4.1 Systematic review of the current evidence on factors contributing to risk and protection of refugee children`s mental health
The databases Medline, PsycINFO, Web of Science, and Cochrane were searched for English studies published in peer-reviewed journals between August 2010 and May 2020. The following search algorithm was used: (“asylum seeker” or “refugee” or “displaced person” or “migrant”) and (“child”
or “adolescent” or “young” or “minor” or “teenage” or “youth”) and (“psychiatr*” or “psycholog*” or
“psychosocial” or “mental” or “well-being” or “adaptation” or “adjustment” or “emotion” or
“behaviour” or “behavior” or “trauma” or “traumatic” or “PTSD” or “posttraumatic stress” or
“internalizing” or “externalizing” or “anxiety” or “depression”) and (“resilience” or “protective factor”
or “modifying factor” or “recovery” or “outcome” or “risk factor” or “vulnerability factor”). The literature search yielded 2413 potential studies, of which 63 fulfilled all inclusion criteria and were therefore included in the narrative synthesis. Forty-one studies were conducted in high-income countries and 22 studies in low- and middle-income countries with refugee children coming from overall 53 different countries. Only 8 studies were conducted in refugee camps. Most studies (51) were cross-sectional and only 7 of those included a comparison group, while 12 studies used a longitudinal one-group design. According to the Systematic Assessment of Quality in Observational Research (SAQOR; Ross et al., 2011), 13 studies were of low quality, 26 of moderate quality and 24 of high quality. The factors contributing to risk and protection of the mental health of refugee youth identified by this systematic review across different socio-ecological levels (individual, family, community, society/culture) and stages of the refugee experience (pre-. peri- and postmigration) are displayed in Table 2. Pre-migration individual (risk: exposure to war-related trauma, female gender) and post-migration family factors (risk: parental mental health problems and impaired parenting, protective: family cohesion) have received wide support across a variety of different resettlement contexts. Post-migration community (protective: school connectedness, support by peers) and
sociocultural factors (risk: discrimination and acculturative stress, protective: integrative acculturation) appear to play a role as well, but have only been investigated in high-income countries.
Table 2: Risk and protective factors according to socio-ecological context and stage in the refugee
Living with at least one biological parent (protective)2
Parental mental health problems (risk)10 (2) Negative parenting behaviors (risk)5
Society/Culture Detention (risk)2 Perceived discrimination (risk)4 (3) Integrative acculturation style
(protective)6
Exposure to acculturation stressors (risk)4
Resettlement in a poor region (risk)2
Low-support living arrangements (risk for unaccompanied minors)3 Asylum granted in host country
(protective)4 Note: Only factors that were found in at least two studies are shown. Factors not included in the previous reviews by Fazel and colleagues (2012) and Reed and colleagues (2012) are highlighted in bold. The numbers indicate the number of studies that found the respective factor in the current review (without brackets) and in the reviews by Fazel and colleagues (2012) and Reed and colleagues (2012) (with brackets).
4.2 Prevalence of traumatic experiences and mental health problems among Burundian refugee families and familial patterns of morbidity
Children reported to have experienced an average of 7.53 (SD = 5.28) potentially traumatizing events with a maximum of 27 traumatic event types. Almost every child (98.7%, n = 227) had been exposed to at least one potentially traumatizing event and two thirds (65.2%) had experienced five or more events. The most common trauma was the death of a close person (84.3%), followed by seeing
someone who was beaten up, shot at or killed (55.7%). Almost one half reported to have experienced a dangerous flight (45.7%). Less common events included being raped or sexually assaulted (7.4%), being beaten or tortured by armed personnel (4.8%) or being forcefully abducted (0.9%). There were no differences between girls and boys and between older (> 11 years) and younger children in total trauma exposure.
Mothers had been exposed to a mean number of 16.91 (SD = 6.19) potentially traumatizing events with a maximum of 30 traumatic event types. Every woman had experienced at least one potentially traumatizing event, 86.5% (n = 199) indicated to have experienced 10 or more potentially traumatizing events during their life. Fathers reported the highest levels of traumatic exposure (M = 20.80 SD = 5.72, Max. = 34). Every man indicated to have experienced at least two potentially traumatizing events, 95.7% (n = 220) 10 or more events and almost two third (61.7%, n = 142) 20 or more events. Over 80% of mothers and about 90% of fathers reported to have experienced a dangerous flight and being in close proximity to combat situations, crossfires and burning houses. More than half of mothers (53.9%) and two thirds of fathers (67%) had witnessed the murder or killing of someone.
