School-based mental health services

Challenges and Opportunities

Mina FazelNIHR Post-Doctoral Research Fellow, Department of Psychiatry, University of OxfordConsultant in Child and Adolescent PsychiatryChildrens Psychological Medicine, Oxford University Hospitals

Developing Mental Health Services for Refugee Children

1

AimsOverview of mental health need of refugee childrenHigh-incomeGlobal Risk and Protective factorsDescribe a service in OxfordInterviews with the service usersOpportunities and challenges

Global overview of refugeesHighly diverse groupStressors of war, organised violence, persecutionLoss of a place and sense of home13.9 million newly displaced in 201420 million refugees worldwide44% children500,000 travel each year to seek asylum in high income countriesMost remain in a neighbouring or nearby country86% hosted in developing regions38 million internally displaced

Issues specific to refugee childrenIn addition to all the issues that socially under-included and marginalised populations sufferForced migrationExperiences of persecution, emotional and physical traumaInsecurity at a formative stage of developmentDouble disruption to developmental and cultural continuityCan enhance or threaten well-beingEver-changing nature of resettlement programmesDiverse needs for support: PsychologicalEducationalFinancialSocial

Challenges facing refugees in high income vs lower & middle income (LAMIC) contextsHigh income:Complex asylum processDispersal policiesLanguage, cultural and religious differenceSocial exclusionEducation system+ve = usually basic survival needs met; organised violence rare

LAMIC:Prolonged uncertaintyPoverty/local tensions Spreading conflictRefugee camps rape, violence, abuse+ve = shorter migration journey; transplantation of community/family; fewer language and cultural differences

5

5

Prevalence of mental illness in refugee populationsHigher than host populationsEstimates in settled refugee populations High levels of anxiety disorders and PTSD DepressionConsiderable comorbidityChronicity of conditionsImportance of post-migration settingChildren: Studies suggest considerable prevalence of psychological disturbanceAnxiety disordersDepressionPost-traumatic stress disorder (11%)

6M. Fazel, J. Wheeler, J. Danesh. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review The Lancet 2005;365:1309-14M. Fazel, A. Stein. The Mental Health of Refugee Children Archives of Disease in Childhood 2002;87:36670

Three Stages of traumatic experiencesIn country of origin

Flight to safety

Having to settle in country of refuge

7

CommunityFamily

A conceptual framework to understand the determinants of mental health in refugee childrenIndividual

PremigrationPerimigrationPostmigration

Society

8R. Reed, M. Fazel, L. Jones, C. Panter-Brick, A. Stein. Mental health of displaced and refugee children resettled in low and middle-income countries: risk and protective factors The Lancet 2011 379(9812):250-265

8

Influences on Mental Health for forcibly displaced populations (Miller, Rasmussen 2010)Exposure to armed conflictDaily Stressorscaused or worsened by armed conflictMental HealthDaily stressors unrelated to armed conflict

9

Some studies of psychiatric disorders in forcibly displaced childrenStudyYear & locationSampleFindingsLMIC studiesMorgos2007 Sudan331 internally displaced children75% met criteria for PTSD, 38% for depressionMels2010 DRC819 adolescentsInternally-displaced reported the highest scores for post-traumatic symptomsPaardekooper et al. 1999 Uganda316 Sudanese refugees in Uganda compared to 80 local Ugandan childrenSudanese children reported significantly more depressive and post-traumatic symptoms and behavioural difficultiesHigh-income country studiesNielsen2008 Denmark246 children in detention centresChildren with at least 4 relocations had worse mental healthStudies of unaccompanied asylum-seeking children (UASC)Bronstein2012 UK222 Afghan unaccompanied adolescents34.6% scored above cut-offs for anxiety, and 23.4% for depressionBean2007 Belgium582 unaccompanied refugee children from 48 countriesPsychological distress higher: girls and older age, unaccompanied had experienced twice as many traumatic events

Chapter 44: Refugee, Asylum-Seeking Children and Internally Displaced Children. M Fazel, R Reed and A Stein. 6th edition of Rutters Child and Adolescent Psychiatry 2015

10

Summary of risk and protective factors for mental health outcomes for forcibly-displaced children in high-income settingsPredictor variable examinedDomain examinedNumber of studiesTotal number of childrenRisk or protective factorExposure to premigration violence Individual133099riskFemale sexIndividual113425risk (mainly for internalising/ emotional problems)High parental support and family cohesionFamily41576protectiveSelf-reported support from friendsCommunity4397protectiveUnaccompaniedFamily33690riskPerceived discriminationCommunity31548riskExposure to postmigration violenceIndividual31489riskSelf-reported positive school experienceCommunity31441protectiveSeveral changes of residence in host countryCommunity31031riskParental exposure to violenceFamily3517riskPoor financial supportFamily21601riskSame ethnicity foster careFamily2386protectiveSingle parentFamily2359riskParental psychiatric problemsFamily2162risk

M. Fazel, R. Reed, C. Panter-Brick, A. Stein. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors The Lancet 2011 379(9812):266-282

11

Summary of risk and protective factors for mental health outcomes of forcibly-displaced children in low and middle-income settingsFactor examinedDomain examinedNumber of studiesTotal number of childrenRisk or protective factorExposure to premigration violenceIndividual127382riskFemale sexIndividual72667risk (for internalising/ emotional problems not PTSDSettlement in refugee campSocietal44742riskMale sexIndividual31678risk (for externalising/ behavioural problems)RepatriationSocietal31101protectiveInternal displacement (within country of origin)Societal21574risk

R. Reed, M. Fazel, L. Jones, C. Panter-Brick, A. Stein. Mental health of displaced and refugee children resettled in low and middle-income countries: risk and protective factors The Lancet 2011 379(9812):250-265

aOnly included if validated in 2+ studies bReported as one study if the same sample was reported in multiple publications cIncludes forcibly displaced children and comparator groups hence participant numbers high dRepatriation refers to those who sought asylum in a different country and then returned to their country of origin and were compared to those who had remained in original countries, typically with longer conflict exposure 12

The Oxford School Refugee ProjectSchool-based mental health service for refugee and asylum seeking children4 Oxford SchoolsWhy school-basedAll children attendNatural focus for familiesSafe environmentPotentially provides a stable external social support (protective factor for resilience)Consultation with teachersRemoves a barrier to mental health services

Common clinical issuesTrauma reactionsGrief reactionsOther lossesDifficulty adjusting to new environmentsChild protection concernsThreats of harm to self and othersAssisting unaccompanied minors

14

The Refugee school-based mental health serviceWeekly meetingLink teacher

Mental health professional

Discuss Child of Concern

More information: Class teacher Direct observation in school

Watch and wait

Give information on useful local resources that might be of assistance e.g. charities, guidance clinics etc..

Need to see directlySchool approaches child + parent/carer

Meeting with childTeacher can introduce at first meetingArrange meeting in school location

Advise teachers with possible strategies to use with the child

Family meeting

Group

15M Fazel, H Doll, A Stein. A school-based mental health intervention for refugee children: an exploratory study Clinical Child Psychology and Psychiatry 2009, 14(2): 297- 309

Baseline Comparative Study (=11.882, P