Refugee Minors Research Articles

Refugee Minors’ Perspectives Explored with the Bridge Drawing and Children’s Hope Scale

AbstractMoving from one’s home country to a foreign country due to unforeseen circumstances such as war and unrest is a distressing life event. For minors, such an experience can impact their perception of the past and present alongside future goals and desires. With this background, a pilot study was done to assess the life transition reflected in the Bridge Drawing Test (BDT) of refugee minors who have moved from either Ukraine or Eritrea and are currently living in Israel, with a control group. A mixed-methods design involving BDT and the Children’s Hope Scale (CHS) was administered to a sample (N = 35, 20 girls and 15 boys) consisting of 16 refugee minors and 19 controls aged 4 to 14 years (M = 8.3 years, SD = 2.8). The BDT was assessed using indicators from the original bridge drawing directive and the Formal Elements Art Therapy Scale (FEATS) by two Art Therapists (Cohen’s Kappa ranged from 0.6 to 1). Results showed significant group differences in indicators: Prominence of colour, details of objects and environment, obviousness of Solidarity of bridge attachments and high versus low hope from the BDT (Medium effect size & p < .05). Associations between Pathway and Agency with BDT indicator and FEATS were seen. Refugee status also moderated the relationship between the CHS Total score and the subscale of Pathway and BDT indicator, namely Directionality (p = .01 & p = .02). Bridge drawings of refugee minors have differences that can aid in understanding their hope and goals, offering benefits as a diagnostic and therapeutic intervention tool. Future studies with larger samples, and diverse cultural groups are warranted to explore the same.

Health assessments of refugee minors arriving in Norway – a modified Delphi study among health professionals in primary care settings

BackgroundRefugee minors are considered particularly vulnerable to negative health consequences from war, flight and resettlement. Offering health assessments after arrival in a host country could uncover unmet health needs and provide access to treatment. In Norway, a national guide describes these assessments, but little is known about its implementation especially for refugee minors. Thus, the aim of this study was first to explore how health assessments of refugee minors are carried out, second how health professionals perceive the needs of refugee minors and third, the competencies they perceive as necessary to meet the needs of refugee minors.MethodA modified Delphi study in three rounds was conducted using online surveys and one focus group to collect data on the needs and resources of refugee minors, essential factors for a good and health assessment practice. Participants were 54 health professionals responsible for early health assessments of refugee minors, throughout the Norwegian municipalities, working in primary care settings. Quantitative data was analysed descriptively, and qualitative data with content analysis.ResultsHealth assessments of refugee minors were predominantly conducted by public health nurses, but the organisational structures surrounding assessments varied greatly according to the size of the municipalities and to how much resources were allocated. The feeling of safety was found to be paramount to ensure a good start in a new country for refugee minors. The top four competences professionals should have, were ‘general communication skills’, a ‘health professional background’, ‘expertise in children’s health’ and ‘knowledge about the national guide’. To ensure good health services for refugee minors, improved, more comprehensive, and mandatory directives for children and young individuals was highlighted.ConclusionAlthough most refugee minors were invited and attend health assessments, one third of participating municipalities did not offer health assessments to all newcomers and the organisation and content of the assessments were diverse. Several topics, especially mental health, were postponed or not routinely addressed, contrasting with current knowledge of unmet health needs for this group. Missing documentation, practical barriers and providing general health information took time away from doing the actual assessments. The perceived needs of refugee minors were safety and stability, combined with meaningful activities, thus a coordinated effort from several services is necessary. Suggestions for improvements were more time given to assessments, better organisation and co-operation, improved competence and guidelines adjusted for age.

Examining psychological flexibility in unaccompanied refugee minors: A network analysis

