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Prepared by Trang Thomas and Winnie Lau
Abstract
Major Research Findings i. Post Traumatic Stress Disorder and Symptomology ii. Co-existence of several disorders and symptomology iii. Risk (Vulnerability) and Protective (resilience) factors
Conclusions
References and Suggested Readings
About the Authors
Abstract
This paper outlines major international research findings of the past ten years reflecting knowledge gathered about the psychological health of child and adolescent refugee/asylum seekers. In doing so, several key areas of consistency are identified. First, with the majority of research in this area centered on the prevalence of psychopathology, and particularly post-traumatic stress symptoms, it has been clearly demonstrated that refugee children and adolescents are vulnerable to the effects of pre-migration, most notably exposure to trauma. Second, particular groups in this population constitute higher psychological risk than others, namely those with extended trauma experience,

unaccompanied or separated children and adolescents, and those engaged in the uncertain process of sought asylum. Third, certain risk and protective factors appear to exist that temper or aggravate poor psychological health.
These include family cohesion, parental psychological health, individual dispositional factors such as adaptability, temperament and positive self-esteem, and environmental factors such as peer and community support.
The research is less clear however in a number of areas. These include the mechanisms by which risk and protective factors exacerbate and temper the effects of trauma and migration experience, as well as the role of culture as a mediator in the experience of trauma and migration.
Despite being a perennial issue, circumstances of irregular migration across the world have only recently impelled psychological interest into the mental health of refugee and asylum seekers. The Office of the United Nations High
Commissioner for Refugees (UNHCR) estimates that there are 22.3 million refugees worldwide. A refugee is someone who "owing to well founded fear of being persecuted for reasons of race, religion, nationality or membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside that country of his former habitual residence as a result of such events, owing to such fear, is unwilling to return to it"
(Article 1A(2), Convention relating to the Status of Refugees (1951)). This definition is contrasted with that of an asylum seeker, whose status as a refugee is yet to be formally determined by the host society (Human Rights and
Equal Opportunity Commission, 2001). More importantly, these definitions are to be differentiated from that of an economic migrant whose mobilisation is voluntary and primarily motivated by improved material circumstances as opposed to human rights and safety (Morrow, 1994).
While there is considerable and growing literature in the mental health of adult refugee/asylum seekers, current research acknowledges a lack of understanding in the mental health of child and adolescent refugee/asylum seekers
(Dybdahl, 2001; Hicks, Lalonde & Pepler, 1993; Hyman, Vu & Beiser, 2000). This is particularly the case regarding the mental health of child and adolescent refugee/asylum seekers in detention. This is surprising given that as many as half the world's refugee population is comprised of children and adolescents (Cole, 1998). Such limited investigation however, may in part be due to the difficulties associated with population access, systematic sampling, cultural and language barriers, limited cross culturally validated measurement techniques, and wariness of parents and participants to trust researchers (Richman, 1993; Silove, Sinnerbrink, Field, Manicavasagar & Steel, 1997).
Though not all refugee and asylum seeking children and adolescents are subjected to these circumstances, experiences often claimed to be encountered by them include the violent death of a parent, injury/torture towards a family member(s), witness of murder/massacre, terrorist attack(s), child-soldier activity, bombardments and shelling, detention, beatings

and/or physical injury, disability inflicted by violence, sexual assault, disappearance of family members/friends, witness of parental fear and panic, famine, forcible eviction, separation and forced migration (Burnett & Peel, 2001; Davies & Webb,
2000).
Other forms of trauma might include the endurance of political oppression, harassment and deprivation of human rights and education (Burnett & Peel, 2001). Such experiences not only make refugee/asylum seeking populations heterogeneous, they also create vulnerability in children and adolescents due to their incomplete biopsychosocial development, dependency, inability to understand certain life events (Kocijan-Hercigonja, Rijavec & Hercigonja, 1998) and underdevelopment of coping skills (Ajdukovic & Ajdukovic, 1993).
This summary outlines major international research findings of the past ten years reflecting knowledge gathered about the psychological health and well-being of child and adolescent refugee/asylum seekers. It incorporates a search of literature from the psychINFO, Medline, BioMedNet, Academic Research Library, EBSCO, Proquest, Science Direct and Wiley-Interscience databases using criteria restricted to articles from 1990 to date and in the English language.
Search terms included single and combined forms of the following descriptors: refugee camp, refugee detention, imprisonment, child and/or adolescent refugee, asylum seeker, displacement, Australia, development, long term effects, long term stress, post-traumatic stress, stress, psychopathology, mental health, psychiatric effects and psychological well being.
The review is divided into major sections of studied areas in the literature, namely post-traumatic stress disorder
(PTSD), co-existence of several symptoms and disorders (a term that broadly means serious problems), and risk
(vulnerability) and protective (resilience) factors at both pre- and post- migration phases. It should be noted that this paper does not aim to provide an exhaustive discussion of theoretical issues, methodological considerations (e.g., problems in retrospective data collection) or treatment issues, but rather to highlight major findings and conclusions of this research. It should also be noted that the paucity of research in child and adolescent refugee/asylum seekers necessitates at times reference to knowledge from adult populations. Where such reference is made, caution should be taken to avoid overgeneralisation of these findings to this new risk population of children and adolescents.
Major Research Findings i. Post Traumatic Stress Disorder and Symptomology
Given that war and political violence are major causes of forced migration, many child and adolescent refugee and asylum seekers migrate with a history of traumatic stress exposure (Almqvist & Brandell-Forsberg, 1997).
Investigations directed at the evaluation of the impact of trauma on psychological well being in these groups have

