ECAP editorial calls for more European support and research

“Child refugees and unaccompanied minors require far greater attention”

“Refugees are at high risk of mental health problems, many of which arise as a consequence of their living conditions in the hosting countries. (..) Child refugees and unaccompanied minors are very sizable vulnerable groups which require far greater attention in terms of service provision and also investigation to identify the most effective treatment models.”

Matthew HodesThis comment is given by Matthew Hodes et al. in their editorial for the April 2018 ECAP focused issue on mental health problems in refugees. The editorial provides an overview of the post 2015 immigration crisis in key European countries with a special focus on current demographics, refugee children, mental health studies, policies and practical support available for refugees. The authors assume that the development of better services and research into effective treatment will require resourcing, but “it is expected that over time the improved mental health and effective social integration of refugees will result in huge benefits for the refugees themselves and also for the host communities.”

European network
The authors would assign a crucial role for ESCAP (the European Society for Child and Adolescent Psychiatry), and other academic institutions, and European Universities in the development of a European network, to promote and facilitate research focusing on the needs of the current arrival of refugee children and families. These investigations should be aimed at the support of intervention programmes as well as preventive actions for refugee families raising infants, children and adolescents.

European Child + Adolescent Psychiatry (ECAP) is the official ESCAP journal.

View the full table of contents of the focused issue on young refugees.

Refugees in Europe: national overviews from key countries with a special focus on child and adolescent mental health


Matthew Hodes, Melisa Mendoza Vasquez, Dimitris Anagnostopoulos, Kalliopi Triantafyllou, Dalia Abdelhady, Karin Weiss, Roman Koposov, Fusun Cuhadaroglu, Johannes Hebebrand, Norbert Skokauskas

Many European countries are becoming multicultural at a previously unseen rate. The number of immigrants including refugees has considerably increased since 2008, and especially after the beginning of the war in Syria. In 2015, 88,300 unaccompanied minors sought asylum in the Member States of the European Union (EU) and most came from Syria, Afghanistan, Iran, Iraq, Somalia and Eritrea. As a reaction to increased immigration, governments in many countries including Germany, Sweden and Norway implemented more restrictive immigration policy. A requirement for all countries, however, is the protection and welfare provision for all arriving children, regardless of their nationality, ensured by international and national legal frameworks. This paper provides an overview of the post 2015 immigration crisis in key European countries with a special focus on current demographics, refugee children, mental health studies, policies and practical support available for refugees.

Mental health problems of Syrian refugee children: the role of parental factors


Seyda Eruyar, John Maltby, Panos Vostanis

War-torn children are particularly vulnerable through direct trauma exposure as well through their parents’ responses. This study thus investigated the association between trauma exposure and children’s mental health, and the contribution of parent-related factors in this association. A cross-sectional study with 263 Syrian refugee children-parent dyads was conducted in Turkey. The Stressful Life Events Questionnaire (SLE), General Health Questionnaire, Parenting Stress Inventory (PSI-SF), Impact of Events Scale for Children (CRIES-8), and Strengths and Difficulties Questionnaire were used to measure trauma exposure, parental psychopathology, parenting-related stress, children’s post-traumatic stress symptoms (PTSS), and mental health problems, respectively. Trauma exposure significantly accounted for unique variance in children’s PTSS scores. Parental psychopathology significantly contributed in predicting children’s general mental health, as well as emotional and conduct problems, after controlling for trauma variables. Interventions need to be tailored to refugee families’ mental health needs. Trauma-focused interventions should be applied with children with PTSD; whilst family-based approaches targeting parents’ mental health and parenting-related stress should be used in conjunction with individual interventions to improve children’s comorbid emotional and behavioural problems.

The impact of detention on the social–emotional wellbeing of children seeking asylum: a comparison with community-based children