BackgroundRefugees, particularly unaccompanied refugee minors (URM), often report poor mental health. Psychological Flexibility (PF), derived from Acceptance and Commitment Therapy (ACT), appears to positively impact mental health in various populations, including adolescents and refugees. ObjectivesThis study aimed to examine the structure of the PF model and the connections among its core processes, as well as the structure and connections between mental health constructs (i.e., post-traumatic stress, depression, anxiety, stress, quality of life) and PF in URM. Methods100 URM aged 13–18 years living in shelters in the Republic of Cyprus completed four self-reports, assessing depression, anxiety, and stress (DASS-21), PF (Psy-Flex), PTSD (CRIES-13), and HRQL (KIDSCREEN-10). Network Analysis was used to examine the structure and connections of the constructs. ResultsMost core PF processes showed positive connections amongst each other, with the strongest edge between committed action and values. Together with self as context, these core processes exhibited the highest expected influence. The strongest positive connections in the mental health network were found among stress, anxiety, and depression. Stress had the highest expected influence, whereas PF had the lowest. A post hoc Johnson-Neyman analysis suggested a buffering effect of PF on the impact of PTSD on anxiety and stress. ConclusionsProposed areas of focus for clinicians working with URM include incorporating strategies that address stress symptoms and facilitate individuals in pursuing value-based behavior. It is equally important to encourage critical reflection on values and the conceptualized self in the context of culture.

Mental health disparities of sexual minority refugees and asylum seekers: Provider perspectives on trauma exposure, symptom presentation, and treatment approach.

Refugees and asylum seekers who identify as sexual minorities and/or who have been persecuted for same-sex acts maneuver through multiple oppressive systems at all stages of migration. Sexual minority refugees and asylum seekers (SM RAS) report experiencing a greater number of persecutory experiences and worse mental health symptoms than refugees and asylum seekers persecuted for reasons other than their sexual orientation (non-SM RAS). SM RAS are growing in numbers, report a need and desire for mental health treatment, and are often referred to therapy during the asylum process. However, little research has been conducted on the treatment needs of SM RAS in therapy or the strategies therapists use to address these needs. This study sought to identify these factors through qualitative interviews with providers at a specialty refugee mental health clinic (N = 11), who had experience treating both SM RAS and non-SM RAS. Interviews were transcribed and coded for themes of similarities and differences between SM RAS and non-SM RAS observed during treatment and factors that could be leveraged to reduce mental health disparities between SM RAS and non-SM RAS. Clinicians reported that compared to the non-SM RAS, SM RAS reported greater childhood trauma exposure, increased isolation, decreased support, identity-related shame, difficulty trusting others, and continued discrimination due to their SM identitiy. Suggested adaptations included reducing isolation, preparing for ongoing identity-based challenges, creating safe spaces to express SM identity, and a slower treatment pace. Providers reported benefits and drawbacks to centering the client's SM identity in treatment and encouraging community involvement for SM RAS, and noted additional training in cultural awareness would be beneficial. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Conducting Research with Unaccompanied Refugee Minors within an Institutional Context: Challenges and Insights

The main goal of this paper is to explore the difficulties the refugee minors face in the process of seeking inclusion in Portugal. The project conducting this research takes place in a shelter for refugee minors in Portugal, and its inhabitants are the main focus of the analysis. The research is guided by Applied Anthropology which means that, in methodological terms, we use active listening, participant observation, and artistic workshops in drawing and photography in order to get to know them better and establish a closer relationship with the minors. Our interlocutors are refugee minors, boys and girls, aged between 15 and 18, who have been institutionalized by an NGOD responsible for hosting them in Portugal while they await their residence permit. These minors are characterized by a diversity of nationalities, socio-cultural and ethnolinguistic references and different life projects. The artistic focus (drawing and photography) is explored as a non-invasive methodology, a tool that best helps to express emotions, perceptions and desires in a creative and uncompromising way. We chose to focus our analysis not on the traumatic past, as is usually the case when it comes to refugees, but on the future. In other words: we invite these minors to think about their future, what they want for themselves in Portugal and the European Union. As we discuss our difficulties of conducting fieldwork in the institutionalized context, we conclude the article with the idea that working with refugee minors in that environment should not be an end in and of itself, but rather an opportunity to do more profound research. This investigation should continue, preferably outside the institutional gates, on a more personalized basis. As a practical goal, we also propose the idea of organizing an exhibition with the results of the workshops to facilitate the two-way process of inclusion.

The effect of successful educational actions in transition from primary to secondary school.

