Refugee children

May need a lot of psychiatric help

War and persecution have resulted in large migrations, and current estimates suggest there are 23 million refugees in the world.1 About 120 000 of them are in Britain, mostly living in inner London, where they constitute significant minorities. At least 40% (50 000) are aged under 18 years, and they include increasing numbers of unaccompanied refugee children—nearly 500 in 1995. Despite their growing numbers, these children's mental health needs and service provision have received little attention.

Studies from the United States, mostly in refugee children from South East Asia but more recently those from former Yugoslavia, indicate that serious psychiatric disorder is present in 40-50%.2-4 Since refugee children will have been exposed to similar stressors wherever they find refuge, it is reasonable to take that figure as an estimate of prevalence in Britain. This is far higher than the estimates of psychiatric disorder among non-refugee children in London (about 25% in 10 year olds5 and 7% in infants6).

Refugee children have the full range of psychopathology: they may bring with them disorders they would have had at home as well as those worsened or caused by recent adversities. Disorders include psychological developmental difficulties, post-traumatic stress disorder, depression,2-4 emotional disorders, anxiety symptoms including fears of separation, and somatic symptoms.7 These disorders may be persistent8 and may occur even in children born after their parents fled persecution. 9 10 Disorders associated with greater social impairment, including eating disorders11 and psychoses,12 also occur.

Not surprisingly, adversities that seem to put children at the highest risk of psychopathology include direct experience of or witnessing violence, loss or death of parents and family, and being looked after by parents who themselves have psychopathology and cannot cope with the children's demands.13 The children also have to cope with learning a new culture and language and adapting to school. Growing up in a culture different from that of their parents may cause family tensions.

Reducing children's psychological distress should be seen in the context of the needs of the community and family. Providing a safe haven, including access to housing and welfare support, is important. The persecution and murder of parents and other adult relatives may mean that the care of the young is inadequate and special help is needed, perhaps involving social service departments.14 Refugee children have the same rights as British children under the Children Act 1989. If unaccompanied they may be cared for by the local authority and defined by the Children Act as children in need. They should then be considered in the social service departments' plans and should have routine health assessments.

Many refugees can access primary care services and some are referred to mental health services, though these are underused by this group for various reasons. Parents and guardians may be unaware of or unable to consider the children's psychological distress. Culturally they may have a radically different understanding of psychological functioning. The various services established for children's needs may be bewildering, and practicalities of getting to services and fears about confidentiality, especially if the parents have not been granted formal asylum, may further reduce access.

Several initiatives have been developed to tackle these problems. Firstly, counselling services have been developed by refugees themselves, with refugee doctors becoming counsellors to their own communities.15. Secondly, a specialist service, the Medical Foundation, was established in London to provide care and treatment for the victims of torture. Much of its work is psychiatric assessment and treatment, and users include families and young children. Thirdly, refugee children and adolescents have recently been targeted through special school based mental health projects. Psychological help in schools may include therapy for the children and families and consultation with teachers, educational psychologists, and social workers. Liaison with the school health service to which children may present with physical symptoms will be facilitated.

Despite the difficulties, child and adolescent mental health services may provide help to many distressed young refugees. Collaboration between mental health, social, and education services is often required. Further research is needed to investigate the levels of psychiatric morbidity and service use, including the benefits of outreach services such as those based in school. The mobility of refugees and the unpredictability of future disasters, however, will always make detailed planning impossible.