Mental health among refugee children

Daniel Tawfik Advocacy morning report 11 May 2012

Case
Continuity clinic. New patient 6 year WCC History taken with aid of Arabic interpreter CC/HPI: Not eating well. Mainly just drinks juice at mealtimes. Sad all the time and will frequently hit his parents repeatedly for several minutes at a time

6yo boy with poor appetite and anger

PMH: unremarkable Meds: none Allergies: Penicillin (rash) FHx: unremarkable SHx: Family moved from Iraq to Romanian refugee camp 3 years ago, and to Utah 2 years ago. In Iraq, patient witnessed wartime violence and deaths. Family had rushed departure from Iraq due to death threats against the patients father. Father smokes (outside).

6yo boy with poor appetite and anger

Weight 40th %tile, Height 54th %tile. P 75, R 14, BP 97/57 Quiet child, poor eye contact. No apparent distress. No active defiance. Exam otherwise unremarkable.

Refugee child psych: Background

44 million forcibly displaced people worldwide
28 million internally displaced persons 15 million refugees 1 million asylum-seekers

98,800 refugees re-settled in 2010

71,400 of these to the USA in 2010
Approx 1000 new refugees in Utah yearly

265,000 refugees in the USA at end-2010

Estimated 27,000 refugees in Utah

44% of refugees are less than 18 years old

Sources: United Nations Refugee Agency, Utah Refugee Services Office

Refugee child psych: Background

Source: United Nations Refugee Agency

Refugee child psych: Background

Source: United Nations Refugee Agency

Refugee child psych: Background

Refugees from 42 countries to Utah in the past 10 years
Somalia 18% Yugoslavia 13% Burma 12% Sudan 9% Iraq 7% Iran 7% Bhutan 6%
Source: Utah Refugee Services Office

Refugee child psych: Epidemiology

Stressful experiences are common
Loss of family Loss of culture, forced migration War Persecution Torture Rape Violence

Stressors can be in pre-migration, migration, or post-migration phases

Source: Bronstein et al. 2011

Refugee child psych: Epidemiology

Psychiatric sequelae are more frequent in children than adult refugees
Post-traumatic stress disorder: 9-69% Depression: 5-63% General population: 2-9%
General population: 6-9%

Anxiety: 5-60% Sleep problems: 28-80% Somatic symptoms Note: school and social function are often preserved Conduct disorders

After natural disaster: 5-25% Victims of terror: 4.5-14%

Appropriateness of applying western psych diagnoses is debated

Sources: Bronstein et al. 2011, Montgomery 2011, Crowley et al. 2009

Refugee child psych: Risk factors

Older age
Higher rate of internalizing/externalizing problems More PTSD

Girls
More internalizing, emotional problems, depression

Boys
More total difficulties, conduct problems
Source: Crowley et al. 2009

Refugee child psych: Risk factors

Pre-migration experiences
Separation from parents Being unaccompanied Witnessing parents fear Direct personal injury Violent death of family member Combat experience Long-lasting or frequent violence exposure
Sources: Bronstein et al. 2011, Craig et al. 2011, Crowley et al. 2009

Refugee child psych: Risk factors

Migration experiences
Separation from parents Refugee camp exposure Witnessing violence Lack of adequate food/water Lack of adequate medical care

Sources: Bronstein et al. 2011, Craig et al. 2011, Crowley et al. 2009

Refugee child psych: Risk factors

Post-migration experiences
Failed asylum claims/uncertain residency status Parental unemployment > 6 months Discrimination/racial violence Language difficulties Financial difficulties/low socioeconomic status Cultural bereavement

Sources: Bronstein et al. 2011, Craig et al. 2011, Crowley et al. 2009

Refugee child psych: Recognition

Screening exam on entrance to Utah
Performed by Dr. Swoboda or Dr. Rabin Screening for children >15yo with RHS-15 All families asked about history of violence/torture and who was present

Regular health maintenance your responsibility!

Ask about violence/torture history
Family does not have to answer Make sure you have time for the response

Ask about other risk factors Ask about mood or behavior disturbances

Refugee child psych: Recognition

No validated screening tool for children <15yo Strength and Difficulties Questionnaire (SDQ)
For children 3-17yo www.sdqinfo.com Parent/Teacher version Self-report version for 11-17yo 25 questions
Emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, prosocial behaviors

Free to download in many languages Has not been validated in refugee populations

Refugee child psych: Management

Individual-based
Cognitive behavioral therapy
Controversial if talking about past experiences exacerbates the problem Efficacy varies from population to population

Refugee child psych: Management

School-based
Assist in integration into community Important for educational, social, and emotional development

Refugee child psych: Management

Family-based
Often more culturally-sensitive May strengthen families Increases likelihood of requesting mental health services Establishes ties with fellow refugee families

Sources: Nickerson et al. 2011, Bronstein et al. 2011

Refugee child psych: Management

Community-based
Not widely studied

Refugee child psych: Prognosis

Resilience is common
Rate of psych problems decreases by ~50% within 9 years Does not reach general population rate

Source: Montgomery 2011

Refugee child psych: Community Resources

Valley Mental Health
www.vmh.com, 888-949-4864 Inpatient/Outpatient mental health services School-based services Medicaid

The Childrens Center

www.tccslc.org, 801-582-5534 Children <8yo Therapeutic Preschool Trauma Treatment

Utah Health and Human Rights

www.uhhr.org, 801-363-4596 Individual/Group psychotherapy Psych clinic Medical services Case management and legal assistance

Asian Association of Utah

www.aau-slc.org, 801-467-6060 Counseling Employment and Language services

Refugee child psych: Internet Resources

Cultural Orientation Resource Center
www.cal.org/co/

Refugee Health Technical Assistance Center

www.refugeehealthta.org

United Nations Refugee Agency

www.unhcr.org

State of Utah Refugee Office

http://refugee.utah.gov

Catholic Community Services of Utah

www.ccsutah.org

References
Birman et al. International family, adult, and child enhancement services (FACES): A community-based comprehensive services model for refugee children in resettlement. Am J Orthopsych (2008) 78:121-132. Bronstein et al. Psychological distress in refugee children: A systematic review. Clin Child Fam Psychol Rev (2011) 14:44-56. Carswell et al. The relationship between trauma, post-migration problems and the psychological well-being of refugees and asylum seekers. Int J Soc Psych (2011) 57:1007. Craig et al. Mental health care needs of refugees. Psych. (2009) 8:351-354. Crowley C. The mental health needs of refugee children: A review of the literature and implications for nurse practitioners. J Am Acad Nurs Prac (2009) 322-331. Lindert et al. Depression and anxiety in labor migrants and refugees A systematic review and meta-analysis. Soc Sci & Med (2009) 69:246-257. Lustig et al. Review of child and adolescent refugee mental health. J Am Acad Child Adolesc Psych. (2004) 43:2436. Montgomery E. Trauma, exile, and mental health in young refugees. Acta Psych Scand (2011) 124:s440. Murray et al. Review of refugee mental health interventions following resettlement: best practices and recommendations. Am J Orthopsych. (2010) 80:576-585. Nickerson et al. A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clin Psych Rev (2011) 31:399-417. Peltonen et al. Preventive interventions among children exposed to trauma of armed conflict: A literature review. Agg Behav (2010) 36:95-116. Tol et al. Political violence and mental health: A multi-disciplinary review of the literature on Nepal. Soc Sci & Med (2010) 70:35-44. UNHCR Global Trends 2010. UN Refugee Agency. 2010. www.unhcr.org.