Children Refugees Fleeing War Trauma

Regina MusicaroHarvard Extension School

July 14th, 2009

Main PointsTreatment for child refugees requires flexibility and creativity beyond the scope of traditional western psychotherapy.

- Children refugees face imminent health challenges.

- Cultural knowledge is crucial.

- Atypical practices (e.g. deliberate avoidance, religion, art expression and story-telling).

This Presentation

1) Definitions and Facts about refugees. -World -United States

2) Trauma: Overview of Preflight, Flight, Resettlement.

3)Treating Stress: Symptoms, Clinical Intervention

Definitions• Refugees - fear of persecution for reasons of race,

religion, nationality, membership of a particular social group or political opinion.

• Asylum-seekers - refugee status not yet gained. • Internally displaced persons - forced from habitual

residence.

Facts• Forcibly displaced people worldwide 2008 - 42 mil. • Children – 44%. • Urban – 50%, Camps – 33%

• 7/10 refugees in sub-Saharan AfricaReside in camps.

Facts: Tracking Refugee Movement

• Number of refugees per 1 USD GDP (PPP) per capita (means “economic capacity”).

• Require the use of a country’s resources for human services and housing.

Pop Quiz: Which country hosted the largest number of refugees in relation to its economic capacity?

(A)Sudan (B) United States

(B) Pakistan (C) England

© Pakistan hosted 733 refugees per 1 USD GDP.

• Democratic Republic of the Congo 496.

• United Republic of Tanzania 262.

• Developed nations: Germany, 26th place with 16. What about the U.S.?

Facts

"Give me your tired, your poor, Your huddled masses yearning to breathe free,

The wretched refuse of your teeming shore.

Send these, the homeless, tempest-tost to me,

I lift my lamp beside the golden door!”-The New Colossus, By Emma

Lazarus, 1883

Refugees in the United States

• The United States accepted 48,300 refugees for resettlement and granted asylum to 23,000 in 2008.

• Not everyone stays. E.g. 1,600 Haitians and more than 3,200 Cubans intercepted.

Facts

Facts: United StatesChildren as an unaccompanied minor:-Navigate the legal system without adult

representation.

-Are often put in juvenile detention centers or jails.

- 5,000 minors detained in jails each year.

This Presentation

1) Definitions and Facts about refugees. -World -United States

2) Trauma: Preflight, Flight, Resettlement.

3)Treating Stress: Symptoms, Clinical Intervention

Development occurs within four systems:Macrosystem - societal and cultural belief systems Exosystem - community and neighborhood factorsMicrosystem - family factorsOntogenic level - individual factors

How do we view challenges faced by refugee children?

Ecological Systems Theories (Cichetti et al., 1997)

Trauma: Preflight During War National Child Traumatic Stress Network Refugee Trauma Task Force, Review of Child and Adolescent Refugee Mental Health

• Limited access to schools.• Threats to safety of self and family.

• Entire villages suddenly devoid of adults.

A Kenyan boy screams as he sees Kenyan policeman approach his home.

Child refugee in Lebanon.

• Mozambique, 77% of over 500 children saw murders or mass killings (Boothby, 1994; Boothby et al., 1991).

• 33 of 40 Cambodian teens, Pol Pot work camp went long time without enough food (Kinzie et al., 1986).

Trauma: Preflight During War

Refugee child from Mozambique in Malawi.

• About 300,000 kids fought in armed conflicts.

• Front line combat = risk for:rapetortureinjuries

substance abusedepressionanxiety

suicidal ideation

Trauma: Preflight During WarChild Traumatic Stress Network Refugee Trauma Task Force, Review of Child and Adolescent Refugee Mental Health

Child soldier in Thailand.

Trauma: Preflight During War• Witness repeated acts of violence significant others.TortureSexual ActsPublic executions (Klingman, War and Trauma).

• Economic Damage (Klingman).

• Intensification of prewar anxieties (Ronen, 1996a, 1996b)

• Trauma – Flight.Exercise:-Name of the state you are living in.-What state would you travel to?

-You can take five small things. -Where would you sleep on the first night on your journey?

Trauma: FlightTraumatic Stress Network Refugee Trauma Task Force, Review of Child and Adolescent Refugee Mental Health

• Uncertainty about the future.

• At the mercy of external resources. E.g. water.

• Children are born.

• Separation from parents and caregivers is common.

Girl in Darfur waits for water and her family.

From War to Witches: Refugee Trauma for Children

http://www.youtube.com/watch?v=Ew4rd1YyD7A

Trauma: Resettlement • Belief systems, religious/cultural (Papadopoulos, 2001).• New family roles and patterns (Foner, 1997). • More educational experiences and rapid attainment

language acquisition = may act as cultural liaisons for elders (Birman, 1998; Coll and Magnuson, 1997).

San Diego Internet Relay Chat held a backpack drive for every refugee child starting school in fall. 20 groups and individuals donated 90 backpacks filled with school supplies. “The generous donors helped to make sure these refugee children had a good first day in the US school system.”

This Presentation1) Definitions and Facts about refugees. -World -United States

2) Trauma: Preflight, Flight, Resettlement.

3)Treating Stress: Symptoms, Clinical Intervention

Treatment: Symptoms

• A large body of research has documented that refugee children exhibit symptoms of Post-Traumatic Stress Disorder (PTSD) at alarmingly high rates, as high as 75% in a community sample (Allwood et al., 2002).

