Mental Health in children refugee of war (PTSD focused).

Mental Health in children refugee of war (PTSD focused).

Liliana Altamirano「愛麗利」

January 9, 2017
National Dong Hwa University

Abstract
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In this paper we will address the susceptibility of refugee children’s mental health, focusing on PTSD. Pre-migration and post-migration stressors often affect mental health of refugee children. Compared to other types of immigrants, refugee children are more susceptive to encounter problems associated with malnutrition, diseases, physical injuries, brain damage and may experience sexual or physical abuse. This can affect the child's cognitive, social and emotional development, leading to serious mental health issues including post-traumatic stress disorder (PTSD), anxiety and depression. We will initially look at an overview definition of the refugee status and further we will address the different characteristics of the social and psychological factors most affected in refugee children.

The 1951 United Nations Refugee Convention defines a refugee as “well-founded fear of being persecuted for reasons of race, religion, nationality, 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 the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it” (189 UNTS 137/ [1954] ATS 5).

Refugees in flight are frequently exposed to brutal death, traumatic effects of dangerous escape, violence, physical injury, mutilation, rape, malnutrition, loss of friends, home and their community, as well as bereavement associated with the loss of loved ones.

Studies of war refugee children and their families have revealed a spectrum of psychiatric disorders including PTSD, mood disorders, the spectrum of anxiety reactions, disruptive behaviors, and somatoform disorders (Shaw, 2003 p. 240).

Exile for these refugees was associated with temporary sorting camps, living in barracks, crowded conditions, and culture shock. Refugee status in a new country is frequently associated with separation from loved ones, the loss of language and customs, xenophobia, poverty, and downward social and professional mobility.

Estimates

Approximately 80–90% of all victims of warfare today are civilians, women and children. It is estimated that there are approximately 22 million refugees throughout the world, half of that population are children and an additional 20–25 million are internally displaced persons living in their own countries but unable to return to their homes  (Shaw, et al., 2003). 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 (Fazel & Stein, 2002 p. 366).

A particularly vulnerable group of refugee children are those who are “unaccompanied” which is defined as “separated from both parents and for whose care no person can be found who by law or custom has primary responsibility”. The numbers of unaccompanied children are rising significantly in Western countries and are estimated to comprise 2–5% of any refugee population. At any one time there may be up to 100 000 separated children in Western Europe alone. Their vulnerabilities are not only because they are bereft of support systems such as family and often community life, but also because they are at increased risk of neglect, sexual assault, and other abuses (Fazel, et al., 2002). Those children may display more behaviour problems and emotional distress than refugee children with caretakers. Parental wellbeing plays a crucial role in enabling resettled refugees to transition into a new society so it’s for that if a child is separated from his/her caretakers during the resettlement process, there is an increased likelihood that he/she develops a mental illness.

The smuggling of children across borders has become a growing international concern. Children can be exposed to potential abuse and exploitation en route or in the country of destination. The children often arrive with false documents or with no papers at all. Many are unwilling or unable to tell their age. Relatively few separated children applying for asylum are awarded refugee status; the average recognition rate in 1999 for Europe was around 5% (Fazel, et al., 2002). Other might have temporary protection as they are granted with asylum until they become 18 years old, and as this may mean while provide the child with temporal safety, it also leaves the child with uncertainties about his/her future that can be emotionally demanding as well as having significant consequences while trying to reintegrate into the refuge country community.

One case example is in Syria. The United Nations through UNICEF estimates from September 2015, 82% of Syria’s population lives in poverty; malnutrition among children and pregnant women is rife.

There are more refugees coming out of Syria than any other nation. Estimates from September 2015 suggest that just over 2 million children have fled Syria and are living as refugees in neighboring countries in the Middle East, or North Africa; nearly 11 000 children crossed the Syrian border on their own, and more than 140 000 were born as refugees.

In 2014, two-thirds of Syrian refugees in Jordan, and half of Syrian refugees in Lebanon, lived below the national poverty line. Later on by July 2015, this share had risen to 70% in Lebanon (Sirin, Selcuk and Rogers-Sirin, 2015). The United Nations and charity organizations provide humanitarian assistance in with food, shelter, and medical aid, but the surpassing numbers of refugees and insufficient funding make it difficult to meet even the most urgent needs. Nonetheless, in the midst of deteriorating conditions in countries of first asylum, growing numbers of Syrians have attempted to find protection outside refugee camp regions. And though many countries have increased the number of refugees they will accept through resettlement, family reunification, emergency scholarship, and humanitarian admission programs, demand better supply.

Until October 2, 2015 still thousands await for resettlement. However, 130 408 resettlement places had been made available to Syrians worldwide.

Impact of war-related traumas at the developmental stage in childhood

War-related traumas are diverse, cumulate over time, affect the family and social infrastructure, and may have immediate and enduring psychological effects on children, a spectrum of secondary stressors in the aftermath of war, which continue to impact on the child and his family (i.e., economic–social disruption, separation from loved ones, malnutrition, and illness).