One fifth of all mothers (20.9%) reported having been raped or sexually assaulted. Less frequently reported was perpetration of severe physical or sexual violence by parents themselves and these events were reported more often by fathers, for example raping (5.7%) or killing (4.8%) someone.
The prevalence rates of mental health problems among children and parents are displayed in Table 3. The rates of increased mother-reported internalizing symptoms and of father-reported externalizing symptoms were almost twice (27.8%) and four times (5.4%) as high respectively as in the child report (16.5% and 1.3%). There were no age or gender differences in children`s mental health problems except that fathers reported significantly more externalizing problems in younger compared to older children (U = 4462.00, n1 = 75, n2 = 152, p = .008). Mothers had significantly higher levels of PTSD symptoms, t (447) = -3.26, p = .001, and other mental health problems, U = 20140.00, p < .001, compared to fathers.
Moving from a variable-oriented to a person-oriented approach and from a categorical to a more dimensional conceptualization of PTSD symptomatology, the application of latent class analysis revealed four distinct classes of families indicating an accumulation of PTSD symptoms and related functional impairment within families. In the largest class labelled “traumatized families” and containing 35.4% (n = 80) of all families, every member had a high probability of scoring above the median in PTSD symptom severity and being functionally impaired. The second largest class (27.4%,
n = 62) consisted of families in which every member had a low relative probability of endorsing high levels of PTSD symptoms and impairment and was therefore called “non-traumatized families”. The next class (20.8%, n = 47), “traumatized mothers”, was characterised by families in which only mothers were highly likely to report high levels of PTSD symptoms and functional impairment. The smallest class (16.4%, n = 37) was labelled “traumatized fathers” because all fathers in these families had high levels of PTSD symptoms and were impaired by these symptoms, while mothers had a medium and children a low probability of morbidity. The validity of these classes was supported by further analyses showing that “traumatized families” had significantly higher scores in their individual members` traumatic exposure and child-reported maltreatment than “non-traumatized families”
(Pillai’s trace = 0.44, F (15, 660) = 7.46, p < 0.001, η2 = 0.1). Moreover, the classes corresponded well to the prevalence of PTSD diagnoses. For example, all but one child with PTSD diagnosis belonged to the “traumatized families” class and 75.7% of fathers in the “traumatized fathers” class met diagnostic criteria for PTSD.
Table 3. Prevalence rates of mental health problems among children, mothers and fathers Children (n = 230)
M SD
Mothers (n = 230) M SD
Fathers (n =230) M SD PTSD Symptom Severitya b 14.55 11.29 38.39 19.28 32.90 16.44
PTSD DSM-5 Diagnosisa b % (n) 5.7 (13) 32.6 (75) 29.1 (67)
Emotional/behavioral problems (SDQ)c 10.63 5.04 10.84 6.04 9.30 5.56
High SDQ Score c % (n) 10.9 (25) 15.9 (36) 11.5 (26)
General distress (BSI-18)d - 31.11 16.53 24.33 14.21
High Score BSI-18d % (n) - 90.9 (211) 83.9 (193)
For Children: Assessed with the University of California at Los Angeles posttraumatic stress disorder reaction index for DSM-5 (UCLA PTSD RI); Value range 0 – 88.
b For caregivers: Assessed with the PTSD Check List for DSM-5 (PCL-5); Value range 0 – 88.
c SDQ, Strengths and Difficulties Questionnaire; Difficulties Score is composed of sum scores in Subscales Conduct Problems, Hyperactivity, Emotional Symptoms and Peer Problems (Value range 0 – 40). The values in the parents` columns refer to the parent-report. Cut-off score ≥18 for self-report and ≥17 for parent-report.
d BSI-18, Brief Symptom Inventory Short Form; Global Severity Index is the sum score of all 18 items (value range 0 – 72).