Karen Zwi, Sarah Mares, Dania Nathanson

Accumulating literature demonstrates that immigration detention is harmful to children. However, there is a scarcity of scientifically rigorous and reliable data about the health of children held in detention facilities. The aim of the study was to compare a community-based population of recently arrived refugee children flown into Australia, not detained, resettled in a non-urban area, with a population of children who arrived by boat seeking asylum, detained since arrival. The parent-version of the strength and difficulties questionnaire (SDQ) of children aged 4–15 years was compared in children living in the community with those held in detention. We compared 86 children who had a parent-completed SDQ performed, 38 (44%) in the community group and 48 (56%) in the detention group. The community sample had been living in Australia for 325 days, with no time in detention. The detention sample had been living in detention for a mean of 221 days. The mean age was similar for the community and detention sample at 8.4 years (P = 0.18). In the total sample, children in the detention group had significantly higher SDQ total difficulties scores than children in the community group (P < 0.0001). There was no difference between age groups (P = 0.82). The children in the detention group had, on average, an SDQ total difficulties score that was 12 points higher than children in the community group. Four of the five SDQ subscale scores indicated greater disturbance amongst children in detention (< 0.0001) compared to children living in the community. The detention group had significantly higher scores (P < 0.001) for all except Pro-social scores as compared to Australian norms for the 4–6 and 7–15 years age group. This study presents a rare opportunity to compare the wellbeing of displaced children who were detained following arrival in Australia with those settled in the Australian community since arrival. The community children’s scores approximated data from the general Australian childhood population. Children held in detention had significantly more social, emotional and behavioural difficulties than children living in the community, and at levels resembling a clinical cohort. Despite the small sample size, data restrictions and other limitations of the data, statistical significance in differences between the community and detention children is marked and arguably demonstrates the negative impact of post-arrival detention in children who are presumed to have similar levels of pre-arrival adversity. If the objective is to optimise the health and wellbeing of children seeking asylum, removal of post-arrival detention is one of the most powerful interventions available to host countries.

Refugee children’s sandplay narratives in immigration detention in Canada


Rachel Kronick, Cécile Rousseau, Janet Cleveland Pages

Asylum seeking children arriving in Canada regularly face incarceration in medium-security-style immigration detention centres. Research demonstrates the human cost of detaining migrant children and families and the psychiatric burden linked with such imprisonment. This study aims to understand the lived experiences of children aged 3–13 held in detention. Informed by a qualitative methodology of narrative inquiry, child participants created worldsin the sand and generated stories to express their subjective experience. Results suggest that children’s sandplay confirms the traumatic nature of immigration detention while also revealing children’s sometimes conflicting understanding of the meaning of detention and their own migration. The results are contextualized by a description of detention conditions and the psychiatric symptoms associated with immigration incarceration. The study highlights the need for more research examining the impact of immigration detention on children’s mental health, while also underlining how refugee children’s voices provide important direction for policy change.

Incidence of psychiatric disorders among accompanied and unaccompanied asylum-seeking children in Denmark: a nation-wide register-based cohort study


Marie Norredam, Laura Nellums

One in four asylum applicants in Europe are children, and 23% of whom are unaccompanied and may be at increased risk of mental illness. This study contributes to the limited evidence base by comparing the incidence of psychiatric disorders among unaccompanied and accompanied refugee children. We linked a cohort of refugee children who obtained right of residency in Denmark between 01 January 1993 and 31 December 2010 to the Danish Psychiatric Central Register, and calculated incidence rates per 100,000 person years and incidence rate ratios of overall psychiatric disorder, psychotic disorders, affective disorders, and neurotic disorders for accompanied and unaccompanied minors using Poisson regression. We adjusted the analyses for sex, age at residency, and age at arrival (aIRR). Stratified analyses were conducted by nationality. Unaccompanied minors had significantly higher rates of any psychiatric disorder (aIRR: 1.38, 95% CI 1.14–1.68) and neurotic disorders (aIRR: 1.67, 95% CI 1.32–2.13) than accompanied minors. Among children from Afghanistan, unaccompanied minors had significantly higher rates of any psychiatric disorder (aIRR: 2.23, 95% CI 1.26–3.93) and neurotic disorders (aIRR: 3.50, 95% CI 1.72–7.11). Among children from Iraq, unaccompanied minors had higher rates of any psychiatric disorder (aIRR: 2.02, 95% CI 1.18–3.45), affective disorders (aIRR: 6.04, 95% CI 2.17–16.8), and neurotic disorders (aIRR: 3.04, 95% CI 1.62–5.70). Unaccompanied children were found to experience a higher incidence of any psychiatric disorder and neurotic disorders. Strategies are needed to address the specific mental health and social needs of unaccompanied minors.

Community violence exposure and substance use: cross-cultural and gender perspectives


Sandra Löfving-Gupta, Mimmie Willebrand

The negative effects of community violence exposure on child and adolescent mental health are well documented and exposure to community violence has been linked both to a number of internalizing and externalizing symptoms. Our aim was, therefore, to investigate cross-cultural and gender differences in the relationship between community violence exposure and substance abuse. A self-report survey was conducted among 10,575, 12–18 year old adolescents in three different countries, Czech Republic (N = 4537), Russia (N = 2377) and US (N = 3661). We found that in all three countries both substance use and problem behavior associated with it increased similarly along with severity of violence exposure and this association was not gender-specific. It was concluded that in spite of the differences in the levels of violence exposure and substance use cross-culturally and by gender, the pattern of their association is neither culturally nor gender bound.

