Mental health of young asylum seekers and refugees in the context of COVID-19

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In this podcast, we are joined by Dr. Matthew Hodes, Consultant Child and Adolescent Psychiatrist and Honorary Clinical Senior Lecturer in Child and Adolescent Psychiatry at Imperial College London.

The focus of this podcast is on the mental health of young refugees and asylum seekers.

To set the scene, Matthew starts by providing us with a brief introduction of how he came to be interested in the mental health of young refugees and asylum seekers and comments on the impact of psychological distress and psychiatric disorder as it relates to child and young asylum seekers and refugees.

Matthew discusses his Editorial Perspective, published in the CAMH, on the mental health of young asylum seekers and refugees in the context of COVID-19, and provides insight into what additional burdens the pandemic has posed to child and adolescent asylum seekers and refugees.

With his Editorial Perspective having suggested that services are increasingly inadequate for asylum seekers and refugees, Matthew comments on access to and provision of services for asylum seekers and refugees, as well as the types of barriers and challenges that affect this group.

Matthew then discusses what he has learnt from his experience as a practitioner, and from evidence-based research, in terms of need and best practice when it comes to the mental wellbeing of child and adolescent refugees and asylum seekers, plus shares his advice for CAMH professionals working with this group.

Having touched on hostile government policies, Matthew also comments on what socioeconomic interventions are known to support young asylum seekers and refugees and shares his message to policy makers.

Furthermore, with ‘Healing’ as the theme of Refugee Week 2022 (20 – 26 June), Matthew comments on how optimistic he is that healing is possible for dislocated children and young people.

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Dr. Matthew Hodes
Dr. Matthew Hodes

Dr. Matthew Hodes is an Honorary Clinical Senior Lecturer in Child & Adolescent Psychiatry, and also works as a Consultant Child and Adolescent Psychiatrist in the NHS with Central and North West London NHS Foundation Trust.

Matthew carries out research into the mental health of young people in two main areas. Firstly, he investigates sociocultural influences on child and adolescent mental health. He has studied risk and protective factors for psychopathology, and service use. A major focus has been the mental health of young refugees and asylum seekers. Secondly, he investigates the interface between physical and mental health. Recent studies address maternal and child anxiety associated with childhood food allergy. Another area of interest is evidence based practice, and he has been active in synthesising and disseminating research findings, especially in the field of child and adolescent depression. (Image and bio from Imperial College London)

Transcript

[00:00:30.280] Jo Carlowe: Hello, welcome to the “In Conversation” podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. I’m interviewing consultant child and adolescent psychiatrist, Dr. Matthew Hodes, honorary clinical senior lecturer in child and adolescent psychiatry at Imperial College London.

Today we will focus on the mental health of young refugees and asylum seekers. If you’re a fan of our “In Conversation” series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review. And do share with friends and colleagues. Matthew, thank you for joining me. Can you start with a brief introduction about who you are and what you do?

[00:01:11.988] Dr. Matthew Hodes: OK, well, thank you very much, Jo. I’m a child and adolescent psychiatrist. I trained in medicine and psychiatry and then child and adolescent psychiatry in London. I did my training in the Maudsley Hospital and I also studied social anthropology to MSC level in various breaks that I took during that time. And I carried out research at Maudsley Institute of Psychiatry. It was then gaining a PhD, actually that was in family treatment of eating disorders in adolescents.

[00:01:44.080] Jo Carlowe: My next question is, how did you come to be interested in the mental health of young refugees and asylum seekers?

[00:01:50.985] Dr. Matthew Hodes: Well, what happened, as I mentioned, I studied social anthropology, so I was always interested in cultural influences on mental health. Then when I got a consultant job in West London in the 1990s, this was a time of the Yugoslavian Civil War, and many refugees came to West London and in many other parts of the UK. And I was called to a meeting in a school to address the needs of young Bosnian children, and I realized then that very little was known about them and there was no specific provision.

So, at that time, I was a lead clinician for the area. I started to develop outreach services for young refugees in the community. And these services expanded. And then I was able to start a number of research projects that were stimulated by that experience. But my work continued actually since the 1990s. And even though the outreach refugee medical service closed after about 10 or 12 years, I was able to carry on with a number of research projects and continued to do so.

