The mental health plight of unaccompanied asylum-seeking children in detention.

Abstract

Children are at risk of physical and psychological injury due to the escalation of war and conflict across the globe. Consequently, children often become refugees with their families, or worse, alone as orphans. Asylum is sought across a diverse range of nations, sometimes close to home and sometimes far away in nations of different language and cultural identity to their own. Many nations impose incarceration in detention centres, and other interceptive immigration practices on asylum seekers (Dudley, Steel, Mares, & Newman, 2012). As refugees, they may then become forcefully displaced and detained as immigrants in a milieu that may be far from the safe, loving, nurturing environment they require for their development. Indeed, persistent symptoms of psychiatric disorders have been reported subsequent to resettlement (Marshall, Schell, Elliott, Berthold, & Chun, 2005), which highlights the protracted impacts of stress, loss, and trauma that face child asylum seekers. The challenges of refugees seeking protection from conflict and trauma looks set to continue with increasing numbers predicted in the times ahead. The United Nations High Commissioner for Refugees (UNHCR) reports 65.3 million people were displaced in 2015, compared with 59.5 million 12 months prior (Edwards, 2016). At the end of 2016, this figure had risen to 65.6 million of which 22.5 million were refugees (Edwards, 2017). Regardless of the conditions of detention, a detainees’ mental health is inevitably disturbed by the very act of being held—a common phenomenon experienced by refugees and asylum seekers held in detention (Puthoopparambil, Maina-Ahlberg, & Bjerneld, 2013). The psychophysiology of entrapment mobilizes the fear cascade, but leaving the individual immobilized, a state that is often associated with dissociation and disempowerment (Kozlowska, Walker, McLean, & Carrive, 2015). The sense of disempowerment that comes with detention means one experiences a loss of the ability to exercise control, make decisions independently, and take action. Experiences of trauma or terror can have an impact on this disempowerment which can have a further impact on the detainees’ well-being. Dissociation is also potentially pernicious, leading to a sense of disconnection between aspects of personal organization and impacting the sense of self (Meares, 2012) and requiring integration, an opportunity not available in ongoing unsafety. The picture of psychological impact of displacement on children remains unclear given that many may well have encountered extraordinary experiences prior to becoming refugees (Drury & Williams, 2012). Furthermore, adult refugees are a vulnerable population with reports of having an average of nine serious traumatic events including physical abuse and near-death experiences (Cleveland & Rousseau, 2013). Having escaped from such traumatic experiences to then be detained in an unfamiliar, unfriendly environment can only add to the demands on their physical and mental health resources of hope and resilience, which are further impacted by insecurity of finance, work and an insecure future. At the very least the establishment of safety and stabilization in which to process previous trauma is denied them. The risk of disabling mental illness from detention cannot be ignored in these children and moves us as mental health practitioners to act. Children often appear resilient but the impact of detention on their psychological being in relation to lifespan development, needs further exploration. The challenges are often not readily evident, as resilience does not mean the absence of post-traumatic stress disorder (PTSD) (Almedom & Glandon, 2007). Childhood is a formative period during which children are nurtured towards adulthood. Many complex variables play their part within the nature-nurture framework, and the literature on psychosocial impacts of detention on children has been increasing over the past decade (Drury & Williams, 2012; Fazel & Stein, 2002; Phillips & Lorimer, 2005). One question is whether there is a risk of children internalizing the challenges of their experiences, appearing resilient on the surface when they do not have the resources to deal with the impacts of displacement and detention. The thin veneer of such seemingly unaffected appearance by internalizing major challenges may lead to such responses as social withdrawal, negative affect, dissociative disorders and various physical symptoms (Regier, Kuhl, & Kupfer, 2013). In unnatural detention environments, the reduced capacity for parents to assume normal healthy parenting roles can compromise the essential need to build secure attachments with their children. Subsequently, parents who feel unsafe are more likely to transfer their own anxieties to their children and behave in emotionally unresponsive ways which impact the child's well-being (Kalverboer, Zijlstra, & Knorth, 2009). The development of insecure attachment styles could lead to potentially damaging traits, such