Prevalence of mental health problems among refugee youth

A meta-analysis of 56 studies on the mental health of refugees and internally displaced persons

indicated that refugee children and adolescents had relative better mental health outcomes compared to adult refugees, with an effect size of 0.28 for children and 0.53 for adults (Porter & Haslam, 2005).

Most systematic reviews have focused on refugee children and adolescents who resettled in high-income countries. Fazel and colleagues (2005) synthesized evidence from 5 surveys on 260 refugee children from Bosnia, Central America, Iran, Kurdistan and Rwanda who had resettled in Sweden, Canada and USA and reported a pooled 11% prevalence rate of PTSD. A systematic review of 22 studies conducted in Europe, Canada and USA found varying rates of 19 – 54% for PTSD and of 3 - 30% for depression (Bronstein & Montgomery, 2011). Large heterogeneity between studies has also been noted by Kien and colleagues (2019) in their recent systemic review of 47 studies on the prevalence of mental disorders in refugee and asylum-seeking minors in Europe: prevalence rates for PTSD ranged between 19% and 52.7%, for depression between 10.3% and 32.8% , for anxiety disorders between 8.7% and 31.6% and for emotional and behavioral problems between 19.8% and 35%. Only few studies reported on other mental health outcomes such as suicidal ideation and behavior, psychosomatic complaints and enuresis, while no studies on the prevalence of psychotic disorders, eating disorders and substance abuse were identified by this review (Kien et al., 2019).

The immediate experience of war-related violence is a particularly important factor in determining the risk of developing PTSD for refugee children. In a systematic review of 17 studies including 7920 children exposed to war, the pooled prevalence of PTSD was 47% and 12 studies reported rates of PTSD above 40% (Attanayake et al., 2009). Studies conducted in the wake of the Yugoslav wars suggested that forcibly displaced children had worse mental health outcomes than their non-displaced peers (Allwood et al., 2002; Kocijan-Hercigonja et al., 1998; Sikić et al., 1997;

Sujoldžić et al., 2006).

Similar to research with adults, studies comparing refugee children with native populations in the host country were also mainly conducted in high-income countries, with mixed results. While some studies found higher rates of psychopathology in refugee children and adolescents compared to host peers (Bean et al., 2007; Björkenstam et al., 2020; Tousignant et al., 1999), others reported no

differences (Rousseau et al., 2000; Wahlsten et al., 2001) or that refugee youth even showed lower rates of anxiety and depression than native youth (Björkenstam et al., 2020; Derluyn et al., 2008;

Slodnjak et al., 2002). Refugee minors fleeing and resettling without the presence of protective family members appear to constitute a particularly vulnerable group and display high prevalence rates of PTSD, depression and anxiety (El Baba & Colucci, 2018). Studies with clinical and community samples consistently found higher levels of mental health problems among unaccompanied compared to accompanied refugee minors (Bean et al., 2007; Hodes et al., 2008; Norredam et al., 2018; Pinto Wiese & Burhorst, 2007).

The little evidence on long-term mental health outcomes of refugee children comes from few prospective longitudinal studies mainly conducted in high-income countries. In the longest cohort study to date, levels of PTSD and depression among a small sample of Cambodian adolescent refugees declined from 50% and 53% respectively at baseline to 35% and 14% respectively after 12 years (Kinzie et al., 1986; Sack et al., 1999). The findings of a systematic review suggests that levels of PTSD remain relatively stable among resettled refugee children over time (Tam et al., 2017). Both levels of pre-migration traumatic experiences and post-migration stressors seem to be crucial in predicting refugee children`s trajectories of mental health problems over time (Hjern & Angel, 2000;

Jakobsen et al., 2017; Jensen et al., 2019; Montgomery, 2010).

The relative scarcity of research in low- and middle-income countries is even more

pronounced in the child compared to the adult literature. However, evidence suggests that the mental health of refugee children in these settings is particularly strained (Reed et al., 2012). Vossoughi and colleagues (2018) recently reviewed 20 studies, all but one conducted in low-and middle income countries (World Bank, 2019), on mental health outcomes of youth currently living in refugee and IDP camps. Consistent with previous systematic reviews with adults (e. g. Steel et al., 2009) and children (Kien et al., 2019), they reported highly varying prevalence rates for mental health problems among camp-based refugee youth due to clinical, e.g. war exposure, and methodological, e. g. use of different informants and instruments, factors. For example, one study with Guatemalan refugee children living in Mexican camps did not find any significant levels of PTSD (Miller, 1996), whereas some studies reported rates as high as 57% (Rothe et al., 2002), 75% (Morgos et al., 2008) and 87% (Ahmad et al., 2000). Similarly, rates for anxiety (1.4 - 35%) and depression (35 - 90%) were highly varying in this review (Vossoughi et al., 2018). There is little evidence on how refugee youth resettled in low-and middle-income countries fare compared to host peers. South Sudanese refugee children living in a Ugandan camp had higher levels of PTSD, depressive, behavioral and somatic symptoms than local Ugandan youth (Paardekooper et al., 1999), while Kosovo Albanian children and adolescents who had fled to Turkey had higher levels of anxiety and depression than their Turkish peers (Yurtbay et al., 2003). The few studies that compared refugee children living in camps and in other settings, e.g.

private accommodations, suggest that residence in camps increases the risk of developing mental health problems (Reed et al., 2012).