predominantly focused on the prevalence of Post Traumatic Stress Disorder (PTSD) and/or its symptomology
(Richman, 1993; Weine, 2002).
Post Traumatic Stress Disorder (PTSD) refers to a configuration of symptoms experienced after a traumatic event and is classified as an anxiety disorder, which may in nature be acute or chronic, and of short or long term duration
(Cunningham & Cunningham, 1997).
Children and adolescents who present with PTSD may exhibit symptoms of confused and disordered memory about events, repetitive play themes related to trauma, personality change, imitation of violent behaviour and pessimistic expectations regarding survival (Hicks et al., 1993). Although symptoms vary across age groups, in preschoolers, they are generally manifested in very high anxiety, social withdrawal and regressive behaviours. In school-aged children, symptoms can include flashbacks, exaggerated startle responses, poor concentration, sleep disturbance, complaints of physical discomfort and conduct problems. In adolescents, symptoms may include acting out, aggressive behaviours, delinquency, nightmares, trauma and guilt over one's own survival (Hicks et al., 1993).
Despite controversy surrounding the application of PTSD to refugee/asylum seeking children and adolescents (e.g., the diagnostic approach 'medicalises' and 'westernises' emotional disturbance and 'pathologises' perfectly normal reactions to abnormal situations), investigations across various countries have shown that trauma symptomology is common in refugee children and adolescents (Ajdukovic & Ajdukovic, 1993; Hjern, Angel, & Hoejer, 1991; Kinzie,
Sack, Angell, Manson & Ben, 1986; Mollica, Poole, Son, Murray & Tor, 1997; Sack, Clarke & Seeley, 1996; Sack,
Seeley & Clarke, 1997).
While the nature and extent of trauma exposure varies cross culturally, and from direct to indirect and single to repeated events, studies particularly document the prevalence of post-traumatic stress symptomology. Though not conducted within the last ten years, the pioneering work of Kinzie et al. (1986) is cited frequently throughout the recent literature. In this classical study, these authors interviewed 46 Cambodian refugees aged between 14-20, all of who were exposed between the ages of 8-12 to starvation, separation, beatings and executions. Almost half of these subjects having been exposed to trauma, exhibited PTSD symptoms alongside less effective adaptation, which was considered to be within clinical range.
In a larger study with 209 Cambodians aged between 13-25 resettled in the United States, Sack and colleagues
(1994) found an 18% prevalence rate of PTSD and an 11% rate of depressive disorder in their participants. High rates of psychiatric disorder were also observed in participants' parents, with 53% of mothers reporting symptoms consistent with a PTSD diagnosis, and 23% with a diagnosis of depression. Amongst fathers of this sample, 29% indicated PTSD

symptomology and 14% indicated depression.
Examining the case records of 191 clients presenting for service and treatment at a torture and trauma rehabilitation centre in Australia, Cunningham and Cunningham (1997) identified patterns of torture and trauma experience and symptomology. Of the six core patterns of symptomology revealed in the analysis, PTSD symptoms featured most dominantly. Saigh (1991) similarly administered the children's PTSD inventory to 840 Lebanese children aged between 9-12 living in Beirut. While violent traumatic exposure varied from direct to indirect among children, no comparable differences were observed in PTSD scores. In all, 27% of these children met PTSD criteria, supporting the view that children can be traumatised in numerous ways (Berman, 2001).
The relationship between trauma exposure and PTSD symptomology however is not confined to South East Asian and
Lebanese children (Kinzie et al., 1986; 1989; Macksoud & Aber, 1996; Sack et al., 1994). Over recent years, such findings have been established cross culturally among children and youth from regions such as:
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Afghanistan (Mghir, Freed, Raskin & Katon, 1995);
 Bosnia (Geltman, et al, 2000; Papageorgiou, et al, 2000; Weine, et al, 1995);
Chile (Hjern, Angel & Hojer, 1991);
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Croatia (Ajdukovic & Ajdukovic, 1993);
 Central America (Arroyo & Eth, 1996; Espino, 1991; Rousseau, Drapeau & Corin, 1997);
El Salvador and Nicaragua (Arroyo & Eth, 1996);
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The Gaza Strip (Thabet & Vostanis, 2000);
 Iraqi-Kurdistan (Ahmad, Mohamed & Ameen, 1997);
Israel (Laor, et al, 1996);
 Iran (Almqvist & Brandell-Forsberg, 1997; Almqvist & Broberg, 1999);
 Sudan (Paardekooper, de Jong & Hermanns, 1999); and
 Tibet (Servan-Schreiber, Le Lin & Birmaher, 1998).
Although studies have consistently linked trauma symptomology with the experience of trauma related events, which are usually attributed to organised violence and war, fewer investigators have attempted to relate exposure to a diagnosis for PTSD. Hence, the focus on symptomology renders it unclear as to whether a complete diagnosis can be applied to trauma experience (Green, et al., 1991). The implications of such issues are important to consider given the position of those seeking formal refugee status. Notwithstanding, Almqvist and Brandell-Forsberg (1997) are among few researchers to demonstrate effectively the applicability of PTSD criteria to symptomology expressed in children.
Similar diagnoses have been demonstrated by Schwarz and Kowalski (1991a).
One controversy noted throughout the literature relating to refugee children and adolescents and PTSD is whether it is the totality of exposure to war related stress that is harmful, or whether in fact trauma responses are dependent on the nature, type, amount and duration of exposure to stress (Athey & Ahearn 1991; Jensen & Shaw, 1993, cited in
Berman, 2001; Mghir et al., 1995). Reviews of such studies indicate evidence for the suggestion that the greater the

