Europe is experiencing a large-scale migration crisis, which has implications for healthcare provision across the region. According to the United Nations High Commission for Refugees (UNHCR) (2018a), a refugee is someone who has had to leave their country of origin due to ‘a well-founded fear of persecution because of reasons including their race, religion, nationality, membership of a particular social group or political opinion’. An officially recognised refugee must be afforded protection, provided with access to services and have the right to work in another convention country. On the other hand, an asylum seeker is an individual who has requested international protection, but whose claim for refugee status has not yet been determined (UNHCR, 2015). Unaccompanied asylum-seeking children (ASC) are defined as individuals under the age of 18 years who are separated from their legal guardian and are seeking protection. According to the UNHCR (2018b), there are about 25.4 million refugees in the world; 52% of these are aged under 18 years, which represents a significant number of children and youths.
In the Republic of Ireland, asylum seekers are accommodated through the direct provision system. A bed, canteen meals and a weekly allowance of €21.60 per individual is provided (Reception and Integration Agency, 2018). Since its introduction in 2000, the system has been a topic of major debate and criticism (Ní Raghallaigh and Thornton, 2017), with concerns being raised about child safety in direct provision centres. The accommodation has been criticised as providing an unsafe and unsuitable domestic environment for children (Arnold, 2012).
Unaccompanied ASC who arrive in Ireland are cared for by TUSLA, the Child and Family Agency, until they reach the age of 18 years. The unaccompanied ASC social worker arranges their asylum application. If the minor reaches the age of 18 years before their application is finalised, they enter into the adult system of direct provision (Ní Raghallaigh and Thornton, 2017). The World Health Organization (WHO) (2016) identifies refugees, asylum seekers and migrants as being at a high risk of experiencing social adversity and ill health.
Nurses have a moral, legal and professional obligation to provide the best care possible to all members of society; however, they often struggle with providing culturally competent care (Markey et al, 2018). To reduce health disparities, it is important that health professionals understand the specific needs, culture and norms of individuals, children and families (Danna et al, 2015). Nurses need to be aware of and understand the experiences of ASC and the challenges that they may have encountered. Such knowledge will help nurses to provide sensitive empathetic care for this group of children and their families (Murray and O'Donnell, 2013).
Aim
This article reviews studies that explored the psychological status and needs of ASC and families. The aim is to raise awareness of their needs and suggest ways nurses can provide culturally sensitive care for ASC and their families in diverse healthcare settings.
Methods
A literature search was conducted of Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycARTICLES and PsycINFO databases. Different synonyms for the terms ‘asylum seeker’, ‘children’ and ‘psychological impact’ were used. The term ‘refugee’ was excluded due to the different legal status of refugees and asylum-seekers (UNHCR, 2015). No time limit was applied to the searches. The search took place in February 2018 and the results were: CINAHL (n=260 articles), PsycARTICLES (n=593 articles) and PsycINFO (n=19 articles).
The titles of the articles were scanned and papers were excluded based on the relevance of the title. If the titles were relevant to the topic they were then screened on the basis of the abstracts (Coughlan et al, 2013). Although the literature search was global, articles from the USA and Australia were excluded after reading the title because in those countries the asylum processes are very different to the European context. An English language limit was applied to the search.
A total of 27 articles were retrieved from the searches for full reading (CINAHL, n=13, PsycARTICLES, n=1, PsycINFO, n=13). Fourteen articles were excluded after full reading because their focus was on policy rather than experiences. Two further studies were found from hand searches. This led to a total of 15 studies for inclusion and data extraction. One of the authors (CF) used a critical appraisal tool to critique the studies (Cronin and Huntley-Moore, 2015). The studies were from: the UK (n=5), Ireland (n=3), Norway (n=2), Finland (n=1), Denmark (n=1), Sweden (n=1), the Netherlands (n=1) and Belgium (n=1). Data from each article were extracted into a table. Thematic analysis of the data resulted in two themes: past trauma and daily life as an asylum seeker.
Results
Theme 1: past trauma
Eleven articles explored past trauma as an influencing factor on ASC's psychological state (Sourander, 2003; Montgomery and Foldsprang, 2005; Hodes et al, 2008; Michelson and Sclare, 2009; Groark et al, 2011; Seglem et al, 2011; Chase, 2013; Sanchez-Cao et al, 2013; Ní Raghallaigh, 2014; Thommessen et al, 2015; Oppedal and Idsoe, 2015).
