is being increasingly ignored for
asylum seeking children
No statutory provision for those that
are detained
Tighter immigration controls Placing a fine on carriers
Improving border controls, e.g.
gamma scanners
Greater likelihood to turn to illegal
and/or dangerous means to enter the
country, and exposure to other forms
of abuse by traffickers
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objective is unclear; however, it is evident that it has made life
much “less welcoming” for those who have entered the coun-
try. The possible impact of these policies on children can be
substantial and needs to be carefully planned (see table 3). For
example, the government has stated that it is “committed to
removals and the use of dedicated detention facilities”, but
how this can be done humanely, especially when children are
involved, needs careful consideration. In fact, it may be that
such removals may infringe children’s rights.
When considering the impact of the dispersal system on
refugee children, this newer government policy may have fur-
ther aggravated their plight. The aim of this policy is to lift the
burden of numbers away from the southeast of England.
However, it disrupts the education and stability of children
who have been placed in local schools by forcing them to move
suddenly or risk losing any rights to future support. School
transition is a significant event for any child and can lead to a
decline in the perception of support from school41; frequent
relocation is associated with failing academic achievement
and behavioural difficulties.36 42 43
Unaccompanied children
A particularly vulnerable group of refugee children are those
who are “unaccompanied” and defined as “separated from
both parents and for whose care no person can be found who
by law or custom has primary responsibility”.7 8 The numbers
of unaccompanied c