• Psychotherapists focus on on PTSD- need to intervene, diagnosis or not

- no attention to positive coping

- overlooks significant symptoms in isolation or alterative maladaptive behaviors

Treatment: Clinical Application (Boothby,

2006 )

• “It is argued, as in Israel during the 1991 Gulf War, that nonwar traditional therapeutic approach, with it’s focus on pathology and its emphasis on personal (as opposed to societal) recovery and well-being and its professed neutrality of values, may be inappropriate, even damaging, in times of war.”

Treatment: Clinical Application (Klingman,

Children and War Trauma).

During the year of the snake, the God of the sun came to stay in my body. It made my body shaky all over. Upon wakening I can remember that it was very dark. I then went to the rice fields to find someone to ask what time it was. A voice shouted 10 o’clock. Suddenly the animals began to cry and all of the animals representing death were howling all around me. I could barely see a small group of people whispering to each other in the forest. I became so frightened that I tried to calm myself by praying to all the Gods and the angels in heaven to protect me from danger. I was so paralyzed with fear that I was unable to walk wither backward or forward.

Treatment: Clinical Application (Mollica,

Healing Invisible Wound: Paths to Hope and Recovery in a Voilent World).

You are a clinician assessing this self-report.

• Do you use the DSM?

• Does this woman have a disorder?

• Prescribed treatment was becoming a Buddhist nun.

Treatment: Clinical Applications (Mollica,

Healing Invisible Wound: Paths to Hope and Recovery in a Voilent World).

What about children?

Treatment: Reported Symptoms• Symptoms reported by refugee children in resettlement:

anxietyrecurring nightmaresinsomniasecondary enuresisintroversiondepressive symptomsrelationship problemsbehavioral problemsacademic difficultiesanorexiasomatic problems (Allodi, 1980; Arroyo and Eth, 1985; Cohn et al., 1980; Gibson, 1989; Hjern et al., 1991a; Kinzie et al., 1986; Krener and Sabin, 1985; Williams and Westermeyer, 1983).

• According to Educational interventions for refugee children by Richard J. Hamilton, Dennis Moore

• Most common symptoms: anxiety and fear.

Treatment: Reported Symptoms

Case Study of Child Sodiers in Mozambique

• Qualitative quote and statistics describing

• 1) Behavior• 2) Subjective Symptoms• 3) Treatment (or reintegration into civilian

life)

Treatment: Symptoms (Boothby, 2006 )

• Child soldiers, Mozambique’s rebel military.

• Longitudinal study, 39 boy soldiers (6 - 16), had been abducted from their families and forced to take up arms.

• Adults used physical abuse and humiliation to indoctrinate.

• Children’s ecologies were assessed using a Documentation, Tracing, and Reunication (DTR) protocol.

• A Child Behaviour Inventory Form (CBI) was also established to assess aggression, traumatic symptoms, and high-risk to pro-social behavior.

• None of the former child soldiers declined to be interviewed.

• Trauma Symptoms Checklist (TSCL) used in 2003/ 2004 phase.

Treatment: Symptoms (Boothby, 2006 )

PTSD Symptoms in this Subgroup

• Length of time as a soldier was associated with difficulty refraining from learned, morally wrong behaviors (Boothby, 1994; Boothby et al., 1991).

• Qualitative quote describing the boys’ initial behavior . . .

• “Some appeared listless and numbed and unable or unwilling to talk, or engage in organized activities. Others were talkative, anxious, and active. A number of younger boys interacted with adult caretakers; many of the older boys avoided contact or communication with others altogether. Some did not interact with peers; others engaged openly with one another, a few older boys bullied younger ones, and some engaged in fights and other high-risk behaviour” (Boothby, 2006).

Treatment: Clinical Application (Boothby,

2006)

Treating Stress: Clinical Application(Klingman, Children and War Trauma)

Western theory applied?Erickson’s Stage 1 - Basic Trust vs. Mistrust

* Developing trust is the first task of the ego, and it is never complete. * The child will let mother out of sight without anxiety and rage because she

has become an inner certainty as well as an outer predictability. * The balance of trust with mistrust depends largely on the quality of

maternal relationship.

Psychotherapy:• may be unfamiliar.• viewed unfavorably.• or impractical

• Quote about rebuilding trust.

“We [the caretakers] were frightened of the boys, too. None of us wanted to work with them at first. We thought they were going to hurt us. But day-by-day, each side began to get to know the other better. After about a month, the situation improved. I think the boys realized that we were different than Renamo. I guess we realized they weren’t going to hurt us either. After a while, we just started treating them like our own children. We joked with them, watched their football games, encouraged them to do their homework, made the younger ones sit in our lap. It was difficult because some of them insulted us at first, and argued when they did not get what they wanted.”

Treatment: Clinical Application (Boothby,

2006 )

• Avoidance of stimuli proved adaptive.- avoidance as a coping mechanism scored lower on

the TSCL (Trauma Symptoms Checklist) than those that do not employ these same strategies.

• Reintegration into former life – kind welcome home.

Treatment: Clinical Application (Boothby,

2006 )

• Israeli Children, Gulf War 1991• Displaced to hotels after bombing.• Community focused activity versus one-one-

one therapy.• Continuation of “ordinary activities” such as

education.• Artwork – decorating gas mask boxes.• Expectation of return to normalcy.

Treatment: Clinical Applications (Klingman, Children and War Trauma)

Therapeutic Artwork

Main PointsTreating for child refugees requires flexibility and creativity beyond the scope of traditional western psychotherapy.- Children refugees face imminent health challenges that take precedence over other interventions.- Cultural knowledge is crucial.- Atypical practices (e.g. deliberate avoidance, religion, art expression and story-telling) should not be overlooked and are often most appropriate in clinical intervention.