This presentation explores the challenges and opportunities of developing mental health services for refugee children, paticularly in school-based environments. Presented by Mina Fazel, NIHR Post-Doctoral Research Fellow, Department of Psychiatry, University of Oxford and Consultant in Child and Adolescent Psychiatry, Children’s Psychological Medicine, Oxford University Hospitals

1. Challenges and Opportunities
Mina Fazel
NIHR Post-Doctoral Research Fellow,
Department of Psychiatry, University of Oxford
Consultant in Child and Adolescent Psychiatry
Children’s Psychological Medicine, Oxford University Hospitals
Developing Mental Health Services
for Refugee Children

2. Aims
 Overview of mental health need of refugee
children
 High-income
 Global
 Risk and Protective factors
 Describe a service in Oxford
 Interviews with the service users
 Opportunities and challenges

3. Global overview of refugees
 Highly diverse group
 Stressors of war, organised violence, persecution
 Loss of a place and sense of home
 13.9 million newly displaced in 2014
 20 million refugees worldwide
 44% children
 500,000 travel each year to seek asylum in high
income countries
 Most remain in a neighbouring or nearby country
 86% hosted in ‘developing regions’
 38 million internally displaced

4. Issues specific to refugee
children
 In addition to all the issues that socially under-
included and marginalised populations suffer
 Forced migration
 Experiences of persecution, emotional and physical trauma
 Insecurity at a formative stage of development
 Double disruption to developmental and cultural continuity
 Can enhance or threaten well-being
 Ever-changing nature of resettlement programmes
 Diverse needs for support:
 Psychological
 Educational
 Financial
 Social

5. Challenges facing refugees in high income vs
lower & middle income (LAMIC) contexts
 High income:
 Complex asylum process
 Dispersal policies
 Language, cultural and
religious difference
 Social exclusion
 Education system
 +ve = usually basic
survival needs met;
organised violence rare
 LAMIC:
 Prolonged uncertainty
 Poverty/local tensions
 Spreading conflict
 Refugee camps –
rape, violence, abuse
 +ve = shorter
migration journey;
transplantation of
community/family;
fewer language and
cultural differences

6. Prevalence of mental illness in
refugee populations
 Higher than host populations
 Estimates in settled refugee populations
 High levels of anxiety disorders and PTSD
 Depression
 Considerable comorbidity
 Chronicity of conditions
 Importance of post-migration setting
 Children: Studies suggest considerable prevalence of
psychological disturbance
 Anxiety disorders
 Depression
 Post-traumatic stress disorder (11%)

7. Three Stages of traumatic
experiences
1. In country of origin
2. Flight to safety
3. Having to settle in country of refuge

8. Community
Family
A conceptual framework to understand the
determinants of mental health in refugee children
Individual
Society

9. Influences on Mental Health for forcibly displaced populations (Miller, Rasmussen 2010)
Exposure to armed
conflict
Daily Stressors
caused or worsened
by armed conflict
Mental Health
Daily stressors
unrelated to armed
conflict

10. Some studies of psychiatric disorders in forcibly displaced children
Study Year & location Sample Findings
LMIC studies
Morgos 2007 Sudan 331 internally displaced
children
75% met criteria for
PTSD, 38% for
depression
Mels 2010 DRC 819 adolescents Internally-displaced
reported the highest
scores for post-traumatic
symptoms
Paardekooper et al. 1999 Uganda 316 Sudanese refugees
in Uganda compared to
80 local Ugandan
children
Sudanese children
reported significantly
more depressive and
post-traumatic symptoms
and behavioural
difficulties
High-income country studies
Nielsen 2008 Denmark 246 children in detention
centres
Children with at least 4
relocations had worse
mental health
Studies of unaccompanied asylum-seeking children (UASC)
Bronstein 2012 UK 222 Afghan
unaccompanied
adolescents
34.6% scored above cut-
offs for anxiety, and
23.4% for depression
Bean 2007 Belgium 582 unaccompanied
refugee children from 48
countries
Psychological distress
higher: girls and older
age, unaccompanied had

11. Summary of risk and protective factors for mental health outcomes
for forcibly-displaced children in high-income settings
Predictor variable
examined
Domain examined Number of studies Total number of children Risk or protective factor
Exposure to premigration
violence
Individual 13 3099 risk
Female sex Individual 11 3425
risk (mainly for internalising/
emotional problems)
High parental support and
family cohesion
Family 4 1576 protective
Self-reported support from
friends
Community 4 397 protective
Unaccompanied Family 3 3690 risk
Perceived discrimination Community 3 1548 risk
Exposure to postmigration
violence
Individual 3 1489 risk
Self-reported positive school
experience
Community 3 1441 protective
Several changes of
residence in host country
Community 3 1031 risk
Parental exposure to
violence
Family 3 517 risk
Poor financial support Family 2 1601 risk
Same ethnicity foster care Family 2 386 protective
Single parent Family 2 359 risk
Parental psychiatric
problems
Family 2 162 risk

12. Summary of risk and protective factors for mental health
outcomes of forcibly-displaced children in low and
middle-income settings
Factor examined Domain examined Number of studies Total number of children Risk or protective factor
Exposure to premigration
violence
Individual 12 7382 risk
Female sex Individual 7 2667
risk (for internalising/ emotional
problems not PTSD
Settlement in refugee camp Societal 4 4742 risk
Male sex Individual 3 1678
risk (for externalising/
behavioural problems)
Repatriation Societal 3 1101 protective
Internal displacement (within
country of origin)
Societal 2 1574 risk

