Q&A: Common questions about trauma in refugee children

CrossCurrents

by Lesley Young

This Q&A is based on an interview with Dr. Lucie Nadeau, a child psychiatrist with the Transcultural Child Psychiatry Clinic at Montreal Children’s Hospital. Nadeau offers helpful insights from her work counselling young newcomers to Canada in need of specialized mental health care.

 

Every year Canada welcomes thousands of immigrant and refugee children. In 2005, almost 20,000 refugees arrived, according to the Office of the United Nations High Commissioner for Refugees. Given that almost half of the world’s 20 million refugees are children, it’s safe to say that many of these new arrivals to Canada are also children. Most refugees are vulnerable because of cultural differences and language barriers and, in some cases, traumatic experiences. Between 1992 and 2002, two million children worldwide were killed in war zones and six million were injured or permanently disabled; among child survivors, one million were orphaned, and 20 million were displaced to refugee camps, according to a 2004 study in the Journal of Child Psychology and Psychiatry. As a result of trauma, refugee children have high rates of post traumatic stress disorder (PTSD) – as high as 90 per cent among Bosnian refugee children, according to a 2006 study in the Journal of Nervous and Mental Diseases.

 

How do mental health issues in child refugees manifest themselves?

Child refugees suffer similar conditions as adults, such as depression, anxiety, (PTSD) and somatoform disorders (the most frequent symptoms). Children under age 4 don’t understand trauma fully because they don’t have the language or fully formed visual memories, so sometimes it will manifest itself as body sensitivity. Children from age 6 to 12 may experience autonomy issues and PTSD, as well as frequent night­mares. They may have a lot of fear in general and be hypervigilant. But it can take between six months and one year after they’ve arrived before they actually begin to experience mental illness symptoms.

 

What unique mental health challenges do war-exposed child refugees experience?

These children experience a very different social context growing up. They may have seen their parents killed, or may even have been child soldiers. Quite a few grow up in or experience refugee camps, some with a lot of insecurity, including hunger and malnutrition. So it is necessary to understand how each child has coped with his or her circum­stances. Some have developed unique survival mechanisms, such as lying. While you have to go into their world to help undo what’s been done, you can’t think of them as having anti­social tendencies, for example. Another important issue is avoiding re-traumatizing the child. We all have a tendency toward voyeurism, and we need to recognize that and refrain from going straight to the trauma in therapy.

 

How can the risk of misdiagnosis be minimized?

First, it’s important to decipher whether there are cognitive difficulties as a result of malnutrition, as many refugees need physical healing as well as mental healing as part of their recovery. There is also the potential to confuse psychosis with dissociative disorder. Children who experience a lot of losses may have hallucination-like symptoms that aren’t necessarily the result of psychosis. But it’s important not to rule out the fact that they may indeed have mental illnesses such as bipolar disorder. We also need to look at the specific family dynamics because there may have been a pre-war dynamic at play that needs to be assessed. We must be cautious about giving meaning to something or supposing that we can help children find ways to heal using traditional methods. Every child needs to be treated individually and creatively.

 

What therapeutic approaches can be used?

With young children we use play therapy. Often, children will express their trauma by playing violent games, such as shooting over and over again. For adolescents, all types of talk therapy and psychiatric pharmaceutical interventions can be used. But because of the unusual circumstances of these children, we also get creative. For example, I treated two siblings together so they could appreciate a sense of security from each other. Another good example is having a family counsel meeting. In some regions, such as the Congo and Rwanda, a family counsel is important for resolving conflict and you can conference call in an elder to conduct a family counsel meeting from the originating country if necessary.

 

How does culture play a role in assessment, diagnosis and treatment of trauma?

Language and culture can be barriers. It is important to ask the child how he or she experiences or feels about something instead of assuming they understand something the same way we do. There is a difference in meaning behind symptoms. For example, in China, depression is thought of quite differently. It is called neurasthenia and is much more likely to be experienced as fatigue or pain. In Sri Lanka, sorrow is valued and integrated in the Buddhist approach to life. When we try to make sense of symptoms, we have to avoid attaching meanings from our own culture to them.

That’s the beauty of it, actually. Adolescents who manage to keep a part of their cultural traditions, perhaps with the help of their parents, along with the new culture tend to negotiate well in the new country. It gives them a richness in life that helps protect against the negative impact of the new culture. Otherwise you could have the situation that has happened in Quebec. Some schools and families insist that refugee children speak French only. But that is a big mistake because if their parents can’t speak it, communication for the child can be vastly reduced.

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