nature and extent of exposure, the poorer one's psychological outcome in terms of onset and severity of PTSD symptoms (Espino, 1991; Papageorgiou et al., 2000).
Extending their diagnostic approach to trauma symptomology, Almqvist and Brandell-Forsberg (1997) also investigated whether the amount of trauma exposure is related to the prevalence and stability of PTSD over time.
Whilst finding it is possible to diagnose PTSD during initial stages of assessment and one year later, these authors also found that one fifth of children directly exposed to organised violence and persecution (e.g., through assault on parents or bomb attacks within 50 metres) were at risk for developing chronic states of PTSD.
Similarly, though not drawing directly from a refugee but rather displaced and war exposed population, Macksoud and
Aber (1996) examined the relationship between the number and type of war traumas and psychosocial development among 224 Lebanese children aged between 10-16. Using measures of war exposure, war trauma, mental health,
PTSD and adaptation, these investigators assessed ten categories of war exposure. As predicted, the number and type of traumatic exposure were positively related to PTSD symptoms. Children exposed to multiple traumas (e.g., shelling, combat) and those who were bereaved, victimised by or had witnessed violent acts, showed more PTSD symptoms than those who had not witnessed such acts. Moreover, depressive symptoms were more evident in children who had experienced separation from their parents and displacement than those who remained with their parents.
Finding that 34% of adolescent and young adult refugees from Afghanistan met criteria for PTSD, major depression or both, Mghir et al. (1995) similarly demonstrated an association between the presence of these disorders and the total number of events experienced. In her investigation of Khmer adolescent refugees exposed to community violence,
Berthold (1995) also noted the impact of multiple traumas before and following resettlement in the US on PTSD.
Sinnerbrink and colleagues (1997) also examined the relationship between exposure to violence and mental health outcome in Khmer adolescents in the USA. A quarter of these subjects partially or fully met criteria for PTSD with the number of violent events experienced predicting PTSD and level of functioning. Not only was pre-migration exposure predictive of PTSD, the number of violent events exposed to across subjects' lifetime (i.e., time in Cambodia and US) also and more strongly predicted PTSD and level of functioning. This finding is noteworthy as it demonstrates the cumulative effect of trauma and its predisposing features to future distress and function (Sinnerbrink et al., 1997).
Lonigan and colleagues (1991, cited in Almqvist & Brandell-Forsberg, 1997) and Pynoos, Steinberg and Wraith (1995) in their investigations of school-aged children have also shown a correlation between the amount of traumatic exposure and PTSD prevalence. The association between severity of exposure in terms of number and proximity of experienced events and the presence of PTSD in children and adolescents has been supported in different cultures

including Bosnian (Papageorgiou et al., 2000); Vietnamese (Mollica et al., 1997); Cambodian (Sack, Clarke & Seeley,
1996); Palestinian (Garbarino & Kostelny, 1996; Thalbet & Vostanis, 1999), Middle Eastern (Montgomery, 1998) and
Central American (Espino, 1991).
So far, the studies reviewed have clearly outlined the shorter-term consequences of organised violence and war and their resultant traumatic outcomes for children and adolescents from a cross sectional perspective. Little research however, has been conducted into the evolution of PTSD symptoms and its long-term development and persistence in refugee/asylum seeking children and adolescents (Punamaki, 2001). The preliminary nature of longitudinal research in this area therefore, has produced equivocal findings. Nevertheless, there are some studies that demonstrate the persistence of PTSD symptoms across time.
The work of Kinzie et al. (1986; 1989) represents one of the few attempts to evaluate the persistence of PTSD over several years. As discussed earlier, these researchers examined the effects of massive trauma on 40 Cambodian refugees who had been imprisoned for up to two years in concentration camps during the Pol Pot regime. All subjects had endured separation from family, forced labour and starvation and many had witnessed killings and other forms of torture. Four years after leaving Cambodia, up to 50% of subjects developed PTSD. Mild but prolonged, depressive symptoms were evident in 38% of subjects. Results of a 3-year follow up with 30 of the 40 original subjects revealed that although depressive symptoms had diminished, 48% of subjects still exhibited symptoms meeting the criteria for
PTSD, supporting the notion that traumatic symptoms endure over time. Subjects with poorer PTSD outcomes also showed poorer social adjustment. Six years following the initial study, 38% of subjects still exhibited PTSD criteria, though there was a reduction in the rate of depression (Sack, Clarke, Him, Dickason, Goff, Lanham & Kinzie, 1993).
Twelve years after the initial study, 35% of subjects still exhibited criteria for PTSD and 14% had depression (Sack,
Him & Dickason, 1999).
These authors add increasing empirical weight to the idea that PTSD in children and adolescents can persist from several up to twelve years. These authors also note however, along with the prevalence of depression, the intensity of
PTSD symptoms tend to diminish over time. Where depression was initially shown to co exist with PTSD symptoms, depressive symptoms were no longer evident after six years. Such findings are important as they sustain the theoretical argument that PTSD symptoms are distinct from symptoms of depression and are indeed a manifestation of massive trauma, contrary to the result of resettlement stress (Sack et al., 1993; Sack et al., 1995). Despite the persistence of PTSD, participants in Sack et al's. (1993) study were generally adaptive. Most, for instance, were able to pursue some forms of college education. As Kinzie et al. (1990) and Sack (1998) state though, the impact of trauma is likely to affect child development over time resulting in fluctuating symptom profiles of both PTSD and depression.
Of the more recent studies investigating the long-term consequences of trauma, Almqvist and Broberg (1999)

assessed the prevalence of PTSD in Iranian preschoolers following two and a half years of resettlement in Sweden.
For a fifth of children previously exposed to trauma, PTSD diagnoses remained stable. Supporting the argument that
PTSD can be enduring, these authors also remarked on the problem of much research, which relies heavily on parental interviews for data (Almqvist & Broberg, 1999; Geltman et al., 2000). In their interviews with both children and parents, a significant difference was observed in the initial investigation, where according to parents, only 2% of children met criteria for PTSD. When the children were interviewed however, 21% met PTSD criteria. That is, parents were found to underestimate and/or deny symptoms of trauma re-experience in their children, a major criterion for
PTSD.
Though these findings might be attributable to parents' desires to protect their children, they demonstrate that parents may also down play the presentation of symptoms in children. This is supported by arguments that PTSD is difficult to observe in young children due to problems in identifying avoidance symptoms, a further criterion of PTSD. Lastly,
Macksoud and Aber (1996) and Ahmad et al. (1998) have also observed chronic/continuous PTSD in samples of
Lebanese children exposed to single events in civil war and Iraqi Kurdish children respectively. The high level of PTSD persistence in the above studies is consistent with general studies regarding children who develop PTSD following exposure to other trauma (McFarlane, 1987, cited in Hodes, 2000). Regarding the long-term effects of trauma, age at the time of traumatic experience does not appear to influence its persistence (Dreman & Cohen, 1990).
It should be noted that disagreement and inconsistencies regarding mental health in refugee populations does exist despite evidence for poor psychological adaptation (Dybdahl, 2001; Beiser, Dion, Gotowiec, Hyman & Vu, 1995). Of studies which have produced equivocal findings, Becker, Weine, Vojvoda and McGlashan (1999) investigated the psychiatric sequelae of Bosnian adolescents after a year of resettlement to assess delayed PTSD onset. Of those initially diagnosed with PTSD, none met criteria for diagnosis a year later and only one subject not previously diagnosed, displayed PTSD symptomology. Becker et al. (1999) concluded that the diminution of PTSD over time might reflect the fact that symptoms are transient and not representative of enduring psychopathology. Hence, while there is evidence to support the chronic nature of PTSD in refugee children and adolescents, there is also evidence to suggest that such long-term effects may be mediated by other factors. Becker et al. (1999) did nevertheless observe that the symptoms shown at one year follow up remained similar to the clusters of symptoms observed in their initial investigation and that Bosnian adolescents had also remained with their parents, potentially offsetting PTSD symptomology. Indeed, Ajdukovic and Ajdukovic (1998) cautioned that the child's exposure to extreme intense trauma can have delayed effects and can cause difficulties in psychological functioning in adulthood.
As indicated above, parental psychological well-being is a key factor in the mental health of child/adolescent refugee and asylum seekers (Papageorgiou et al., 2000; Sack et al., 1994). Research directed at parental and familial

