Previous studies have found high prevalence of mental health problems among junior and teen war refugees. This research reviews current knowledge of the mental health in refugee children due to war environment upbringing. In order to ease relevant information for the creation and design of psychological interventions, an according to sex contrast analysis was carried out. The bibliography data base used: PsycInfo, PubMed and Scopus restricting the search to studies published between 2008 and 2018 on ages about 0 to 18 years. Eighteen studies accomplished all the inclusion criteria, while exclusion ones were rulled out, findings have shown huge variability in the prevalence of mental health problems in refugee children. Although eight of the studies analysed do not show significant differences by sex, the rest of the researches do find them. Higher prevalence of internalized disorders has been found in girls whereas higher prevalence of internalized disorders has been found in boys. To these sex differences is added the greater number of boys than girls living with their parents Finally, the fact that only between 13% and 21% of refugee minors go to a mental health service, together with the results of mental health disorders in refugee minors, highlights the urgent need of developing specific intervention policies for child refugees.
Keywords: Mental healthrefugeeschildrenteenagers and sex
A huge number of minors around the world are forced to migrate due to war conflicts, economic reasons, religious reasons or others. These minors are called refugees in the article 1A of the 1951 Refugee Convention referring to all people that as a result of events occurring before 1 January 1951 and owing to well-founded fear of persecution 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.
In this study, with the aim of ease relevant information to the elaboration and design of specific psychological interventions to this group, a first approximation to the mental health of refugee people due to war conflict reasons is going to be made, including a review of sex differences in psychological disorders.
All the situations to which these minors are subjected carry, in many cases, psychological disorders in them. Mental health research shows variable rates of psychological disorders in refugee minors (Tol, Song, & Jordans, 2013). Fluctuating the prevalence rate of post-traumatic stress disorder between 11 and 36%, of depression between 19.5 and 26% and of anxiety between 3 and 50% (Meyer, Steinhaus, Bangirana, Onyango-Mangen, & Stark, 2017).
It is important to highlight the role that sex plays in these prevalences. Higher rates of externalizing disorders have been found in male sex and higher incidences of internalizing ones, such as depression, in females. Although, studies in refugee population have not taken into account the same incidences of internalizing and externalizing disorders according to sex found in non-migrant population (Navarro-Pardo, Meléndez, Sales, & Sancerni, 2012).
This literature review aims to provide a summary of the current knowledge in children and teenagers mental health deepening in the existence of differences between men and women. A research in mental health services use is also going to be made as well as a comparison between mental health disorders in refugee and non-refugee children and teenagers. As it has said before it is expected to find differences in the mental health disorders incidence between men and women.
Purpose of the Study
In this research in order to provide relevant information for the development and design of specific psychological interventions for this group, a first approach to the mental health of refugee minors due to war reasons will be made, studying psychological disorders according to sex.
In this study searches of relevant researches were conducted in Pubmed; PsycInfo; and Scopus with the following terms: refugee children (all) and mental health or mental illness or mental disorder or psychiatric illness (all). The search was limited to studies conducted in population from 0 to 18 years; published between 2008 and 2018; available in English or Spanish. In addition, to identify other relevant studies, the references section of previous literature reviews on mental health in refugee minors (Graham, Minhas, & Paxton, 2016; Reed et al., 2012; Tol et al., 2013) and the studies that met the inclusion criteria of our search were revised. Searches were conducted between August and September 2018 and repeated on November 13, 2018. Finally, only 18 studies were selected.
Eighteen articles that met inclusion criteria and none of exclusion ones were identified. The majority were carried out with people from Afghanistan, Somalia, Iraq and Iran. The participants of seventeen studies were between the ages of 10 and 16 years, presenting two studies sample between 0 and 4 years old. Regarding the methodology, twelve studies were composed of less than 200 participants and seven included samples of more than 200 subjects.
The studies organized by categories according to their object of analysis are presented, including a final category with investigations that, due to their objective, could not be framed in any subsection.
Studies carried out in refugee minors without their parents
This category shows two researches that evaluated mental health of teenagers from Afghanistan and other countries and are currently without their relatives or any other figure of reference.
In order to know the psychological situation of refugee junior that are without family support Jensen, Skardalsmo, and Fjermestad (2014) evaluated a sample of 93 minors composed of men and women: 81% and 19%, respectively, in two time periods: six months after arriving Norway and around two years of residing in Norway. No significant differences were found between the first and the second follow-up in symptoms of post-traumatic stress (mean differences=0.8, SD=2.6) and general mental health (mean differences=2, SD=16.4). Although the item suicidal ideation of the HSCL scale increased between the first and the second administration of the scales. The analyses carried out to examine sex differences showed the hyperarousal subscale, belonging to CPSS, as the only one with significant differences (p=0.098) with women obtaining a higher score than men. The authors conclude that chronic courses of stress and mental health reactions do not fluctuate significantly over time. In addition, they emphasize the need of paying special attention to suicidal ideation, who suffered 11% of the sample.