The interface between child/adolescent and adult mental health services: results from a European 28-country survey


Giulia Signorini, Swaran P. Singh

Transition-related discontinuity of care is a major socioeconomic and societal challenge for the EU. The current service configuration, with distinct Child and Adolescent Mental Health (CAMHS) and Adult Mental Health Services (AMHS), is considered a weak link where the care pathway needs to be most robust. Our aim was to delineate transitional policies and care across Europe and to highlight current gaps in care provision at the service interface. An online mapping survey was conducted across all 28 European Countries using a bespoke instrument: The Standardized Assessment Tool for Mental Health Transition (SATMEHT). The survey was directed at expert(s) in each of the 28 EU countries. The response rate was 100%. Country experts commonly (12/28) reported that between 25 and 49% of CAMHS service users will need transitioning to AMHS. Estimates of the percentage of AMHS users aged under 30 years who had has previous contact with CAMHS were most commonly in the region 20–30% (33% on average).Written policies for managing the interface were available in only four countries and half (14/28) indicated that no transition support services were available. This is the first survey of CAMHS transitional policies and care carried out at a European level. Policymaking on transitional care clearly needs special attention and further elaboration. The Milestone Study on transition should provide much needed data on transition processes and outcomes that could form the basis for improving policy and practice in transitional care.

When addiction symptoms and life problems diverge: a latent class analysis of problematic gaming in a representative multinational sample of European adolescents


Michelle Colder Carras, Daniel Kardefelt-Winther

The proposed diagnosis of Internet gaming disorder (IGD) in DSM-5 has been criticized for “borrowing” criteria related to substance addiction, as this might result in misclassifying highly involved gamers as having a disorder. In this paper, we took a person-centered statistical approach to group adolescent gamers by levels of addiction-related symptoms and gaming-related problems, compared these groups to traditional scale scores for IGD, and checked how groups were related to psychosocial well-being using a preregistered analysis plan. We performed latent class analysis and regression with items from IGD and psychosocial well-being scales in a representative sample of 7865 adolescent European gamers. Symptoms and problems matched in only two groups: an IGD class (2.2%) having a high level of symptoms and problems and a Normative class (63.5%) having low levels of symptoms and problems. We also identified two classes comprising 30.9% of our sample that would be misclassified based on their report of gaming-related problems: an Engaged class (7.3%) that seemed to correspond to the engaged gamers described in previous literature, and a Concerned class (23.6%) reporting few symptoms but moderate to high levels of problems. Our findings suggest that a reformulation of IGD is needed. Treating Engaged gamers as having IGD when their poor well-being might not be gaming related may delay appropriate treatment, while Concerned gamers may need help to reduce gaming but would not be identified as such. Additional work to describe the phenomenology of these two groups would help refine diagnosis, prevention and treatment for IGD.

Emotion regulation difficulties in traumatized youth: a meta-analysis and conceptual review


L. Villalta, P. Smith, N. Hickin, A. Stringaris

This article provides a quantitative and conceptual review of emotion regulation difficulties in trauma-exposed young people, and informs future directions in the field. Despite long-standing interest in the influence of emotion regulation difficulties on different internalizing and externalizing psychiatric disorders in childhood, several questions remain unresolved with respect to children and adolescents with PTSD (post-traumatic stress disorder). Meta-analytic data from adult victims suggest that emotion regulation problems are associated with PTSD, but this has never been studied in children and young people. We therefore provide a conceptual review of features related to the phenomenology, assessment, severity and treatment of emotion regulation difficulties in trauma-exposed children and young people. We combine this with a meta-analysis of published literature. We searched studies in Medline, PsychINFO, and Embase databases based on pre-selected criteria. Eight hundred and eighty-six papers were identified and 41 were included. We found that children and adolescents with a diagnosis of PTSD reported more emotion regulation difficulties than those who did not develop PTSD, and that the overall association between the two symptom dimensions was moderately strong. We identify a number of research priorities: the development of instruments to assess emotion regulation difficulties in children, the design of studies that describe its prevalence in young epidemiological traumatized samples, its predictive role in the onset, severity and persistence of post-traumatic symptoms, and its relevance as a moderator, outcome or treatment target for young survivors.