However, when trying to understand how war affects a child’s life, we have to ask how old is he or she. His/her developmental stage determines what the child is doing, thinking and feeling when facing danger and threat. Activity, coping strategies, understanding of traumatic events, and delineating one’s own and others’ emotions follow specific developmental paths (Punamäki, 2002 p.181).

War and violence compromise child development by interfering with the smooth transition from an earlier developmental stage to the next. Literature presents, however, opposing views about the direction of the impact. On the one hand, according to the classic observation by Freud and Burlingham (1943) children are at risk of losing previously acquired developmental skills, and regressing to less mature behavioural modes. For instance, traumatized adolescents may excessively cling to their parents and preschoolers lose newly acquired speech abilities. On the other hand, ‘war children’ are described as growing up too fast and losing childhood too early. War conditions forces them to protect their family members and to solve serious moral and emotional conflicts before their ample maturation. The earlier in life a trauma occurs, the more severe the psychiatric consequences (Punamäki, et al., 2002). As for how children cope with trauma and stress, some people will say that because they are less cognitively developed, their capacity to remember, understand and process trauma would lessen, however a meta-analysis by Fletcher (1996) resulted in no differences across developmental stages and PTSD. Table 1 expresses the differences across developmental ages of a child and the traumatic impact on emotional, cognitive and behavioural development.

Among those children exposed to war-related stressors, it is generally estimated that the prevalence of posttraumatic stress symptomatology varies from 10 to 90%, manifested by anxiety disorders such as posttraumatic stress disorder and other psychiatric morbidities including depression, disruptive behaviors, and somatic symptoms. War-related traumas vary enormously in their intensity, from exposure to brutal death and witnessing of explosive-violent acts, to the derivative effects of war such as displacement, relocation, sickness, loss of loved ones, and starvation (Shaw, et al., 2003).

Highlighting that there are different types of war related trauma, some children may be continuously exposed to low intensity violence; for example, those who live in communities where drug cartels are in a constant battle of power, leading to high numbers of deaths and violent strikes in public places. Children are not directly affected by it but are rather informed through mouth-to-mouth, family, peers, or news media about such violent facts, habituating themselves to low intensity war-related experiences. Nonetheless, habituation can be altered with sudden exposure to increased intensity experiences of war-related stressors like terrorism and civil wars where their psychological response is heightened with increasing morbidity.

Refugee children can suffer from physical trauma and mental trauma due to prolonged confrontation with violence. 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 (Mental health of refugee children, 2016, June 3).

Psychopathology

The biological impact of war-related traumas is directly related to the intensity, duration, and the impact of the stressors on bodily integrity, the stress response system and/or its interference with life sustaining support systems. It is known that exposure to intense acute and chronic stressors during the developmental years has enduring neurobiological effects vis-a`-vis the stress response and neurotransmitter systems with subsequent increased risk of anxiety and mood disorders, aggressive dyscontrol problems, hypoimmune dysfunction, medical morbidity, structural changes in the CNS, and early death (Shaw, et al., 2003).

Children who are exposed to war and violence are at high risk of suffering for mental health problems. Research on refugee children identifies posttraumatic stress disorder (PTSD) as the most common psychological issue, followed by anxiety and depression. Refugee children also tend to have higher levels of behavioral or emotional problems, including aggression and other affective disorders.

The onset of these mental health problems can have long-term negative consequences for children. Children who suffer from PTSD or depression, or exhibit difficult behaviors, must find ways to cope with their symptoms while living in refugee camps, a setting that provides little, if any, support to address such problems, which furthermore are intensified when caring adults (parents or others) are missing from the lives of refugee children, perhaps because they have died or been left behind.

For example, studies of newly arrived refugee children show rates of anxiety from 49% to 69%, with prevalence dramatically increasing if at least one parent had been tortured or if families have been separated. 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 this study were 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 (Fazel & Stein, et al., 2002).

Adults who lost a parent in childhood present a greater vulnerability for depression. A key predictor for such vulnerability is the quality of care giving the child received after the loss itself.

Individuals with mental health problems require more resources in school but long-term effects can limit their educational performance and employability attainment, as they grow older. Additionally, girls represent a higher risk when they do not enroll in school as they may become targets for sexual assault, sexual exploitation, and early marriage; factors which may also contribute to developing depression, PTSD and other mental health disorders.

Personality and temperament: Key factors for prevention of children’s mental health disorders

Different factors predict symptoms in an acute trauma and chronic PTSD. Child temperament that combines biological resilience and vulnerability factors with developmental interactions may explain some of the differences in the course of posttraumatic reactions. Children differ from a very early age in valence and intensity of mood and emotional expression, threshold for pain, need for rhythm and regularity and tolerance for excitement, as well as distractibility, activity and novelty seeking. Temperament involves behavioral and emotional characteristics that are constitutional and stable over time, have neuropsychological underpinnings, and are to some degree inherited.