Vervliet, Lammertyn, Broekaert, and Derluyn (2014) also carried out a longitudinal study evaluating 103 unaccompanied minors in Belgium. Their evaluation took place three times: during the first week of their arrival, at six months of residing in Belgium and at eighteen months. The results showed an increase in daily stressors throughout the three evaluations, as well as a maintenance of mental health symptoms over time, presenting high levels of anxiety (36%), depression (35.1%), internalizing symptoms (35.5%) and post-traumatic stress disorder (53.2%). Regarding sex differences, women scored significantly higher than men in internalizing symptoms. Researchers indicate that mental health problems persist over time and accentuated the influence of traumatic experiences and daily stressors on refugee mental health.
These two studies have found a high prevalence of mental health disorders in unaccompanied refugee adolescents, as well as sex differences in some subscales. Girls obtained a statistically significant higher score than boys in hyperactivation and internalizing symptoms Moreover, the longitudinal studies analysed shows a clear tendency to the maintaining of mental health symptoms over time. This stand out the need of developing specific interventions for this population.
The impact of acculturation on the mental health of refugees after settlement
The two studies presented below analyse the impact acculturation has on refugees. Understanding as acculturation the set of internal and behavioural transformations experienced by a person who is immersed in a situation of contact with a different culture, with consequent changes both in the individual and in the host culture.
To study the effects of acculturation and, particularly, of discrimination in refugee children and teenagers Ellis et al. (2010) evaluated 135 Somali refugees that have been residing in the United States for at least one year. Results indicated a significant correlation between discrimination and depressive and post-traumatic stress symptoms, finding significant differences by sex in discriminatory frequency. The results showed more discriminatory frequency towards women than men, which entailed greater severity of depressive and post-traumatic symptomology. Given the relationship found between discriminatory acts and mental health, the authors suggest working with minor’s response to these in the interventions.
Lincoln, Lazarevic, White, and Ellis (2016) also studied the effects of acculturation on the mental health of refugee children and teenagers. To do so they evaluated 135 Somali refugees who had lived in the United Stated 5.4 years (SD=3.32) having stayed 76% of the sample in refugee camps more than two years. The results obtained from these tests indicated symptoms of post-traumatic stress in 93% of the sample and depressive symptoms in 29%. These authors found that there is a positive relationship between trauma and the severity of acculturative damage with post-traumatic stress disorder and depression. They did not find significant differences by sex between the obtained scores in the tests. In any case, the snowball sampling limits the generalization of the results.
The studies’ results show a significant correlation between discrimination and depressive and post-traumatic stress symptoms. In addition, the greater frequency of discrimination against women presented in one of the studies could be behind the higher prevalence of depressive and post-traumatic symptoms presented by these. In this way, like Ellis et al. (2010) indicated it is especially important to include minor’s response to discriminatory acts in interventions that are carried out to prevent the increase of depressive symptoms and post-traumatic stress disorder in this population.
Trauma affectation to the mental health of refugees
The studies of this section evaluate mental health of minors as well as traumatic experiences suffered in their origin countries. It is important to know about the situations to which refugee children and teenagers have been exposed in their countries of origin in order to better understand their current psychological situation and to be able to develop specific support resources and interventions to them.
In 2011 Betancourt, Borisova, de la Soudiere, and Williamson focused on the evaluation of 273 minors from Sierra Leona recruited as child soldiers. For the exposure to war the results showed equal prevalence of injuries, tortures, murders and experience of violent deaths between sexes. Significant differences were found between men and women in the loss of a parent during the war and in the rate of sexual abuse with women having higher percentages than men in both areas. Specifically, the percentage of parents’ deaths during wars was 38% in women and 23% in men and percentages of sexual abuse in women was 44% compared to 5% in men. On the other hand, results referred to mental health showed significantly higher rates of anxiety and depression in women with more girls scoring in the clinical range for depression (80% girls vs 52% boys) and for anxiety (72% girls vs 55% boys). The authors raise the need of considering the different adversities faced by boys and girls and the lack of opportunities of girls in interventions and resources.