[00:02:59.590] Jo Carlowe: We know that adult asylum seekers and refugees have elevated rates of PTSD and depression compared to their non-refugee peers. What can you tell us about the impact of psychological distress and psychiatric disorder as it relates to child and young asylum seekers and refugees?

[00:03:18.858] Dr. Matthew Hodes: OK, well, there are a number of parts to that question. Firstly, we need to think about psychological distress and how that arises. So psychological distress arises in this group partly because of threat events, fear of persecution or direct aggression. And partly because of loss events, loss of family, loss of community. And then thirdly, I’d add to that actually the experience of migration and culture change. And we can think about these three areas in a particular time frame that reflects the life course of refugees. So, starting off with their experience often in their home communities, where they may be exposed to organized violence and then they may be contemplating journeys. When the journeys are carried out, they’re very variable in terms of the duration and the level of security or the degree of threat during those migration journeys, often with great hardship.

But of course, for some who have support from international agencies, they may be granted refugee status quite early on in their experiences and that will make their journeys much more easy often. And after the migration journey, then they will be experiencing resettlement stresses often and that could be associated with further experiences of loss, and also sometimes further experiences of direct aggression and threat often because of racism or direct attacks. And we’ve all seen pictures of attacks on asylum hostels in European countries. So those experiences understandably are associated with a lot of changes in emotional state and that explains the very increased level of psychiatric disorder in the asylum-seeking refugee population.

There have been a number of reviews, systematic reviews, and meta-analyses looking at the prevalence of psychiatric disorder in children and adolescents. One was published in 2005 and another good one in 2020. And just looking at these two reviews, which I’ve selected because they both rely on interview-based studies, it’s been shown that the prevalence of psychiatric disorders are much elevated. So, for example, the most recent review shows prevalence of PTSD above 20%, and depression above 13%, and anxiety disorder also would be elevated. So, these are much higher rates than you would find in a comparison group of same age peers.

Of course, there have been many other difficulties experienced by asylum seeking refugee children, depending on their age and maturation. So for example, problems like bed wetting and clingy behaviour, difficulties in separation typically are not measured in many of these studies, but they are often highly prevalent. And then of course, there are rarer problems and disorders, which are still very significant amongst those who experienced them. So, we know that these background adversities and ongoing stressors are associated with elevated rates of hopelessness, suicidality, deliberate self-harm. And also because of the very high arousal associated with these experiences, there’s a higher rate of psychosis as well.

So even though psychosis was a rare, relatively rare disorder in adolescence, even if we have twice the prevalence of psychosis, it’s still a significant increase even if still relatively rarely encountered. But it does mean if you are working in, for example, a specialist psychiatric inpatient unit, [INAUDIBLE] since there may be a higher number of asylum seekers and refugees than one might expect, simply in terms of the numbers.

[00:07:09.430] Jo Carlowe: I wanted to ask you about the impact of COVID-19. And in March 2022, the CAMH published your editorial perspective on the mental health of young asylum seekers and refugees in the context of this. What additional burdens has the pandemic posed to child and adolescent asylum seekers and refugees?

[00:07:29.038] Dr. Matthew Hodes: Well, firstly, I think that the young asylum seekers and refugees and their families may have had a direct experience of COVID. They may have been less likely to have been vaccinated. So, parents in particular may have caught COVID and have been affected. And this will have an impact, of course, on the children, for whom they are caring. Of course, the children themselves are less likely to have severe COVID. So, the effect of the COVID directly is going to be on the parents and their management of the children, support for the children. But I think far beyond that, and much more general impact was the mitigating processes put in place by the government to reduce the prevalence of COVID. So having to stay at home and work from home obviously would have had a much bigger impact on those in inadequate overcrowded accommodation.

Not only because of the obvious stressors, but also of course that would increase the spread of COVID. And then associated with that time, of course, were school closures. The school closures for a lot of children will be very stressful, but for asylum seekers/refugees, school actually is a very hopeful and normalizing environment in which they can learn English, develop friendships, and it helps them to become integrated. So, the closure of school would have much higher threat and be much more difficult for this group than for many others.