influences has demonstrated that disorders associated with child and adolescent refugee experiences cluster in families. Sack, Clarke and Seeley (1995) for example, interviewed 118 Khmer adolescent refugees and one of their parents (usually mother). These authors found that the risk for PTSD increased for adolescents when one parent exhibited PTSD. When environmental influences to this relationship such as separation/divorce of parents, therapeutic intervention and socio-economic status were examined, no significant impact was found.
While such findings may underscore a genetic susceptibility to PTSD (Sack et al., 1995; Hodes, 2000), they also implicate the role of learning factors in the concurrence of PTSD in children and their parents. Lukman and Bach-
Mortensen (1995, cited in Hodes, 2000) provide support to the role of learning factors in PTSD and argue that such is the established link between parent and childhood disorder that children of torture victims, who seek asylum in resettlement countries, may have high levels of emotional and physical symptoms such as stomachache or headache, even when not exposed to the traumatic events themselves. Moreover, parents' own experience of persecution, war violence, terrorism, powerlessness and exhaustion can compromise their ability to care for their children, increasing child/adolescent susceptibility to PTSD and other psychopathology (Sack et al., 1986). Garbarino, Kostelny and
Dubrow (1991) and Richman (1993) further maintain that PTSD can be evident in multiple family members, particularly when marital relations are strained.
The findings observed above are consistent with Green et al. (1991) and Punamaki (2001) who argue that parental capacity and family cohesion after traumatic exposure are of equal or greater importance in the post-traumatic stress reactions of young children. These authors provide evidence that family dysfunction before exposure may predispose
PTSD in children and adolescents. Drawing similar conclusions, Arroyo and Eth (1996) found that those children and adolescents in nuclear families were less likely to receive psychiatric diagnoses than those who lived alone or were fostered.
While psychological problems in the family are significantly related to child psychopathology in refugee children and adolescents, the role of mothers appears to be particularly important as shown by Ajdukovic and Ajdukovic (1993) who found that mothers' emotional well-being best predicted emotional well being and adaptation in children.
So far, consistent psychological outcomes have been reported in the literature for children and adolescents regardless of their different experiences, backgrounds and cultures. While these consistencies in the literature are important to identify, the specific effects of culture have been largely unexamined across studies. The complex role that culture plays in the psychological health of child and adolescent refugee and asylum seekers is highlighted by Rousseau,
Drapeau and Corin (1997). Comparing Central American and South East Asian refugee children, Rousseau et al.
(1997) showed that the impact of family factors on post-traumatic symptomology is mediated by contextual as well as

cultural factors. In Central Americans, greater trauma exposure in families was found to be more related to family conflict and depression, whereas in South East Asians, increased trauma exposure was found to be associated with less parental depression.
Arroyo and Eth (1996) have similarly observed contrasting symptom profiles between Latin American and South East
Asian refugee children, where the former display more prevalent academic and conduct problems. While not replicated, these differential findings across cultures reflect the need to investigate systematically cultural influences on child and adolescent mental health among the refugee and asylum seeking populations. ii. Co-existence of several disorders and symptomology
Although the majority of literature lies in the investigation of trauma sequelae and family psychopathology as a mediating and moderating factor of trauma, there have been investigations of other psychological outcomes among child and adolescent refugee/asylum seekers. It should be noted in any discussion of psychological problems however, that refugee and asylum seeking children and adolescents are more likely to have serious health problems associated with malnutrition, disease, physical injuries, brain damage and sexual or physical abuse (Westermeyer,
1991). Hence, the influence of these potential health problems cannot be overlooked when considering psychological health and disorder in this population (McCloskey & Southwick, 1996; Westermeyer, 1991).
Simultaneous presence of more than one disorder associated with PTSD is a common finding in the literature concerning the mental health of refugee children and adolescents. For example, Kinzie et al. (1986) noted depression and anxiety as problems most commonly associated with PTSD symptomology. Similarly, Hubbard, and colleagues
(1995) found that the existence of more than one disorder in their sample of 59 Cambodian adolescents and young adults exposed to trauma as children. Of the 24% of adolescents and young adults that were diagnosed with PTSD,
57% of these had at least one additional diagnosis, all being affective and anxiety related.
Using the Child Behavior Checklist (CBCL) [1] , Sourander (1998) also found that in addition to PTSD, depression and anxiety were most common among their participants. When interviewed, most children also reported somatic complaints, uncertainty about the future and in some cases expressed suicidal thoughts. While the presence of anxiety is not surprising given its overlap with PTSD, Clarke et al. (1993, cited in Hodes, 2000) note that depression may commonly occur due to ongoing adversity following resettlement.
Tousignant and colleagues (1999) present the results of a psychiatric epidemiological survey of 203 refugee adolescents aged between 13-19 from 35 different countries resettled in Canada. Using the Diagnostic Interview
Assessment Scale [2] and global assessments of general functioning, these authors showed a 10% difference against