While data show improvement in terms of educational access, dropout rates are significant in many countries. In Spain, 28% of students drop out of school without finishing secondary school, more than double the EU average. Thus, extensive research has shown the consequences of the dropout phenomenon, including negative effects on employment, welfare dependency, as well as health and emotional problems. The transition from primary to secondary education is a critical turning point. This situation worsens in the case of refugee and migrant minors who are refugees or with migrant backgrounds. Although there is strong evidence revealing the potential of SEAs to advance educational success for all in different contexts, no research has yet explored the effect of SEAs on enabling a successful transition from primary to secondary education, which could considerably impact decreasing dropout rates. Drawing on a qualitative case study of a secondary educational centre in Spain, this study analyses the impact of the implementation of three SEAs in key aspects related to primary-secondary transitions. Findings show how the systematic implementation of SEAs impacts the ease of the primary-secondary transition: positive relationships between the educational community are promoted, school connectedness across transition is strengthened, and academic support networks are enhanced. The study therefore suggests the benefits of SEAs as strategies that can enhance positive primary-secondary school transitions in terms of students' perception of belongingness, and academic performance.

Psychometric properties of the Children’s Revised Impact of Event Scale (CRIES-8) among refugee adolescents from Afghanistan, Syria, and Somalia

ABSTRACT Background: High levels of post-traumatic stress are well documented among refugees. Yet, refugee adolescents display high heterogeneity in their type of trauma and symptom levels. Objective: Following the recurrent plea for validated trauma screening tools, this study investigated the psychometric properties of the Children’s Revised Impact of Event Scale (CRIES-8) among refugee adolescents from Afghanistan (n = 148), Syria (n = 234), and Somalia (n = 175) living in Europe. Method: The model fit for the confirmatory factor structures was tested, as well as measurement invariance between the three groups. The robustness of results was evaluated by testing measurement invariance between recently arrived and settled adolescents, and between different response labelling options. Reliability (α, ω, and ordinal α), criterion validity, and prevalence estimates were calculated. Results: The intrusion subscale showed a better stable model fit than the avoidance subscale, but the two-factor structure was mainly supported. Configural measurement invariance was achieved between Afghan and Somali adolescents, and strong measurement invariance between Syrian and Somali adolescents. The results were robust considering the time living in the host country and response labelling styles. Reliability was low among Afghan and Syrian adolescents (.717−.856), whereas it was higher among Somali adolescents (.831−.887). The total score had medium-sized correlations with emotional problems (.303−.418) and low correlations with hyperactivity (.077−.155). There were statistically significant differences in symptom prevalence: Afghan adolescents had higher prevalence (55.5%) than Syrian (42.8%) and Somali (37%) adolescents, and unaccompanied refugee minors had higher symptom prevalence (63.5%) than accompanied adolescents (40.7%). Conclusions: This study mostly supports the use of the CRIES-8 among adolescents from Afghanistan, Syria, and Somalia, and even comparative analyses of group means. Variation in reliability estimates, however, makes diagnostic predictions difficult, as the risk of misclassification is high.

Perspectives of refugee parents and unaccompanied minors on initial health assessment and access to care

To explore the needs, expectations, and experiences of asylum-seeking parents and unaccompanied minors under the age of 18 years on the initial health assessment for children and adolescents and access to care upon entry in the Netherlands, We conducted five semi-structured focus group discussions with asylum-seeking parents and unaccompanied minors, from Syria, Eritrea, Afghanistan, and other Middle-East and African countries, supported by professional interpreters. To triangulate findings, semi-structured interviews with health care professionals involved in care for refugee children were conducted. Transcripts of focus group discussions were inductively and deductively coded and content analyzed; transcripts of interviews were deductively coded and content analyzed. In total, 31 asylum-seeking participants: 23 parents of 101 children (between 0 and 18 years old), 8 unaccompanied minors (between 15 and 17 years), and 6 healthcare professionals participated. Parents and minors expressed that upon entry, their needs were met for vaccinations, but not for screening or care for physical and mental health problems. Parents, minors, and health professionals emphasized the necessity of appropriate information and education about health, diseases, and the health system. Cultural change was mentioned as stressful for the parent–child interaction and parental well-being. Conclusion: The perspectives of refugee parents and unaccompanied minors revealed opportunities to improve the experience of and access to health care of refugees entering the Netherlands, especially risk-specific screening and more adequate education about health, diseases, and the Dutch health care system.What is Known:• Refugees have specific health needs due to pre-flight, flight, and resettlement conditions. Health assessment upon entry was non-obligatory in the Netherlands, except for the tuberculosis screening. Health needs were not always met, and refugees experienced barriers in access to care.What is New:• The initial health assessment met the needs concerning vaccinations but mismatched the needs regarding physical and mental health assessment. Screening for specific risk-related diseases and mental health could enable refugee parents and minors to engage better with the health system.

