Montgomery E. Trauma, exile and mental health in young refugees.
Objective: To review evidence of trauma and exile-related mental health in young refugees from the Middle East.
Method: A review of four empirical studies: i) a qualitative study of 11 children from torture surviving families, ii) a cohort study of 311 3–15-year-old asylum-seeking children, iii) a qualitative study of 14 members of torture surviving families and iv) a follow-up study of 131 11–23-year-old refugees.
Results: The reactions of the children were not necessarily post-traumatic stress disorder specific. Seventy-seven per cent suffered from anxiety, sleep disturbance and/or depressed mood at arrival. Sleep disturbance (prevalence 34%) was primarily predicted by a family history of violence. At follow-up, 25.9% suffered from clinically relevant psychological symptoms. Traumatic experiences before arrival and stressful events in exile predicted internalizing behaviour, witnessing violence and frequent school changes in exile predicted externalizing behaviour. School participation, Danish friends, language proficiency and mother’s education predicted less long-term psychological problems.
Conclusion: Psychological problems are frequent in refugee children, but the extents are reduced over time in exile. Traumatic experience before arrival is most important for the short-term reaction of the children while aspects of life in exile are important for the children’s ability to recover from early traumatization.
• Asylum-seeking children suffer from a high level of psychological problems, but over time in exile, this level is considerably reduced.
• The children’s traumatic background seems only to a limited extent to determine their long-term mental health while exile-related stresses, including discrimination, seem to be of prime importance.
• The individual perspective on mental health of refugee children needs to be complemented with a perspective focusing on the social life context in exile.
• Assessment of mental health at baseline and follow-up did not use the same methodology, preventing a direct comparison of symptom level.
• The sample sizes of the various studies are limited calling for caution in the conclusions.
• The study groups are highly selected (refugees in a Western country), and the results cannot be generalized to other groups, e.g. children exposed to organized violence remaining in their home country.
The Faculty of Health Sciences at the University of Copenhagen has accepted this review, together with the following eleven previously published papers, for public defence for the doctoral degree in medicine. Copenhagen, June 14, 2011. Dean Ulla Wewer.
The line of studies presented in this review was conceived in the context of a military coup d’état in Manila, the Philippines, in December 1989. The Rehabilitation and Research Centre for Torture Victims (RCT) was the initiator and promoter of an international project called ‘Children in Crisis’, and a qualitative study of children of torture survivors in treatment had been carried out at RCT. A colleague and I presented the results of this study during a 2 weeks’ conference in Manila in conjunction with presentations from other participating countries, and a plan for the continuation of the international project was discussed. The coup disrupted our plans, but while our Philippine hosts were, naturally, mostly concerned with the political situation and the potential impact on the human rights situation in the country; the international delegations, being confined to the conference hotel because of the violence in the streets, had ample time to discuss and plan future research projects. The military coup was overthrown within a few weeks and the human rights situation stabilized, but for me, the experience in Manila set the stage for my continuing work within the field.
My point of departure was my experience as a clinical psychologist working within the Danish school system with children having emotional and behavioural difficulties. I had been involved in the introduction of systemic family therapy to this area of work and was engaged in a systemic training programme. I started working as a part-time consultant at RCT the year before the Manila conference and, together with two other clinical psychologists and a paediatrician, I was immediately attached to the ‘Children in Crisis’ project.
After having attended the Manila conference, I continued my clinical work at RCT and took part in the development of the child and family-oriented rehabilitation work, culminating in the establishment of the first multidisciplinary family team at RCT in 1994. Mainly through the clinical work, the importance of the family environment for traumatized children became obvious. The individual trauma perspective, focussing on the links between specific traumatic experiences and resulting psychopathology, was then complemented with a systemic-constructionist perspective with its focus on meaning-making processes and the socially constructed ‘realities’ in relation to which the families understand their lives and organize their experience. Later, both through the clinical experience and through the research findings, the importance of the wider social network for the children’s mental health and development became more apparent, and I became interested in the ecological perspective where people’s reactions are studied and understood in relation to the various contexts within which their lives are embedded, and where the focus for research and intervention is the relations between various factors contributing to psychopathology as well as to resilience.
From 1990, I was a full-time employee at RCT and was, parallel with the clinical work, given the opportunity, first, to do my PhD study at the centre and afterwards to continue my research on refugee children. I wanted to expand the earlier clinical studies of the mental health consequences of torture and organized violence for children to non-clinical populations of asylum-seeking and refugee children to be able to identify and understand risk and protective factors and processes in the children’s social ecology. Over the course of my early work in the field, I found that it is through the interplay between quantitative and qualitative research methodologies that we are provided with the most thorough understanding of central themes on which to base our interventions. Thus, modern epidemiology and statistical analysis seemed relevant for this purpose, in combination with qualitative methods.
At the time when the studies were started, most asylum-seeking families who arrived in Denmark were from countries in the Middle East and, because the majority of the clients at RCT came from the Middle East, they became the target of my research.
The review is based on the following eleven scientific publications (numbered in the order of appearance in the review) about refugee children and youth in Denmark:
Montgomery E, Foldspang A. Validity of PTSD in a sample of refugee children: can a separate diagnostic entity be justified? International Journal of Methods in Psychiatric Research 2006;15(2):64–74. (1).
Foldspang A, Montgomery E. Criterion-validity-based assessment of four-scale constructs. Scandinavian Journal of Public Health 2000;28:146–153. (2).
Montgomery E, Krogh Y, Jacobsen A, Lukman B. Children of torture victims: reactions and coping. Child Abuse & Neglect 1992;16:797–805. (3).
Montgomery E, Foldspang A. Traumatic experience and sleep disturbance in refugee children from the Middle East. European Journal of Public Health 2001;11:18–22. (4).
Montgomery E. Tortured families: a coordinated management of meaning analysis. Family Process 2004;43(3):349–371. (5).
Montgomery E, Foldspang A. Predictors of the authorities’ decision to grant asylum in Denmark. Journal of Refugee Studies 2005;18(4):454–467. (6).
Montgomery E, Foldspang A. Seeking asylum in Denmark: refugee children’s mental health and exposure to violence. European Journal of Public Health 2005;15(3):233–237. (7).
Montgomery E. Self- and parent assessment of mental health: disagreement on externalizing and internalizing behaviour in young refugees from the Middle East. Clinical Child Psychology and Psychiatry 2008;13(1):49–63. (8).
Montgomery E. Long-term effects of organized violence on young Middle Eastern refugees’ mental health. Social Science & Medicine 2008;67:1596–1603. (9).
Montgomery E. Trauma and resilience in young refugees: a 9-year follow-up study. Development and Psychopathology 2010;22:477–489. (10).
Montgomery E, Foldspang A. Discrimination, mental problems and social adaptation in young refugees. European Journal of Public Health 2008;18(2):156–161. (11).
Data used in the studies by Montgomery and Foldspang (1), Foldspang and Montgomery (2) and Montgomery and Foldspang (4) were collected during my PhD project, and the weighted anxiety scale examined by Foldspang and Montgomery (2) was used as one among other dependent variables in the PhD project, but none of the papers were part of the PhD thesis. I participated in the design and implementation of the qualitative study (3) together with the co-authors. I designed and conducted the qualitative study (5) and the follow-up study (6–11) as principal investigator.
To enhance readability of this review, the usual format of scientific presentations, which was applied in the original publications, is compressed. After a short introduction and a presentation of the study populations and methodologies, each section will: i) introduce and comment on the specific theme, ii) briefly present main findings in the studies and iii) present main perspectives for discussion and conclusion. Literature reviews are primarily presented in tabular summaries organized according to year of publication and with own studies marked by shading. In this way, the reader can follow what was known before a particular study was conducted, what was found in the study and what has been found in subsequent studies.
In 2002, a new law was introduced in Denmark with the explicit aim of reducing the numbers of foreigners coming to Denmark (12). While asylum continued to be granted to applicants who fulfilled the criteria of the Geneva Convention (13), the ‘de-facto’ status, according to which refugees who had a substantial subjective fear of going back because of previously traumatizing experiences, such as torture or rape, could be granted permission to stay, was abolished and replaced by a new more limited ‘protection’ or B-status, according to which permission to stay could be granted to persons who would risk the death penalty, torture or other inhuman or degrading treatment or punishment, if they return to their home country. As planned, the new law resulted in a steady decline in the numbers of asylum applications from 10 347 in 2000 to 1029 in 2007; however, the numbers have increased again in 2008 to 2409, and the increase seems to have continued in 2009.
In 2008, 1453 people were granted refugee status in Denmark (14) and 157 were granted humanitarian leave to remain. The granting of refugee status amounted to 2% of the total number of residence permits granted during this period. As of 1 January 2009, 526 036 immigrants and their descendants lived in Denmark; of these, 353 751 came from non-Western countries (15).
The reduction in numbers of asylum seekers and refugees in Denmark does not, unfortunately, mirror a reduction in the numbers of refugees worldwide. According to UNHCR statistics, the numbers of people uprooted by armed conflict continued to rise in 2006 and 2007 and remained high in 2008, resulting in 16 million refugees and asylum seekers worldwide, of whom well over 1.6 million live in Europe (16). During 2008, at least 839 000 individual applications for asylum or refugee status were submitted to governments and UNHCR offices in 154 countries, which constitute a 28% increase, compared with the previous year. A little less than half of the worldwide refugee population is estimated to be children under the age of 18. The populations of concern to UNHCR worldwide (refugees, asylum seekers, internally displaced and repatriated refugees) add up to about 25 million (as of 1 January 2009). In comparison with these worldwide figures, the numbers of refugees and asylum seekers arriving and living in Denmark seem negligible. Nevertheless, issues concerning refugees, including problems in relation to integration, work, health and family life, continue to occupy a prominent place in political debate and media coverage in Denmark. This review attempts to provide scientific evidence in relation to some of these issues, focussing specifically on children and youth.
Before about 1980, only a few studies of children’s reactions to various forms of traumatic events existed (17), and these consisted primarily of collections of clinical case descriptions [see for instance, the study by Freud and Burlingham (18)]. The diagnosis, post-traumatic stress disorder (PTSD), was included in DSM-III in 1980 (19); however, no diagnostic criteria for traumas in children were reported before the publication of DSM-III-R in 1987 (20). In the early 1980s, Leonore Terr described the reactions in a group of children who had been kidnapped and buried alive in a school bus (21, 22). She documented how normal children reacted to their experience with a number of psychological symptoms; however, her observations were not immediately acknowledged by health professionals, a scenario which, among others, has been described as ‘the concept of clinician denial’ (17 p. 4). In a review from 1985 (23), it was further concluded, based on previous studies, that although some children could react with emotional difficulties to immediate and serious events, the reactions were short term in most of the cases. At this early stage of the research within this field, the children’s reactions were viewed, first and foremost, as being dependent on their parents’ reactions; if their parents remained calm, the children would not react even to serious events. Simultaneously, clinical documentation from working with referred children suggested that traumas could lead to serious cognitive and emotional disturbances and possibly lead to a permanently disturbed personality development, unless the experiences were treated with, for instance, therapy (24).
The Rehabilitation and Research Centre for Torture Victims (RCT) was established in 1982. The studies that figure in this review were initiated in the end of the 1980s based on the experiences arising from routine assessments, carried out by RCT’s paediatrician, of children of torture victims. The few studies that existed at the time, primarily conducted in clinical populations, showed that children of torture victims generally have a number of emotional, behavioural and psychosomatic problems (25–29). This fact challenged the views held by similar centres, which were still relatively new at the time and which focused mostly on individual treatment of the actual torture victims themselves. The extent of the psychological symptoms suggested the necessity to add a psychological component to the work with the children; however, the knowledge within this field was limited at the time, as was knowledge about the magnitude of the problems within unselected populations of refugee children.
The studies discussed here are about a group of children who were born and lived their first years in countries in the Middle East, where war and human rights violations were part of everyday life. They escaped from the violence and most of them arrived in Denmark with at least one of their parents during the early 1990s. Many families had experienced the Iran–Iraq war (1980–1988), and in Iran, the revolution and establishment of the Islamic Republic in 1979 had resulted in several decades of serious human rights violations such as persecution, detention, torture and execution of political opponents. In Iraq, the Kurdish resistance was crushed by means of chemical weapons, massacres and massive forced resettlement, and any opposition against the dictatorship of Saddam Hussein was fiercely crushed, for example by the bombing of densely populated areas. During the Iraqi invasion of Kuwait in 1990, civilians were used as ‘human shields’ against military attack. Lebanon had witnessed decades of civil war and in the early 1990s, large parts of the country were outside government control. Palestinians were exposed to constant harassment both by national and Syrian intelligence operations and by various militias, and life in the refugee camps was very insecure. In Syria, political opponents were detained without trial, the use of torture was widespread and the Palestinian population had very limited civil rights.
The children and their parents applied for asylum in Denmark, where 60% of them were allowed to stay. With the exception of one of the articles (3) included in the review, the rest are about the children’s situation at arrival and after 8–9 years in Denmark.
Aims of the study
The aims of the studies among Middle Eastern refugee children were to
i) Inspect the validity of central concepts such as post-traumatic stress disorder and anxiety
ii) Identify the extent and determinants of psychological problems at arrival in Denmark
iii) Identify determinants of receiving a residence permit in Denmark
iv) Identify the extent and determinants of psychological problems 8–9 years after arrival in Denmark.
Material and methods
The review summarizes findings and considerations from four empirical studies:
i)Children of torture victims, a qualitative study of torture surviving families who started their rehabilitation at the Rehabilitation and RCT in 1989 (3).
ii)Refugee children from the Middle East, a cohort study consecutively including 3–15-year-old children from the Middle East, who were registered as asylum seekers in Denmark with at least one parent, in 1992–1993 (1, 4). A segment of the participants further participated in a Validity study (2). The studies by Montgomery and Foldspang (6) and (7) are based on data from the study Refugee children from the Middle East as well as information on the families’ residence permit status obtained from the Danish official registries in 1997.
iii)The torture surviving family, a qualitative study of torture surviving families interviewed in 1993–1995, after they had been granted asylum in Denmark (5).
iv)Mental health and integration of young refugees from the Middle East, a follow-up study of the young refugees from study ii), who had been granted permission to stay in Denmark, conducted in 2000–2001 [studies by Montgomery and co-workers (8–11) are based on data from both studies ii) and iv)]. A segment of the participants further participated in a second Validity study [referred to in the study by Montgomery (10)].