refugee adolescents in rates of psychopathology compared to normative data obtained from a province wide survey of
Quebec adolescents. 21% of participants displayed psychopathology in forms of simple phobia (25%), overanxious disorder (13%), depression (5%); conduct disorders (6%) and attempted suicide (3%). Elevated rates of phobia and overanxious disorder according to these authors were probably due to their association with PTSD. Females displayed more psychopathology than boys in this sample with similar ratios evident in the Quebec survey, but neither age at arrival nor cultural differences were found to be significant factors. Despite the high rates of psychopathology when compared with a normative population, according to global functioning assessments, these adolescents had good social adaptation.
Good adaptation following multiple traumas has also been reported by Berthold (1995) and Punamaki (2001). Such unexpected findings of positive adaptation imply that while diagnosis does not always suggest severe functional impairment (Sack, 1995), the changeability of dysfunction does, in fact, demand further investigation into the mechanisms that promote such adjustment.
Kocijan-Hercigonja, Rijavec and Hercigonja (1998) also investigated the existence of more than one disorder and alternative problems in refugee and displaced children. They compared three groups of children aged between five and fourteen. The first group comprised of Muslim refugee children from Bosnia and Herzegovina; the second of displaced children from Croatia and the third of non-displaced local children. Using structured interviews, coping and adjustment measures, self-rating behaviour scales, and anxiety and depression scales, these authors found significant differences in the prevalence of eating disorders, with displaced children exhibiting more eating disorders than nondisplaced and refugee children. Significant differences were also observed in sleeping disorders with more sleep problems found in displaced children followed by refugee and non-displaced children. Refugee children used significantly fewer coping strategies than displaced and non-displaced children and effectiveness of these strategies were reported to be greater in displaced and non-displaced children. In terms of adjustment, displaced children were less satisfied with their present situation than other children. Refugee children also felt generally worse than other children and were less optimistic about the future. Displaced children were lower on anxiety than refugee children, however, no differences across the sample on depression measures were found.
When Kocijan-Hercigonja et al. (1998) compared parent and child assessments, parents did not report their child's fatigue, palpitation, breathing problems, trembling or crying, reinforcing earlier suggestions of the importance of attaining data directly from children. Kocijan-Hercigonja et al. (1998) attributed sleeping and eating problems in displaced children to the severity of trauma these children experienced. Furthermore, displaced children tended to evaluate their life at present as worse than others because of difficulties associated with camp life. Elevated anxiety in refugees was attributed to trauma whereas in displaced children, this was attributed to uncertainty in status and the

future.
In all, these findings highlight that children have negative beliefs and expectations about their futures, indicating potential adjustment problems (Kocijan-Hercigonja et al., 1998). Obradovic and colleagues (1993) similarly investigated 102 children and young people aged between 8-19 from Bosnia, Herzegovina and Croatia in collective accommodation. 88% reported feeling sadder than before the war, 87% reported being more worried and 62% reported feeling more tense. Satisfaction from play was reduced in 65% of participants. Of the physical symptoms reported, all increased following the war and included lack of appetite, disturbed sleep, excessive perspiration, headaches, respiratory problems and gastric complaints.
In their investigation of varied psychological outcomes, Howard and Hodes (2000) note the distinction between disorders observed from neuropsychiatric origins (i.e., causes attributable to biological functioning) and those from psychosocial ones (i.e., causes attributable to family and social processes). In their study of problems such as PTSD, minor affective disorders, anxiety, conduct, eating and sleep in three groups of refugee, immigrant and British children, these researchers found that refugee children received more diagnoses of a psychosocial nature than the other two groups of participants. While similar social impairment was observed across comparative groups, refugee children were more isolated and disadvantaged. This tendency to manifest disorders of a psychosocial nature is consistent with Rousseau, Drapeau and Corin (1996) who found a positive association between learning difficulties, academic achievement and emotional problems in South East Asian and Central American refugee children in the US.
Furthermore, the tendency of traumatised refugee children to report more psychological problems, diagnostic and otherwise (e.g., guilt, uncertainty) has been found to be associated with the occurrence of more daily stressors and less perceived social support (Paardekooper, 1999). Although the exact rates of disorder and dysfunction tend to vary across studies and frequently reaches 40% to 50% prevalence, there is nevertheless consensus across studies investigating PTSD and other psychological problems, which show these rates to be much higher in refugee than nonrefugee populations (Hodes, 2001)).
Although evidence is weighted towards PTSD related problems in refugee children and adolescents, some studies have nonetheless observed findings that challenge the relationship between trauma experience and stress outcomes.
Loughry and Flouri (2001) for example, investigated the behavioural and emotional problems of 455 former unaccompanied refugee children and youth aged between 10 and 22, three to four years after their repatriation to
Vietnam from refugee centres in Hong Kong and South East Asia. Collecting data using measures of internalising and externalising behaviour, self efficacy, trauma and social support, these authors found no differences between age matched controls who never left Vietnam and repatriated children. Similarly, no differences between the groups were

