Unaccompanied Refugee Minors: Assessment and Treatment

Unaccompanied Refugee Minors: Assessment and Treatment

           This project explains some of the difficulties unaccompanied refugee minors face when coming from war torn countries having experienced multiple traumatic events. There are theoretical explanations as to why traumatized people become stuck in the horror of their past. However, there is hope that through proper assessment and treatment unaccompanied refugee minors can let go of their past, heal, and move forward to live in freedom released from traumatic memories that once controlled their lives.   

Global overview

Definition of Terms

Refugee. A person who is unable or unwilling to return to their country of origin due to fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion (United Nations, n.d, p.2).

Asylum Seekers. Asylum seekers are refugees that migrate from home countries into a foreign country to escape war, persecution and extreme economic deprivation, requesting asylum based on race, religion, nationality as central reason for persecution of the applicant (Sidhu, 2016).

Unaccompanied Refugee Minors. Unaccompanied refugee minors are children under the age of 18 who have migrated without their parents or guardian and without legal status seeking asylum in a foreign land (Keles, Friborg, Ids?e, Sirin, & Oppedal, 2016).

Trauma. Psychological trauma is “the experience and psychological impact of events that are life-threatening so severe that the person is horrified, feels helpless, and experiences a psychological alarm response during and shortly after the experience” (Schauer, Elbert, & Neuner, 2012, p.7)

Complex trauma. Complex trauma refers “to both specific type of trauma exposure as well as the devastating Impact it makes and is defined as traumas that are multiple, chronic, and interpersonal in nature and begin at an early age, and include war, violence, and experience of being a refugee” (Cohen, Mannarino, & Deblinger, 2017, p. 53).

Posttraumatic stress disorder. “Traumatic experiences as those events that involve experiencing or observing actual or threatened death, physical injury, or threat to physical integrity that result in feelings of terror, horror, or helplessness” (Blaustein & Kinniburgh, 2019, p. 3).

Complex posttraumatic stress. Can be defined as “prolonged trauma, especially childhood sexual abuse or torture during political incarceration, may have clinical presentation that differs from PTSD, features impulsivity, dissociation, somatization, affect lability, interpersonal difficulties, and pathological changes in personal identity” (Friedman, 2015, p. 35).

Organized violence. Organized violence is “perpetrated by members of a group guided by political orientation that targets individuals or groups who have different political attitudes or nationalities and is characterized by the violation of human rights and disregard for women’s and children’s rights” (Schauer et al., p.11).

Traumatization. Traumatization is defined as “suffering from memory of a traumatic experience that has happened in the past by reliving through experiencing flashbacks or nightmares, accompanied by intense feelings of fear and anger” (Schauer et al., 2012, p.14).

Global Statistics

           Global statistics of unaccompanied refugee minors is staggering, in 2014, 230 million children lived in countries and areas affected by armed conflicts (Kangaslampi, Garoff, & Peltonen, 2015) and over 68 million people were displaced by conflict or persecution (Jensen, Sk?rdalsmo & Fjermestad, 2014). In 2016, over 64,000 unaccompanied refugee minors applied for asylum in Europe, and due to civil war in Syria and other conflicts, displace individuals worldwide exceeded 59.5 million with 19.5 million being refugees of which 51% were children under 18 years of age (Pfeiffer & Goldbeck, 2017, Gadeberg & Norredam, 2016).

Prevalence

Mental Health

           There are many mental health concerns with unaccompanied refugee minors that migrate to foreign countries.   According to Kangaslampi, Garoff, & Peltonen (2015), “numerous studies demonstrate exposure to war and trauma-related stress symptoms and specific types of war experiences that are particularly traumatizing result in 47% of children exposed to war may suffer from posttraumatic stress disorder (PTSD) and 43% from depression (Kangaslampi et al.,  2015).

Some studies indicate that about one in ten unaccompanied refugee minor’s has posttraumatic stress disorder, and about one in twenty has significant depression, and one twenty-five has a generalized anxiety disorder, with the probability of comorbidity (Gucht, Glas, Haene, Kuppens, & Raes, 2019). There is a strong association between violence-related traumatic events and posttraumatic symptoms, especially in the prevalence of posttraumatic stress disorder among refugee children exposed to violence either in war or within the family between 37% and 65% (Peltonen & Kangaslampi, 2019).

Long-term consequences. Some of the long-term consequences of posttraumatic stress disorder in children also appear connected to lower verbal memory function, and overall cognitive performance and linked to impairment in academic performance decreased quality of life (Kangaslampi et al., 2015). 