So, some of these points have been made by Michael Marmot, who is the expert on inequality, writing about the way in which COVID has had a differential impact on people from more deprived backgrounds than from those who are in more comfortable environments. I suppose the final thing to say is that asylum seekers and refugees make up very diverse cultural backgrounds with very different understanding of disease, often with experience of distrust in governments and government recommendations. And so they may be less likely to get vaccinated and may require a bit more help in understanding how vaccines can prevent future disease later on.

[00:09:29.605] Jo Carlowe: It ties in with the next question I want to ask you, which is about access to and provision of services and the types of barriers and challenges that affect this group. I mean, we know for general CAMHS and specialist services, there are already long waiting lists. In your CAMH editorial, you suggested services are increasingly inadequate for asylum seekers and refugees. Can you say a bit more about this?

[00:09:56.830] Dr. Matthew Hodes: OK, well, the difficulties in access may have been exacerbated by COVID, of course, when services themselves were under strain. But even prior to COVID, there are a number of challenges often for asylum seekers/refugees in obtaining appropriate services. Firstly, in some areas there have been accounts of difficulty in registering with general practitioners. And for many GPs are the first line of referral to CAMHS.

There’s another group of young children who are distressed, of course, who will be identified in school settings. And as I said, school is a very important environment for asylum seekers/refugees. Now as compared to [INAUDIBLE] asylum seeking or non-refugee peers, they may be more likely to experience internalizing problems, which could mean that they’re very quiet, withdrawn, maybe a bit socially anxious. And in combination often with language difficulties, this may make it more difficult for the teachers to recognize significant psychological distress. And therefore, difficulties which teachers might have picked up for other children who are showing externalizing behaviour, which of course attract the attention of very busy teachers, these difficulties may be overlooked.

The other thing to say is that some of the difficulties we know are experienced at particular times of the day. So often asylum seekers/refugees may experience difficulties a night-time when they have nightmares and so on. So sometimes actually the difficulties may be less manifest in the school setting and sometimes more manifest at night. This may be more true for the unaccompanied asylum seeking children who some of them are actually living in low support arrangements. So, they go home back to a homeless accommodation and for some of them that distress will increase and night-time as they spend more time on their own.

[00:11:48.590] Jo Carlowe: So, what should teachers and other adults who come across these children, what kind of clues, if you like, should they be looking for of signs of distress in a child that’s perhaps quiet and withdrawn.

[00:12:01.965] Dr. Matthew Hodes: Well, it would be very varied. So, depending on the age and the language fluency of the children. So younger children, for example, may show preoccupation with traumatic events through their drawings or through the pattern of play. Other children, young children, may have clingy behaviours, difficulty separating from parents. Of course, it is possible to talk to parents, teachers may get an idea about whether the child in the school setting is very different to how he or she was in the school, in the country of origin. That may or may not be possible to find out because of language and other barriers. Then some of the teachers may identify in the children who are emotionally distressed, the point of being tearful and so on. And of course, those children who are showing visible signs that would be easier then for the teacher to identify that they might need help. In fact, teachers who get to know the children usually are pretty good at detecting the difficulties. And quite often they will detect difficulties which are not brought to the attention of the GP.

[00:13:02.730] Jo Carlowe: Let’s look at need and best practice. So, from your experience as a practitioner and from evidence-based research, what have you learned in terms of need and best practice when it comes to the mental wellbeing of child and adolescent refugees and asylum seekers?

[00:13:19.080] Dr. Matthew Hodes: There’s a kind of a long and a short answer to that question. So, I’ll just try and give a rather succinct answer. So, I think the first thing to say is that it’s very important with this group to be able to think in terms of multi-level interventions and systems. There may be many agencies involved in helping refugee children and asylum seekers. So, liaison with the appropriate agencies, whether it’s social care, volunteer organizations would be important and alongside that, expressed support for improved service provision and access may be possible and the CAMHS commission may be able to support that.