as detachment, coupled with the challenges of PTSD possibly increasing future risks of delinquent behaviours (Akmal & Foong, 2018). In a longitudinal study to determine predictive outcomes of youths with different war experiences in Northern Uganda, Amone-P'Olak and Ovuga (2017, p. 1) reported the “witnessing of violence”, “deaths”, “threat to loved ones” and “sexual abuse”, all potentially disorganizing experiences, to be associated with conduct problems such as postconflict violence. The challenge is that some of the disorganizing effects of a parent's fear or overwhelm are unconsciously, rather than consciously transmitted to children, potentially impacting their developing personal organization (Hesse & Main, 2000). Amidst such consequences for mental health, one issue of concern is the silent voices of refugee children (Fazel & Stein, 2002). Increasingly, children are applying for asylum alone and remain trapped in a highly complex system that is deleterious to their developmental needs (Bhabha & Schmidt, 2008). One Norwegian study identified that among these unaccompanied children, most “experienced life threatening events (82%), physical abuse (78%), or loss of a close relative (78%) in their former life” (Jakobsen, Demott, & Heir, 2014, p. 53). Jakobsen et al. (2014) further point out that 41.9% of the unaccompanied adolescents fulfilled diagnostic criteria for a psychiatric disorder, the most prevalent being PTSD. As of the end of 2016, the UNHCR reported 75,000 asylum claims by children either travelling alone or separated from their parents (Edwards, 2017). Protecting the psychological development and health of these children becomes a greater challenge when there is a lack or loss of parental support due to war and civil strife, and thus absence of a parental figure to provide protection and advocacy (Llabre & Hadi, 2009; Masten & Narayan, 2012). The risk of exploitation, abuse and being misled by others in such desperate situations are alarmingly prevalent. The resilience and the power to recover in children depend on the basic human protective systems which derive from family support and the powerful attachments and bonds that are formed developmentally (Caffo & Belaise, 2003). To illustrate the sequelae of detachment, unaccompanied asylum-seeking children (UASC) have been found to be over-represented in inpatient psychiatric care in Sweden (Ramel, Taljemark, Lindgren, & Johansson, 2015), have a higher level of psychological symptoms, especially post-traumatic stress, and are particularly vulnerable due to the interplay between traumatic experiences and the loss of a primary carer (Sanchez-Cao, Kramer, & Hodes, 2013). PTSD symptoms experienced by UASC may not be raised as an issue, nor visible, and paradoxically good social function is often seen in refugee children, who suppress their trauma, and believe they are a product of their experiences that cannot be treated by any interventions (Sanchez-Cao et al., 2013). Unfortunately these coping mechanisms lead to unhealthy problems later in life as shown in a follow-up study of Cambodian refugee children who experienced war trauma, which found that PTSD remained prominent (Sack et al., 1993). Jakobsen, Meyer DeMott, Wentzel-Larsen, and Heir (2017) follow-up study of UASC from Afghanistan, Somalia, and Iran reported that adolescents experienced high levels of psychological distress upon arrival and their symptom levels remained unchanged over time. Furthermore, those placed in low-support facilities were found to experience higher levels of PTSD in the follow-up period of 15 months and 26 months compared with those placed with other youths. This is illustrated by elevated symptoms of psychological distress in cases where children are placed in centres for adults (Jakobsen et al., 2017). Children as a group have specific physical, behavioural, emotive, and cognitive needs for their development including from outside sources such as schools, neighbourhood and peer groups, sports clubs and other community resources. This becomes more significant when that child is unaccompanied by responsible adults who can advocate and care for the child during the trauma of displacement and detention. Refugee children remain a silent group that may be overlooked. Globally then, government bodies and communities need to turn their attention urgently to the mental health needs of this vulnerable population (Fazel & Stein, 2002). This response needs to include specific actions to address the mental health needs of these children, including expanded education of all nurses to understand the risks posed by displacement and detention for these children, and direct lobbying of government by health professional groups to ensure mental health is treated as a priority for asylum-seeking children. Improving Mental and Critical Care Health (MaCCH)—UTAS funding awarded under the UTAS Research Themes: Better Health Research Development Grant Scheme, supported by the Office of the Deputy Vice-Chancellor and FoH (C0025653). Authors declare that there is no conflict of interest.