13. The Oxford School Refugee
Project
 School-based mental health service for
refugee and asylum seeking children
 4 Oxford Schools
 Why school-based
 All children attend
 Natural focus for families
 ‘Safe’ environment
 Potentially provides a stable external social support
(protective factor for resilience)
 Consultation with teachers
 Removes a barrier to mental health services

14. Common clinical issues
 Trauma reactions
 Grief reactions
 Other losses
 Difficulty adjusting to new environments
 Child protection concerns
 Threats of harm to self and others
 Assisting unaccompanied minors

15. The Refugee school-based mental health service
Weekly meeting
Link teacher Mental health professional
Discuss Child of
Concern
More information:
• Class teacher
• Direct observation in
school
Watch and wait
Give information on useful local
resources that might be of
assistance e.g. charities,
guidance clinics etc..
Need to see directly
School approaches
child + parent/carer
Meeting with child
Teacher can introduce at first
meeting
Arrange meeting
in school location
Advise teachers with
possible strategies to use with
the child
Family meeting
Group

16. Baseline Comparative Study
(=11.882, P<0.01)
0
5
10
15
20
25
30
caseness
refugee
ethnic minority
white
national
average

17. Qualitative In-depth interviews:
 40 adolescents
 Directly seen by a school-based mental health
service
 Oxford, Cardiff and Glasgow
 Seen either individually or in groups (15)
 Interviewed at length about their impressions of
being seen by a school-based service

18. Pre or post displacement factors
Pre 13/32 41%
Post 13 41%
Both 6 18%

19. Interviews with refugee children discharged from
school-based mental health services:
Preferred location
School better 27 (71%)
Does not matter 2
Outside school better 9

20. Location 1: Advantages in school
safe
familiar
Can find
therapist
easily
convenient
Get to
lesson
on time
simple
efficient

21. Location 2: Advantages out of school
Private
People
don’t
make fun
of you
Calm
Don’t like
school
anyway

22. School: Location quotations
 I don’t know maybe it would be more complicated
or something …. Maybe just to find it and maybe
she doesn’t know who you are, where you come
from, … I don’t know it’s just different. I think in
the school is better
 Good to have it in school, if come to hospital it is
scary, I don’t know if I would go if it was in a
hospital …no one likes hospital
 Outside don’t know who you can trust

23. Conclusion 1
 Warehouse
 Those seen by therapeutic service
Good understanding of why referred
Felt problems had been helped
 I don’t know I think it was just like a tumour…and she was
operating and she took away the tumour
 I could socialise with people much easier since I said what I
had to say, maybe not to the whole world, but at least
somebody knows what I’m going through and what I went
through

24. Conclusion 2
 2 main themes
 Isolation
 If arrived with families or alone
 Want to blend into environment
 Little contact with other professionals
 Insecurity
 Racism
 Asylum applications
 Longing for acceptance
 Importance of peers
 How to help: visibility, community, dignity

25. Opportunities and challenges

26. 5 main problems beset research in
the area
 Most of the research focused on victims of
isolated catastrophic events
 PTSD focus rather than range of psychological
distress
 Diagnostic validity of methods used
 Complex ethical and practical issues, often in
dangerous circumstances
 Selection of appropriate representative samples

27. Mental Health
Intervention
Creativity & Arts
• Painting/ drawing/ writing
• Music/ song writing
• Movement
• Drama/role playing
• Games
• Child centred play therapy
• Guided imagery
Self soothing and
distress
tolerance skills
• Relaxation training
• Progressive muscle
relaxation
• Meditation
• Imagery (Safe place)
• Coping self
statements
• Skill building
Clinical management
• Supportive
therapy
• Comprehensive
case management
• Future planning
and resource
identification
Interpersonal skills
• Relationship
building
• Developing social
skills
• Interpersonal
therapy
• Confidence-
building games
Psycho-education
• Normalising
• Stress reactions
• Fear hierarchies
Reflective exercises
• Exploration of self-identity
• Sharing and discussing
stories
Predominantly verbal processing of past
experiences
• Narrative Exposure Therapy
• Trauma Focused CBT & CBT
• EMDR
• Graded exposure
• Intrusion imagery technique
• Interpersonal Therapy
Dealing with
past memories
Dealing with
present & future
challenges
Figure 2: Diagram to show the range of mental health interventions included in the selected studies
INDIVIDUAL
FAMILY/PARENT
GROUP/CLASSROOM
Other components
• Provision of outreach
supportive services
• Community resilience
building

28. Examples of Randomised controlled
trials
Interventio
n domain
Study Year Sample Intervention Findings
Individual
therapy
Ertl 2011 85 Ugandan
former child
soldiers
Narrative
Exposure
Therapy-8
sessions
conducted in
camps
Improvements in
PTSD
symptoms
School-
based
Rouss
eau
2005 138 immigrant
children in
Canada
Creative
expression
classroom
programme over
12 weeks
Beneficial
effects on self-
esteem
Communit
y-based
Bolton 2007 Ugandan
IDPs living in
refugee
camps
Group
Interpersonal
Therapy -16
sessions
conducted in
IPT-G helped
reduce levels of
depression,
especially in
girls and older

29. The Oxford CAMHS InReach Service
Consult
with teachers
and other
key school
professionals
Specific
school
Group
interventions
Give
assemblies,
talk to parents
1:1
treatment
CAMHS
worker
Half a day
each week

30. mina.fazel@psych.ox.ac.uk