observed for perceived self-efficacy and the number and experience of social support. These authors concluded that the exposed trauma and experience of living without parents in refugee camps did not lead to increased behavioural and emotional problems in the immediate years following repatriation.
While these findings may reflect adaptive capacities despite traumatic experience, they also pose additional questions regarding the reliance of PTSD as a single outcome measure. Although alternative outcomes of trauma are currently being addressed by research into the presence of accompanying disorders and problems, the differential response to trauma that children and adolescents from different cultures may exhibit has been largely unexplored by research
(Rousseau, 1995). Equivocal findings in the research nonetheless, warrant further examination of the mediating variables that are likely to diminish and potentiate adaptive capacity (Beiser, et al, 1995). iii. Risk (Vulnerability) and Protective (resilience) factors a) Pre-Migration Risk and Protective factors
Although the dynamic interplay between various risk and protective factors in refugee psychological health is not fully understood, there is widespread agreement that of those pre-migration factors that pose serious risk, trauma exposure is the single most identified (Berman, 2001). Alongside the associated existence or absence of parental psychopathology, trauma has been discussed in detail above. Other major pre-migration risk factors include child disposition, environmental factors, as well as individual and family functioning before the traumatic events.
Individual and family functioning before migration have been found to influence psychological outcome in refugee children and adolescents. Almqvist and Broberg (1999) for instance, have suggested that family climate and cohesion before and after migration are the best predictors of mental health in children. These claims are supported by Green et al. (1991), Hicks et al. (1993), Rumbaut (1991) and Thabet and Vostanis (2000) who argue that family dysfunction, parental incapacity, qualities of family life prior to exposure and resettlement are influential in post-traumatic stress reactions and adjustment in young children.
Psychiatric disturbance in refugee children is also related to mental health difficulties experienced by other family members prior to migration. As discussed earlier, parents' experiences of persecution, war violence, terrorism, powerlessness and exhaustion compromise their ability to care for children (Fox et al., 1994; Hicks et al., 1996;
Matthey et al., 1999; Miller, 1996; Sack et al., 1986). Ajdukovic and Ajdukovic's (1993) study of the influence of maternal mental health on children's stress reactions and stress indexes emphasised the emotional and behavioural state of mothers as major mediators between children's traumatic experience and psychological functioning.
Rousseau et al. (1997) also argue that while the family enables a child to rediscover safety and security amidst

destruction, parental stress on the other hand is conducive to destroying parent-child relationships due to parent physical and psychological unavailability.
Alongside family and parental factors, child disposition and environmental factors prior to migration are also implicated in the psychological health of refugee children and adolescents. In their review of children's responses to stressful situations, Garmezy and Rutter (1985) in addition to the protective role of families, highlight two other protective factors - dispositional attributes of the child and a supportive environment. Regarding both factors, these authors argue that a child's ability to respond to new situations, positive self-esteem and positive environmental support through strong peer relationships are protective.
Though age, gender and other individual characteristics such as social ability, coping style, temperament, good health and development have been shown to buffer against adverse life events, these characteristics are not systematically discussed in relation to how they influence children affected by organised violence (Almqvist & Broberg, 1999). Good temperament however, has been shown to decrease vulnerability to poor psychological outcome (Almqvist & Broberg,
1999). Social support, especially from parents is emphasised as a factor of resilience during war in the literature, so long as they are not pushed beyond stress-absorption capacities (Dybdahl, 2001; Garbarino et al, 1991). b) Post-migration Risk and Protective factors
While there are few empirical studies investigating unaccompanied children and adolescents and those separated from family members, these populations are consistently argued to be at greater risk for psychiatric and mental health problems than their accompanied peers (Ajdukovic & Ajdukovic, 1993, 1998; Hicks et al., 1993; Kinzie et al., 1986;
McCloskey, Southwick, Fernandez-Esquer & Locke, 1996; Rumbaut, 1991; Servan-Schreiber, Le Lin & Birmaher,
1998; Sourander, 1998). By definition, an unaccompanied refugee/asylum seeking minor is an individual under 18 years of age who has been separated from both parents and is not being cared for by an adult who has a responsibility to do so (Sourander, 1998).
Among those studies focused directly on unaccompanied minors, Felsman, Leong, Johnson and Crabtree-Felsman
(1990) compared three groups of Vietnamese refugees encamped in the Philippines- adolescents, young adults and unaccompanied minors. Whilst anxiety remained high across the three groups, young adults and unaccompanied minors were over represented in clinical ranges on measures of psychological distress. The findings that children and adolescents accompanied by family members are less distressed than those who arrive accompanied by relatives corroborate the findings of Kinzie et al. (1986; 1989) who demonstrated that it was neither the amount nor type of trauma witnessed, nor the child's age or gender that predicted PTSD in Cambodian refugees. Psychiatric effects rather decreased in the presence of a nuclear family member. Although these refugees had lost an average of three

family members, those who had been able to re-establish contact with at least one family member reported fewer adjustment problems than those without family contact.
Sourander (1998) examined traumatic events and emotional and behavioural symptoms of 46 unaccompanied refugee minors awaiting placement in an asylum centre in Finland. Having experienced a number of losses, separations and threats, most of these minors exhibited symptoms of PTSD, depression and anxiety. Half of these children and adolescents were found to be functioning within clinical or borderline ranges on the Child Behaviour Checklist with children aged younger than 15 years found to be particularly vulnerable.
Procedures related to awaiting asylum also contributed to elevated stress levels in these children and adolescents.
When interviewed, they reported several complaints of physical nature, uncertainty about the future and suicidal thoughts. Sourander (1998) concluded that unaccompanied children and adolescents are highly vulnerable towards emotional and behavioural symptoms, which are exacerbated by asylum-seeking stress. In a systematic investigation of unaccompanied Vietnamese Americans, McKelvey and Webb (1995) showed that high rates of psychopathology prior to forced migration were significantly exacerbated during stays in a processing centre in the Philippines. Findings of these studies are pertinent as they reflect areas of research in unaccompanied samples and direct effects of the asylum seeking process that are largely under investigated in the empirical literature.
Rousseau (1995) notes that the majority of unaccompanied children and adolescents are boys, reflecting either the family's or boy's decision, the goal of which is to remove them from war given their vulnerability to soldier activity and their ability to support the family in the future. Such realities underscore the increased risk to psychological health, given the added burden faced by these children and adolescents.
The interaction between traumatic experience and multiple separations has also been noted to increase the psychological risk to unaccompanied youth (Rousseau, 1995). Moreover, it has been suggested that unaccompanied adolescents and youths are particularly vulnerable as their increasing autonomy causes them to relive past separations creating difficulties in adjustment (Lee, 1988, cited in Rousseau, 1995). According to the research in this area, adaptive strategies that are most effective with these populations are those that promote continuity with the past and balance the demands of the external reality (Rousseau, 1995). This is supported by research, which has shown that unaccompanied children have better mental health outcomes when they are placed with foster families of the same ethnic group (Linowitz & Boothby, 1988, cited in Rousseau, 1995; McCloskey & Southwick, 1996). Hicks et al.
(1993) particularly note the exacerbation of problems in unaccompanied children and adolescents when placed with adults of dissimilar cultural backgrounds.
It must be noted, however, that irrespective of whether substitute caregivers are of similar or dissimilar ethnic and