Theoretical framework of the integration and well-being of migrant and refugee minors in Europe

Migrant and refugee children face specific challenges that strongly affect their well-being during the integration process in host societies. The institutions and entities in the field dedicated to childhood and migration remark the need to better nuance the factors involved in fostering migrant and refugee children’s well-being, leaning upon researchers to obtain a more accurate portrayal of these childhood experiences. After carrying out a critical narrative review of current models of child well-being and integration, a child-centred analytical frame linking conceptual contributions from both bodies of literature is provided. Upon this basis, a comprehensive theoretical framework that encompasses ecological theory, the new sociology of childhood and interculturalism is discussed thoroughly, with its application in specialised research on this population. These results should be useful for impact policy-making and develop evidence-based psychosocial interventions for migrant and refugee children in Europe.

The impact of the COVID-19 measures on the lives of unaccompanied refugee minors

Background:Recent research found that the COVID-19 pandemic and the measures to contain it had a largely negative impact on well-being. In addition, a vast number of studies have shown significantly increased levels of traumatization and behavioural problems amongst URM, pointing out the vulnerability of this population. This study aimed at evaluating both the adaptive functioning and life satisfaction of URM, as well as the impact of the COVID-19 pandemic on life satisfaction. Methods:101 URM completed the questionnaires. Results: URM had higher levels of trauma symptoms (t(100) = 8.69; p < .001) and more behavioural problems (t(100) = 6.83; p < .001) as compared to Belgian peers. Nevertheless, we did find higher levels of resilience (t(100) = 2.33; p < .05) amongst our sample. In addition, the COVID-19 pandemic negatively impacted both experiences and satisfaction across all life domains. Conclusions: These findings all point out that the development of URM is at risk even after arrival in the host country and that the likelihood of mental health problems is high also in the host country. Offering professional mental healthcare and facilitating social bonds and integration is important. In addition, given the negative impact of the COVID-19 pandemic on wellbeing, extra attention and support should go out to more vulnerable populations, such as URM, during times of (inter)national crisis.

Agency in Silence: The Case of Unaccompanied Eritrean Refugee Minors in the Netherlands

Following the so‐called refugee crisis, unaccompanied refugee minors (URMs) from Eritrea were portrayed negatively in Europe. Although such portrayals are often amplified by media and policy discourses, the main reasons for this negative view were a lack of understanding of URMs’ subjectivities, the institutional silencing process they face in their everyday lives, and the ways they show agency in such precarity. This article addresses institutional silencing practices that Eritrean URMs encounter and the various ways they engage with them. Using data gathered during 2016–2018 from Eritrean URMs in the Netherlands, we explore how participants navigate the exclusionary processes they encounter in relation to institutions, such as refugee reception centres, refugee protection organizations, immigration authorities, and schools. Inspired by Sherry Ortner’s and Saba Mahmood’s work, we show the importance of less dominant forms of agency (delayed or docile forms) in how URMs engage with the power of institutional silencing practices. We then show the (often unseen) agency of these young people as the desire of the “less powerful” or “less resourceful” to “play their own serious games even as more powerful parties seek to devalue and even destroy them” (Ortner, 2006, p. 147).

Developing a Collaborative Approach to Support Access and Acceptability of Mental Health Care for Refugee Youth: An Exploratory Case Study with Young Afghan Refugees.

Despite an increased prevalence of psychiatric morbidity, minor refugees resettled in Western host societies are less likely to access mental health care services than their native peers. This study aims to explore how a collaborative approach can be implemented to promote access to specialized mental health care. Collaborative mental health care embeds specialized intervention in primary care settings and emphasizes the inclusion of minority cultural perspectives through an interdisciplinary, intersectoral network. In this study, we analyze how such a collaborative approach can support access to specialized mental health care for refugee youth. The study presents findings from a qualitative multiple-case study (n = 10 refugee patients), conducted in the setting of a psychiatric day program for young refugees that develops an intersectional, collaborative practice in supporting minor refugees' trajectory from referral to admission. Building on in-depth interviews, participant observation and case documents, within-case analysis and cross-case inductive thematic analysis identify the specific working mechanisms of a collaborative approach. The results indicate how this intersectoral approach addresses the interplay between traumatic suffering and both cultural and structural determinants of mental health. To conclude, a discussion identifies future research directions that may further strengthen the role of collaborative practice in promoting mental health care access for refugee youth.

