More than 43 million people worldwide are now forcibly displaced as a result of conflict and persecution. Over half of these are children. One-third of all refugees are living in camps or camp-like settings, with many likely to remain in them for several years.
Refugee camps present challenging living conditions, such as ongoing insecurity, malnutrition, limited access to education, lack of work for parents, poor health and exposure to further violence and abuse. The trauma of the violence and persecution that forced children to leave their homes, and the adversity they face in camps is a double whammy that can jeopardize their development into healthy productive adults.
Mental health problems in child refugees
Studies of refugee youth consistently report high levels of trauma exposure – conflict, disaster, community and domestic violence, for example – and profound adverse psychological consequences, including behaviour problems, mood and anxiety disorders, and post-traumatic stress disorder (PTSD).
Compared with children from local populations, refugee children have consistently demonstrated higher prevalence rates of psychological distress. This extends across anxiety problems, depression and PTSD.
Additionally, problems with adjustment, such as social connectedness, acculturation stress and academic proficiency, are all challenges faced by refugee youth and have been found to exacerbate psychological distress.
The post-migration experience, and in particular the process of sociocultural adaptation, can be marred with challenges, as refugee youth attempt to coalesce the values, norms and practices of two distinct cultures. Sudden exposure to a new education system can be confronting, and racial discrimination and bullying are sadly widespread.
For some youth, particularly unaccompanied humanitarian minors, the ongoing threat to the safety of their family residing in their country of origin or in transit in equally perilous living conditions, offers the additional suffering of anticipatory fear.
The refugee experience for a young person is likely to also directly impact on their progression through key developmental milestones, such as identity formation, social inclusion and attachment development, self-esteem, future aspirations, distress tolerance skills and the formation of one’s worldview. In the absence of appropriate psychological and psychosocial interventions these problems can increase morbidity and mortality, place a significant burden on healthcare and increase healthcare costs and, in the long-term, decrease productivity.
What can be done?
“Refugees have been deprived of their homes, but they must not be deprived of their futures,” UN Secretary-General Ban Ki-moon has said. This raises a critical question about how child development and wellbeing can be best supported in the wake of events and transitions that threaten to destabilize them either directly or through the erosion of ecological factors that protect them, such as the wellbeing of the family unit.
Unfortunately there is very little research on child mental health interventions in refugee camps, and this is an area where more investment is urgently needed. In 2014, Rebecca Tyrer and Mina Fazel looked at 21 studies of which seven had been conducted in refugee camps in low- and middle-income countries. They identified two broad classes of interventions in refugee children: talking therapies and creative art techniques.
Talking therapies include cognitive behaviour therapy (CBT) and trauma-focused interventions, such as narrative exposure therapy (NET). Broadly, the former helps children deal with present and future challenges while the latter helps them come to terms with past memories. The creative techniques draw on an array of different therapies including music therapy, creative play, drama and drawing. These give children a safe space to express their feelings and to make sense of their experiences. Interventions were delivered either in the school, community or refugee camps. Significant improvements were seen for depression, anxiety, PTSD, functional disturbances and peer problems in both types of interventions. Individual as well as group interventions were effective, as were both short and long-term treatments.
What might be most helpful are comprehensive or multi-modal interventions delivered by front-line workers to children and their families. Such interventions could aim to concurrently address issues of psychological functioning, social and cultural adaptation, physical health and ongoing psychosocial difficulties.
At the societal level, they might try to influence the wider environment through pushing for basic needs such as health, nutrition and housing, promoting language proficiency, improving the bureaucratic procedures for immigration, and advocating for educational and employment opportunities. The restoration of a supportive network for the young person and their family is likely to be key to stabilizing their mental health and developmental trajectory. The importance of harnessing cultural and traditional resources for coping is likely to also be important. The multi-modal approach ensures that all the needs identified by the individual or family are addressed in a holistic and integrated manner.
The need to act quickly
The UN resolution on a World Fit for Children endorses the commitment that “every child has the right to develop his or her potential to the maximum extent possible to become physically healthy, mentally alert, socially competent, emotionally sound and ready to learn”.
Millions of refugee children do not possess this basic right. The global community is quick to mobilize resources and expertise when faced with immediate challenges emanating from infections or terrorism. We ignore the mental health consequences of the forced displacement of a generation of children at our peril.
The promotion of refugee child and adolescent mental health is a worldwide challenge, but a potentially rewarding one. The evidence suggests that early interventions can provide long-term health and socioeconomic benefits by prevention of the onset of mental health problems and their development into chronic disorders. What happens to these millions of children tomorrow depends on what we do to them today. In the words of the Nobel Laureate, Gabriela Mistral:
“We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the fountain of life. Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made, and his senses are being developed. To him we cannot answer ‘Tomorrow’, his name is today.”
This is part of a series of articles linked to the 2016 World Humanitarian Summit, including: