My practice

Many refugee and asylum-seeking children have suffered direct trauma, as well as the impact of trauma on their family and community. Not surprisingly, mental health problems result.

Although these do not apply to all (or even most) refugee children, a significant proportion experience emotional difficulties that affect their overall functioning well beyond the definition of “transient distress”. While the nature of these difficulties varies, care professionals are often specifically concerned about the presence of post-traumatic stress reactions. There is still a debate over whether these should constitute specific mental health conditions per se.

However, there is also a large body of evidence describing similar conditions following natural and human-induced disasters, exposure to violence (domestic, community, political), accidents and life-threatening illness. The concept is characterised by repetitive images and thoughts related to the trauma – regular fear of recurrence, nightmares, emotional numbing and detachment.

Internalised distress can be easily missed if a child appears settled in their behaviour, if adult carers do not pick up clues (such as nightmares), or if they do not ask the child. The latter can be difficult without knowing the family, or because of anxiety that asking might exacerbate the problem.

On a positive side, if a child experiences post-traumatic stress, there are different levels of help. Sharing their worries with somebody they trust is a good starting point, and often brings enormous relief. Reassurance, normalisation of activities and routines, work with their parents, and a few “low key” discussions can help.

A judgement can then be made for those with multiple, severe and persistent complaints who might require specialist intervention such as cognitive or psychodynamic therapy.

Equally, there is a risk of oversimplifying the causes leading to emotional or behavioural difficulties by automatically attributing them to trauma. Refugee children are faced with a series of difficult adjustments at school, at home and in the community. The uncertainty about the future, frequent moves, disruption of social networks, and language and cultural barriers need to be addressed alongside any trauma-related therapeutic work.

It is not always easy to explain why a five year old had a tantrum on return from school. Some explanations may be similar to those for all other children, such as frustration with school work, peer relationships problems, or parenting issues.

In a comprehensive welfare system there should be opportunities to address all these levels of need and adjusting our thinking and services as far as possible.

Panos Vostanis is professor of child psychiatry, University of Leicester.