During the chaos of war: US adoptions and risks for unaccompanied Ukrainian refugee children

The adoption of Ukrainian children, by US citizens, is examined as the Ukrainian government ceases adoptions of children during the chaos of war. Intercountry adoption dynamics are presented with data from 2021, prior to the conflict in 2022. Then, the situation regarding child rights and the official Ukrainian government position are considered. Implications for guardianship and foster care of unaccompanied refugee minors are presented along with other critical risks to Ukrainian children living in another country. Implications for social work practice are concluded and child rights advocacy is encouraged as a macro intervention.

Protective factors associated with resilience among unaccompanied refugee minors after settling in Norway: a matched cross-sectional study

This study aimed to examine protective factors associated with resilience among unaccompanied refugee minors in comparison to their Norwegian peers and to examine associations between resilience factors and characteristics related to positive outcomes among unaccompanied minors. Data stem from the Pathways to Independence study conducted in Bergen municipality, Norway in 2018–2019 where 81 unaccompanied minors aged 15–20 participated (83.3% male; 80% response rate). An age- and sex-matched control group of 324 adolescents was retrieved from the youth@hordaland study conducted in Norway in 2012. Resilience factors were assessed by the Resilience Scale for Adolescents. Unaccompanied minors reported lower scores on Goal Orientation (d = 0.4), Social Competence (d = 0.4), and Social Support (d = 0.7) compared to Norwegian adolescents. Being male was associated with lower scores on Goal Orientation (standardized mean difference [SMD] = − 0.9) and Social Support (SMD = − 0.9) among unaccompanied minors, while being in frequent contact with family in the home country was associated with higher scores on all resilience factors (SMD range = 0.6–1.1). The number of leisure activities was associated with Social Competence (SMD = 0.22). There were no significant associations between the resilience factors and amount of support in the living arrangements or contact with the child welfare services. Unaccompanied minors reported fewer resilience factors compared to Norwegian adolescents, indicating that they may have different needs compared to other adolescents. Our study also suggests that frequent contact with family in the home country may be important to bolster positive development for unaccompanied minors after settlement.

(Nanny) State as family by proxy

In this article, we extend the boundaries of research on family language policy (FLP) by addressing the situation that occurs when the State takes over the care of unaccompanied minor refugees and asylum-seekers, thereby assuming by proxy the responsibilities normally assigned to families. We analyse media discourses involving unaccompanied minors (UMs) in Norway, a Scandinavian country perceived as having liberal policies, in a corpus of 30 articles published between 2016 and 2017, a significant period of immigration in a European context. Our analysis reveals a polarized debate around these children, often termed anchor children, who allegedly aim for future biological family reunification. Assuming the family role as proxy, Norway is referred to as a Nanny State, making decisions for the UMs regarding their well-being, education and language learning. Engaging with recent calls for decolonizing and southernizing critical discourse studies (CDS), we anchor our analysis onto decoloniality. We argue that this epistemological move allows us to identify opposing understandings of culture undergirding two competing sides in debates about UMs in Norway. The study has both theoretical and methodological implications for future conceptualizations of the family in FLP research.

Special Proceedings and Alternatives to Detention for Migrant and Refugee Children

The Author presented an analysis of the procedures and alternatives to the detention of migrating and refugee children in the Polish legal system, significantly influenced by European Union law. The Author pointed out legal solutions within the Polish legal system entangled with international law. It was emphasized that the continued use of child detention contradicts commitments made in international and regional legal instruments aimed at eliminating this practice. Detaining children can have serious negative consequences for their physical and mental health; therefore, alternatives to detention should be considered. Attention was drawn to the necessity of interpreting and applying Polish law in accordance with international human rights standards, including the principle of the best interests of the child to ensure the safety and protection of minor migrants and refugees.