cultural backgrounds, the vulnerability of these unaccompanied minors is evidenced by research that shows when natural caregivers are substituted, antisocial behaviours may be exhibited(Kinzie et al., 1991).
Again, while the negative effects of separation and sole migration are evident in children and adolescents (Richman,
1993), there are some studies that report good adaptation following separation and unaccompanied migration
(Krupinski et al., 1986; Rumbaut, 1991; Wolff et al., 1995). Krupinski et al. (1986) for example, found that while separation contributes to difficulties experienced during the first year of resettlement, psychological problems are not influenced by separation after this time. Additionally, Wolff et al. (1995) compared 4-7 year old Eritrean refugee children and Eritrean children orphaned due to the loss of parents. Whilst emotional and behavioural distress was experienced by children who had lost both parents, these children were found to function better than accompanied refugee children on measures of cognition and language. Given the lack of generalisation in these findings and as is the case with trauma, little is known about how separation distress persists or diminishes over time in children and adolescents.
In addition to separation and unaccompaniment, increased psychological risk also occurs as a result of the process of sought asylum (Silove et al., 1997; Sourander, 1998). This element constitutes particular risk as children and adolescents awaiting asylum are subjected to the compounded stress of being supervised and/or communal living with others outside their family/cultural group. Among adult populations, Sinnerbrink et al. (1997) assessed 40 adult asylum seekers attending English classes at a community welfare centre in Sydney. These authors found that asylum seekers experienced ongoing sources of severe stress including fears of being repatriated, barriers to social work services, separation, and issues related to the process of refugee claims. More than a third of participants had difficulties attaining health services. Thus, salient aspects of the asylum seeking process may compound the stressors suffered by an already traumatised group (Sinnerbrink et al., 1997).
Whilst noting difficulties in accessing samples of asylum seekers who have not been accorded residency status, Silove et al. (1997), interviewed and assessed trauma, anxiety, depression and living conditions in forty asylum seekers attending a community resource centre in Sydney. In these subjects, high anxiety scores were associated with female gender, poverty, and problems with immigration officials. Loneliness and boredom were associated with anxiety and depression. Of the 79% of the sample who had experienced a traumatic event, 37% obtained a PTSD diagnosis. This diagnosis was significantly associated with greater exposure to pre-migration trauma, delays in application processing, dealing with immigration officials, obstacles to employment, racism, loneliness and boredom.
Regarding children and adolescents in the process of sought asylum, the study of Ajdukovic and Ajdukovic (1993) stands among very few in the published literature. These authors compared two groups of children who were uprooted

and displaced together with their families into two different housing arrangements: those living with host families and those living in communal shelters. According to parental reports, children in host families showed lower rates of stress related signs than those living in sheltered environments. 43% of those in homes showed no signs of abnormal functioning while 24% in shelters showed no signs. During displacement, the number of stress related symptoms in host family children decreased for 25%, but symptoms decreased in only 10% of children in shelters. Nearly half of the children in host families no longer experienced nightmares (47.6%) and more than half ceased their fearfulness (59%).
31% were no longer despondent and 24% were no longer unsociable. Among those in the collective shelter, 20% still showed aggression and 28% still showed despondent emotions.
These authors also correlated difficulties in the adaptation of these displaced children and youth. They found that those in shelter had significantly higher incidences of stress reactions than those in host families. These scores were then correlated with their internal and environmental sources of stress. Results showed that childrens' stress indexes were associated with mothers' ability to cope with displacement. Those mothers who reported adaptive problems, worsened relations with children since displacement, negative perceptions of communal housing and burdened conflicts also had children with higher stress indexes.
Ajdukovic and Ajdukovic (1993) attributed their findings to the unfavorable living conditions in shelters where families are generally larger with decreased socio-economic status and where displacement duration is longer or in occupied territory. They concluded that there is a considerable range of stress reaction in displaced children with a higher incidence of stress associated with mothers' poor ability to cope with the stresses of displacement. Similarly, in a large-scale survey of 600 Vietnamese children living in a refugee centre in Hong Kong, McCallin (1992) observed anxiety and depression in a majority of children surveyed, with pronounced effects among those children unaccompanied.
Together, these findings corroborate that children and adolescents living in shelters, camps and processing centres are subjected to increased risk for psychological dysfunction (Rudic, Rakic, Ispanovic-Radojkovic, Bojanin & Lazic,
1993).
Though it is unclear which specific factors exist to exacerbate problems of well being in these particular risk groups, some researchers have suggested that such negative psychological outcomes are attributed to the inability to maintain traditional mother and father roles, the loss of perceived control and learned helplessness (Garbarino & Kostelny,
1996). Indeed where traditional roles are maintained and length of communal living, such as in refugee camps, is decreased, less adverse psychological effects have been observed (Markowitz, 1996; McKelvey & Webb, 1997).
Given the risk and protective factors of parental pressure, parental psychopathology and family problems in the pre-