The second thing I’d say is that in clinical work, one’s got to be rather pragmatic. And often there are things that you really don’t know, and it can be hard to find out because of language reasons, often issues of trust, fear of disclosure of what happened. Of course, the migration routes mean that– and the hostility arising from government policy mean that lots of people have entered the country in a way that it’s called illegal. And so that may heighten fear of disclosure of background difficulties. Often one’s having to make assessments and do clinical work without full knowledge and often developmental assessments are not really very complete. The child may have been out of school for many years, for example. And so looking at certain milestones like reading age or how or when he or she could read may have very different meaning, may not be possible to ascertain.

So, the kind of pragmatic approach and then talking to parents about– and the family about what they want and what the child wants. The final thing to say I think is that I think some of the principles of an evidence-based practice are still applicable here, but they just have to be adapted to people who may be mobile, beyond settled homes, but if they’re adopted, they can be taken up. But I think beyond the specificity of evidence-based practice is the need to communicate hope, and warmth, and concern to the families. So those non-specific qualities in our relationship are important in this area as well.

[00:15:26.242] Jo Carlowe: So, given the challenges that you’ve described, what advice do you have for CAMH professionals working with young refugees and asylum seekers?

[00:15:33.958] Dr. Matthew Hodes: Well, if they’re new to the field, I think it would be worthwhile just to find out a bit about the background of the asylum seekers, the refugees they’re going to be working with, by reading, by talking to people from those communities. And then talking with people who have carried out this work. I think the kind of pragmatism that I was mentioning is important to bear in mind. The final thing would be that even though we’ve been talking a lot about adversity and risk, and how that may impact on mental health, of course, when we’re dealing with very large migrations, if we just take the Ukrainian refugees. So, millions of people have left Ukraine now. I know the number of coming to UK is only in the hundreds of thousands, but even with that number, what we have to remember is that some of the children will have developmental difficulties or disorders that they would have had even if they hadn’t experienced war.

So, you shouldn’t overlook the fact that some of these neurodevelopmental or other related problems might arise. And they could be a little bit harder to detect because of the difficulty of the child settling in school and the teacher identifying them. So, for example, children who are the shy/inhibited, their inhibitory control will be greater, it can take longer time, for example, a child with ADHD to present. And for the teacher to recognize those difficulties, because of as I say, the emotional state and maybe because of language difficulties.

The usual psychiatric and developmental difficulties that we see in all children could still occur in this group. So that’s something I’d say, and then just bear that in mind. It does mean that those difficulties may become apparent over time, even if it’s hard to be sure about them at the time of first contact or soon after settlement in the UK or other resettlement countries.

[00:17:19.185] Jo Carlowe: Matthew, you talked earlier about hostile government policies. What socioeconomic interventions are known to support young asylum seekers and refugees? And what is your message to policy makers?

[00:17:32.090] Dr. Matthew Hodes: We know that very high levels of homelessness or very low levels of support are associated with more psychological distress and high prevalence of psychiatric disorder. So, people are more supported in appropriate refugee centres and unaccompanied asylum-seeking children who are placed, what we call high support living arrangements, which could be foster families or high supported hostels for the older adolescents. That’s the kind of support that’s needed.

Longer duration with uncertainty around asylum and refugee status is associated with more distress, at the time when asylum applications are being reviewed causes distress. I think the government policies are– many of them actually have been regarded as being illegal. They’ve been criticized by UNHCR. And many, many court challenges have been made and often government home office decisions have been struck down by courts.

And the portrayal of refugees and asylum seekers in much of the press often is very hostile. So for example, people who are arriving across the channel or in the back of lorries or whatever are soon to be illegal immigrants. And in fact, what’s happened is that the access to UK and other resettlement countries have become so restricted that the only way of entering is through those routes. They are called illegal, and in fact, they can’t really be legal without it being ascertained whether they have a legitimate claim. So, the government, for example, is communicating in a hostile way, creating a hostile culture. And we’ve seen this in a very extreme form, of course, with the Windrush generation, but what’s happened to asylum seekers and refugees is a continuation of a policy of hostility. So, I’d say that the policies should be more and more benign, more supportive. Restricted accommodation for asylum seekers should be changed where some people may be making inappropriate or illegal claims. This should be managed in a more humanitarian way.