Study populations and data
The study Children of torture victims included interviews, participant observation and psychological testing of 11 children (three boys and eight girls), 5–13 years old. One eligible family refused to participate, and another did not receive the offer because the father’s psychotherapist refused to pass it, as he found the father’s condition too poor. The children came from five families, all intact nuclear families, originating from Chile, Uruguay, Turkey, Afghanistan and Iraq. The families had lived in Denmark between 2.5 and 10 years, except in one case, where the mother and children had recently arrived. All had been granted asylum.
Table 1 provides an overview of the epidemiological study populations included in the review and the determinants, the outcomes and the statistical tests used in the analyses. Data for the study Refugee children from the Middle East were collected through structured interviews with parents shortly after arrival in Denmark. The study group comprises 311 refugee children from the Middle East (160 boys and 151 girls; mean age 7.5 years at arrival in Denmark, range 3–15). The 311 children originated from 146 families, and 187 of them arrived in Denmark with both of their parents. Nationality and ethnicity of the children is presented in Table 2. A total of 344 children from 168 families arrived during the inclusion period, and thus, 90.4% of the children and 88.7% of the families participated in the study (Fig. 1). There were no differences between non-participants and participants with regard to sex, age and nationality, except where Syrian nationals were concerned (21.2% among the non-participants vs. 4.2% among the participants, P < 0.0005).
Table 1. Study populations, determinants, outcomes and statistical analysis in the epidemiological studies
Refugee children from the Middle East; 311 children aged 3–15 years, 1992–1993
PTSD symptom complex
Factor analysis based on original item scores (0–2): (1) Exploratory factor analysis including varimax rotation, and (2) confirmatory factor analysis using the chi-squared statistic, comparative fit index and the root mean square error of approximation to estimate model fit
Refugee children from the Middle East; 149 asylum-seeking families, 1992–1993 (information on residence permit status from 1997)
Social and demographic background
Residence permit status
Families with and without residence permit were compared in chi-squared tests and predictors of being granted residence permit were identified in multiple logistic regressions using forward selection of variables
Refugee children from the Middle East; 311 children aged 3–15 years, 1992–1993 (information on residence permit status from 1997)
Social and demographic background
Residence permit status
Children in families with and without residence permit were compared in chi-squared tests and the residence permit determination pattern in either group compared using multiple logistic regressions with forward selection of variables
The first Validity study comprises 99 refugee children from 46 families (47 girls and 52 boys; mean age 7.3 years, range 3–15), who arrived consecutively in the main refugee reception centre from 15 May to 15 June 1992 or 1 September 1992 to 15 January 1993. Another 46 children arriving during the same period of time could not be reached because of immediate transferral to refugee centres in other Danish regions. None of the families, who could be reached, refused participation. To establish a clinical reference for the assessment of the individual child regarding psychological symptoms exceeding the normal range for the particular age, the parents participated in a semi-structured psychological interview about their children, conducted by the author, blinded for the results of the structured interview. This interview was intensive and conducted as an empathic talk and included examples of the reactions of the child in different situations. Directly following the interview, the child was classified as symptomatic or non-symptomatic in relation to the same qualitative dimensions on which the structured interview was based. At this point, a detailed case description was produced, after which final classification took place. The final classification is applied in the analysis.
Three families with altogether 14 members participated in the study The torture surviving family. Purposive sampling (30) was used among participants in the study Refugee children from the Middle East whose family had been granted asylum, who had participated in the Validity study and who had a father who had been imprisoned and tortured. Interviews were carried out shortly after the families had obtained asylum in Denmark and included a family interview as well as interviews with the individual family members separately. The interviews were conducted by the author according to open interview guides, developed for this investigation, for adults and older and younger children. Interviews were conducted with the help of a professional Arab interpreter.
Data in the study Mental health and integration of young refugees from the Middle East were collected through structured interviews with parents and children and by use of self-administered questionnaires filled out by parents and children. The structured interview questionnaires were developed by the author for this investigation based on, among other things, focus-group interviews with five 18–21-year-old male refugees and qualitative interviews with two 17-year-old female refugees from the Middle East. None of these young refugees were members of the study population itself. Mental health was assessed using part of the Achenbach system of Empirically Based Assessment (ASEBA) of youth and young adults (31–33) (see later).
Information on the families’ residence permit status was obtained from the Danish official registries based on the individual person identification number (udlændingenummer). A final decision on whether to grant a residence permit had been reached in all cases within 5 years, by July 1997 (mean follow-up time, 4.7 years) and 190 children from 90 families had been granted permission to stay.
Of the 190 who had been granted permission to stay, 182 were available for follow-up. The final study group comprises 131 young refugees (76 boys and 55 girls; mean age 15.3, range 11–23) from 67 families; thus, 72% of the available children and 77% of the available families participated (69% of the 190 children and 74% of the 90 families who had been granted permission to stay). Nationality and ethnicity appear in Table 2.
Of the 190 children who had been granted permission to stay, one had died, six had emigrated and one could not be found in the Danish registry, leaving 182 to be contacted (Fig. 1). The parents of 37 young refugees refused to participate, and access to their children was therefore not possible; nine young refugees refused to participate even though the parents had accepted and been interviewed. Thus, 136 young refugees accepted to participate, but in five cases, data turned out to be too incomplete for analysis. Non-participants did not differ significantly from participants as concerns nationality (mostly Iraqi and Iranian), ethnicity (Kurdish and Palestinian), parents’ religion (mostly Islam), psychological problems at arrival (anxiety, sleep disturbance and ‘sad or miserable appearance’) or numbers of types of traumatic experiences before arrival. However, more girls participated (79.2% girls vs. 64.0% boys, P < 0.05), and younger age predicted participation [odds ratio (OR) 0.90 per year, P < 0.04].
A section of the young refugees further participated in a second Validity study, selected from among all the participants on the criteria of living in municipalities with specific postal codes (reachable in about 1 h journey from the office of the author). Upon being granted permission to stay, refugees are placed in municipalities by the authorities based on availability of housing, so the selection criterion for the Validity study was not assessed to introduce a systematic bias. Seventy-six young refugees were contacted for the Validity study, five refused participation and four of the interviews could not be used for analysis because of incomplete data in the structured interview. The validation sample thus consists of 67 young refugees. All interviews were carried out by the author.
The interviews of parents and young refugee were conducted using the Danish translation of the Schedule for Affective Disorders and Schizophrenia for School-aged Children (K-SADS-PL) (34). This is a semi-structured diagnostic interview tool developed for assessing present or earlier episodes of psychopathology in children and adolescents in accordance with the criteria in DSM-III-R and DSM-IV. It consists of questions and objective criteria for classifying individual symptoms. In the analysis used for establishing proper cut-off levels for the self-reports and parent checklists in the follow-up study, the dichotomy ‘with or without a diagnosis’ was applied.
Main variables included in the analysis
In the following section, the main variables included in the baseline and follow-up study are described. All dichotomous variables were coded as the presence of the particular factor (e.g. a particular nationality) in relation to all others.
Age and sex. The age groups applied in the studies by Montgomery and Foldspang (1) and (4) followed broad developmental phases: preschool (3–5 years), school-age (6–11 years) and early adolescence (12–15 years) (24). The exact number of years was applied in the studies by Montgomery and co-workers (8–11). The sex and age of the child were included in all multiple regressions.
Nationality and ethnicity. Nationality and ethnicity were coded at arrival in Denmark. Following the Danish procedure for asylum seekers, the child was registered with the father’s nationality if he accompanied his family, and if not, the child was registered with the mother’s nationality. Ethnicity (Palestinian or Kurdish) was always registered with reference to the father (35).
Socio-economic background in the home country. Owing to the difficulties in differentiating between different types of education, parents’ education was measured as the total number of years including schooling, vocational training and university studies. Division into different professional groups was performed based on open answer categories after all interviews had been completed. Religion was based on formal adherence rather than personal belief. Information on social class (upper, middle and lower) was based on self-assessment by the parents, as it was difficult to establish more objective criteria in this culturally diverse group.
Trauma complex. At arrival, individual children were classified according to a total of 34 specific violent exposures that were not mutually exclusive, all of which were included in the study by Montgomery and Foldspang (1). Other studies only included a segment of these exposures; thus, 17 main types were included in the study by Montgomery and Foldspang (4), while several specific experiences were combined to form five major types of violence in the studies by Montgomery and co-workers (7–10): living under conditions of war, residing in a refugee camp, imprisonment and torture of parents, witnessing events of violence (house search, arrest of family members, intimidation, torture and killing) and death or disappearance of a parent. The study of Montgomery and Foldspang (6) included violent exposure targeting the family rather than the individual child: war, refugee camp, being on the run, detention of one of the parents, torture of one of the parents, death or disappearance of one of the parents because of violence. Concerning specific exposures, the parents were asked about the age of the child when first exposed to violence, the intensity of the experiences (one to two times, more than two times) and the length of the exposure, when relevant. This specific information was used in the study by Montgomery and Foldspang (4). A scale ‘Number of types of traumatic events before the birth of the child’ was constructed by summarizing three types of experiences occurring in the family before the birth of the child (grandparents’ violent death before the birth of the child, father and/or mother imprisoned and tortured before the birth of the child) and another scale, ‘Number of types of traumatic experiences before arrival in Denmark’, by summarizing the occurrence of 22 war- and organized violence-related experiences happening to the child before arrival. Both scales were included in the multivariate analysis in the study by Montgomery (9), and the scale ‘Number of types of traumatic experiences before arrival’ was used in the study by Montgomery (10).
Finally, based on the results of the first qualitative study (3), the parents were asked if they had informed their child about the eventual imprisonment and torture of one or both parents and the reason for escape.
Life in exile
Social situation. Parents provided information on family structure at baseline and at follow-up, the time it took for getting a residence permit, their own education and work experiences, income and housing as well as language proficiency in specific situations (speaking, reading and writing), measured on a 0–3 scale from ‘not at all’ to ‘well’. Based on this information on language proficiency, dichotomous variables were constructed (with the cut-off between 0 and 1) for use in the analysis. Information on how many schools the young refugees had attended since arrival was based on specific information on the different schools from parents and the young refugees themselves. The young refugees provided information on their own education and work experience, friends, free time activities and Danish reading and writing proficiency rated on a 0–3 scale from far below average to above average.
The composite indicator ‘social adaptation’ was separated into two qualitatively different parts; actual participation (behaviour): attending school or work, participation in organized leisure activities, has been with friends the last month and criminal behaviour, all coded dichotomously based on a combination of closed and open answer categories after all interviews had been completed; and second, prerequisites for participation: proficiency in reading and writing Danish, measured on a 0–3 scale, number of Danish friends and number of schools attended.
The young refugees also provided information on their own religion at follow-up, and this information, rather than parents’ religion, was used in the studies by Montgomery and co-workers (8–11).
Stressful experiences. At follow-up, the parents and the young refugees were asked about the young refugees’ experience of potentially stressful or traumatic experiences in Denmark since arrival, through structured questions. Based on parents’ information, the occurrence of eight specific stressful events happening to their child during the time in exile was summarized to form the scale ‘Number of types of stressful events in exile’ (been attacked, witnessed attack on others, been in an accident, involved in illegal acts, been arrested, imprisoned, in hospital and placed outside the home), and this scale was used for analysis in the studies by Montgomery (9) and (10). The young refugees’ own experience of the occurrence of five specific types of events (been attacked, witnessed attack on others, been in an accident, death of family member or friend, parents’ separation) was also included in the analysis in the study by Montgomery (9). Furthermore, the young refugees were asked about their experience of five specific types of experiences of being rejected or harassed because of being a foreigner (teased, derogatory remarks, refused at discotheque, refused by friends and ignored by a teacher), and the variable number of types of discriminating events were computed from this. The decision on which types of events to include was based on the focus group and qualitative interviews conducted prior to the investigation.
Family relations. Both parents and children were asked about intrafamily communication. Questions concerned specific events (Do you speak with your mother/father if you have experienced something nice/have problems/are sad/have been teased/are happy? Do you quarrel with your mother/father?). Answers were rated on a 0–2 scale (rarely, sometimes or frequently). Differences in parents’ and children’s perception of the same type of communication were used in the study by Montgomery (8).
Mental health assessment.
Baseline study. At arrival in Denmark, the mental health of the children was assessed through a questionnaire developed for the study Refugee children from the Middle East (36). Specific emotional symptoms and behavioural problems of the child were allocated to one out three occurrence levels, 0: ‘rare’, 1: ‘somewhat or sometimes’ or 2: ‘frequent or intense’. Three questions on sleep disturbance focused on nightmares, difficulty in falling asleep, and difficulty in staying asleep. For the statistical analysis in the study by Montgomery and Foldspang (4), sleep disturbance was defined as at least one of the above-mentioned three problems at the highest level (frequent or intense). In the studies by Montgomery and co-workers (7–10), mental health at arrival was indicated by three frequent symptoms: anxiety, the assessment of which was based on regression-based empirical scoring of interview questions that were criterion validated by in-depth psychological interview [see the study by Foldspang and Montgomery (2)]; sleep disturbance (as described earlier) and the frequent and/or intense occurrence of the depressive symptom ‘sad or miserable appearance’, which has previously been shown to be a significant discriminator between referred and non-referred children (37). PTSD symptoms in the study by Montgomery and Foldspang (1) were based on 14 specific items including re-experience (dreams about traumatic events, speaking about traumatic events, suffers from nightmares, becomes scared when hearing shooting from the military drill ground close to the refugee reception centre), avoidance (does not play with other children, has lost previous interests, avoids talking about traumatic events, feels hopeless about the future) and arousal (has problems falling asleep, has problems staying asleep, is easily upset and angry, is easily aroused, lacks concentration when watching TV and when told a story).