Severity

Psychosocial Problems and Comorbid Disorders

 Mental health issues.  Some behavior manifestations of unaccompanied refugees include; exhibiting suicidal and self-harming behaviors more than non-refugee youths (Unterhitzenberger & Rosner, 2016). Southwest key programs in Brownsville, Texas, works with unaccompanied refugee minors and typically there are at least two or three self-harming suicidal gestures made by youth daily of a population of 1,100 minors housed at a specific children’s shelter. Some studies have shown that unaccompanied refugee minors are overrepresented in psychiatric inpatient care (Jensen, Sk?rdalsmo, & Fjermestad, 2014). 

Impact of childhood trauma exposure. Childhood trauma can lead to “disturbed attachment patterns, shifts in emotional states, regulation problems, regressive behaviors, aggression, sleeping and eating problems, somatic problems, anticipatory anxiety, and lack of self-esteem” (Horlings & Hein, 2017, p. 163).  According to Katsounari (2013), some mental health symptoms experienced by unaccompanied refugee minors include experiencing flashbacks and nightmares, depression, anxiety, issues of grief, sadness, and severe feelings of guilt (Katsounari, 2013, p. 300). Many of these symptoms are often linked to trauma exposure before migration and the loss of the primary caregiver (Jensen et al., 2014).

Social withdrawal. Many children traumatized by war experiences struggle with connecting with others and experience difficulties in social and emotional functioning (Schauer et al., 2012, p.7). Acculturation issues contribute to difficulties experienced by unaccompanied refugee minor children because they must learn new language and a new culture while at the same time adapting to new life circumstances (Keles, Friborg, Ids?e, Sirin, & Oppedal, 2016).

Physical illness. There is a deep connection between stress and physical illness, infectious illnesses; posttraumatic stress patients show high morbidity with increased risk for many diseases including cancer, coronary heart disease, and autoimmune disorders (Schauer et al., 2012, p.14). 

Best Practices for Treatment

Bio-psychosocial Assessment

           Undocumented refugee minors often arrive with little or no medical or family history and need a full-scale assessment that includes physical exam, mental health, vision, hearing, dental, and trafficking issues (Katsounari, 2013, p. 304). Southwest Key Program children shelters provide a complete medical and dental assessment to ensure all minors are medically healthy and provide them with child vaccinations.            

           Physical health. Many unaccompanied refugee minors struggled with physical illnesses and depending on what country they came from dictated what types of common ailments, for example, refugees from Serbia presented with middle ear infections, bronchitis, sinusitis, dehydration, blisters, and diarrhea (Hebebrand, et al., 2015).

Mental Health Assessment

           Structured interview. The most important aspect of the mental health assessment for the unaccompanied refugee minor is the initial interview because structured interviews provide a clinical context to gather pertinent information, give options for support and building of trust and development of the client/therapist relationship (Sigvardsdotter, et al., 2017). 

           Mental health screening tools. The initial mental health assessment of unaccompanied refugee minors is of the utmost importance but often overlooked and neglected. “Some of the barriers to proper mental health assessments include; language, a mental health stigma, low priority given to mental health screening, and lack of knowledge of the healthcare system in their home country” (Horlings & Hein, 2017, p. 163). Unaccompanied refugee children constitute an overlooked and vulnerable population, and the use of non-validated screening tools jeopardizes clinical assessments and the results of scientific studies (Gadeberg & Norredam, 2016).

           Trauma specific screening tools.  Gadeburg & Norredam (2016) identified validation studies for the following screening tools for unaccompanied refugee minors; Child Behavior Checklist (CBCL), Child Posttraumatic System Scale (CPSS-I), Hopkins System Checklist (HSCL-37), Risk Assessment Tool (RATS), UCLA PTSD, Post-Traumatic Stress Symptoms in Children (PTSS-C), and Impact of Event Scale (IES) (Gadeberg & Norredam, 2016, p. 929). The specific screening tool depends on child -specific presentation, trauma related issues and circumstances, and what part of the world the minor originated (Horlings & Hein, 2017). 

Interventions 

            Trauma-focused treatment. Trauma-focused treatment can be defined as treatment that focuses on the patient’s memories of their traumatic events and the personal meanings of the trauma (Heide, Mooren, & Kleber, 2016). The majority of intervention techniques among children traumatized by war derive from CBT-based interventions for traumatic stress that include; creative narrative, and cognitive elements including creative-expressive exercises, cognitive restructuring, attention control, body-oriented methods, building a sense of safety, and providing psychoeducation (Horlings & Hein, 2017). 