[00:19:29.420] Jo Carlowe: The theme of Refugee Week 2022 held in June was healing, defined as recovering from a painful experience or situation so that we can continue to live. Matthew, how optimistic are you that healing is possible for dislocated children and young people?

[00:19:45.392] Dr. Matthew Hodes: Well, I’m quite optimistic about that. I think that even though we’ve focused rather a lot on the negatives and the stresses of migration and refugee experiences. In fact, for many, coming to resettlement countries is an opportunity. Whether people can take that opportunity often depend on not only the background adversities, but their personalities sensitivity to those experiences, family function, and family strengths, and the outlook of their families and hopes for the future.

So those who have many of the strengths and high family support and a positive outlook may settle and integrate very well. So, asylum seeking refugee children typically learn English in about six or eight months, when they’re attending school full time. So, at the beginning, of course, it’s very bewildering for them, but they do very rapidly learn English. And if they’re in schools or areas which are multicultural, it may be more easy for them to develop friendship groups.

So I think actually many of them will largely recover in terms of achieving a good social function. It’s not to say they won’t have memories of difficult journeys, but living with those memories will become much more easy. And the positives over time may significantly outweigh the pain of the losses and the journeys.

Of course, for parents it may be rather different because for parents to integrate and adjust may be more difficult because of difficulties in learning English. They may be excluded from the labour market for a long time, unlike their children, of course, integrated into school. And then obtaining jobs for the parents commensurate with their previous skills and occupational level may be difficult. So often you have a generational difference between how children see settlement as compared to the struggles that may last much longer for the parents, who may then continue to miss their home country much more. And of course, they’ll have a much longer memory of their home country community than the children.

[00:21:53.635] Jo Carlowe: Matthew, what else is in the pipeline for you that you’d like to mention?

[00:21:57.538] Dr. Matthew Hodes: Oh, for me personally, I’ve just been collaborating with some colleagues from Scandinavia and Ukraine, and we’ve been looking at a data set of adolescents exposed to the first Russian invasion. This was in 2014 when parts of the Donbas were occupied, and we’ve just been analysing this data sets comparing in a sample of 2,700 adolescents, the level of war exposure of those in that region as compared to those in neighbouring regions outside of the occupied zones, and looking at risk of psychiatric disorder, PTSD, and depression, and anxiety. And actually, our first papers in press. It does show three times the risk of PTSD in those who are exposed to the war.

So, this is of interest because these are children who are not displaced. They’re not actually refugees, they’re just living in the area which is occupied by Russian supported troops. And of course, with a large sample, and so on. There’s some [INAUDIBLE] strengths and there’ll be a couple of other papers coming from that data set. The other thing actually because of the Ukrainian crisis I’ve been asked to write a short article for the journal “Clinical Child Psychology and Psychiatry,” which I’m just about to finish and hopefully will be accepted. And there’s various other projects that I’m working on in the field still.

[00:23:14.585] Jo Carlowe: Finally, Matthew, what is your take home message for those listening to our conversation?

[00:23:19.542] Dr. Matthew Hodes: My take home message would be that asylum seekers and refugees are people who need support, but can also offer a lot. And we should think in a positive way about what they can bring and communicate hope to them. And bear in mind that, of course, despite the challenges, some of which we’ve been discussing, most will be psychiatrically well. But a small group may need additional help, but that a practical and pragmatic response to their difficulties may go a long way, even though sometimes we’re not always quite sure how what we’ve offered has helped them because of mobility reasons. They may be moving locations, and language issues, and so on. Sometimes it’s a little bit hard to know exactly how much we’ve helped. But I think on balance what we’re offering is highly appreciated where we can mobilize services to help them.

[00:24:09.140] Jo Carlowe: Matthew, thank you so much, so it’s a message of hope. For more details on Dr. Matthew Hodes, please visit the ACAMH website, www.acamh.org. And Twitter @acamh, ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.

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