Follow-up study. The Achenbach System of Empirically Based Assessment consists of checklists for parents and self-reports and covers important aspects of adolescent and young adult psychopathology. For the present study, the Child Behaviour Checklist (CBCL), the Young Adult Behaviour Checklist (YABC), the Youth Self-Report (YSR) and the Young Adult Self-Report (YASR) were applied.
All checklists and self-reports are constructed in the same way, containing closed questions concerning a wide range of behavioural and emotional problems referring to the young person’s behaviour over the past 6 months. Each question is rated on a 0–2 scale according to whether the description is ‘not true’, ‘somewhat or sometimes true’ or ‘very or often true’. For each scale, a total score, an internalizing and an externalizing score, is computed based on general as well as age-specific behaviour (31–33).
In accordance with the recommendation in the Danish manual and standardization (37, 38), parents were asked to fill out the CBCL (32) for children and youth up to 16 years of age and the YABC (33) for young people 17 years and above. Similarly, young refugees who were up to 16 years old were asked to fill out the YSR (33) and young refugees above 16 the YASR (31). However, two young refugees filled out the YSR as they had just turned 17. Only the ‘problem’ items of the checklists and self-reports were used. The official Danish translations of the CBCL and the YSR were used, although parents were given the possibility of filling out the official Arab translation of the CBCL if their command of Danish was insufficient. The YABC and the YASR were translated into Danish for this investigation in co-operation with the Danish CBCL distribution centre (Det Børnepsykiatriske Hus, Odense University Hospital, Odense) following the recommended procedure with two independent translators. Parents were given help from a professional interpreter if necessary.
The CBCL consists of 118 items and the YABC of 105 with an overlap of 88 between the two. The YSR consists of 100 items and the YASR of 110, with an overlap of 90 items. In linear regressions (8, 9), only the items shared between the applied scales were used. Correlations (rs) and linear regression estimates (R2) between the age-specific, self-reported scales and scales consisting only of items shared between the YSR and the YASR varied between 0.92 and 1.0 (rs), P < 0.01 and 0.90 and 0.99 (R2), P < 0.0005. Similar estimates concerning the age-specific parent checklists and scales consisting of the shared items varied between 0.94 and 0.99 (rs), P < 0.01 and 0.89 and 0.99 (R2), P < 0.0005 (Table 3). As recommended by Achenbach (31–33), scales with more than eight missing items were discarded.
Table 3. Problem scores at the self-reports (N = 131) and parent checklists (N = 122) among 11–23-year-old refugees from the Middle East, 2000–2001
*Combined scales, consisting of items shared by the two self-reports and the two parent checklists respectively.
Youth Self-Report (N = 82)
Total problem score
Young Adult Self-Report (N = 49)
Total problem score
Combined self-report (N = 131)
Total problem score
Child Behaviour Checklist (N = 80)
Total problem score
Young Adult Behaviour Checklist (N = 42)
Total problem score
Combined Checklist (N = 122)
Total problem score (N = 120)
Parents’ health situation. No information on parents’ health situation was included in the baseline study. In the follow-up study, indicators of parents’ health were based on specific questions on types of treatment, types of prescribed medication used regularly and self-reports on six specific types of psychological and somatic health problems (rated on a yes/no scale).
In the qualitative study Children of torture victims, data from interviews, participant observations and psychological testing were first summarized in case descriptions, then relevant themes developed and data coded and interpreted. In the qualitative study The torture surviving family, all interviews were recorded on tape, the Danish translation transcribed, a system of codes developed and data coded and recoded several times before final interpretation.
Data in the studies Refugee children from the Middle East and Mental health and integration of young refugees from the Middle East were analysed statistically in most cases by the use of chi-squared tests for 2 × 2 and 2 × k tables, Fisher’s exact test, Spearman’s rank correlation coefficients (rs) and linear and logistic regressions (39). In multiple logistic regressions, a weighted OR was calculated, conditional on several circumstances. P < 0.05 was applied as a general level of significance in all the studies. Specific analyses from each study are summarized in Table 1.
All studies were approved by the Regional Committee for Ethics in Medical Science. Written information was produced for each study and translated into the appropriate languages. All studies followed the ethical rules for medical scientific studies (Declaration of Helsinki), and the studies Refugee children from the Middle East, The torture surviving family and Mental health and integration of young refugees from the Middle East were submitted to and approved by the Danish Data Protection Agency. The visiting nurse conducted the structured interviews in both the baseline and the follow-up study. When conducting the baseline study, she was also employed part time in the main refugee reception centre and any cases of children or adults who needed medical attention could be followed up directly after the interview and appropriate referrals made. In the follow-up study referrals to the family’s general practitioner could be made by the visiting nurse after the interview, with the permission of the parents (or of the young refugee, if above 18 years old). Cases needing attention after the psychological interviews in the follow-up study were followed up by the author, and contact was established with the appropriate authority (social worker or general practitioner) based on permission from the parents or the young refugee.
Construct validity of post-traumatic stress disorder. As previously mentioned, DSM-III-R (and later DSM-IV) covers the diagnosis of PTSD in children. A number of studies of children’s reactions to traumatic events are based on this diagnosis, and several studies find a high frequency of PTSD in refugee children (see Table 4). One of the criteria for identifying the diagnosis of PTSD is that the person has been exposed to an extreme event, after which the person demonstrates a number of characteristic symptoms. Thus, the diagnosis contains an a priori assumption of a relationship between an event and a number of psychological reactions; this has been subject to criticism and has, among other things, been viewed as an indication of a medicalization of human misery and suffering (40, 41).
Table 4. Literature review of prevalence of psychological problems in community samples of refugee and asylum-seeking children and adolescents (shading indicates own studies)
The study Refugee Children from the Middle East included both information on a number of traumatic events in the child’s life and the occurrence of a number of specific PTSD symptoms (42, 43) in addition to a number of other symptoms, that is, anxiety, depression and aggression, conditions that are not part of the PTSD diagnosis. With the purpose of testing the legitimacy of this specific conceptualization of trauma in children, a construct validity assessment was carried out, studying the degree of association between one or more traumatic events and 14 specific symptoms of PTSD (1).
The specific PTSD symptoms did not cluster in an exploratory factor analysis including also other registered psychological symptoms and reactions. The 14 specific PTSD-related symptoms were fitted in a confirmatory factor analysis testing the hypothesis of a one-factor (general PTSD) model, a three-factor PTSD model (re-experience, avoidance and arousal) and a two-factor model (based on the results of the exploratory factor analysis). It was not possible to identify a PTSD model that could support the assumption of a PTSD structure in the data. Two violent exposures, both of a type that could be interpreted as an attack on the attachment relationship, namely ‘mother tortured’ and ‘father disappeared’ were identified that independently and significantly predicted the PTSD symptom complex in accordance with age and two behavioural and three social background predictors. The two identified traumatic situations, however, also had independent associations with other symptoms. It was concluded that children’s reactions to traumatic experiences manifest themselves as much more wide ranging as what is included in the PTSD diagnosis, and it thus seems to be insufficient to focus on PTSD symptomatology when you want to examine and understand refugee children’s situation, including their mental health. The individual components, which are part of the PTSD diagnosis, and their individual combinations were frequent in the data set, but the justification of postulating a specific PTSD structure with an implicit relationship between cause and effect was challenged.
Other studies have also found significant, but rather unspecific, relationships between exposure to organized violence and PTSD-specific symptomatology (44–46). The three-factor PTSD model was confirmed in a study testing the validity of the ‘Reaction of Adolescents to Traumatic Stress Questionnaire’ (RATS) in four populations of adolescents, but the scale also correlated highly with non-PTSD specific symptoms of anxiety and depression (47). Exposure to interpersonal violence increased the risk of PTSD but also of major depression and substance abuse, and nearly ¾ of adolescents with a diagnosis of PTSD qualified, in addition, for at least one of the other two diagnoses in an American study of 4023 adolescents (48).
A new diagnosis DESNOS (Disorder of Extreme Stress Not Otherwise Specified) has been suggested and is currently being field-tested for inclusion in the next version of DSM as a better description of the more complex psychopathological reactions that can arise after specifically serious, long-lasting and early initiated traumatic life experiences such as child misuse (49, 50). This diagnosis is more comprehensive than PTSD and requires alterations in six areas of function: affect regulation, consciousness, self-perception, interpersonal relations, somatization and systems of meaning. However, it is questionable whether it is possible to describe a coherent pattern of reactions in relation to traumatic events and life circumstances in general. Thus, studies of the associations and developmental pathways between various types of risk factors and psychological disturbances suggest that different developmental pathways can lead to the same psychological disturbance, and that various risk factors can lead to different forms of psychological disturbances (51, 52). Apart from living with a traumatic past, refugee children have to manage the challenges of a new life in exile, which can, in its own right, have an impact on their mental health.
Criterion validity of anxiety. Rating scales are used in many studies as a tool to indicate an increasing amount or concentration of a certain individual characteristic, such as anxiety. The aims of the analysis in the study by Foldspang and Montgomery (2) were to compare and discuss the empirical validity of four anxiety scales based on 12 items from the same empirical data set. Three of the scales were based on traditional weighting and summary scaling (scale 1: summing up individual ordinal item scores; scale 2: counting the number of symptoms present; and scale 3: counting the number of frequent or intense symptoms), whereas the fourth scale was produced by estimation of the multivariate probability of the child being anxious, as assessed by psychological interview. The scales were compared as concerns their accuracy in the identification of children assessed as anxious by psychological interview.
The four scales correlated mutually, and each of them was significantly associated with anxiety as assessed by psychological interview. The weighted scale, however, performed significantly better than the unweighted scales as concerns sensitivity but not regarding specificity. In the present data set, the overall amount of misclassification was, however, significantly less than in the unweighted scales (misclassification was Scale 1, 21.1%; Scale 2, 21.2%; Scale 3, 25.3% and Scale 4, 13.1%) [Scale 4 had a maximum of 86 correctly classified cases and not 68 as cited in Table 5 of (2)].
Table 5. Literature review of predictors* of psychological problems in refugee child and adolescent populations (shading indicates own studies)
Background-context for trauma
Trauma complex – before immigration
Child’s mental situation at immigration
Life context after immigration
Trauma complex – after immigration
Present mental health
Parents’ nationality and ethnicity
Family exposure to violence before the birth of the child
Time between arrival and residence permit
Exposure to violence
Parents’ social background
Traumatic life circumstances
Parents’ social situation
Death or disappearance of a parent
Changes in marital status
Loss and separations
Direct exposure to violence
Youth’s social situation
Parents’ health situation
It was concluded that the empirically weighted scale was superior to the unweighted scales, in identifying the anxious children. The superiority of an empirically weighting procedure over the traditional weighting and summary scaling approach had not been demonstrated previously to our study. In the presence of a blinded criterion measurement, and if the goal of scaling is the ordering of individuals according to their dichotomous probability of having or not having a certain characteristic (e.g. anxiety), empirical regression-based weighting of scale items thus constitutes an accessible and valid alternative to traditional methods of health and social scaling. If the sample on which the empirical weighting is based is representative of a larger population, coefficients from the analysis may be generalized to this larger population. Thus, the variable ‘clinical anxiety’, applied in later analyses, is based on this empirically developed scale.
Empirically weighted symptom scores were used in two studies prior to the present study, both applying the total score from the Child Behaviour Check List (53, 54); however, in these studies, no significant improvement was gained through weighting. Later, using a similar procedure, Zwirs et al. (55) developed and validated a brief screening tool for predicting externalizing disorder in native Dutch as well as non-Dutch immigrant children. They found that externalizing disorders could be significantly predicted in both groups with a scoring rule, based on only four items from the Hyperactivity and Conduct Problems Scale of the Strengths and Difficulties Questionnaire.
Mental health and its determinants at arrival in Denmark
Coping strategies in children of torture victims. The first Danish study of children of torture victims was conducted in the early 1980s and showed that 78% of the 85 participating children suffered from emotional or somatic symptoms and more than half suffered from anxiety and sleep disturbance accompanied with frequent nightmares (27). At a follow-up 3–4 years later, the numbers of symptoms were considerably higher (56). A retrospective study of 76 children, who were assessed and treated at RCT between 1983 and 87, similarly showed a high level of psychological symptoms in the children, with anxiety symptoms as the most frequent [results from this study were available in 1989; however, the scientific publication came later (25)].
It is against this background that a qualitative study of 11 children from five torture surviving families in treatment at RCT was conducted in 1989 with the aims of describing the psychological and behavioural reactions in the children and obtaining a deeper insight into the coping process underlying the children’s reactions in terms of individual coping components and main types of coping strategies (3).
By coping strategy (57), we understood a rather specific but complex process constituted by intrapsychic mechanisms and behavioural patterns, which are consistent and identifiable as regards goal-directedness and relevance. The children displayed a range of psychological symptoms and behavioural problems, and based on the dimensions active vs. passive problem-solving, outer vs. inner problem-solving, and social interaction vs. isolation, four principal types of coping strategies were identified in these data: i) Isolation and withdrawal, ii) mental flight, iii) eagerness to acclimatize and iv) strength of will and fighting.
Most of the children seemed to maintain their use of one particular coping strategy, which might have served a purpose during the traumatic situation in their home country, but which was no longer suitable in Denmark. The two active and extroverted coping strategies (iii and iv) seemed to a larger extent to facilitate both survival and development, while the more passive strategies primarily seemed to have sustained self-protection and thus secured survival in the prevailing traumatic situation. Lack of support from the surroundings, particularly from the parents, reduced the child’s possibility of revising and developing better coping strategies. The ability and will of the parents to communicate openly with their children about their own experiences while in prison were found to be particularly important.