The death of family members and witnessing violence were common traumatic events, and psychological reactions to such events included depression and post-traumatic stress disorder (PTSD). Having a parent who had been tortured or having experienced torture themselves was also prevalent. The trauma experienced and psychological impact are summarised in Box 1. Consequently, admission to hospital and the clinical environment can often trigger traumatic memories for torture survivors, and this applies to both the child and/or their parents (Murray and O'Donnell, 2013).
| Unaccompanied children | Accompanied children |
|---|---|
| Trauma experienced: |
Trauma experienced: |
| Reported psychological impact: |
Reported psychological impact: |
Unaccompanied asylum-seeking children
Hodes et al (2008) investigated the levels of PTSD and depressive symptoms among unaccompanied ASC (n=78, aged 13-18 years) compared with accompanied ASC (n=35, aged 14-19 years) living in the UK. Past war trauma, psychological symptoms and depression were assessed using the Harvard Trauma Questionnaire (Mollica et al, 1992), the Impact of Event Scale (Stallard et al, 1999) and the Birleson Depressive Self-Rating Scale (BDSR) (Birleson et al, 1987) respectively. The cross-sectional survey showed that unaccompanied ASC experienced higher levels of traumatic events compared with their accompanied peers. Unaccompanied ASC reported deprivation from food/water (37.2%), medical care (36.4%) and shelter (27.6%). Some had experienced imprisonment (17.9%), serious injury (32.5%), combat (45.5%), brainwashing (26.7%), rape or sexual abuse (11.7%), forced isolation (25.7%), near-death experiences (55.8%), forced separation from family (72.4%), murder of family/friends (58.7%), unnatural death of family/friends (64.4%), witnessed murder of strangers (44.2%), kidnapping (28%), torture (38.5%), and other frightening situations (82.7%). Sixty-one per cent of males and 73% females were at high risk of or had PTSD.
Using the same sample of unaccompanied ASC used by Hodes et al (2008), Sanchez-Cao et al (2013) assessed psychological distress and mental health service contact. Only 12 participants had accessed mental-health services, despite 47 having been identified as being at high risk of PTSD and nine at risk of depression. The reasons suggested for this included a lack of fluency in English, limited knowledge of services, high residential mobility, lack of GP services and personal factors.
Groark et al (2011) explored the experiences of six unaccompanied ASC (aged 16-18 years) living in the UK. The children reported loss of community, homes, loved ones, culture, freedom, trust, security, wealth and self-identity. They expressed feelings of loneliness and isolation as a result of the deaths of family and loved ones. Past trauma had inflicted a loss of certainty, control and safety. All participants expressed feelings of anger and frustration. Some reported disrupted sleep and eating patterns, low mood and difficulty completing tasks. Those who reported a low mood also felt dissociated and experienced intrusive thoughts of past memories resurfacing spontaneously (Groark et al, 2011). Chase (2013) conducted interviews with unaccompanied ASC (n=54) residing in the UK to assess their sense of ontological security and subjective wellbeing. They found that the ability of unaccompanied ASC to cope with past trauma depended on the predictability of their future.
Seglem et al (2011) investigated the level and predictors of depression among unaccompanied ASC (n=414) from 33 countries after resettlement in Norway. Their findings showed that females had higher rates of depressive symptoms, with the country of origin being an influencing factor. Depressive symptoms were measured using a Norwegian version of the Centre for Epidemiologic Studies-Depression Scale (CES-D) (Radloff, 1977). Youth from Somalia had fewer depressive symptoms, with children from Iraq having the highest mean depression score. Another Norwegian study assessed acculturation and mental health status among a large sample of unaccompanied ASC (n=895) (Oppedal and Idsoe, 2015). Depression was measured using a translated version of the CES-D scale for adolescents and Oppedal and Idsoe's, (2015) findings were similar to those in other studies. Many unaccompanied ASC reported war-related trauma (n=79%), and 52% of those had experienced intrusive symptoms associated with those events.
Thommessen et al (2015), in their study involving six unaccompanied ASC from Afghanistan living in Sweden, described the traumatic journey that four of the children had endured in order to get to Sweden. Participants' difficult experiences included hiding under trucks and cars without food or water for prolonged periods, being alone and living as an illegal immigrant.