migration period, it is not surprising that such factors also pose risk and protection in the period of post-migration.
Kinzie et al. (1986) for example have noted the protective effects of re-established parental contact following migration. The protective presence of family is similarly noted by Arroyo and Eth (1996) who found that children and adolescents remaining in nuclear families were less likely to receive a psychiatric diagnosis than those who lived alone or were fostered. Similarly, Masser (1992) and Melville and Lykes (1992) have also found less emotional distress and better adjustment following migration in children who arrive with family members than children who survive the refugee process alone.
Parental depression and anxiety secondary to trauma or to post- migration difficulties are also often associated with more serious symptoms in children (Hjern, Angel & Jeppson, 1998; Meijer, 1985, cited in Rousseau, 1995). As shown in Hjern et al's. (1998) study of Chilean and Middle Eastern refugee children in exile, important family life events such as the birth of a sibling and divorce among parents play a significant role in the mental health of child and adolescent refugee and asylum seekers.
Acculturative stress (that is stress due to difficulties associated with adapting to a new culture) also place refugee/asylum seeking children and adolescents at greater psychological risk. For example, difficulties at school and in language acquisition have been shown to predict poor adaptation. In contrast, academic achievement as influenced by language acquisition and good peer relations is predictive of good psychological outcomes (Rousseau, 1995).
More widely noted throughout the literature, however, are two important factors in the adaptation to a new culture that either increase or decrease susceptibility to poor mental health. First, conflict in the development of identity among adolescents has consistently been related to poor psychological adjustment (Rousseau, 1995). Second, even though the adaptive process to a new culture can make provision for good outcomes, it can also increase psychological vulnerability through the creation of inter-generational stress.
Intergenerational conflict arises when children and adolescents, particularly adolescents, adapt much faster than their parents. As such, the authority of parents is often compromised by virtue of their dependence on children for language and cultural access to the host society. Lastly, high parental expectations have also been shown to significantly predict intra-personal conflict in refugee children and adolescents, thereby posing further risk to poor adaptation (Hyman, Vu
& Beiser, 2000).
Other factors to have a negative influence on the mental health in refugee children and adolescents include low socioeconomic status (Howard & Hodes, 2000); long-term unemployment in parents, particularly fathers; school problems, language problems; and discrimination and bullying (Hyman et al, 2000).

With regard to individual characteristics, those found to enhance resilience in children and adolescents at a postmigration level have included a realistic expectation of adjustment (McKelvey & Webb, 1996, cited in Hodes, 2000).
Inconsistent findings regarding individual characteristics however are more common throughout the literature. For example, contradictory findings have been obtained for the protective nature of age and gender. While some suggest the cognitive immaturity of younger children is protective at migration (Dybdahl, 2001; Elbedour, ten-Bensel & Bastien,
1993; Garbarino & Kostelny, 1996; Papageorgiou et al., 2000), others suggest it is the inability to articulate and express distress or the attribution of egocentric explanations in younger children, which constitute risk (Berman, 2001).
Similarly regarding gender, it has been found that boys are more vulnerable than girls (Elbedour et al., 1993; El Habir et al., 1994) and where under conditions of accumulative risk factors such as injury through political violence and physical violence or maternal depression in the family unit, boys are particularly vulnerable to emotional and behavioural problems (Garbarino & Kostelny, 1996). Contrarily, the results of studies on children exposed to the Gulf war have found that females show higher frequencies of stress reactions than males (Greenbaum, Erlich & Toubiana,
1993; Klingman, 1994) and greater decreases over time in boys relative to girls in post-traumatic stress, anxiety and depression (Stein, Gardner & Kelleher, 1999). Differences in gender may reflect cultural expectations for the display of emotion or females being more adept to openly report symptoms. Importantly, they also reflect the complex and dynamic interplay between risk and protective factors yet to be understood by the research.
The availability of support systems facilitates successful adaptation even when children and adolescents have survived extreme trauma (Fox, Cowell & Montgomery, 1994). Almqvist and Broberg (1999) for example, investigated the relevance of peer relationships, exposure to bullying or harassment, marital discord/harmony and parental mental health in the mental health and social adjustment of refugee children and adolescents in Sweden. They noted the protective nature of good paternal and maternal mental health, marital harmony and positive peer relationships.
Conversely, isolation from support has been found to be a major predictor of poor psychological adaptation (Jupp &
Luckey, 1990).
In line with the positive influence of social support, the maintenance of close ethnic community ties has also been shown to be a protective factor to mental health in children and adolescents, alongside cultural and religious traditions which assist to restore continuity in the past and present (Punamaki, 1996; Rousseau, 1995; Sack, 1995).
Though discussion of treatment issues is beyond the scope of this paper, early intervention and psychosocial assistance have frequently been reported as crucial protective factors PUNAMAKI (2001) despite low rates of help seeking behaviour in refugee populations (Howard & Hodes, 2000). Indeed, in her assessment of young Chilean adults who experienced childhood war related traumas of parental loss, Punamaki (2001) concluded that both the

nature of trauma and the timing and duration of assistance were critical to wellbeing in adulthood.
Conclusions
Although preliminary in nature, the research in the psychological well-being of children and adolescent refugee and asylum seekers has identified key areas of consistency. It is apparent that most research in this area is directed at the prevalence of psychopathology, with particular emphasis on post-traumatic stress symptomology. This research clearly demonstrates that refugee children and adolescents are vulnerable to the effects of pre-migration, most notably exposure to trauma. It is also apparent that particular groups in this population constitute higher psychological risk than others, namely those with extended trauma experience, unaccompanied or separated children and adolescents and those still in the process of seeking asylum. Finally, it is apparent that certain risk and protective factors exist to temper or aggravate poor psychological health. Such factors include family cohesion, family support and parental psychological health; individual dispositional factors such as adaptability, temperament and positive esteem; and environmental factors such as peer and community support.
The psychological research however is less clear in a number of areas. These include the mechanisms by which risk and protective factors exacerbate and temper the effects of trauma and migration experience and the role of culture as a mediator in the experience of trauma and migration experience.
Though not presently discussed, future research needs to be directed at the improvement of methodologies (e.g., cross cultural validation of measurement techniques); the extension of knowledge and outcomes beyond PTSD and psychopathology (e.g., the development of theoretical models incorporating systematic effects of risk and protective factors), the influence and comparison of cultural context; the investigation of long term effects and impact of acculturation and the investigation of treatment issues centered around individual and family systems (Weine, 2002).
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About the authors
Trang Thomas, Ph.D is Professor of Psychology at the Royal Melbourne Institute of Technology
Winnie Lau, BBSc (Hon) is a Clinical Psychology Researcher at the Royal Melbourne Institute of Technology

1.The Child Behaviour Checklist is a commonly used test for children from 2 to 16 years of age to monitor their well being, such as whether they are anxious, uncommunicative, depressed, aggressive, delinquent, withdrawn or hyperactive.
2. The Diagnostic Interview Assessment Scale are structured interview schedules employed to yield information about the presence, absence, severity of symptoms or give a global indication of psychopathology.