We did not find any studies identifying coping strategies in children of torture victims, prior to our study. We attempted to incorporate the results of this study when planning the study Refugee children from the Middle East, that is, we included an assessment of the children’s coping in relation to the dimensions active vs. passive problem-solving and social interaction vs. isolation in the psychological interviews of the Validity study. Interviews with parents, however, turned out to be insufficient as a method to assess coping in the way it was understood in our study, and this approach was dropped. Only a few later studies of refugee children conceptualize the children’s reactions in terms of specific coping strategies, none of them based solely on interviews with parents. Kocijan-Hercigonja et al. (58) conceptualized coping in terms of specific types of behaviour and used a structured questionnaire for children, interviewing 35 refugees, 35 displaced and 35 non-displaced 6–14-year-old children in Croatia. Refugee children used fewer behavioural coping strategies than displaced and non-displaced children, and they perceived them as less effective in reducing stress. Halcon et al. (59) in their study of 18–25-year-old Somali and Oromo refugees in the US similarly focused on behavioural strategies (which could help when feeling sad) and concluded that while young women coped with sadness by talking about their problems with friends, young men were more likely to use physical exercise as a coping strategy. Almqvist et al. (60) conceptualized coping in terms of emotion-focused and problem-focused strategies in their study of 39 Iranian refugee children, and their parents in Sweden included both structured assessments and clinical examinations of the children. Children primarily described emotion-focused coping strategies (such as positive thinking or daydreaming), while parents described more problem-focused coping strategies (such as moving to better living areas). Parents deliberately encouraged or discouraged certain coping strategies in their children, and they themselves were influenced by their children’s ways of coping, which suggests a transactional dynamic between the children and their parents regarding coping. The dominant strategy of the parents for dealing with traumatic memories was to avoid the topic and discourage their children from talking about the war. Goodman (61) identified four themes reflecting coping strategies in the narratives of unaccompanied refugee youth in the US from the Sudan: ‘collectivity and the communal self’, ‘suppression and distraction’, ‘making meaning’ and ‘emerging from hopelessness to hope’. Participants, who represented a highly selected group of survivors of intense violence and long-lasting hardship, made use of all of these strategies, but at various times and intensities, during their life history. The strategy of ‘suppression and distraction’ resembles the strategies of ‘isolation and withdrawal’ and ‘mental flight’ from our study and, similar to our study, seemed to have been effective in securing survival during dangerous and life-threatening times before arrival but less effective as a long-term strategy in exile.
Anxiety and sleep disturbance. Studies of children’s psychological reactions to war, other organized violence and being a refugee, became more frequent during the 1980s, and greater attention was paid to the importance of multiple traumatic experiences in children who had been exposed to armed conflicts (36). Table 4 provides an overview of systematic studies of the prevalence of psychological problems in populations of young refugees from the mid-1980s until today (2009).
A study of 40 17-year-old Cambodian high school students in the US revealed that half of them suffered from PTSD, 27 from depression and 10 from anxiety, and a total of 27 were diagnosed with at least one disorder of some kind (62). In a Swedish study of 63 refugee children from Chile and the Middle East (63), a similarly high level of psychological problems was found, with 60% suffering from anxiety and 55% from sleep disturbance. However, subsequent studies through the 1990s of various populations of children and young refugees showed a somewhat lower frequency of symptoms (Table 4). Only one of these previous studies included children who were still asylum seekers (64). In most cases, the study populations were small, and there was limited information regarding participation and attrition.
On this background, the study Refugee children from the Middle East was conducted through 1991–1992 (36). With the purpose of clarifying the extent of, and the predictors for, psychological problems among children, parents of 311 3–15-year-old children from the Middle East were interviewed about their children’s background, life situation in their home country and experiences of war and other organized violence, including the parents’ experiences of imprisonment and torture (65), their present family situation and their children’s current psychological condition. The study showed that the children had a number of psychological symptoms, mostly related to anxiety. Thus, as indicated by the empirical scale score presented previously, 67% of the children were classified as suffering from ‘clinical anxiety’, that is, they showed a pattern of symptoms that, in relation to the more in-depth psychological interviews with 99 of the children’s parents, suggested the occurrence of anxiety exceeding the normal range for the particular age (2). Another frequent reaction in the children was sleep disturbance (4); thus, 30% of the children showed at least one frequent or intense type of sleep disturbance at arrival in Denmark. Finally, 34% of the children were sad or depressed, and a total of 238 of the 311 children (77%) suffered from at least one of these conditions.
Symptoms of anxiety frequently occur in children who have been exposed to traumatic experiences, and anxiety is part of almost all forms of emotional disturbances in both children and adults. Bowlby (66) defines anxiety as the emotion evoked when the child’s primary attachment figure is not available, which in this context means both being present and being responsive to the child’s needs. Attachment is established and developed over the first years of life, and children who experience an insecure attachment will more often react with anxiety later in life, in situations that do not generate anxiety in children who are securely attached. Anxiety warns a person of future dangers and creates motivation to avoid and/or defeat the danger; when it comes to children, this involves seeking refuge with an attachment figure, usually a parent. Thus, separation anxiety is one of the first types of anxiety that a child experiences, and this type of anxiety is a precursor to future types of anxiety (67). Therefore, it is assumed that traumatic events which are experienced as a threat to the child’s attachment relationship will have the greatest impact on the development and health of the child.
Anxiety can express itself in different forms of specific and observable symptoms, and one or more symptoms can, in combination, be part of various concepts of anxiety. From the 12 specific symptoms of anxiety, five qualitatively different concepts of anxiety were constructed in this study: re-experience, arousal, regressive anxiety, future anxiety and separation anxiety (36). Further, the occurrence of nightmares was added as an independent type of anxiety together with the previously mentioned ‘clinical anxiety’ (2).
A high prevalence of sleep disturbance in refugee children is also documented in other studies; thus, Hjern (63) found that 55% of the children in his study suffered from sleep disturbance shortly after arriving in Sweden. Sleep disturbances are an integrated component in the PTSD diagnosis, and later studies have shown that sleep disturbances are frequent in relation to traumatic experiences in adults (68–71) and in children (72, 73); however, ‘sleep disturbance’ is often not studied on its own but only as part of the PTSD diagnosis in studies involving refugee children (see Table 4). The consequence of this could be that substantial problems in the children are overlooked and that they therefore will not receive relevant help, resulting in possible negative consequences to their further development.
Traumatic experiences and life conditions. Although in the 1990s, there were few studies that utilized a multivariate statistical method when analysing the associations between traumatic life circumstances and psychological problems among refugee children, more such studies have been published during the last 10 years (Table 5). The few studies that were available at the time when the study Refugee children from the Middle East was carried out suggested that both traumatic experience and factors related to the family or the exile situation could be associated with the children’s psychological problems; however, the research methods and the extent of the studied risk factors varied, with the result that no final conclusions could be reached.
A main objective in the study Refugee children from the Middle East was to identify the specific events or life circumstances that were associated with the children’s reaction of anxiety and sleep disturbance upon arrival in Denmark. The analytic strategy in both this study and the subsequent follow-up study Mental health and integration of young refugees from the Middle East was devised based on an overall time perspective (Table 6) and inspired by Bronfenbrenner’s ecological model (74–76). In this model, contexts are perceived as a number of embedded levels that vary according to the level of intimacy with an individual (that is, culture, local community, family). Those levels interact with each other over time, and through these interactions they have an impact on the individual’s development and adaptation, as later documented by Khamis (77) and Luthar et al. (78). According to this model, when analysing the risk factors in children’s development, one has to pay attention to several simultaneous levels of influence, such as the impact of ideology, social life conditions, schooling, friends and family, the inclusion of which was not common during studies of refugee children at the time when the actual study was carried out (79).
Table 6. Theoretical framework for empirical investigation and prediction analysis in the baseline (1992–1993) and follow-up (2000–2001) studies
The present statistical analytic strategy was organized with an increased time perspective in relation to the outcome variable; thus, predictors within the same levels of explanation and time frame were analysed initially after which the results from these subanalyses were combined successively to create an overall picture (80). The traumatic events were categorized into conditions (lived during war, in refugee camps, with tortured parents) and specific events and changes of life conditions (direct experiences of violence, witnessing violence, loss and separations) (81). This was, as far as we know, the first study that involved aspects of parental torture in combination with other types of experiences of organized violence.
Predictors for anxiety and sleep disturbance appear in Fig. 2. One significant finding was that having lived during prolonged conditions of organized violence (living in refugee camps, mother and/or father exposed to torture, lack of opportunities for play because of war) rather than experiencing specific events and changes of life conditions, was associated with anxiety at arrival in Denmark. On the other hand, sleep disturbance were primarily associated with more specific and accumulated exposure to violence against family members, that is, the violent death of grandparents or torture of parents (4).
In connection with the follow-up study of 131 of the original 311 refugee children, a re-analysis of predictors for anxiety, sleep disturbance and depression at arrival in Denmark was carried out (Table 7), now including cumulative trauma variables (the number of types of traumatic events within the family before the birth of the child, and the number of types of traumatic experiences after the birth of the child). The analytic strategy was the same but when more children from the same family were part of the population, a hierarchical model was employed that takes this into consideration (82). While the number of types of traumatic events was a significant predictor for anxiety, sleep disturbance and depression, the strongest predictor for sleep disturbance was the number of types of traumatic events within the family before the child was born, and the strongest predictor for anxiety was the parents’ experience of torture.
Table 7. Multiple logistic regression risk estimates* of psychological problems at arrival in Denmark in 131 Middle Eastern refugees aged 11–23
Sad and depressed
Further analysis of the dataset presented in the study by Montgomery and Foldspang (4, 36).
*Predictors: Social and demographic background, trauma complex using HLM.
No. of traumatic events before the child’s birth
No. of traumatic experiences after the child’s birth
Torture of parent(s)
‘Intergenerational transmission of trauma’ is a concept that has been used to describe the phenomenon of children reacting to their parents’ traumatization with trauma-related symptoms (83). The children do not necessarily have traumatic experience themselves; however, the trauma is passed on and communicated to the children through their parents’ reactions and the impact of these reactions on the parents’ ability to be actively present and attentive to their children’s needs. Thus, anxiety and sleep disturbance can be associated with the lack of resources in the parents for taking care of their children, as a result of their own traumatization. The child has to be able to let go of control to be able to fall asleep and sleep through the night; this can only happen when the child is in possession of a certain amount of security, usually provided by the parents (the attachment figures). Children with prolonged or repeated experience of violence can loose their belief in their parents’ ability to protect them, a situation which has been found to be associated with anxiety-related sleep disturbance (84). According to attachment theory, a mother’s previous interpersonal relations are of the greatest importance to the quality of her ability to act as a parent (85, 86), and traumatization can thus have an impact through several generations. It was found, primarily in later studies, that there is a connection between sleep disturbance in children and their mothers’ depression (87, 88), their mothers’ separation anxiety (89), their mothers’ stress and poor health (90, 91) and their fathers’ generally poor health (90).
An assessment of the parents’ psychological condition was not included in the current study; however, it is well-known that torture leads to a number of psychological problems such as sleep disturbance, including frequent nightmares, chronic anxiety, depression, memory difficulties, reduced ability to concentrate and changes in self-image (92, 93), resulting in the parents’ incapability to be adequately attentive to their children’s needs. A recent study of 15 refugee families with torture surviving parents, compared with 15 families with similar backgrounds but without having been exposed to torture, suggests that the parents’ trauma can indeed be passed on to the children (94, 95). Children of torture survivors showed a higher level of psychological symptoms than refugee children without this family background, and there was a significant association between parents’ and their children’s symptoms, and more children from the torture surviving families showed an insecure type of attachment.
The process of seeking asylum in itself constitutes a stressful life condition. When the study Refugee children from the Middle East was carried out, the existing knowledge regarding the association between asylum seeking and mental health was limited. Subsequently, repeated studies of adult asylum seekers have suggested an association between refugee status and asylum seeking and poor mental health (96–105). In addition, later studies have confirmed that asylum-seeking children suffer from poor mental health as well; for instance, 58% of the 11–16-year-old asylum seekers in Denmark were found to have signs of a mental illness (106) according to a combination of information from teachers and the children themselves. Being placed in detention during the asylum-seeking period can cause additional stress to adults as well as children (107, 108). In structured psychiatric interviews with 10 families, with a total of 20 children who were detained for a prolonged period in remote refugee camps in Australia (104), all the adults and children met the diagnostic criteria for at least one mental illness, and 52 mental illnesses were identified among the 20 children. Unaccompanied asylum-seeking children seem to be particularly at risk (109–112).
All the families in the study population for Refugee children from the Middle East were asylum seekers, which could have been important for the extent of the children’s psychological problems. On the other hand, the interviews were carried out shortly after the families’ arrival in Denmark, while the above-mentioned studies of children from asylum-seeking families were carried out after a prolonged residence in asylum camps, hence, living a life with an insecure future; also, the length of the asylum-seeking process has been found to predict the extent of psychological problems. When the parents’ psychological problems increase, it influences their relationship with their children, and it will have an impact on the children’s development and ability to function.
Tortured families. In the qualitative study Children of torture survivors carried out at RCT in 1989 (3), the parents’ ability and the will to speak, and speak openly, with their children about their experiences in prison were found to be of utmost importance for the children’s capability to handle their own traumatic experience. Often, the parents did not talk to the children about the events that happened before fleeing their country, partly because they wished to protect the children from the terror they had experienced themselves, partly because it can be a difficult task for traumatized parents to talk about the horrors they themselves had been exposed to (60, 113). However, the children were very preoccupied with these events, and without certain factual information, they were left with their own fantasies and efforts to comprehend and understand their parents’ experiences (3, 114). Therefore, in the study Refugee children from the Middle East, we included the questioning of parents about whether they spoke with their children about the reason for fleeing their home countries, imprisonment and torture. Contrary to the hypothesis, giving such information to their children was found, to a certain degree, to be associated with anxiety (36).
With the purpose of obtaining a greater understanding of this apparent contradiction, another qualitative study was carried out (4). The study included in-depth interviews with 14 members of three families from the Middle East where the father had been exposed to torture. To obtain an understanding of how different aspects of the family’s history was communicated by the parents to their children, the interviews and the following analysis focused on each family member’s understanding of the family’s history (including the parents’ history of torture), and how this understanding was organized and expressed in hierarchically organized meaning-providing levels. The three families experienced their life stories and situations as refugees in Denmark in very different ways, ranging from meaninglessness, discontinuance and alienation to a sense of community, solidarity and openness. Communications about past events were related to such meaning-providing contexts and could be conceptualized in relation to ‘stories told’ and ‘stories lived’ (115). When the ‘stories told’ are in contradiction to the ‘stories lived’, a situation of ambiguity and uncertainty arose; for instance, this could be the case when the parents insisted on their children not knowing anything about imprisonment and torture, and on it not being spoken about (the story told), at the same time as the father, in his desperation, at times would talk about details from his experienced torture in the presence of the children (the story lived). The meaning-providing contexts for making sense of the family history of violence and exile could be more or less coherent or contradictory and might result in a strengthened relationship or confusion, powerlessness and action paralysis.