A year after Betancourt et al. (2012a) analysed data from 60 children and teens. The most prevalent event lived by those participants was terrorist violence followed by traumatic loss and sexual abuse or maltreatment being 29.09%, 2.73% and 9.09%, respectively. Although in the first two categories there were no sex differences in abuse or sexual maltreatment the prevalence among women was 29% compared to 1% in men. Psychological interviews indicated presence of criteria compliance with DMS-IV for post-traumatic stress disorder (30.36%), generalized anxiety disorder (26.79%), somatization (26.79%), traumatic grief (21.43%) and behavioural problems (21.43%). In addition, they showed probable disorders such as depression (39.29%), dissociation (37.5%), separation disorder (23.21%) and sleep disorders (19.24%) No significant differences were found by sex in clinical problems or severity. The authors consider the data obtained relevant for being able to train clinical professionals in the specific mental disorders found in refugee minors.
In 2017 Betancourt et al. retake their analyse of post-traumatic experiences and mental health of refugee children and teens but this time they compared the results with those of immigrant and U.S. children and teens. The results show higher rates of traumatic events in refugees with higher communitarian violence, interpersonal violence, traumatic loss and forced displacement. They also shown higher rates of phobic disorder (7.1%), dissociation (50%), somatization (42.9%) and traumatic grief (46.4%) than U.S. children and teens. Finally, higher number of refugees than immigrants and U.S. had received psychological attention and primary curative treatments. There were no sex differences in any scale.
Hanes, Sung, Mutch, and Cherian (2017) analysed mental health and traumatic events in 204 children and teens. Results shown that 37.3% have at least one psychological symptom in the Strengths and Difficulties Questionnaire having 56% multiple internalizing and externalizing symptoms. Specifically, 13.4% had sleep difficulties, 11.4% separation anxiety, 10% excessive crying and 9.9% nocturnal enuresis. Separation from nuclear family was common in 61.8% having suffered a parent death 19.1%, a sibling death 13.7% and being orphans 6.4%. There were no statistically differences by sex. The authors of the study emphasise the importance of working longitudinally with this population to enhance the resilience of the minors.
These results tally with those obtained from the Save the Children (2017) report with high prevalence of terrorist violence as well as traumatic loss and abuse or sexual maltreatment. In this regard it should be noted that there is no difference in mental health by sex despite the higher incidence of abuse and sexual maltreatment suffered by women than by men in the studies of Betancourt et al. (2011) and Betancourt et al. (2012a). Finally, the higher incidence of previous traumatic events suffered by refugees than by immigrants and Americans may be behind the higher rates of mental health disorders found in refugee population.
Emotional problems and service use
The following section includes two studies whose objective was the analysis of the use that refugees made of mental health services as well as the incidence of emotional problems in this population.
With this aim Ziaian, de Anstiss, Antoniou, Sawyer, and Baghurst (2012) divided 348 children and teens in two groups and administrated different scales to them, their parents and their teachers. The scores analyses showed that 7.2% of the sample had high depressive symptomatology. In addition, ethnic differences were found in the total and emotional scores with people from Iran and Iraq having higher prevalence. Regarding sex, significant differences were found in the age group 13-17 years, with men obtaining higher scores than girls in total (p=0.009) and functional (p=0.002) scales. Finally, despite the scores obtained from the CDI only 21.1% of the sample had attended or were going to a mental health service. According to the results shown in this and other studies, the authors suggest the need of improving mental health services for refugees and minority ethnic groups.
A year later the same authors (Ziaian, de Antiss, Antoniou, Barghurst, & Sawyer, 2013) made another research which analysed emotional and behavioural problems of refugee children as well as mental health services use. This time they evaluate 490 children. According to scores 11.2% of the sample had emotional and behavioural problems. Regarding sex no significant differences were found in the group of 4 to 12 years, but in the group of 13 to 17 years women presented higher scores than men in prosocial behaviour. Finally, mental health services use was made only by 13% of the sample with serious difficulties. The authors highlight again the lack of adequate services for the needs of refugees and the need of implementing these resources for both prevention and intervention.
Given the prevalence of depressive disorder in refugee children and teenagers one would expect high rates of attendance to mental health services yet only between 13 and 21.1% of the sample had attended or were going to a mental health service. In this regard it is pertinent to point out two needs, on the one hand, the need of developing resources focused on this population and, on the other hand, the need of a realization of a more in-depth analysis of the reasons underlying this poor assistance in order to remedy and enhance access of refugees to mental health services when they are available.
Mental and physical health of refugee minors
The studies in this section, like those in the previous ones, study the mental health of refugee minors, but also analyse the presence of psychosomatic and physical problems.