Accompanied asylum-seeking children
Two studies described past trauma for accompanied ASC (Sourander, 2003; Montgomery and Foldspang, 2005). In Sourander's study (2003) with 10 families living in an asylum centre in Finland, parents reported that their children (n=25, aged 3-16) had depressive symptoms, fears, developmental delays and behavioural problems. In four families, at least one family member had been tortured, and in nine families one member had experienced political persecution. Marriage and parenting were adversely affected in families where a member had been tortured. In four families, the father had been murdered or disappeared. As in the unaccompanied ASC studies, separation from family members who were living in danger was a major source of upset.
Similar results were reported in a Danish study that assessed the mental health of accompanied ASC and their exposure to violence (Montgomery and Foldspang, 2005). Interviews were held with parents of 311 children aged 3-15 years, with assistance from a professional interpreter. Children came from Middle Eastern countries: 89.4% had lived under conditions of war and 92.6% in refugee camps. Many had witnessed violence (70%), had a parent detained (66.9%), lived in a family with at least one tortured parent (51.1%), and had a parent disappear or die (20.3%). Many children suffered from sadness, anxiety and sleep disturbances.
Theme 2: Daily life as an asylum seeker
Twelve articles addressed the reality of daily living as an asylum-seeking child resettled in a European country (Fanning et al, 2001; Sourander, 2003; Mels et al, 2008; Michelson and Sclare 2009; Ní Raghallaigh and Gilligan 2010; Groark et al, 2011; Seglem et al, 2011; Chase, 2013; Goosen et al, 2014; Ní Raghallaigh, 2014; Ogbu et al, 2014; Thommessen et al, 2015). All the participants described the anxiety and mental distress caused by living with an undetermined immigration status. Participants flagged fear of deportation and an uncertain future as their main source of psychological distress. In three qualitative studies, asylum-seeking parents reported a lack of space and control, feeling powerless and hopeless, poor parental mental health, and financial worries (Fanning et al, 2001; Sourander 2003; Ogbu et al, 2014). The range of adverse effects on families are summarised in Box 2.
In Ireland, Fanning et al (2001) examined the impact of direct provision on child poverty and social exclusion for asylum-seeking families (n=43). Children in these families were found to experience extreme deprivation and exclusion due to household income and inappropriate accommodation. Participants (83%) reported that one or more of their family members had experienced illness in the past 6 months. Parents were anxious about the uncertainty of their situation and the possibility of having to relocate to another centre involuntarily. Parents believed that their children were expressing stress psychosomatically, but the families felt powerless over their health. Language difficulties made the doctor–patient relationship complex and communication was not always optimum. Some parents became dependent on their children to act as translators, which made parents feel that they could not protect their children from adult worries. Hospitalisation presented particular problems and expenses; the cost of transport was an extreme burden on families during times of illness. Having no child care for the other children in a family was also an issue. A lack of autonomy and enforced inactivity was seen to contribute to lethargy, tiredness and depression. Participants felt deskilled and deprived of opportunity to contribute to Irish society.
Ogbu et al (2014) researched parents' perspectives of direct provision centres in Ireland. Despite a 13-year gap from the time of Fanning et al's (2001) study, the findings were similar. Parents highlighted that the environment of direct provision significantly challenged their ability to carry out parental duties effectively. Living in one room severely affected family life because the small space contributed to their children's sleep disturbances and behavioural problems. Communal spaces often served as a source of frustration, anger and anxiety between families. A lack of appropriate space for children to play caused frustration.
This issue was also reported by parents in Sourander's (2003) study. Parents expressed a lack of control over who their children associated with and disapproved of children being left alone unsupervised. This was seen as contributing to bullying, abuse and undue influence by older children (Ogbu et al, 2014). Parents also felt that an absence of study space put their children at an educational disadvantage. After-school study was available at some schools; however, like the parents in Fanning et al's (2001) study, parents struggled to pay for transport. Parents stated that the situation had a detrimental impact on their mental health, which in turn affected their children. The lack of certainty about the future made parents feel that their children were growing up insecure, non-assertive and with an inferiority complex. Parents felt that children who were born in direct provision had no concept of home. Most parents highlighted the need for parenting support while acknowledging that some of their parenting practices may not be considered acceptable in Ireland (Ogbu et al, 2014). Those who were active in religious communities found this a positive social support, which was also reported by Ní Raghallaigh and Gilligan (2010), and Ní Raghallaigh (2014).
