Approximately half of the world’s displaced population are children and a significant proportion of these are unaccompanied asylum-seeking children (UASC). UASC are the most vulnerable of all refugee populations. Up to 90% of UASC have been subjected to exploitation, including trafficking or being drafted into military groups. Having survived the perils of flight, UASC are confronted with continued challenges, including the uncertainties regarding their residential rights in host counties. Unsurprisingly, the prevalence of mental health problems is higher amongst UASC than in any other refugee group. Yet, Mental Health and Psychosocial Support (MHPSS) appears to neither reach nor engage UASC. This begs for re-examination of what and how MHPSS is offered. Despite high levels of adversity, UASC often have considerable resilience, and make remarkable recoveries. However, literature exploring their resources or their own views of what helps or hinders recovery is scarce. In this narrative review, we explore individual and systemic factors promoting recovery in UASC. We consider theoretical understanding of resilience, emerging data and user perspectives. From these we deduct four areas of resilience in UASC:
Irene Mateos Rodriguez and Veronika Dobler contributed equally to this work.
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By the end of 2019, 79.5 million people were forcibly displaced worldwide (UNHCR,
The prevalence of mental and physical health problems amongst refugee children and adolescents is significantly higher than in the general population (El Baba & Colucci,
The factors associated with the higher prevalence of mental health difficulties amongst UASC have been divided into pre-, during, and post-migration factors; and these are influenced by individual, family, community, and societal risk and protective factors (Fazel & Betancourt,
The high prevalence of mental health problems amongst UASC puts pressure on the host country to address these needs through Mental Health and Psychosocial support (MHPSS). When exploring access to MHPSS, cumulative data from various European countries suggest, that, while almost 60% of UASC perceive a need for psychological support, only 12-36% of these actually access mental health services (Bean et al.,
Even once access to CAMHS has been facilitated, engaging and retaining UASC in treatment remains a challenge (Sanchez-Cao et al.,
In addition, both trauma-focused cognitive behavioural therapy (TF-CBT) and narrative exposure therapy (NET) have significant evidence showing their effect in reducing psychological distress amongst children and adolescents who have experiences trauma, or with a diagnosis of PTSD (Gutermann et al.,
In summary, mental health problems in UASC are highly prevalent; however, only a fraction access MHPSS, and of these, only two thirds remain engaged. Further, even where potential treatments may be available, there is a rarity of studies focusing on UASC to prove effectiveness for this group. Therefore, there is a need for further investigation of how best to engage and support these highly vulnerable young people.
There are clearly considerable challenges for UASC in accessing and/or accepting MHPSS support which warrant further exploration of what might make interventions more accessible, acceptable and adapted to their perceived needs. Nonetheless, it is worth highlighting that many of these youngsters are survivors against all odds. Despite the extent of their traumatic experiences, not all of them develop mental health problems, and many of those who do, recover to a good functional level (Keles et al.,
When resilience first emerged as a concept, it was described as the ability to ‘do well’ despite adversity or risk, and this ability was thought to be a more or less static feature inherent to a particular individual (Masten,
There is extensive literature on resilience in children and adolescents who have suffered from childhood trauma (Fritz et al.,
Overall, these findings highlight a central role for factors that promote positive relationships in fostering resilience amongst children and adolescents. However, these factors have been mainly drawn from studies conducted in Western cultures (USA, Canada, Australia, and Israel), and therefore the extent to which they mirror the ranges of cultures that constitute the current refugee population in Europe is undetermined.
An importance difference between the resilience literature of childhood adversity and that of refugee children, is the nature of the trauma. Many UASC have experienced multiple types of trauma, and are thus poly-victims, which underscores the diversity of this group. However, the trauma in childhood adversity studies is largely associated with care-giver perpetrated attachment trauma, whereas amongst refugee children, despite multiple trauma, these are more likely associated with contextual/circumstantial trauma, on the background of preserved attachment relationships. This distinction in the type and number of traumatic experiences may result in different resilience factors, and thus warrants future exploration. In addition to the type and number of trauma, adversity factors that are specific to the refugee populations include having to navigate high levels of uncertainty, cultural diversity and adaptation to a foreign country. More specifically for UASC is the physical absence of trusted carers throughout their migration journey and during the acculturation process. While it is likely that both intrapersonal and interpersonal resources ultimately promote resilience in the host country, it is important to determine how exactly relationships and other contextual factors are perceived as helpful in promoting recovery and well-being in this group.
Children and adolescents have long been victims of war and trauma. There is probably an equally long history of children alone or separated from their families seeking refuge in foreign countries. The narratives of children who fled during or after the second world war offer one well-documented source of retrospective assessments of experiences of unaccompanied minors after arrival in the host country (Freud & Dann,
Although the literature on resilience in UASC is thin, a number of studies have focused on resilience in UASC recently arriving in Europe. In keeping with a multilevel framework, these can be summarised under the headings of individual factors, and factors relating to the past and present social ecology.