Mace, Mulheron, Jones, and Cherian (2014) assessed 332 Asiatic refugees. Scores showed that 29.2% of the sample had symptoms of post-traumatic stress disorder, meeting diagnostic criteria 5.7% and being at risk of meeting it 12.3%. In addition, 12.3% of refugees had nocturnal enuresis, 7.8% had poor appetite and 2.1% encopresis. No differences by sex were found. After analysing the scores, the authors support the importance of understanding the effects that previous experiences have on refugees in order to provide them with more adequate services.
The study made by Hamdan, Abdel Razeq, AbdulHaq, Arabiat, and Khalil (2017) with Syrian minors who were living in refugee camps in Jordan completes the above results by providing information on the perception that refugee minors have of coping with problems. In this way, they evaluated 250 children. The scores referring to physical and psychosocial health of refugee showed that 59% had dental problems, more than 50% headaches and 25% suffered from loneliness. As for somatic pains, those of the stomach, back and other parts of the body were frequent in 18% of the children. They also found anger levels from medium to high and feelings of anger in 75% of the children. Despite this, 50% of the children were satisfied with their coping with difficulties during the last month and 66.4% indicated that they had carried out actions that improved their situation in the last month. Moreover, 74.8% of children believed that they could solve their difficulties in the future. Significant differences were found by sex, with men obtaining higher scores in anger expression and women in control of anger. Men also scored significantly higher than women in behavioural problems. As in the previous study, the authors point out the importance of knowing in greater depth the impact that war generates on refugee in order to develop action policies adjusted to this group.
Beyond the high rates of aches found in these studies the satisfaction perceived by the participants with respect to coping with problems should be noted. It is a very encouraging result in the development of specific interventions and resources and should be considered. Thus, interventions should not only focus on providing resources to these children, but also on enhancing the capabilities they already have.
Other studies regarding mental health of refugee minors
This section includes those researches that, because they do not have the same object of study of the previous studies, could not have been introduced before.
In their research Catani, Jacob, Schauer, Kohila, and Neuner (2008) worked with 293 refugees. The analysis showed that 95.6% had lived at least one violent event at home. Moreover, the depression and post-traumatic disorder incidences were high, accomplishing diagnostic criteria of post-traumatic stress disorder 30.4% of refugees and major depression disorder 19.6%. Past suicidal ideation was found in 22.6% of the sample and current suicidal ideation in 17.2%. The major depression disorder (p<0.001) and the actual suicidal ideation (p<0.001) were higher in the group diagnosed from post-traumatic stress disorder, disorder in which women (32.6%) had higher incidence than men (28.5%). The authors stipulate the need of developing psychological interventions for children who had suffered violent armed conflicts.
Working with people affected by the Balkan War Goldin, Hägglöf, Levin, and Persson (2008) assessed 48 refugees. The analysis of the results obtained from these instruments indicated statistically significant symptoms of depression in 31% of the sample, anxiety in 15% and psychosomatic complaints in 13%. In contrast, no statistically significant symptoms of stubbornness or aggressiveness were found, and the prevalence of hyperactivity was 6%. In addition, 23% of children met criteria for post-traumatic stress disorder according to the DSM-IV-TR. No statistically significant differences were found between sex at any level. Due to these results, the authors of the study raise the need of assessing children and teenagers who arrive from the refugee camps in order to understand their thoughts, feelings and behaviours.
The study conducted by Khan et al. (2018) with 622 children from Burma complete the above ones by providing information on the presence of neurodevelopmental disorders and problems with peers. The results showed that 6.05% of children scored positive in the screening of neurodevelopmental disorders. In addition, 52% of the sample were in abnormal range of emotional symptoms and 25% had peer problems. No significant sex differences were found. The authors raise the urgent need to offer psychosocial support to children living in refugee camps including monitoring of their physical and mental health status.
The research of Barghadouch, Carlsson, and Norredam (2018) performs rate ratio analysis (RR) to study differences between men and women in affective, psychotic and anxiety disorders. They assessed 124 refugees. The results indicated that women had higher adjusted RR than men in affective disorders (RR: 1.85, 95% CI: 1.29-2.65) and in anxiety disorders (RR: 1.34, 95% CI: 1.10-1.63). In contrast, they presented lower adjusted RR than men in psychotic disorders (RR: 0.32, 95%, CI:0.20-0.53). The authors emphasize the need of developing evaluation measures for refugee minors in order to improve the early detection of psychiatric disorders and ensure the necessary care.