In Ogbu et al's (2014) study, unaccompanied ASC (n=12, aged 15-18 years) reported conflict in asylum centres, as did those in Mels et al's (2008) Belgian study. Adolescents felt stigmatised and different from the other children with whom they attended school (Mels et al, 2008; Groark et al, 2011; Ní Raghallaigh and Gilligan, 2010; Ní Raghallaigh, 2014). Ní Raghallaigh and Gilligan (2010) carried out a study in Ireland, interviewing unaccompanied ASC (n=32, 14–19 years) from 13 countries about their coping strategies. Participants tried to deal with their own difficulties and did not wish to rely on peers or professionals. Distrust and religion helped the participants to deal with the challenges and disruption of resettlement by increasing their sense of self-reliance and by minimising the risk of being hurt or betrayed. Distrust was used as a means of self-protection.
Goosen et al's (2014) longitudinal study in the Netherlands examined the medical records of 8047 asylum-seeking children (aged 4-17 years) to determine whether relocations during the asylum process were associated with the incidence of newly recorded mental distress and whether this association was stronger among vulnerable children. The results showed that a high annual relocation rate (>3 relocations per year) was associated with increased incidence of mental distress. Relative risk associated with a high annual relocation rate was higher for children who had experienced violence and those whose mothers had been diagnosed with PTSD or depression.
Michelson and Sclare (2009) compared data on sociodemographic and psychological characteristics, service utilisation and provision of care between unaccompanied and accompanied ASC attending a specialist mental health clinic in London. The findings showed that, despite having higher levels of psychological trauma in comparison to accompanied ASC, unaccompanied ASC were less likely to have received trauma-focused interventions. Unaccompanied ASC were also significantly less likely to have been treated using cognitive therapy, anxiety management and behavioural training involving their parent/carer, as well as receiving fewer types of practical assistance with basic social needs.
Discussion
The literature review identified that asylum-seeking children and families experience a range of traumatic events that impact significantly on their psychological status and wellbeing. The range of traumatic events and daily living challenges that these children and families have encountered means that they require culturally sensitive care. Furthermore, the clinical environment can trigger traumatic memories (Murray and O'Donnell, 2013), with the consequence that hospitalisation may create considerable stress and anxiety, particularly for unaccompanied children. Where possible, care should be provided within the primary care sector so hospitalisations are avoided.
From a nursing perspective, these studies highlight the importance of taking a child- and family-centred care approach when caring for ASC (Nicholas et al, 2017). Through awareness and knowledge of children's and families' experiences, nurses can provide sustained support and sensitive care. Caring for refugees requires nurses to ascertain families' past experiences and their expectations of health services and professionals. It is essential that nurses use strategies to develop a trusting relationship with the child and parents/carers (Garakasha, 2014). Nurses can help establish trust by explaining procedures in simple words, repeating information, checking understanding and giving the child and carers time to ask questions. Providing information consistently may help reduce communication challenges and thereby reduce anxieties and fears.
An acute hospital admission or visit to the GP may be the first time an asylum-seeking child has encountered health professionals. Therefore, nurses should use the healthcare encounter as an opportunity to assess psychological status and wellbeing, and find ways to promote feelings of security and belonging (Chase, 2013). A thorough assessment could identify psychological distress, thereby enabling referral to appropriate specialist services (Fazel, 2018). However, nurses should not presume that all families will have psychopathology as many demonstrate considerable resilience (Sourander, 2003; Ní Raghallaigh and Gilligan, 2010). Considering that religion was a major source of support for many participants, care plans that address spiritual in addition to cultural and familial needs would be beneficial (Nicholas et al, 2017).
Care provision and patient education need to be non-judgemental and cognisant of asylum-seekers' experiences and living situation. In view of the diverse needs of children and families, nurses clearly require education and skills training to ensure that they provide care that is culturally competent. As cited earlier, parents' dependence on children to act as interpreters could expose them to inappropriate conversations. Nurse managers need to ensure that interpreter services are available and consider the use of technology for translation to aid communication. Furthermore, families may require support with child care, transport and finance during a healthcare encounter or hospitalisation. The key considerations are outlined in Box 3.
Conclusion
Daily living as an asylum seeker in Europe clearly presents many challenges and hardships for most children and families. These studies indicate that past trauma has a profound impact on ASC's mental health, with depression and PTSD common diagnoses. These factors indicate that hospitalisation and healthcare encounters could be challenging and anxiety-provoking for many children and their families. The current refugee crisis in Europe will continue to have long-term implications for health services.
Further research is therefore needed to document and understand migrant children's and families' experiences of health services. Understanding their needs will help nurses to ensure that appropriate child- and family-centred care is delivered to this vulnerable population.