Research on resiliency has revealed some temperamental and other personality characteristic that may explain why some children blossom despite adversities and trauma. The protective characteristics include activity, curiosity (involving novelty seeking) and creativity and mental flexibility. Sociability, involving cooperativeness, extraversion and need for affiliation, may also be protective because it facilitates social support that is crucial in traumatic stress.

We may hypothesize that some temperamental dimensions are especially salient in the course of posttraumatic distress: threshold for pain and pleasure, valence and intensity of fear, sadness and anger, emotional arousal and regulation, and novelty seeking behavior.

Through observations of Middle Eastern mother-child dyads in dangerous situations such as night raids and curfew gathering of information indicated that small children differed greatly in the speed and acceleration of emotional arousal, the intensity of fear, and how easily mothers can calm them down and soothe their distress. It seems that children who show curiosity, activity and novelty seeking tendency tolerate more stress, compared to children who need regularity and show a low threshold for stimuli. The goodness-of-fit between personality and environment seem to be decisive for child endurance even in a highly traumatic situation (Punamäki, et al., 2002).

Temperamental differences reflect a child’s capacity for self-modulation, general arousal of the motor and emotional system, attention persistency, recovery time from distress, and ability to tolerate and deal with negative emotions. Such mechanisms contribute to the different ways in which children perceive and evaluate danger, and how they process emotions as well as how they cope with losses and violence (Punamäki, et al., 2002).

How can Psychology make contributions?

Addressing the treatment needs of refugee children can often seem overwhelming to those involved as they do not easily fit with prescribed care packages and often require working with many different professionals and agencies such as interpreters, legal/immigration teams, voluntary organizations, ethnic support groups, social services, and schools. This unavoidably requires more time and resources. Successful programmes emphasize the role of cross-cultural teams who can work in an extended outreach manner. There is a need for a variety of different treatments, including individual, family, group, and school based interventions.

Interventions should thus be tailored to meet the vulnerabilities and strength of secure and insecure children, and consider the goodness of fit between environment and temperament. In war, conditions where thousands of children are in need for psychosocial first aid and enhancement of self help, consideration of personality factors may sound superfluous. Yet, knowledge about them is essential in tailoring effective interventions. For instance, it is not meaningful to encourage behaviorally active coping strategies or feeling ventilation among insecure-ambivalent children, who rather, would benefit from cognitive reframing and regulating of emotions (Punamäki, et al., 2002)

Conclusion and personal comments

This paper allowed me to deepen my understanding about mental health in children and more specifically, the effects of war-related trauma. Sadly, war is an ongoing situation today, it is taking place in several countries around the world and threatens to escalate to others. PTSD irrupts in the well being and social functioning of refugee children of war, unconsciously developing in the moment previous to flight that is while in their home country, during flight while living in camps or unstable places, and after, when settling into a different country. This may contribute to develop other psychiatric disorders that may influence when trying to reintegrate into a new community (i.e. refuge country) for example, in school or at work. Psychology however, in joint efforts with other health and medical fields can help reduce the risks.

I urge others to make further contributions in this field. First of all, as human beings, and second, as professionals aware of the devastating consequences of warfare that alter not only a child’s mental health state but also whole communities. Exhaustive research is need to be done to help us better understand the different spectrums of this phenomena, and the morbidity that comes along with such events, also, so that better programs of prevention and more accurate intervention techniques to address the mental health of refugees are developed; capable of meeting the needs of those who unwillingly meet such emergency situations and for which children are most vulnerable among them.

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Appendix

Note: Retrieved from The Uninvited Guest of War Enters Childhood: Developmental and Personality Aspects of War and Military Violence by Punamäki, Raija-Leena. Copyright 2002. Reprinted with permission.

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References

Fazel, M., Stein, A. Arch Dis Child (2002) 87: 366-370
doi:10.1136/adc.87.5.366

Mental health of refugee children. (2016, June 3). In Wikipedia, The Free Encyclopedia. Retrieved 10:25, January 7, 2017, from https://en.wikipedia.org/w/index.php?title=Mental_health_of_refugee_children&oldid=723525064

Punamäki, Raija-Leena. (2002). The Uninvited Guest of War Enters Childhood: Developmental and Personality Aspects of War and Military Violence. Traumatology, 8 (3), 181-204.
doi: 10.1177/153476560200800305

Punamäki, Raija-Leena. (2002). The Uninvited Guest of War Enters Childhood: Developmental and Personality Aspects of War and Military Violence. Traumatology, 8 (3), 181-204. [Table 1]
doi: 10.1177/153476560200800305

Shaw, J.A. Clin Child Fam Psychol Rev (2003) 6: 237. doi:10.1023/B:CCFP.0000006291.10180.bd

Sirin, Selcuk R. and Lauren Rogers-Sirin. (2015). The Educational and Mental Health Needs of Syrian Refugee Children. Washington, DC: Migration Policy Institute.

United Nations 1951 Convention Relating to the Status of Refugees art. 1, para. 2.