Cut-off score ≥13 for mothers and ≥10 for fathers
4.3 The interplay of attachment and maltreatment in the transgenerational transmission of psychopathology
While the analyses for the previous manuscript suggested that both parents` traumatization may be a risk factor for children`s well-being, the second manuscript specifically investigated associations between parents` and children`s psychopathology as well as the mediational role of the attachment relationship and child maltreatment. Four families from the full sample were excluded from these analyses because these foster parents had been living with the children only for a short time.
Therefore, the relevant study sample consisted of 226 families. We analysed two separate structural equation models for mothers and fathers each containing the latent factors maternal/paternal psychopathology (PTSD symptoms and psychological distress), maltreatment by mother/father (physical and emotional abuse and neglect), the children`s attachment representations of mother/father and children`s psychopathology (PTSD symptoms and emotional/behavioural symptoms), controlling for children`s cumulative trauma exposure, age and gender. The measurement models using item parcels as indicators of latent variables showed a good fit. Fit indices of the structural models were also good for the model containing maternal {Comparative Fit Index (CFI) = 0.96, Tucker Lewis Index (TLI) = 0.95, Root Mean Square Error of Approximation (RMSEA) = 0.052, 90% Confidence Interval CI [0.040–0.063], Standardized Root Mean Square Residual (SRMR) = 0.077} and paternal variables (CFI = 0.96; TLI = 0.96; RMSEA = 0.050, 90% CI [0.038–0.061]; SRMR = 0.065).
As shown in Figure 3, maltreatment by mothers significantly mediated associations between maternal and child psychopathology in that higher levels of maternal psychopathology were associated with higher levels of child-reported maltreatment by mothers, which were in turn related to higher levels of child psychopathology (β = 0.04, p = .043). Children`s insecure attachment representations of the mother-child relationship also played an important mediational role in the tested model: More psychopathology in mothers was significantly related to children`s more insecure attachment representations, which were associated with more maltreatment (β = 0.05, p = .028) and also with higher levels of child psychopathology through their link to increased maltreatment (β = Ѹ0.06, p = .025). Thus the analyses revealed no direct but complex indirect associations between maternal and child psychopathology involving both maltreatment and attachment representations.
In contrast, higher levels of psychopathology in fathers were directly significantly associated with higher levels of child psychopathology (β = 0.17, p = .012), as displayed in Figure 4. Although Figure 3. Structural model of the hypothesized relationship between maternal psychopathology,
attachment, maltreatment and child psychopathology. Dashed lines indicate nonsignificant effects.
***p < 0.001, **p < 0.01, *p < 0.05.
children`s more insecure attachment representations of the father-child relationship were highly significantly related to more child-reported maltreatment by fathers (β = -0.38, p < .001), these two factors did not play any mediational role. Children`s own cumulative exposure to traumatic events was the strongest predictor of children`s psychopathology in both models (β = 0.55/56, p < .001).
4.4 The mediating role of psychopathology in the association between maltreatment and memory functioning
The previous two manuscripts had established maltreatment by parents as a relevant factor within children`s family microsystem that contributes to children`s psychopathology. The third manuscript brought into focus another facet of children`s adjustment that may equally be impaired by
maltreatment, children`s cognitive and specifically their memory functioning. The associations between maltreatment by parents, children`s psychopathology and their visuospatial short-term, working and long-term memory functioning were investigated in a sub-sample of 11 to 15 years old adolescents (n = 155) using three structural equation models, one for each memory domain. Children`s exposure to war-related traumatic events, their age, gender and grade level were included as
covariates. Psychopathology was modeled as latent factor with sum scores of internalizing problems, PTSD symptoms and posttraumatic cognitions as indicators, which provided a good fit of the
measurement model.
The structural equation models are displayed in Figure 5. The structural model with working memory as outcome showed good model fit, CFI = .95, RMSEA = 0.05 (p = 0.65), SRMR = 0.07.
Higher levels of maltreatment by parents were associated with higher levels of children`s self-reported Figure 4. Structural model of the hypothesized relationship between paternal psychopathology,
attachment, maltreatment and child psychopathology. Dashed lines indicate nonsignificant effects.