Life Satisfaction among Unaccompanied Refugee Minors: Associations with Traumatic Events and Daily Hassles

While there is a growing literature about mental health problems among unaccompanied asylum-seeking and refugee minors (URMs), far less is known about their wellbeing. Such information is important as a subjective sense of wellbeing is associated with a variety of positive health and psychosocial outcomes. The aim of this study was to examine life satisfaction and the association with traumatic events, daily hassles, and asylum status among URMs in Norway. We collected self-report questionnaire data from URMs living in Norway (n = 173, 90.80% male, 71.1% from Afghanistan). Mean age was 16.62 (SD = 1.74) years, and they reported clinically relevant post-traumatic stress symptoms. We explored variation in life satisfaction, URM-specific daily hassles and traumatic events. We also investigated a mediation model, in which we assumed that daily hassles mediated the association between traumatic events and life satisfaction. The participants reported low life satisfaction (M = 4.28, SD = 2.90, 0–10 scale). A negative outcome of the asylum process and URM-specific daily hassles were associated with reduced life satisfaction. URM-specific daily hassles accounted for the relation between traumatic events and life satisfaction. The youth had been exposed to several traumatic events yet the effect of these on life satisfaction appeared indirect, via an increase in URM-specific daily hassles. Reducing the number of, or help URM cope with, URM-specific daily hassles may increase their life satisfaction.

Depression among refugee youth in an outpatient healthcare center-prevalence and associated factors.

Due to armed conflict and other crises, many children worldwide have to flee their home country and are, consequently, at a high risk for mental health problems. As the majority of previous research on refugee minors focused on post-traumatic stress disorder (PTSD), we aimed to assess the prevalence and risk factors for depression in a clinical sample of refugee youth. Data were collected during the standard diagnostic process in an outpatient refugee clinic in Germany. We assessed the prevalence of depression based on a diagnostic interview and investigated the association between age, gender, duration of flight, accompanying status, number of interpersonal traumatic experiences, residence status, and PTSD diagnosis with a depression diagnosis. More specifically, we conducted a Bayesian logistic regression with these associated factors as predictors and the presence of depression as the outcome. Additionally, we conducted a Bayesian network analysis including all these variables. The majority of the 575 included refugee children were male (n = 423, 73.6%) and, on average, 15.1 years old (SD = 2.69). Nearly half of the children (n = 243, 42.3%) met the diagnostic criteria for depression, of which most also showed a comorbid PTSD diagnosis. We found strong evidence that age, gender, number of traumatic experiences, and a diagnosis of PTSD were related to depression. The network analysis indicated that only age, gender, and PTSD were directly associated to depression. Flight-related factors were only indirectly associated with depression due to their associations with number of traumatic experiences and PTSD diagnosis. The high prevalence of depression and its strong associations with PTSD suggest that refugee minors are likely to experience depressive symptoms which might develop from PTSD symptoms. This implies a need for monitoring depressive symptoms in refugee minors, especially when these have a PTSD diagnosis.

Supplemental Material for Mental Health Disparities of Sexual Minority Refugees and Asylum Seekers: Provider Perspectives on Trauma Exposure, Symptom Presentation, and Treatment Approach

Supplemental Material for Mental Health Disparities of Sexual Minority Refugees and Asylum Seekers: Provider Perspectives on Trauma Exposure, Symptom Presentation, and Treatment Approach

Religious Identity and its Relation to Health-Related Quality of Life and COVID-Related Stress of Refugee Children and Adolescents in Germany

Research shows that religious identity is associated with health. The aim of this study was to understand the role of religious identity for refugee minors’ health in greater detail. Middle Eastern refugee minors resettled in Germany and aged 8–18 years completed questionnaires at baseline (T1, n = 246) and follow-up (T2, n = 122) measurement between 2019 and 2022. Religious identity was assessed with a 4-item measure (Cronbach’s α = .89). Associations of religious identity at T1 with health-related quality of life (HRQoL) at T1, change in HRQoL from T1 to T2, and perceived COVID-related stress at T2, as well as the mediating role of resources were examined. The results showed a positive association between religious identity and HRQoL, which was partially mediated by integration into peer group, but not by ethnic identity, sense of coherence or religious practice. No significant associations between religious identity and change in HRQoL or COVID-related stress occurred. Therefore, cross-sectional analyses support the beneficial role of religious identity for HRQoL and the crucial mediating role of integration into peer group, suggesting the promotion of religious identity or peer group integration. However, the absence of significant effects on change in HRQoL from T1 to T2 and COVID-related stress at T2 do not allow drawing any long-term conclusions.