One conclusion was that information about parents’ experiences of imprisonment and torture is not in itself helpful in relation to the children’s ability to cope with their traumatic past. The ability to create meaning of the family’s history depends more on the manner in which the parents and the children communicate with each other about the events than on what is actually communicated to the children – the relation between children and parents thus seems to be the most important factor.
The consequence of avoiding talking about a traumatic event can be good or bad. In a study of Bosnian refugee children in Sweden (116), the fact that the children were able to talk about their war experiences resulted in fewer problems in children who had experienced less stress, but created more problems in children who had experienced extreme stress. In a qualitative study of Bosnian refugee families in the United States (117), the memories of the traumatic events were experienced as painful, which negatively influenced the communication within the family. The parents wanted to forget their traumatic past, and the children avoided talking about it. However, when the family shared their memories with each other, it contributed to the rebuilding of trust within the family, and exactly this form of communication proved to be a healing factor for the entire family. The coping process was facilitated further when the parents talked about ongoing problems, shared happy memories, expressed their feelings and communicated properly with their children.
Determinants of receiving a residence permit in Denmark
As mentioned previously, asylum seeking constitutes a specific form of stressful life condition with consequences for the mental health of both adults and children. However, when the study Refugee children from the Middle East was carried out, there existed practically no knowledge of the implications for obtaining asylum.
As a first step in planning a follow-up study of the participants in the study Refugee children from the Middle East, we sought information about which participants had obtained resident permits in Denmark. In 1997, all applications had been processed and 90 families (60.4%), including 190 children (61.1%), had obtained a residence permit. Of these families, 87 (58.4%) had obtained asylum (as convention refugees or de facto refugees), one family had obtained a residence permit on humanitarian grounds, one family obtained asylum based on family reunification, and one family obtained a working and residence permit. The remaining 59 families (39.6%) did not obtain residence permits, and their destinies remain unknown. Within the follow-up population, the average period between applying and receiving a residence permit was 15.5 months (0–77 months).
On this background, it was possible to illustrate the asylum-seeking process and identify predictors for the decision of granting residence permits to families by comparing profiles of families which obtained residence permits with those that did not (6) and furthermore, to also illustrate the consequences for the children by comparing equivalent profiles within the two groups with regard to experiences of violence and psychological problems in the children (7). The expectation was that the two groups would differ in relation to the experience of torture and organized violence, but not, however, in relation to social, cultural and religious circumstances.
The study showed, though, that families from Iraq, families with religious beliefs other than Islam and families where members had a long-term education behind them, had a higher probability of obtaining a residence permit, while single mothers had the least probability of obtaining a permit. Information about previous exposure to violence and human rights abuse such as imprisonment, torture and disappearance, seemed to have no significant predictive function for whether a residence permit could be obtained at a later stage when families with and without permits were compared. Frequently, those who obtained a residence permit were of Iraqi nationality, the father had an education of 12 years or longer, the father would have been employed in administrative work and the family’s religion would be other than Islam. Particularly frequent characteristics among those who did not obtain a residence permit were that they were ethnic Palestinians and that the father would have been employed in manual work. The consequence for the children was that they were divided into two groups that could not be significantly distinguished from each other regarding experiences of violence and present psychological problems; however, more children within the rejected families had a parent who had suffered a violent death, and there were more depressive children in the rejected families. Thus, the process of granting asylum seems to favour the selection of the socially and culturally well-situated refugees, whereas human rights violations seemed to play a more restricted role in this process. Further, the children’s situation as such seems to have played no role at all in this process.
The study was based on refugees who arrived in Denmark 15 years ago; thus, it is unknown what results a similar study would possibly show today. Therefore, it seems justified to request transparency of case-work and to call for a quality control system with systematic and continuous documentation.
The findings can be interpreted as being a result of the communication process between the asylum seeker and the immigration authorities. The authorities’ assessment of the asylum seekers’ credibility is of vital importance for the process; however, the process is complicated by the fact that torture victims and victims of human rights abuse in general have a tendency to avoid talking about their abuse or, perhaps, to only tell parts of their story. This may be due to more or less subconscious barriers of protection and to deficits of memory as such (118). Many traumatized people suffer from PTSD (119), and a basic feature of PTSD is trauma-related memory disturbances which, for instance, can be manifested in intrusive memories (reactions of re-experience), nightmares and the inability to recall important parts of the traumatic event. It may be possible for the victims to recall the major themes but not the precise details of the events, and their stories may change during repeated interviews, a tendency that has been observed among unaccompanied asylum-seeking children as well (120). Such a reaction may actually support rather than discount the credibility of the torture survivor’s story (121–123), but inconsistencies between information given at different times during an asylum case will tend to be taken as an indication that there are no grounds for the claim for asylum (124–126). This increases the risk of rejection of the asylum application for those who have been exposed to some of the worst forms of human rights abuse, that is, torture victims. This risk can be further increased owing to misunderstandings because of different cultural references, lack of knowledge of common trauma reactions, gender stereotypes or, simply, poor interview techniques or poor translations (127–129). Thus, including an assessment by a health professional would create a better basis for the decision-making process in asylum cases where human rights abuse is involved (130).
Mental health and its determinants 8–9 years after arrival in Denmark
Since the study Refugee children from the Middle East was carried out, various populations of refugee children and adolescents have been subject to research. The diagnosis of PTSD contains, as previously mentioned, by definition, a relationship between a traumatic event and a defined set of psychological symptoms (131, 132); however, as can be seen from Table 4, traumatic experience is related to other types of psychological problems as well, and refugee children who are referred to treatment because of psychological problems display many forms of difficulties other than PTSD (133, 134). In most studies, traumatic experience in the home country has been shown to be an important predictor for psychological problems in exile, although this does not apply to all studies. In a study of 57 young refugees from Cambodia (135, 136), no association was found between traumatic experience before arrival in Canada and later psychological problems, and contrary to expectations, the young refugees whose families had been the most exposed to political violence before the child was born tended to report less psychological problems than the young refugees from less exposed families. Rousseau et al. suggest that the reason for this could be that the young refugees appreciate their parents’ suffering and that it gives them an experience of purpose in their lives, which again can encourage resilience.
The cumulative effect of traumatic experiences has previously been documented among adult refugees (137) and among various populations of youth (138, 139) and children (140). As can be seen in Table 6, this effect has also been documented in several studies of refugee children and adolescents.
Assessment of psychological problems in children and youth. Behavioural and emotional problems in children and adolescents are often divided into two major domains of dysfunctions, namely externalizing and internalizing problems (141). Externalizing problems represent conflicts with other people and with social norms and are marked by defiance, impulsivity, hyperactivity, aggression and antisocial features. Internalizing problems mainly reflect problems within the self, such as anxiety, withdrawal, dysphoria and depression. Some children and adolescents exhibit strong traits of concurrent externalizing and internalizing problems, however, and the causes can be complex. In the study Refugee children from the Middle East, carried out just after the children’s arrival in Denmark, we expected a high symptom level considering the children’s past, and the analysis focused on the understanding of children with clinical, and in a traumatological perspective, relevant symptomatology (anxiety and sleep disturbance). The approach to conceptualizing children’s problems thus was primarily categorical (for instance, by dividing the children into groups who suffered from anxiety vs. those who did not (2)). During the follow-up study 8–9 years later, the traumatological perspective was no longer dominant, and we did not wish primarily to distinguish between children with or without clinical symptomatology, but rather to understand the type and the degree of reaction in the children and the association between this reaction and their life conditions before and after arrival in Denmark. Therefore, we chose a dimensional approach to the children’s reactions, that is, an approach where one indicates, for instance by the use of a rating scale, how much a given condition characterizes an individual. The categorical and the dimensional approach to studying and understanding psychological problems are not contradictory or non-comparable, but the choice of approach depends on the research questions one wishes to answer (142, 143), and the dimensional approach can be converted into a categorical approach by using empirically defined cut-off points.
Moreover, upon the children’s arrival in Denmark, our information about their situation and mental health could only be based on the information we received from their parents. However, during the follow-up study Mental health and integration of young refugees from the Middle East, it was both possible and relevant to carry out interviews with the young refugees themselves. Both parents and children thus filled out a rating scale about the children’s emotional symptoms and behavioural problems. However, several studies, carried out before and after the current study, have shown that there is a low correlation between the parents’ ratings and the children’s self-ratings of their psychological problems (144–147), which applies to refugee populations as well (148, 149).
Analyses were carried out of the differences between the children’s self-ratings of their externalizing and internalizing reactions, and predictors for the difference between the two sets of ratings were identified (8). In general, the children rated themselves higher on the symptom scale than their parents did, a general tendency in non-clinical populations. In particular, boys rated themselves high in relation to parents’ ratings regarding externalizing and girls in relation to internalizing reactions. The parents’ and the children’s ratings correlated moderately (externalizing: rs = 0.33, P < 0.000; internalizing: rs = 0.24, P < 0.008). These differences were predicted by individual (age and sex) and family-related (father’s health) factors and ethnic background. The parents’ circumstances were important when explaining the differences, however, particularly those differences concerning externalizing reactions. Differences between siblings thus will have a tendency to become minimized, in particular when parents speak about their children’s externalizing behaviour. These results indicate that parent ratings and children’s self-ratings are qualitatively different constructs, so that the difference is not just a result of expected interobserver disagreement.
In other studies, concurrent and subsequent to this study, the parents’ own psychological problems, and in most cases, the mother’s psychological problems have also predicted the difference between parents’ ratings and the children’s self-ratings of their own problems (150, 151). Mothers who experienced stress in connection to marital problems (152) observed more problems in their children than other mothers, and both parents, influenced by their own stress symptoms, had a tendency to overestimate their child’s stress reaction in connection to, for instance, an acute injury (153).
Most notable for the current results is the general pattern in the association between the parents’ health and the observed difference between the parents’ ratings and the children’s self-ratings: When the father suffered from a somatic disease, both parents had a tendency to underestimate their children’s symptoms, while parents in families in which the father suffered from psychological problems had a tendency to overestimate their children’s problems. Somatic illness in the parents can reduce their attention towards their offspring’s problems because of difficulties in coping with the challenges of daily life. On the other hand, parents who are anxious or nervous can have a tendency to worry more about their children’s future in exile. The tendency of parents to project their own psychological problems into their perception of their children has previously been observed in studies of children (154–156) but not, as far as we know, of youth. Since traumatized refugee children often will have parents with physical and/or psychological problems (157), this can have great clinical importance when refugee children and youth are referred for examination and treatment.
Change in symptom level over time. Seven follow-up studies of different populations of refugee children, published between 1986 and 2007, could be identified (Table 8). Most of the studies included relatively small populations (below 100), the follow-up time was, in most of the cases, limited to 1–3 years, and compared with the baseline population, the attrition was between a third and a fourth.
Table 8. Literature review of follow-up studies of psychological problems in young refugee populations (shading indicates own studies)
In the majority of the studies, a reduction in symptom levels over time was observed. More than two observation times were included in three of the studies that thus, in a developmental perspective, can provide important information about symptom development and its association with, among other things, age. In a study of 46 Cambodian high school students in the US, of whom 40 students had survived massive human rights abuse in a Cambodian concentration camp when they were between 8 and 12 years of age (62, 158–161), the number of youth with PTSD and depression decreased over time. The most profound reduction with regard to both diagnoses happened during the period between the 3- and 6-year follow-up (the transition from adolescent to adulthood), and in spite of the relatively high symptom level during all the studies, most of the young refugees functioned well in relation to education and work. In a study of 57 Cambodian refugees in Canada (135, 136, 162, 163), the symptom level fell during the period when the adolescents were from 13 to 15 years of age, but rose again in the period between 15 and 17 years of age. Symptom levels did not differ significantly from the level among young Canadians of the same age. In a study of 50 Iranian preschool children in Sweden (164–166), 84% of the parents experienced their children as having improved by the time of the second study, although 21% were diagnosed with PTSD in both cases (60).
These studies suggest that several years can pass before a high initial symptom level is reduced. Therefore, it is important to know how long the refugees have been living in exile when assessing the results of epidemiological studies of refugee children’s and adolescents’ psychological problems.
One purpose in the follow-up study Mental health and integration of young refugees from the Middle East was to illustrate and understand the extent of psychological symptomatology in the children 8–9 years after arrival in Denmark (9, 10). The average score from the two original self-reports and the parents’ checklists varied from 9.0 to 15.9 (internalizing), 8.2 to 13.0 (externalizing) and 28.4 to 47.4 (total score) (Table 3). When using the recommended cut-off points at the 83rd and the 90th percentile of the age and sex standardized original self-rating scales, (31–33), 78.6%, 6.1% and 15.3%, respectively, actually fell in the normal, borderline and clinical range with regard to externalizing, 70.2%, 11.5% and 18.3% and with regard to internalizing, 74.0%, 6.1% and 19.8% when using the total scale. Adolescents (11–16-year-olds) did not differ significantly from older (17–23-year-old) refugees. When using the variable ‘having a psychological diagnosis’ (16 or 23.9% of the youth) from the Validity study carried out with 67 young refugees as a reference, the best cut-off point for clinically significant symptomatology was achieved by the 83rd percentile, that is, by combining the borderline and the clinical ranges (10).
Different study methods prevent a direct comparison between the symptom level at the first and the second study. Nevertheless, the prevalence of relevant clinical symptomatology among the participants dropped from approximately ¾ in the first study to approximately ¼ in the follow-up study 8–9 years later. However, the symptom level found in the follow-up study was still higher than what has been found using the same symptom scales in studies of corresponding age groups in general populations. In the current study, the average score of internalizing and externalizing among the 11–16-year-olds was, for instance, 13.0, as compared to 12.2 and 10.4, respectively, in a study of 11–18-year-olds from seven countries (167).