Recently, many studies looked at the mental health of children who fled from the Syrian civil war as well as atrocities committed by the so-called Islamic State into neighboring countries,

particularly to Turkey. In these studies, between 18.3% and 68.2% of the children fulfilled criteria for PTSD diagnosis (Beni Yonis et al., 2019; Eruyar, Maltby, et al., 2018; Gormez et al., 2018; Gunes &

Guvenmez, 2019; Khamis, 2019; Nasıroğlu et al., 2018; Nasıroğlu & Çeri, 2016) and between 9.6%

and 38.7% had elevated levels of emotional and behavioral problems (Cartwright et al., 2015; Çeri &

Nasiroğlu, 2018; Eruyar, Maltby, et al., 2018; Nasıroğlu et al., 2018). Moreover, prevalence rates for anxiety disorders ranged between 7.3% and 69% (Gormez et al., 2018; Kandemir et al., 2018;

Nasıroğlu & Çeri, 2016; Yalın Sapmaz et al., 2017) and for depression between 13.5% and 59.1%

(Gunes & Guvenmez, 2019; Kandemir et al., 2018; Nasıroğlu et al., 2018; Nasıroğlu & Çeri, 2016;

Yalın Sapmaz et al., 2017). The religious-ethnic group of the Yazidi people suffered particularly as they became victims of genocide by the Islamic State. In a study with 38 Yazidi refugee children, all children had at least one psychiatric disorder and half had at least two disorders (Çeri et al., 2016).

Independent of the studied population and the resettlement setting, some aspects are

noteworthy. First, consistent with findings from adult refugees (e.g. Bapolisi et al., 2020; Tinghög et al., 2017) and non-refugee populations (Famularo et al., 1996; Spinhoven et al., 2014), studies with refugee children and adolescents often noted high comorbidity of mental health problems, particularly among PTSD, depression and anxiety (e.g. Betancourt, Newnham, et al., 2012; Kandemir et al., 2018;

Kia-Keating & Ellis, 2007; Thabet et al., 2004). Second, also mirroring the findings of studies with adult refugees, the current evidence suggests that refugee girls have a higher risk for developing PTSD and internalizing problems, i.e. depression and anxiety, compared to boys (Beni Yonis et al., 2019;

Braun-Lewensohn & Al-Sayed, 2018; Fazel et al., 2012; Jensen et al., 2019; Mohwinkel et al., 2018;

Reed et al., 2012). In contrast, boys appear to be more vulnerable for externalizing problems, e.g.

aggression and hyperactive behavior (Çeri & Nasiroğlu, 2018; Oppedal & Idsoe, 2012; Reed et al., 2012). Third, there are only few studies which investigated the mental health of younger refugee children, i.e. below 8 years of age (Frounfelker et al., 2020). Available studies in diverse settings indicate high levels of parent-reported internalizing and externalizing symptoms in toddlers and pre-school children (e.g. Buchmüller et al., 2018; Hjern et al., 1998; Khan et al., 2019). Also, increased levels of PTSD have been found in pre-school refugee children who had been exposed to severe violence as infants (Almqvist & Brandell-Forsberg, 1997).

The epidemiological findings suggest that many refugee children and adolescents are able to adjust well to the often-times extremely stressful experiences and challenges throughout their life journey (Crowley, 2009; Pacione et al., 2013). This high functioning despite exposure to significant adversity has been termed “resilience” (Luthar et al., 2001; Masten & Narayan, 2012; Rutter, 1985).

Notwithstanding, a substantial number of young refugees develop debilitating and impairing mental health problems as a result of their experiences, which exceed levels typically found in the general population of children and adolescents, even when using conservative estimated rates (Attanayake et

al., 2009; Bronstein & Montgomery, 2011; Ehntholt & Yule, 2006; Kien et al., 2019; Vossoughi et al., 2018). For example, in a systematic review of 41 studies conducted in 27 countries, the worldwide pooled prevalence for any mental disorder was 13.4% (CI 95% 11.3 - 15.9), for anxiety disorder 6.5%

(CI 95% 4.7 - 9.1), for depressive disorder 2.6% (CI 95% 1.7 - 3.9) and for attention-deficit hyperactivity disorder 3.4% (CI 95% 2.6 - 4.5) (Polanczyk et al., 2015). Prevalence rates for PTSD ranged between 1.3 and 6.6% in studies with community samples in high- and low-income countries (Abbo et al., 2013; Kilpatrick et al., 2003; Mullick & Goodman, 2005). Given these figures, it can be concluded that refugee children and adolescents are at an increased risk for developing mental health problems. This particular vulnerability of millions of refugee children worldwide poses a global public health challenge and calls for rigorous and coordinated prevention and intervention approaches to alleviate their suffering and promote their adjustment.

2.3 A socio-ecological theoretical framework