***p < 0.001, **p < 0.01, *p < 0.05.
psychopathology, which were in turn related to a reduced working memory capacity, indicating a significant mediation by mental health symptoms (β = -0.07, p = 0.02). However, there was no direct effect of maltreatment on working memory. Similarly, in the structural model containing short-term memory (model fit: CFI = 0.95, RMSEA = 0.05 (p = 0.58), SRMR = 0.07), no direct effect of maltreatment was observed, but there was a trend towards mediation of the association between more maltreatment and reduced shortterm memory capacity by higher levels of psychopathology (β = -0.05, p = 0.06). The structural model with delayed recall from long-term memory as outcome showed good fit to the data, CFI = 0.96, RMSEA = 0.04 (p = .82), SRMR = 0.06. In contrast to the other two models, there was no indication of mediation by psychopathology, but higher levels of maltreatment by parents were directly significantly associated with stronger recall deficits from long-term memory (β = -0.19, p = 0.02).
Figure 5. Structural model of the associations between maltreatment, psychopathology and memory functioning (short-term, working and long-term memory). The covariates age, gender and class are not shown. Dashed lines indicate nonsignificant effects. ***p ≤ 0.001, **p ≤ 0.01, *p ≤ 0.05.
4.5 Risk, protective and promotive factors for Burundian refugee children`
mental health
The study sample consisted of 217 mother-child dyads with complete data for the relevant study variables. We developed four multiple linear regression models to investigate associations between
individual (war-related violence, engagement coping), microsystem (violence by mothers, friendship quality) and exosystem factors (community violence, maternal social support network) as predictors and children`s PTSD symptoms, internalizing problems, externalizing problems and prosocial behavior as outcomes. Children` age and gender were included as control variables in every model.
The model predicting PTSD symptoms explained 41% of the variability of PTSD symptoms (adj.
R2 = 0.41, F(8, 198) = 18.83, p < 0.001, f 2 = 0.69). Children`s higher exposure to war-related, maternal and community violence as well as more frequent use of engagement coping strategies in daily stressful situations were significantly associated with higher levels of children`s PTSD
symptoms (see Table 4). Children`s higher quality friendships, in contrast, were significantly related to lower levels of PTSD symptoms. The model predicting internalizing problems explained 12% of the variability of internalizing problems (adj. R2 = 0.12, F(8, 194) = 4.46, p < 0.001, f 2 = 0.14). Higher exposure to war-related violence, violence by mothers and within the community as well as more frequent use of engagement coping strategies were significantly associated with higher levels of internalizing problems. The model predicting externalizing problems explained 12% of the variability of externalizing problems (adj. R 2 = 0.12, F(8, 191) = 4.29, p < 0.001, f 2 = 0.14). Higher exposure to violence by mothers was significantly associated with higher and higher quality friendships with lower levels of externalizing problems. Finally, the model predicting prosocial behavior accounted for 19%
of the variability in prosocial behavior (adj. R2 = 0.19, F(8, 200) = 7.20, p < 0.001, f 2 = 0.23). Higher exposure to war-related and community violence, higher quality friendships and mothers` social networks were significantly related to higher levels of prosocial behavior, whereas higher violence by mothers was significantly related to lower levels of prosocial behavior.
Table 4: Results of multiple regression analyses PTSD symptoms
(n = 207)
Internalizing problems (n = 203)
Externalizing problems (n = 200)
Prosocial behavior (n = 209)
β p β p β p β p
Sociodemographic variables
Age .003 .95 -.01 .86 -.10 .18 -.07 .38
Gender -.12 .03 -.11 .12 .12 .09 -.13 .05
Individual
War-related trauma .50 < .001 .20 .03 .09 .22 .26 < .001
Engagement coping .15 .01 .15 .04 -.06 .40 -.05 .51
Microsystem
Violence by mothers .19 .001 .17 .01 .23 .001 -.16 .01
Friendship quality -.12 .05 .10 .20 -.20 .005 .24 .002
Exosystem
Community violence .13 .03 .22 .002 .02 .73 .13 .05
Maternal social network .04 .45 .07 .32 .08 .06 .29 < .001