The following study of Betancourt, Yudron, Wheaton, and Smith-Fawzi (2012b), unlike the previous ones, includes a correlational analysis between parental stress and children´s mental health. These authors assessed 153 refugees. The sociodemographic results showed a statistically significant difference between boys and girls in the probability of living with both parents being higher the percentage of boys (56%) than of girls (41%) living with them. In addition, it was found that refugee whose parents scored above the cut-off point on the distress scale had higher scores on externalizing and internalizing symptoms, not finding statistically significant sex differences. The authors highlight the importance of family well-being in the psychological recovery of children after war.
Finally, the study of Buchmüller, Lembcke, Busch, Kumsta, and Leyendecker (2018) make a mental health comparative between refugee and Americans. They compared the results obtained with normative data of Americans children and found that refugee parents reported a greater number of mental health problems compared to American ones. This was even higher on the internalizing scale where researchers found higher levels of anxiety and depression (T=6.5, P<0.01), attention difficulties (T=3.3., p=0.02) and retracted behaviour scale (T=3.6, p<0.01) in comparison with the normative group. The results also showed higher rates of mental health problems in refugee compared to that given by the US normative group. The incidence of externalizing problems in the clinical range in refugee was 20% and in the subclinical range 35%. No sex differences were found. The authors emphasize the importance of studying the children’s mental health as early as possible due to the future negative consequences for them.
This section findings complete the previous ones, including data on the relationship between the mental health of parents and children and high incidences of neurodevelopmental disorders, problems with peers, past suicide attempts and current suicidal ideation. Regarding the conclusions it is remarkable the one made by Barghadouch et al. (2018) since they stop emphasizing the need of developing specific intervention to highlight the importance of early detection of psychological and psychiatric disorders in refugee through the development of evaluation measures.
The results of the studies highlight the enormous variability in the prevalence of mental health disorders among refugee minors. Thus, the incidence of post-traumatic stress disorder is between 23% and 30.4%, these figures amount to 93% when the symptoms of post-traumatic stress are assessed. The prevalence of depression fluctuates between 5.3% and 39.29% in the studies analyzed and that of anxiety ranges between 15% and 26.79% (Betancourt et al., 2012a; Catani et al., 2008; Goldin et al., 2008; Lincoln et al., 2016; Mace et al., 2014; Ziaian et al., 2012). As these rates fluctuate between studies they should not be taken as normative but as reference data for the psychological situation of refugee minors.
Despite of this the research reflects disparate results in the analysis of sex differences in the mental health of refugee minors. Although eight of the studies analysed do not show significant differences by sex, the rest of the researches do find them. Higher prevalence of internalized disorders have been found in girls whereas higher prevalence of internalized disorders have been found in boys. To these sex differences is added the greater number of boys than girls living with their parents found by Betancourt et al. (2012b).
The studies made by Ziaian et al. (2012) and Ziaian et al. (2013) indicate that only between 13% and 21% of refugee minors go to a mental health service, which, together with the results on mental health disorders in refugee minors, highlights the need of developing resources and specific actions to this population. These interventions should be based on the skills and resources that these minors noticed in the study of Hamdan et al. (2017) where 50% of the children indicated that they were satisfied with their coping with problems and 66% had taken actions that improved their situation. In addition, it would be convenient to develop resources not only for minors but also for their families since the mental health of the parents has an impact on their children's health (Betancourt et al., 2012b). In any case, it is necessary to ask about the reasons that lead this population not to use mental health services when they are already provisioned.
It would be advisable to analyse in greater depth the repercussion of the mental health of the parents or caregivers on the minors, as well as the protective factors in the development of psychological disorders to enhance them and prevent the appearance and development of these or other problems in the development of the minors. Within these protective factors it is worth mentioning the resilience that this population has shown and that has been the subject of previous research studies.
In any case, this review has limitations regarding the sample of the studies analyzed, less than two hundred subjects in twelve of them. Besides, previous research on the subject is scarce due to the difficulty of access to the sample and the recent interest in investigating the mental health of this population.
I thank my colleagues from the University of Oviedo, especially María Yolanda Fontanil Gómez, who provided insight and expertise that greatly assisted the research. I would also like to show my gratitude to María Isabel Martínez Bellido for sharing her pearls of wisdom with me during the course of this research.
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27 May 2020
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Teacher training, bullying, child abuse, abusive relationship, neglected child, neglected teenager, cognitive psychology
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Reviriego-Reinaldo, N. (2020). Junior And Teen Refugee Mental Health: Sex Differences. In C. Salavera, P. Teruel, & J. L. Antoñanzas (Eds.), Observatory for Research and Innovation in Social Sciences, vol 84. European Proceedings of Social and Behavioural Sciences (pp. 265-275). European Publisher. https://doi.org/10.15405/epsbs.2020.05.28