           Transdiagnostic interventions. These interventions target stress, anxiety, and depression but also aim to impact common underlying vulnerability factors such as mindfulness-based interventions (Gucht, Glas, Haene, Kuppens, & Raes, 2019). Mindfulness-based interventions aim “to reduce reactivity to, and avoidance of, internal experiences (cognitions, emotions, physical sensations) and encourage openness and acceptance of these experiences, while encouraging engagement of valued actions” (Gucht et al., 2019). 

           Best practices for treatment. Treatment recommendations for unaccompanied refugee minors include trauma-focused cognitive behavioral therapy (TF-CBT), eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy for children (KIDNET), however they are not yet evidence-based but have promising outcomes (Horlings & Hein, 2017). 

           Social support. There have been numerous studies showing that social support is a protective factor and that strong social support in home country has shown to be important for young unaccompanied refugee minors (Jenson et al., 2019). Other protective factors include reuniting with family when possible, having possibility to go to school, integration of traditional health care, language training, and linkage with others from one’s own country within the community (Jenson et al., 2019). 

Preferred Theoretical Modalities

Narrative Exposure Therapy

Trauma memories. Traumatic memories and posttraumatic cognitions potentially change in PTSD war-affected children (Kangaslampi et al., 2015). There are two networks that respond to stimuli in the brain, the left (prefrontal lobe) and right (amygdala, fear network) During a highly emotional event two differing types of parallel memory representations are encoded; the sensory, cognitive-emotional and physiological features of the event are stored in long-term perceptual memory and have been called hot memories while contextual verbalizable elements of the situation are encoded into episodic memory have been called cold memories (Kangaslampi et al., 2015). 

Repeated traumatization disconnects hot memories (sensory, cognitive, emotional and physiological) from contextual referents of cold memories (time/space) so that one’s fear/trauma network may end up containing sensory elements and disconnected perceptual or physiological memories from many traumatic events all mixed together (Kangaslampi et al., 2015). 

Narrative Exposure Therapy is “a manualized, individual, short-term intervention program based on cognitive behavioral therapy principles and exposure based testimonial therapies, for the treatment of posttraumatic stress disorder resulting from exposure to organized violence or other repeated traumatic events (Kangaslampi et al., 2015). Narrative Exposure Therapy desensitizes associative features of hot memories (sensory, affective, cognitive) and forms an autobiographical narrative through telling one’s life story (Neuner, 2016). 

Course of treatment. Phase one the therapist informs the patient about the intervention including theoretical background, psychoeducation about symptoms, and different elements of the therapy (Neuner, 2016). Phase two the therapist and patient visualize the patient’s lifeline using a rope starting with their birth and marking traumatic events with stones and pleasant ones with flowers (Neuner, 2016). Phase three the patient narrates through their lifeline narrating through each significant event (Neuner, 2016). Phase four the patient narrates through their whole narration providing pertinent empowering feedback (Neuner, 2016).

Case example. Neuner (2016) gave an example of an unaccompanied refugee minor that witnessed soldiers breaking into his home, killing his family and hearing them rape his sister. He struggled with ruminating thoughts and fear from this experience and had flashbacks and nightmares frequently. These flashbacks consisted of him lying on the rug, seeing the soldier’s guns, hearing his sister screaming, thinking how this hurts and that he’s helpless, feeling anger, fear, and horror, remembering his heartbeat and shaking uncontrollably. He had trouble remembering where he was (Mogadishu), that it happened in the afternoon, and that he had just come home from school. 

Through the process of Narrative Exposure Therapy, the unaccompanied refugee minor was able to reconnect his here and now along with where he was during that traumatic event and process and finish the story that had kept replaying in his mind. He was able to empower himself through giving voice to his injustice, finding purpose through his suffering and validating his experience (Neuner, 2016). 

Conclusion

           Millions of children are negatively affected by armed conflict with millions more displaced as a result of war or persecution. Many migrate on their own to foreign countries in pursuit of safety and protection thus becoming unaccompanied refugee minors. However, many times they cannot escape their horrifying experiences that show up as traumatic memories causing mental health consequences including complex PTSD, depression, and anxiety and negatively affecting their ability to move forward in their lives.

           Through proper assessment and intervention using trauma-focused treatment, these unaccompanied refugee minors can begin to heal and come to terms with the awful traumatic experiences they endured and find purpose and meaning as they begin to acculturate into their new communities.   

References

Blaustein, M., & Kinniburgh, K. M. (2019). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation, and competency. New York, NY: The Guilford Press.