Newer reviews of psychiatric epidemiology among children and adolescents without a background as refugees indicate a prevalence of 20–25% for mental illness (168, 169); however, this becomes only 3–18% when significant reduction of functioning is included as a criterion (170); in contrast, 25% scored above the cut-off point in the current study. In a major prospective study of a probability sample of 4175 11–17-year-olds in the US, 17% fulfilled the criteria for a mental illness (171), and in ‘The National Comorbidity Survey’ (48), 16% of the 12–17-year-old boys and 19% of the girls fulfilled the criteria for at least one of the diagnoses of PTSD, depression or drug abuse. In a representative population of children and adolescents in Germany (172, 173), 18.5% of the 3–17-year-olds scored within the clinical or borderline area (174), and 14.5% of the 7–17-year-olds had at least one specific psychological symptom associated with reduction of function (175). In a two-phase epidemiological study in the Netherlands including four different ethnic groups from a population of 2041 6–10-year-olds, 11% of the children had one or more impairing psychiatric disorders, which did not differ between native Dutch and immigrant children (176). Thus, it is necessary to continue to be attentive to the psychological condition of refugee children even after many years of residence in Denmark, and to make sure that they receive the necessary support, so that possible psychological problems do not become an obstacle to, for instance, their future education and working possibilities.
Trauma and exile. The relative importance of traumatic experience and exile-related factors changes over time which, among other things, was found in a follow-up study of refugee children in Sweden from Chile and the Middle East: while previous traumatic experience was found to be the most important predictor at arrival in Sweden, family-related stress (divorce, psychiatric disturbances in parents) was found to be a significant predictor as well at the follow-up study after 18 months of residence in Sweden (63, 177), and 6–7 years later, current family-oriented stress was found to be the most important predictor for the children’s psychological problems (178). Parents’, particularly the mother’s, poor mental health, was found to be associated with their children’s psychological problems, for instance, in situations of war (179, 180), although such associations can, to a certain extent, be explained by the traumatic experiences or difficult life conditions shared by parents and children (116).
One of the purposes of the study Mental health and integration of young refugees from the Middle East was to understand the impact of traumatic experience in the home country in relation to individual family and social life circumstances during 8–9 years in exile (9).
Witnessing attack on others after arrival (30.5%) and number of schools attended (mean 3.6, 1–13) predicted more externalizing behaviour 9 years after arrival, while attending school or work (92.4%), years of mother’s education in the home country (mean 8.6, 0–21) and the young refugees’ increasing age (mean 15.3, 11–23) predicted less externalizing behaviour. Number of types of traumatic experiences before arrival (mean 9.9, 1–17), number of types of stressful experiences after arrival (mean 0.7, 0–4) and number of types of experiences of discrimination (mean 1.8, 0–5) predicted more internalizing behaviour; years of mother’s education, the number of Danish friends (1.5, 0–4), being of Muslim (77.9%) or Christian (10.7%) religion, Danish proficiency at least average (73.3%) and male sex (42%) predicted less internalizing behaviour. Thus, 9 years after arrival, traumatic experience from the home country was still associated with internalizing problems, but other stressful life experiences were equally important, and traumatic experience did not at all predict falling in the clinical or subclinical symptom range.
The negative factors identified in this study relate, to a great extent, to the difficulties associated with trying to integrate into Danish society. Networks of friends, supporting institutions and groups, such as schools, can be deciding factors for whether refugees and immigrants will be able to cope with life in the new society (164, 181, 182). In a recent national household probability sample in the US, it was found that witnessing violence in the family or in the local community was a predictor for PTSD and depression (that is, primarily internalizing reactions), independent of age, sex, ethnicity, income and other traumatic experiences. Externalizing problems were, however, not included in the study by Zinzow et al. (183). In a recent study of 2328 12–18-year-old Palestinians in the West Bank (184), psychological symptomatology was predicted by violence in the family, political violence and financial situation; however, the analytical strategy in this study is unclear, and from the presentation of the results, it seems that more exposure to political violence predicts less psychological symptomatology, although this was not discussed. It has not been possible to get further information by approaching the author.
One of the factors that, contrary to other studies, was not identified as a predictor for psychological problems in the follow-up study was parents’ mental and somatic health. However, as previously mentioned, the relation between parents’ and children’s reactions can be complicated, as was also seen in a longitudinal study of Palestinian families in Gaza (185). Psychological symptom profiles of parents and their 15-, 17- and 19-year-old children, respectively, were compared, and four family types were identified: two types of families where the adults and their children had similar profiles, with either a high or a low symptom level, and two types of families with a reversed relation; that is, the parents had a high symptom level and their children had a low symptom level – or vice versa. This complementary family dynamic could indicate a form of ‘division of labour’ in relation to being able to express one’s difficulties and strengths, with the children trying to avoid burdening their suffering parents, whereas children with resourceful parents are more willing to risk showing their own symptoms. In a qualitative study including 12 adolescents from the present follow-up sample, the adolescents’ experience of being refugees in Denmark was found to be greatly influenced by their family relations (186), particularly when the organized violence in the home country was reflected in continuing violence within the family in exile.
Risk and resilience. Earlier studies suggest that a traumatological perspective is not sufficient when seeking to understand refugee children’s reactions and development. Resilience refers to a dynamic process, characterized by a positive development despite significant adversity (78, 187, 188). Resilience is culturally shaped (189, 190) and depends on individual, relational, community, cultural and contextual factors (191). Resilience is both an outcome of interactions between the individual and its surroundings and the process that contributes to this outcome (192). Psychopathology occurs based on complex interactions between the individual and the multiple systems which the individual is a part of (193). Resilience is, first and foremost, based on relationships (181), and a stressful family situation can disrupt parenting and in this way increase problematic behaviour among children (194). Maladjusted behaviour and reactions occur when the adversity is extensive and when the protective resources are scarce (194). Thus, it is the lack of protective resources within the various ecological systems, of which the individual is a part, rather than the adversity in itself, that results in psychological problems. Various factors have been identified that facilitate resilience in refugee children, such as family cohesion and support and parental psychological health; individual dispositional factors such as adaptability, temperament and positive self-esteem; and environmental factors such as peer and community support (157).
Based on the existing knowledge, trauma and resilience in young refugees in the follow-up study (9–11) was conceptualized and studied with regard to the interrelatedness of the various ecological systems in which the life of the child or young person is embedded (75). In this conceptualization, children are seen as both influenced by and influencing their surroundings and it points to the complexities in studying and understanding the impact of traumatic life experience on child development (see Table 6).
To understand the relative impact of previous traumatic experience and exile-related stress on different patterns of psychological problems in exile, at arrival and at follow-up, the young refugees were divided into four groups based on a dichotomization of the two sets of problems (10): i) the spared – 22.1% (no clinical significant problems at arrival and follow-up), ii) the reacting – 3.1% (unproblematic at arrival, problems at follow-up), iii) the adapted – 51.9% (problems at arrival, no problems at follow-up) and iv) the traumatized – 22.9% (problems at both arrival and follow-up). The number of types of traumatic experiences before arrival in Denmark distinguished the spared from the traumatized, while the number of types of stressful life conditions in exile distinguished the adapted from the traumatized, after correction for age, sex, specific traumatic experiences, parents’ education and health condition and the young refugees’ social situation. The length of the fathers’ education in the home country, and the fact that the young refugee was attending school or work, further distinguished the adapted from the traumatized, while the fact that the young refugee frequently spoke with his/her mother about problems distinguished the spared from the traumatized.
Children who manage well despite growing up in difficult life conditions, for instance in poverty or in malfunctioning families, distinguish themselves from children who do not manage well in relation to the number of chronic, stressful life events (75) or the number of psychosocial risk factors (195). Studies that describe how children with problems make progress suggest that children whose behaviour improves seem to experience less psycho-social difficulties than children with persistent behavioural problems (196).
Moreover, this study further stresses the importance of environmental factors for children’s and young people’s ability to adapt in a healthy way after traumatic experiences related to war and other organized violence.
Discrimination and adaptation. Experiencing discrimination is one of the exile-related factors that can have a negative impact on social adaptation as well as on mental health (197); therefore, a number of questions about the adolescents’ experiences of discrimination were included in the follow-up study. However, the documentation of the associations and pathways between the three areas, discrimination, social adaptation and psychological problems, was limited at the time when the study was carried out.
Structural equation modelling was used to identify associations and pathways between the three areas (11). Discrimination, psychological problems (internalizing and externalizing) and social adaptation (participating in age-relevant social activities together with the prerequisite for such participation, that is, language skills, school attendance and friendships) were strongly mutually associated, without any sex difference. Discrimination predicted internalizing reactions, but not externalizing reactions and was correlated with social adaptation (Fig. 3). Externalizing correlated with internalizing reactions and both correlated with social adaptation. The social adaption of the parents was not associated with any of these factors; however, male sex, Iraqi nationality and Kurdish ethnicity predicted externalizing reactions and age predicted discrimination and social adaptation.
In this study, the assessment of discrimination was based on the young refugees’ own subjective experiences of other people’s behaviour towards them; it is conceivable that socially well-adapted youth do not interpret the same act towards them as discriminatory as do less well-adapted youth. On the other hand, experiencing discrimination may also affect the young refugees’ perception of the exile country at large with the result that they turn away from people whom they identify as the assaulting group (the exile-country population), and strengthen their identification and association with their own ethnic group (198), which thus affects social adaptation negatively. This in turn may enhance the perception of being discriminated against and may thus result in a vicious circle. In a qualitative study of asylum seekers in England (199), problems associated with migration and with adaptation to the English culture and social system and negative settlement experiences, including discrimination, all had an impact on the health of the refugees, and racism was identified as one of the most fundamental barriers to integration in biographical interviews with refugees in 15 EU countries (200).
In addition, more recent studies have documented associations between self-reported exposure to racism and ill health (201) also in studies of refugee populations (202–204); moreover, in a population of young Vietnamese refugees in Finland, discrimination was associated with school difficulties (205). Thus, it could be advantageous to actively focus preventive interventions on counteracting discrimination.
The aims of this chapter are to approach an integrative discussion of the empirical and methodological contributions of the studies and to outline the perspectives for further empirical research, clinical practice and community policy.
The first aim of this review was to inspect the validity of central concepts such as PTSD and anxiety. We found that the PTSD symptom complex is insufficient when studying refugee children’s psychological problems. The individual components seem more important than their summing up in an overarching concept; consequently, using the diagnosis of PTSD does not provide us with a better understanding of the children, and thus, we should not be restricted by it. This fact has implications for both research and clinical practice.
The most frequent symptoms at arrival were different forms of anxiety symptoms. By using a clinical in-depth interview as the blinded criterion for the construction of an empirical weighted scale (criterion validity), we were better able to distinguish between children with and without clinically important symptomatology. This approach could also elucidate the clinical decision-making procedure, that is, it provides a construct validity aspect of anxiety assessment.
The second aim was to identify the extent and determinants of psychological problems at arrival in Denmark. The prevalence of mental problems was high when the children arrived as asylum seekers; about 2 of 3 were assessed to be suffering from clinically important anxiety, and about 1 of 3 from sleep disturbance. Experiences and life contexts associated with war and other organized violence influenced the children’s mental health at arrival in exile, and the cumulative effect seemed important, similar to what has been found in other studies. Family-oriented traumatic experiences, such as parents’ exposure to torture and/or traumatic experiences in the family before the birth of the child, were particularly important; thus, the reaction of the children seems, to a certain extent, to be mediated through the trauma reaction of the parents. The qualitative studies suggested the importance of family communication; however, the children’s ability to make sense of the family’s traumatic past depended more on the way the parents and the children communicated about their experiences than on how much factual information the children had received.
This calls for a thorough assessment of both children and their parents at arrival as asylum seekers with the explicit purpose of offering adequate support to both children and their parents.
The third aim was to identify determinants of receiving a residence permit in Denmark. Contrary to what was expected, the chance of being granted a residence permit was higher among the socially and culturally best functioning asylum seekers, while the experience of torture or organized violence played an insignificant role when comparing those who were granted residence permits with those who were not. We interpreted this as the result of a communication process between the asylum seeker and the immigration authorities, but it is probable that other models, such as those from the area of political science, could add to our understanding. The specific situation and basic needs of the children did not seem to be integrated in the asylum granting decision process, and it could be questioned whether this is actually acceptable in view of the provisions in the Convention of the Right of the Child (206).
The fourth aim was to identify the extent and determinants of psychological problems 8–9 years after arrival in Denmark, that is, to understand the long-term consequences of being a child refugee in Denmark. The high prevalence of psychological problems at arrival was considerably reduced over time, but it was still higher 8–9 years after arrival than what was found in populations of youth without a refugee background. Parents’ and children’s rating of the children’s psychological problems at follow-up differed, and the difference was primarily associated with the parents’ health, which has implications for research and clinical practice.
The children’s traumatic background at arrival seemed only to a limited extent to determine their long-term mental health, while the amount of life stressors in exile, including the experience of discrimination, seemed to be of prime importance. Refugee children with traumatic experience prior to arrival are vulnerable, but the long-term effects of such experience depend on further exposure to individual, family or society-related risk factors. An overall conclusion is that refugee children can show a remarkable resilience; however, being resilient does not imply immunity to negative life events. In this light, a critical review of procedures and practices regarding the reception and treatment of refugee families is necessary.
Theoretical and practical implications
The studies in this review began 20 years ago when we focused on identifying and understanding the children’s individual coping strategies, in terms of intrapsychic mechanisms and behavioural patterns. Without neglecting the individual perspective, the subsequent studies pointed increasingly towards the significance of including and focusing on social life contexts when striving to understand the children’s long-term mental health situation. The results have several implications for clinical practice and community policy. Furthermore, it carries a range of implication for further research.