Forming and maintaining new peer relationships has emerged as a further source of resilience amongst UASC migrating from many regions that include middle eastern countries, African areas of conflict, central/south American countries, and areas of the Kosovo conflict as well as Western countries including the USA, Australia, Belgium, UK, Spain, France and others (Demazure et al.,
Despite significant limitations, when including assessment and perspectives of what helped and hindered recovery and acculturation in refugee groups across time, contexts and cultures, common themes emerge both in quantitative assessment of RFs and the accumulative testimony of survivors. These are distributed over multiple levels (see Table Resources and resiliencies to support recovery and integration amongst UASC 1 1.1 Coping and problem-solving skills 1.2 Personality factors e.g. easy temperament, humour, pro-social behaviours 1.3 Embracing independence 1.4 Forming meaning from their experiences 1.5 Chameleon-like talent - appearing ordinary and normal 1.6 Faith in a higher power or religious orientation 2 2.1 2.1a Physical or virtual contact with families/extended families 2.1b Connectedness of family prior to migration 2.1c Close attachment to other adults e.g. caregiver, guardian, teacher, social worker 2.1d Appeasing uncertainties to loved ones being dead/hurt/disappeared 2.1e Facilitating continuity of experience and connectedness with culture of origin 2.2 2.2a Support from peers and adults from similar cultural backgrounds 2.2b Forming relationships with peers with similar flight experiences 2.2c Forming relationships with peers/mentors at school 2.2d Positive relationship with prosocial institutions e.g. schools or churches 3 3.1 Time spent in the country 3.2 Maintaining aspects of their culture of origin e.g. religion, people from own culture 3.3 Embracing aspects of local culture e.g. language, styles of dressing… 4 4.1 Supportive living arrangements e.g. foster care or small living groups vs reception centres or restrictive environments 4.2 Placements promoting freedom with few restrictions 4.3 Experiencing a positive asylum and age assessment process 4.4 Living with culturally matched families
Overall, pre-migration factors and various post-migration factors are likely to operate together and interact with each other across many levels. Both pre- and post-migration factors appear to contribute to the mental health trajectory of UASC (Keles et al.,
UASC are the most vulnerable group among refugees. A large proportion of UASC have experienced extreme levels of trauma and/or exploitation, including modern time slavery or being drafted by military groups as child soldiers. On arrival, they must negotiate the acculturation and postflight challenges including protracted uncertainties with regards to their residential rights, all without trusted adults. Unsurprisingly, prevalence of mental health problems is extremely high. Though there is insufficient provision of CAMHS, even where interventions are available, engagement has been an almost universal challenge for this population. While there are multiple reasons for this, these difficulties suggest that new approaches to engagement strategies and service provision need exploring. Considering the significant stigma attached to seeking mental health support, fostering resilience might be a promising avenue for adjusting the focus for MHPSS for UASC. In order to guide our hypotheses more specifically we explored strategies that might promote resilience in UASC. We considered current evidence relating to resilience in adolescents in general, and factors promoting resilience in UASC specifically. We included qualitative assessments of UASC individuals’ own current views and retrospective perspectives of what has helped during their postflight periods.
Resilience factors are distributed across a multilevel framework comprising intra-individual, and systemic micro- and macro-ecological factors. General RFs on an intra-personal level which appeared shared across all refugee and non-refugee groups are cognitive flexibility, problem-solving skills, and a stable self-concept. The latter, however, seemed to be promoted in refugee groups by fostering the bi-cultural identity and integration of past and present narratives. Lifetime relationships constituted an important systemic factor. Secure attachment and positive family and peer relationships appeared beneficial across all groups. In UASC it affected postflight recovery in multiple specific ways. Treasuring the happy memories of their past and family was reported as a resource of strength and happiness. Positive past relationships predicted maintaining connections with family members in their homeland and these were associated with positive relationship building in their new environments. Peer relationships played a specific role in UASC as it provided opportunities to share lived experiences, and facilitated engagement in cultural activities such as religious practice, social hubs, or speaking their home language. Peers also appeared to act as ‘bridge builders’ to the new cultures. Interestingly, positive acculturation appeared to include maintaining the connection to the old- as well as adoption of new cultural practices. Appearing ordinary and normal, adopting local habits, building new relationships and engaging in local culture via prosocial institutions like schools or churches equally feature as RFs for UASC alongside treasuring their roots. In addition, UASCS appear to draw resilience from nurturing homes and care arrangements that allow high independence and self-agency. In summary, our main findings highlight the importance of systemic resilience factors distributed over various levels of social connectedness, as well as narratives that integrated social connections and cultural values longitudinally and cross-sectionally. In UASCs, this specifically included lifetime relationships, care arrangements and acculturation in the host-country. Experience and quality of early life relationships, maintaining contact with families postflight, as well as forming relationships postflight with individual caregivers or peers from the same and different cultures, all seem to promote resilience in UASC. These appear alongside intra-individual factors, including embracing a bi-cultural identity.
The capacity to maintain and form positive relationships, highlights an important difference between UASC, and severely traumatised young people with impaired relational capacity due to attachment trauma. Psychological consequences of multiple traumatic experiences, where children became subjected to systematic and organised crimes or war, differs from psychological sequelae of early life adversities perpetrated by attachment figures (e.g. a parent or carer) (Fritz et al.,
Our review suggests that intra-individual factors and inter-individual factors that promote relatedness, connectedness, and relationships are central to resilience amongst UASC. These include lifetime relationships, acculturation. In many ways this is unsurprising in a group that has been uprooted and displaced from their own cultural environments in addition to having lost their immediate supportive network of the family environment, during a critical developmental period that is programmed for social connectedness (Chase et al.,
The review is necessarily limited by the scarcity of literature. The larger body of evidence is derived from quantitative studies where researchers had explored specific factors e.g. relationships, which might mean conclusions were biased by the
Equal contribution of both authors.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The authors declare that they have no conflict of interest.
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