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Trauma-focused CBT for children and adolescents: Treatment applications. New York, NY: Guilford Press.

Friedman, M. J. (2015). Posttraumatic and acute stress disorders. Cham: Springer.

Gadeberg, A. K., & Norredam, M. (2016). Urgent need for validated trauma and mental health screening tools for refugee children and youth. European Child & Adolescent Psychiatry, 25(8), 929-931. doi:10.1007/s00787-016-0837-2

Gucht, K. V., Glas, J., Haene, L. D., Kuppens, P., & Raes, F. (2019). A mindfulness-based intervention for unaccompanied refugee minors: A pilot study with mixed methods evaluation. Journal of Child and Family Studies, 28(4), 1084-1093. doi:10.1007/s10826-019-01336-5

Hebebrand, J., Anagnostopoulos, D., Eliez, S., Linse, H., Pejovic-Milovancevic, M., & Klasen, H. (2015). A first assessment of the needs of young refugees arriving in Europe: What mental health professionals need to know. European Child & Adolescent Psychiatry, 25(1), 1-6. doi:10.1007/s00787-015-0807-0 

Heide, F. J., Mooren, T. M., & Kleber, R. J. (2016). Complex PTSD and phased treatment in refugees: A debate piece. European Journal of Psychotraumatology, 7(1), 28687. doi:10.3402/ejpt.v7.28687

Horlings, A., & Hein, I. (2017). Psychiatric screening and interventions for minor refugees in Europe: An overview of approaches and tools. European Journal of Pediatrics, 177(2), 163-169. doi:10.1007/s00431-017-3027-4

Jensen, T. K., Sk?rdalsmo, E. M., & Fjermestad, K. W. (2014). Development of mental health problems - a follow-up study of unaccompanied refugee minors. Child and Adolescent Psychiatry and Mental Health, 8(1), 29. doi:10.1186/1753-2000-8-29

Kangaslampi, S., Garoff, F., & Peltonen, K. (2015). Narrative exposure therapy for immigrant children traumatized by war: Study protocol for a randomized controlled trial of effectiveness and mechanisms of change. BMC Psychiatry, 15(1). doi:10.1186/s12888-015-0520-z

Katsounari, I. (2013). Integrating Psychodynamic Treatment and Trauma Focused Intervention in the Case of an Unaccompanied Minor With PTSD. Clinical Case Studies, 13(4), 352-367. doi:10.1177/1534650113512021

Keles, S., Friborg, O., Ids?e, T., Sirin, S., & Oppedal, B. (2016). Resilience and acculturation among unaccompanied refugee minors. International Journal of Behavioral Development, 42(1), 52-63. doi:10.1177/0165025416658136  

Neuner, F. (Presenter). (2016). Narrative Exposure Therapy [Video file]. United States: APA Division 56. Retrieved June 23, 2019, from https://www.youtube.com/watch?v=GhyDplT_uIM.

Peltonen, K., & Kangaslampi, S. (2019). Treating children and adolescents with multiple traumas: A randomized clinical trial of narrative exposure therapy. European Journal of Psychotraumatology, 10(1), 1558708. doi:10.1080/20008198.2018.1558708

Pfeiffer, E., & Goldbeck, L. (2017). Evaluation of a trauma-focused group intervention for unaccompanied young refugees: A pilot study. Journal of Traumatic Stress, 30(5), 531-536. doi:10.1002/jts.22218

Schauer, M., Elbert, T., & Neuner, F. (2012). Narrative exposure therapy: A short-term treatment for traumatic stress disorders. Cambridge, MA: Hogrefe Huber Publ.

Sidhu, R. (2016). Navigating unfreedoms & re-imagining ethical counter-conducts: Caring about refugees & asylum seekers. Educational Philosophy and Theory, 49(3), 294-305. doi:10.1080/00131857.2016.1225558  

Sigvardsdotter, E., Nilsson, H., Malm, A., Tingh?g, P., Gottvall, M., Vaez, M., & Saboonchi, F. (2017). Development and preliminary validation of refugee trauma history checklist (RTHC)—A brief checklist for survey studies. International Journal of Environmental Research and Public Health, 14(10), 1175. doi:10.3390/ijerph14101175

United Nations (n.d). The 1951 refugee convention. Retrieved June 29, 2019. From https://www.unhcr.org/1951-refugee-convention.html

Unterhitzenberger, J., & Rosner, R. (2016). Case report: Manualized trauma-focused cognitive behavioral therapy with an unaccompanied refugee minor girl. European Journal of Psychotraumatology, 7(1), 29246. doi:10.3402/ejpt.v7.29246