Risk and resilience and the ecological model. The studies show that refugee children’s psychological problems, following traumatic experience and flight as well as their adaptation to life in exile, must be understood in relation to the possibilities and constraints embedded in both their immediate (family and friends) and their more distant social life contexts (school, work and community). The results of the present studies support the relevance of Bronfenbrenner’s ecological model of development as a framework for understanding the interrelated settings involved in refugee children’s short and long-term responses to organized violence and exile-related life experiences. In this model, individuals are understood to develop and exist in complex interactions with the multilevel ecological systems in which the life of the individual is embedded. The individual influences the people and institutions of their ecology as they are influenced by them. Important systems for a young person include their home, the school, peers, neighbourhood networks and social institutions as well as more general prototypes, such as norms, values and behaviour codes, which are nested within the culture or subculture, setting the pattern for the structures and activities occurring at the concrete level. Repeated developmental disruptions in several of the systems, in which the child/adolescent participates, increase the risk of maladjustment, while supporting relationships associated with several systems reduce the risk. When trying to understand the impact of trauma and forced migration on the mental health of refugee children and youth, the focus needs to be on the relationship between interrelated life contexts rather than primarily on individual vulnerability.
The concept of ‘resilience’ refers to a dynamic process characterized by positive development in spite of exposure to significant risk. In our studies, many of the children were able to ‘bounce back’ from initial problems during their time in exile. I understand this as a special form of resilience: the child’s development is disturbed by his/her experience of adversity (as reflected by a high symptom level closer to the time of immigration), but during time in exile, normative processes take over, and development resumes a more positive trajectory unless interfered with by new stressors. Social networks and family resources promote resilience, while continuing stress and discrimination counteract this. Disruptions of several ecological systems of the young refugee, however, subvert the positive influence of social participation and networks.
Thus, (re) establishing a supportive social ecology in the exile country is of prime importance for the healthy adaptation and development of refugee children. Community interventions should attempt to establish a secure, predictable, coherent and stable life context within which positive experience can enhance healthy development. One aspect of such interventions could be to actively combat discrimination and negative attitudes towards refugees within, for instance, the school setting; another would be to support refugee parents in understanding and dealing with their children’s reactions. Teachers and prosocial peers can play an important role by providing compensatory or additional support when parents are too traumatized themselves to help their children. An example of an intervention targeting several ecological systems is an ongoing project initiated by RCT which seeks to optimize cooperation between traumatized refugee parents with criminal adolescents and the families’ professional network through therapeutic network meetings to prevent younger siblings from developing similar problems (207).
The results, moreover, indicate the existence of a large public health problem which calls for policy change and political action. It was not the aim of the studies to undertake a sociological analysis as such, but it is reasonable to ask what implications it could have for the integration of refugee youth into the Danish community and for their future lives, if they continuously experience alienation and, conversely, how that would influence Danish community life.
Psychological trauma. The studies challenge the standardized trauma discourse, with its implicit causal link between traumatic experience and psychological reaction as included in the PTSD model. There does not seem to be a simple, causal relationship between traumatic experiences and subsequent psychological problems. Immediately after the children’s arrival in Denmark, long-lasting violence-related life conditions rather than specific traumatic events predicted psychological problems, and at follow-up, the amount rather than specific traumatic events, in combination with exile-related disturbances in social networks, was associated with psychological problems. Furthermore, stressful life conditions in exile exerted impact on the children’s ability to adapt following initial problems at arrival rather than previous traumatic experience-related to violence. Thus, to capture the complexities involved, psychological trauma in refugee children and adolescents must be studied and understood in the context of a range of risk and protective processes involved in the pre- and post-flight life conditions of the child or the young person.
Moreover, a dose–response pattern between traumatic experience and psychological problems was identified similar to what has been found in studies of the developmental implication of risk factors in early childhood (139). The number of types of traumatic or stressful events may be an indication of disruption in mutual ecological systems, revealing either that fundamental adaptive systems central to human functioning are not operating well and/or that the organism’s adaptive capacity is overwhelmed (208), and thus traumatic experience could be understood, similar to other early psycho-social risk factors, in relation to the developmental impact on children.
Consequently, the clinician should observe that it is not sufficient to focus solely on PTSD symptomatology when assessing the mental health needs of refugee children. Some refugee children can be diagnosed with PTSD, but children’s reactions to traumatic experience manifest themselves as much more wide-ranging than what is included in the PTSD diagnosis. An assessment of previous traumatic experience should be a part of any assessment of refugee children and adolescents referred to treatment because of psychological problems; at the same time, the clinician must be alert to the fact that not all problems are related to their traumatic past. Social conditions, such as discrimination and aspects of integration (network of friends, school changes and Danish proficiency), can be even more important for understanding the reaction of the children, and our studies support conclusions from other studies – that interventions aimed at improving social conditions are likely to have positive impacts (209).
Our studies did not include individual differences in pretrauma personality, such as intelligence, cognitive capacity, self-efficacy and creativity, which are known to influence the trauma response (210). More research is needed, specifically tailored to understanding the long-term influence of such factors and their interaction with pretrauma life circumstances. There is also a need to better understand how other types of early traumatization, such as being the victim of child abuse or family violence, influence children’s later ability to cope with the experience of war and organized violence (211). To gain a more comprehensive understanding of the trauma process, future studies need to include different outcome measures, such as indicators of function, as well as indicators of challenges and problems (212).
Larger samples are necessary to disentangle the impact of the various factors, and longitudinal studies are needed to study key transitions and changes in children and young people’s lives and to test causal pathways, such as the impact of early experience on psychological development (213), as well as for further understanding the relationship between risk, resilience and psychopathology. Experimental research designs, which could be efficient in disentangling the effect of the different factors, are most often not possible since the studies include aspects of life which cannot be controlled in experimental settings, and because of ethical constraints; thus, observational designs, that is, as applied in the present studies, are most realistic for the mere inspection of causal processes. Furthermore, a combination of studies using quantitative and qualitative analysis seems to provide the best knowledge base.
Differences between boys and girls in their response to traumatic experience have been found in several studies, but patterns are not consistent. Other types of sex differences within refugee families have been identified in the present studies, particularly concerning the impact of parental suffering and family communication. This also merits further investigation.
Intergenerational transmission of trauma. Indicators of intergenerational transmission of trauma were obvious in the studies, but only close to the time of the families’ arrival in Denmark. The importance of intrafamily support and the interrelationship between children’s and parents’ situation and reactions was, however, shown throughout the studies.
A family history of violence, involving parents or even grandparents, was directly related to psychological problems in the child at arrival, even if the violence took place before the birth of the child and therefore could only indirectly have had an impact. The results point to three potential and mutually interlinked pathways for the intergenerational transmission of trauma: post-traumatic disruptions in parental attention to the child because of the parents’ own problems, family violence or neglect secondary to organized violence and aspects of trauma-focused family communication.
Parents who are traumatized following exposure to torture or organized violence can have difficulties in living up to their children’s demands for empathy, sensitivity and presence. Secure attachment and children’s trust in their parents’ ability to protect them against danger are important prerequisites for healthy development. An assessment of attachment relationship was not included in our studies, but other studies have pointed to the role of refugee trauma in disrupting attachment security in both children and adults as well at to the protective role of safe attachment representations in reversing the impact of traumatic events in children (214).
Family violence proved difficult to study through structured interviews, but in the clinical interviews, several young refugees talked about the violence they experienced in their family. In the qualitative study involving 12 young refugees from the present follow-up population (186), a history of internal conflicts in the family including violence and neglect dominated over family narratives of organized violence, which in other cases proved helpful for the young refugees in creating meaning and coherence in the family history.
How families communicate about traumatic experience also seems to be important for the intergenerational transmission of trauma. A secure attachment relationship is related to open and positive expression of emotion and communication and an appropriate balance between promoting both autonomy and relatedness, whereas insecure attachment relationship is associated with communication-inhibiting behaviour (215). Communication between family members can foster resilience and serve a buffering role during critical times in the life of a child, but the quality of the communication depends on the way the family is experiencing its life story and situation as refugees. The refugee parents’ narratives about the past, including the family history of exposure to violence, are crucial to the way their children narrate their experience of being refugees in the present. Moreover, communication in traumatized refugee families can be characterized by the parents’ experience of ambiguity, meaninglessness and alienation, and this will place the child in a situation of confusion and powerlessness.
Further studies are necessary to elucidate the implications of family dynamics, including attachment status, family violence and communication, for different developmental trajectories among refugee children.
The results raise a number of issues for clinical practice regarding assessment and treatment of refugee children and adolescents. The use of multiple informants in the assessment of child and adolescent psychopathology is recommended, but the clinician should be aware of the fact that parents’ assessments of the psychological problems of their children are influenced not only by a specific perception and understanding of the child’s problems, but also by the nature of the parent’s own health problems. Parents may project their own psychological problems onto their children, and parents with somatic illnesses may neglect psychological problems in their children. An assessment of both parents’ health situation thus seems important in order for the clinician to combine and understand differences between parental and self-assessment of psychological problems in children and adolescents.
As the family context is of particular importance for refugee children and adolescents, the clinician should always include parents in the treatment of their children and primarily regard them as an asset to understanding the particular life context of the child. Dealing with families traumatized by torture and organized violence can be a huge challenge to the clinician. An important question is to what extent family members should be encouraged to talk about experiences from the past and to what extent the children, in particular, should be protected against knowledge about such atrocities. There is no clear answer to this. While too much talking about the traumatic past could re-traumatize the child or adolescent refugee, too little talk could leave him/her alone in dealing with the traumatic memories. As stated earlier, traumatic experience is not related to psychological symptomatology in a simple way but depends, among other things, on the meaning attached to the event. The way in which people understand and make sense of the past is not necessarily in accordance with the way in which they live, and the clinician can assist the family in exploring their ‘stories told’ and relating them to their ‘stories lived’, bearing in mind that the needs of the children may be different from those of the parents. The clinician needs to be aware of the fact that a child’s detailed knowledge of a traumatic incident in the home country does not necessarily imply that the child has experienced or has been informed about it or even that it ever occurred. The knowledge may be a result of the way in which the child has pieced together various fragments of the family history, both the lived and the told.
Externalizing and internalizing problems. Young refugees and immigrants have recently taken up much space in the public debate in Denmark, particularly in connection with the media coverage of street gangs and aggressive youth. Moreover, ethnic minorities are overrepresented in the judicial system, and the first generation of children of refugee families comprises 44% of young people who have committed or have been charged of committing crimes so serious that they have been placed in remand in secure institutions for young people (216). A large proportion of this overrepresentation can be explained by demographic and socio-economic differences between citizens of Danish and foreign origin (217), but trauma following war and other organized violence as well as marginalizing, discrimination and stereotyping in exile has been suggested as another possible explanation; however, the evidence is limited.
In the present studies, only a minority of the young refugees had committed illegal acts, and traumatic experience and perceived discrimination were related to internalizing rather than externalizing problems. Few studies of young refugees have focused on externalizing problems, and the results are inconclusive; several studies actually point, rather, to the importance of exile and family-related problems than to traumatic experience for externalizing behaviour, even in conditions of continuous violence such as in Gaza (218, 219). In non-refugee populations, a relation between exposure to violence and both externalizing and internalizing problems is supported (220), but a simple, direct link from early exposure to violence and later antisocial behaviour is not supported (221).
Externalizing and internalizing problems were highly correlated in our studies; thus, a link between trauma and externalizing problems could be indirect. Longitudinal studies, preferably with several observation times, are needed to establish the directions of the possible pathways between traumatic experience, discrimination, social adaptation in exile and different types of psychological and behavioural reactions.
It is apparent that psychological models of analysis and explanation do not offer sufficient tools for the development of effective and socially and ethically acceptable interventions. This warrants further study as well as enhanced political will to ensure that young refugees are received, treated and included in the Danish community in the best possible way to ensure their healthy development and coping.
The present studies included children and families who had been exposed to violence in their home countries and had chosen to, and been able to, escape and to reach a Western country to apply for asylum. Participants in the follow-up study had, furthermore, succeeded in getting a positive answer to their applications for asylum. The study groups thus are highly selected, and the results cannot be generalized to children with the same experience who stayed in their home country. It, however, seems reasonable to generalize the results to refugee children arriving with their families in a Western country in modern times.
Discussion of material and methods
The studies included in this review each have their strengths and weaknesses, which could have influenced the findings and the inferences. The specific implications are discussed in the individual studies, but some general aspects will be noted here.
Study populations and design. The baseline study was a cross-sectional cohort study with a high response rate (90.4%). Inclusion was restricted to children from the Middle East (based on a list of specific nationalities), who were consecutively registered as asylum seekers with at least one parent during a specific period of time. Only one family, with three children, rejected participation, the rest of the non-participants consisted of asylum seekers who could not be reached because of practical reasons, either because they were sent out of Denmark shortly after arrival or because they were, for logistical reasons, transferred to refugee centres in other regions of Denmark. The only information about non-participants we had access to was nationality, age and sex, and the only significant difference between the two groups was concerning nationality (more Syrians among the non-participants). Non-participation was not considered to have introduced a systematic bias in the analysis [see also (36) for a more detailed analysis of non-participation]. Moreover, the results apply to the specific context of young Middle Eastern refugees in exile in a high-income country and cannot, without further investigation, be generalized to other refugee groups.
This study describes the prevalence of exposure to traumatic life conditions and events before arrival and psychological problems shortly after arrival, using parents’ reports. At the time of the baseline study, the asylum-seeking families lived in Danish refugee centres. Thus, their current situation was unstable and insecure, which can have influenced the parents’ assessment of their children, but not in any obvious direction. It is possible that parents of children with many violent experiences would expect the children to be influenced psychologically and would thus observe more symptoms, or parents with children with many symptoms might be more prepared to remember their history of violent exposure, thus introducing a signal bias away from the null hypothesis. On the other hand, a tendency for parents to neglect emotional symptoms in their children can also be hypothesized, because it would be painful for parents to acknowledge that they had not been able to protect their children. Moreover, the parents of the most traumatized children have often had equally traumatizing experiences themselves, and as shown in the study by Montgomery (8), parents’ own health situation impacts the way they assess their children. It is possible that parents were less capable of observing the problems of their children because of their preoccupation with their own problems and this would introduce a bias towards the null hypotheses. The families’ situation as asylum seekers might also have influenced the way they responded, but again not in any obvious direction. Some parents might have over-reported symptoms because they expected this to increase their chances of being granted asylum, others might have underreported symptoms for the same reason, since they were afraid of being rejected if they were considered a burden to the Danish community.
Only interviews with parents were used at baseline and thus symptoms had to be related to behaviour in the children that the parents could actually observe. It was not possible to include symptoms that refer to internal reactions, for example, intrusive symptoms. Similarly, it was difficult for parents to provide accurate information about traumatic experiences of their children, particularly about age at onset and intensity/length of the experiences (constituting a recall bias). Systematic error might have been introduced because of the different errors involved in assessing symptoms, traumatic events and other variables, and this could have influenced the observed associations, but the direction is not obvious.
It would have strengthened the study if information about parents’ mental and somatic health had been collected and entered into the analysis.
The follow-up study was not planned at the time of the baseline study, and the design is therefore similar to a retrospective cohort study. Participants were systematically included based on i) being part of the baseline study and ii) having been granted a residence permit. About one-third had been rejected permission to stay and could not be followed up; the authorities do not keep any record of the whereabouts of rejected asylum seekers. However, as shown in the studies by Montgomery and Foldspang (6) and (7), the rejected and the accepted group did not differ on most of the principal variables studied (traumatic experience and mental health), while there were significant differences with regard to social and demographic background between the two groups. Thus, children and youth available for follow-up originated from families characterized by being relatively resourceful as concerns, for instance, education.
The response proportion was 72% among the 182 children who were available for follow-up 8–9 years after arrival in Denmark, thus excluding the rejected 121 children and those who had emigrated (six children) or died (one child) and the one who could not be found in the Danish registry. Participants and non-participants differed significantly concerning age (younger age predicted participation) and sex (more girls participated). This might have introduced a systematic bias as age and sex are important covariates in the analysis and both, particularly sex, have been found to relate independently to mental health. It is also possible that some young refugees with many problems did not participate in the study. Since non-participation was, however, the result partly of the parents’ refusal and partly of the young refugee’s own refusal, it is not possible to know how this may have influenced the results. Participants and non-participants did not differ concerning mental health at arrival or number of traumatic experiences before arrival. There was no sex difference concerning either specific exposures or number of exposures before arrival in Denmark.
In contrast to the baseline study, indicators of parental health problems (mental as well as somatic) were included in the follow-up study. Assessment of parental health was not, however, based on validated assessment methods, and it is possible that the indicators used were too narrow, which may have influenced the analysis towards the null hypothesis. A similar argument could be put forward concerning the indicators of parental social adaptation.
Since the sample size was relatively small and the number of candidate predictors rather large and since many analyses were carried out, it is possible that some results were coincidental. Although the strategy of analysis was based on a theoretical conceptualization including a time aspect, it is still possible that another strategy might have led to other results. In statistical analysis, for example, in structural equation modelling, small samples tend to favour simpler models over more complex models with more parameters because of loss of precision when more estimates are included in the model (222). This may have influenced the results obtained by Montgomery and Foldspang (11). The limited sample size made it impossible to conduct separate analyses for boys and girls, which would have been preferable; instead, age and sex were included in all analyses.
In some of the analyses, we did not conduct multilevel analysis to correct for clustering of children within families, and as a result of this, random error might have been underestimated. This underestimation was not, however, differentiated.
Mental health assessments. Assessment of mental health at baseline and follow-up did not use the same methodology, preventing a direct comparison of symptom levels. When the baseline study was planned and carried out, we did not envisage a follow-up study; thus, our decision to develop our own assessment scale at that time was based solely on our appraisal of appropriate methods for assessing children who had recently arrived from violent conflict areas in different parts of the Middle East, and whose age range was 3–15 years. The same psychological concept (for example, anxiety) has different content and is expressed differently by children of different ages, which had to be taken into consideration [see the study by Montgomery (36) p.63 for a discussion]. Thus, the scale developed could not be used with young refugees, who had already lived in Denmark for a considerable period of time.
Mental health at follow-up was assessed using the Achenbach System of Empirically Based Assessment. This approach was selected because of several reasons: i) the population included children, adolescents and young adults, and this system includes related scales that encompass all age groups; ii) this system has been widely used in transcultural research and has shown good validity and reliability (148, 223–225); iii) the system includes self and parents’ scales, and iv) two of the four scales applied were already translated into Danish, and one of the scales for parents existed in Arabic. Separate analysis showed that items specific for one age group could be left out in the linear analysis without significant loss of precision (Table 3).
Only parents of 122 children filled out the parent-checklist validly, and thus most of the analyses are based on self-reports. Furthermore, as the results in the study by Montgomery (8) show, parents’ assessments of their children might be qualitatively different from self-assessments, which imply that the two sets of observations should be treated separately. Parent ratings were made primarily by the mother, but sometimes by the father or by the mother and father together, without this being recorded. Both checklists for parents were provided in Danish, but parents could choose to fill the Arabic version of the CBCL if they so preferred. It is possible that parents who depended on an interpreter might have left the task of filling in the checklist to the parent with the better Danish language skills, without this being recorded. Differences in fathers’ and mothers’ assessments of their children have been documented in other studies (149, 152), but not in any consistent way. As factors concerning the parental situation were found to predict differences between self and parent assessment, this could be a bias, but the direction of this cannot be foreseen.
Qualitative studies. The use of multiple methods – epidemiological, biostatistical, psychological in-depth interview and qualitative methods – has made it possible to get a deeper insight into the complexities involved in being a refugee family in Denmark. The information gained from the first qualitative study (3) resulted in the inclusion of indicators of family relations and communication in the two epidemiological studies, and the second qualitative study (5) could, among other things, inform us of apparently contradictory findings concerning parents’ information to the children about family exposure in the first qualitative and the baseline study. The different methods have complemented each other and resulted in a better understanding of the issues involved. This approach has also been recommended based on experiences from other refugee studies programmes (226).
Validity. Most data collection involved structured interviews conducted in the refugee centre (baseline) or in the homes of the participants (follow-up). This method has the advantage that any uncertainties concerning how to understand specific questions can be dealt with immediately, resulting in a more precise response. This was particularly important because most of the informants had limited proficiency in Danish. It is also a strength of this research that the same visiting nurse, with expanded knowledge and experience of working with refugees, collected data both at baseline and at follow-up. Interviewing refugees can be sensitive both in regard to different cultural backgrounds that might imply different perceptions of sickness and health, and with regard to the need of working with interpreters in many instances. The questionnaires also involved rather sensitive and private subjects that demanded empathy from the interviewer. The different languages involved were a challenge. The questionnaires at both baseline and follow-up were revised after having been tested by professional translators to make it easy to translate, primarily into Arabic and Farsi, during the actual interview. Rating scales for assessing the mental health of the young refugee were filled out by the parents and the young refugee in connection with the structured interview. In a few instances, however, the parents’ wished to fill it out after the interview and mail it by post, which was accepted.
Two validity studies were conducted, both involving in-depth psychological interviews, at baseline with the parents and at follow-up with both parents and the young refugee. The purpose of both validity studies was to analyse how well the applied mental health scales captured the mental health of the child/young refugee. At baseline, the validity study was also used to assess the validity of self-reported information about exposure to torture (65). All interviews were carried out by the author blinded for the results of the structured interviews. In both cases, the study involved a systematic selection for participation. Non-participation at baseline was solely based on transferral to other refugee centres before the interview could be conducted, but the inclusion period was prolonged to include about 100 children. At follow-up, however, it proved more difficult to reach an acceptable number of participants, partly because of the practical selection criteria (living within 1 h travel of the office of the researcher), partly because of refusal to participate by five young refugees and the incomplete data in the self-reported mental health scales that made it impossible to use the already conducted interviews of four young refugees. The final study group was therefore limited to 67 participants, and the procedure used at baseline for constructing an empirically based anxiety scale (2) could not be validly employed because of small numbers. However, the results were used to test the appropriateness of cut-off levels of the employed scales that have been proposed based on other studies (31, 33).
Information on exposure, for example to parental imprisonment and torture, was based on the families’ own stories. We did not have access to information on the specific cases from the authorities, and we possessed neither the tools nor other resources to verify the individual case, but self-reports on torture were, based on the results of the validity study, found to be fairly valid (65).
We did not use standardized measures of social adjustment and discrimination but chose to base such indicators on focus-group interviews with five young male refugees and qualitative interviews with two young female refugees, thus implying an ethnographic approach (227). In this way, the concepts of social adjustment and discrimination were well suited to this study population, but comparison with studies of other groups was more difficult.
The structured questionnaires were extensive, but it is not possible to include all factors that might have an influence on the associations studied. Thus, we had no information about other types of stressful events during the young refugees’ childhood, such as family violence or child abuse, or about pretrauma personality factors such as intelligence, creativity and self-efficacy. Apart from the factors already acknowledged to be missing in the study, it is probable that other important but yet not identified relevant factors also have been missed out.
The qualitative analyses were theory based, and the studies are limited both in terms of data material and in terms of theoretical understanding and thus provide informed hypotheses rather than definite conclusions. To improve the validity of the qualitative analyses, categorization and coding was discussed with peers. In the study Children of torture victims (3), a first categorization was developed by all the authors and data coded accordingly. The final categorization, based on the three dimensions, and re-coding accordingly, was done by the first author and discussed with the second author and one peer. The categorization and coding of data from the study The torture surviving family (5) was performed by the author and discussed with one peer.
Summary. This review consists of a summarizing synopsis and eleven papers. The purposes were to inspect the validity of central concepts such as PTSD and anxiety, to identify the extent and determinants of psychological problems at arrival in Denmark, to identify the determinants of receiving a residence permit in Denmark and to identify the extent and determinants of psychological problems 8–9 years after arrival in Denmark. The review is based on four empirical studies: i) Children of torture victims, a qualitative study of 11 children from torture surviving families in treatment at the Rehabilitation and Research Centre for Torture Victims during 1989; ii) Refugee children from the Middle East, a cohort study of 311 3–15-year-old asylum-seeking children, who arrived in Denmark in 1992–93 with at least one of their parents; iii) The torture surviving family, a qualitative study of 14 members of three torture surviving families interviewed shortly after having been granted asylum in Denmark in 1993; and iv) Mental health and integration of young refugees from the Middle East, a follow-up study of 131 11–23-year-old refugees from (2), who had been granted permission to stay in Denmark in 2000–2001.
Trauma reactions in refugee children are often conceptualized in terms of PTSD. We showed that the reaction of the children was not necessarily PTSD specific; thus, focusing on this concept in research and clinical intervention is not sufficient for understanding the children’s trauma reaction. Moreover, rating scales for measuring mental health in adult as well as child populations most often follow the procedure of summing up individual ordinal item scores. However, the purpose of the scale being to identify children with special needs for an intervention, misclassification could be shown to be considerably reduced by using empirical regression-based weighting of scale items. This demands a blinded criterion measurement and, furthermore, a test sample that is representative of the larger population sample, on which regression coefficients are applied.
The main results of the qualitative studies were that children from families suffering from the after-effects of torture seem to have difficulties adapting a previously successful coping strategy to the new life context in Denmark. Information about the imprisonment and torture of parents was not in itself found helpful in regard to the children’s ability to cope with their traumatic past, and the ability to create meaning in family stories seems to depend more on the manner in which the parents and children communicate than what information is actually communicated to the children.
A high prevalence of psychological problems was identified among the children at arrival; thus, 77% suffered from at least one of three conditions at arrival: anxiety, sleep disturbance and/or sad and depressed mood. Sleep disturbances at baseline (prevalence 34%) were predicted by a family history of violence as well as by a stressful family situation in the present.
Contrary to what would be imagined, refugee families who were granted permission to stay differed from those who were not granted permission to stay mainly as concerns social and cultural background rather than exposure to human rights violations. The situation of the children did not seem to have been included in the decision-making process.
At follow-up, the high prevalence of psychological problems was considerably reduced. Thus, based on self-reports, 25.9% were in the combined borderline and clinical range, 28.4% based on parent-reports. The prevalence was, however, still somewhat higher than what has been found in community studies using the same assessment tools. Self-assessments of psychological problems in young refugees only correlated moderately with parents’ assessments, and the difference between the two sets of ratings was predicted by, among other things, the father’s health situation. An assessment of the father’s health situation thus needs to be included when planning treatment of young refugees. At follow-up 8–9 years after arrival, internalizing behaviour was primarily predicted by the cumulated types of trauma experiences before arrival as well as stressful types of events, including discrimination, after arrival, while externalizing behaviour was predicted by having witnessed attacks on others in Denmark and frequent schools changes during the 8–9 years in Denmark. Factors regarding integration, such as school or work participation, Danish friends and Danish language proficiency, as well as mother’s longer education, seemed to reduce long-term psychological problems. The social adaptation of the young refugees was associated with perceived discrimination and psychological problems, but the direction of the pathways was not obvious.
In conclusion, psychological problems are frequent in refugee children and adolescents, but the extent of such problems are reduced over time in exile. Traumatic experience before arrival is most important for the short-term reaction of the children, while the influence of early traumatic experience on long-term mental health is more limited. Aspects of a stressful life in exile seem to be most important for the children’s ability to recover from early traumatization. The quality of family life seems to be important for both short- and long-term mental health.
Professor Anders Foldspang, School of Public Health, Aarhus University, has been a partner in some of the studies of the programme. Structured interviews in both the baseline and the follow-up study were collected by visiting nurse Berit Haahr Rindorf. The studies were supported by the Egmont Foundation, the BG-Fund, the Henrik Henriksens Fund, the Research Fund of the Danish Medical Association/the Hojmosegaard Grant, the John D. and Catherine T. MacArthur Foundation, the United Nations Voluntary Fund for Victims of Torture, the Dr Sofus Carl and Olga Doris Friis Fund, the Torkil Steensbeck Fund, Chief Engineer Walter Christensen and O. Kristiane Christensen Fund, the Steamship Company Torm, Alfred Benzon’s Fund and the Tides Foundation.