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Treating Refugees From Syria and Beyond: A Moral and Professional Responsibility
CLINICAL PERSPECTIVES Treating Refugees From Syria and Beyond: A Moral and Professional Responsibility Balkozar Adam,
W
ar, violence, and persecution have led to unprecedented numbers of people forced out of their homes. The number of refugees worldwide has topped 22 million, many of whom are children.1 In Syria alone nearly 5 million have fled to escape constant attacks and devastating bombings. There is no end in sight for the Syrian civil war that broke out in 2011 and has killed more than 400,000 people.2 Child psychiatrists in the United States have a long history of treating refugees. We are already starting to feel the ripple effect of the current refugee crisis, which is exacerbated by the recent presidential executive orders. Federal judges have refused to uphold parts of the orders, but confusion, fear, and xenophobia remain. Increased Islamophobia and hate crimes have rocked many of the communities where these children are expected to relocate.3 Several organizations released statements after the executive orders that warned of the added risk of stress, trauma, anxiety, bullying, and stigma to an already vulnerable population.4 They referenced the lasting effects on a child’s brain and what happens when a child feels unwanted. Numerous studies went into further detail describing the tremendous stress endured by refugee children, including witnessing murders or mass killings, fighting in armed conflicts, or working in labor camps.5 It is our professional and moral obligation to advocate for the safety and treatment of these children. Their hardships began long before they entered our borders and will stay with them long after. A recent study found that refugee youth experienced greater trauma, such as community violence and loss, than immigrant and US-origin youth, and that refugees can benefit from specialized mental health services and public policies.6 I recently treated a Syrian teenage refugee who eluded death by hiding in a bathroom. His childhood was marked by dead bodies and a stream of funerals for relatives. He evaded terrorists who wanted to recruit him and soldiers who wanted to draft him. These groups would kill him if he resisted. On one occasion, soldiers came to his house under cover of night searching for any antigovernment sympathizers. His father was not home at the time, and as the oldest male person in the house, he carried the weight of his family’s survival. The family sought refuge in a relative’s home, but the relative’s home was burned down, and the family was displaced once again. When I saw him, he had been in the United States for a few months. He had not attended school in years, and he JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 10 OCTOBER 2017
MD
faced poverty and discrimination as a refugee. His elementary school had been attacked, and when the family escaped to another country, they could not afford the bus fare to send him to school. He wrestled with feelings of gratitude and guilt. Why did he survive when so many others didn’t? He didn’t speak English, and he started working a custodial job to help support his family. He was numb and detached. Although he worked, he remained in a state of shock and suffered from severe denial. His family was more concerned about his lack of school attendance than his depression or posttraumatic stress disorder (PTSD) because they viewed education as the key to a successful future. The stigma of mental illness made the family reluctant to seek treatment. The refugee worker assigned to the case encouraged treatment and provided transportation. A car was a luxury the family did not have; so was medical insurance. Because access to insurance remains a problem for refugees and non-refugees alike, providers should be aware of untreated trauma. Many refugees wait months or longer to see a psychiatrist. In addition, one study that looked at a group of Somali refugee adolescents found a low rate of use of mental health services, meaning those who need services often are not getting them.7 Research also indicates that patients, including refugees and immigrants, with depression and anxiety can present with somatic symptoms.8 As with all populations, refugees are not monolithic. For example, unaccompanied refugee minors were shown to have higher levels of PTSD symptoms than accompanied refugees.9 Overall, children of war experienced high levels of PTSD. The absence of stressors was found to decrease PTSD symptoms over time.10 Clinicians have a small but growing number of options to help them in their quest to provide culturally sensitive care. The American Academy of Child and Adolescent Psychiatry’s (AACAP) Practice Parameter for Cultural Competence is a valuable tool.11 It explores cultural values and beliefs, noting that although many support children and their families in times of difficulty, some can act as barriers to mental health care. It is our job as psychiatrists to know the difference. The case of the Syrian refugee illustrates the impact of culture on refugees’ mental health. As child and adolescent psychiatrists, we listen to our patients, hear their pain, diagnose their symptoms, and treat their illnesses. However, many refugees are hesitant to seek help. Instead, they are quick to attribute their mental health issues to temporary lapses, religious tests, or spiritual penance.12 Being cognizant
www.jaacap.org
803
ADAM
of this underscores the need for a cultural approach when caring for this population. The first step and the first principle of the Practice Parameter are to identify possible barriers that can stand in the way of treatment. For example, minorities and refugees alike often wait to access services, in part because they fear the “double discrimination” of being a minority and a person with mental illness. Language also can be a critical component to treatment, and as such, it is strongly recommended to conduct the evaluation in the language the child and family are most comfortable. It keeps practitioners from relying on children to translate for their parents, which could “parentify” the child and blur boundaries. It also can decrease the risk of misdiagnosis stemming from misunderstanding. As difficult as it might be for us to admit, we all have our biases. Our cultural biases and stereotypes can interfere with our ability to treat. These tend to be subconscious thoughts that creep into our actions. Don’t shy away from consulting with a colleague who is familiar with the culture or religion of the patient at hand. Awareness of cultural differences in the expression of distress will help us better understand the needs of our diverse patients. Another Practice Parameter principle calls on clinicians to assess for a history of immigration-related loss and trauma. As noted in the case of the Syrian refugee, several issues were related to stress, trauma, acculturation, immigration, and
prejudice. In children and adolescents, such factors can manifest as conduct disorder, sexual acting out, substance abuse, depression, self-harm, sleep dysregulation, and PTSD. In addition to the AACAP’s Practice Parameter, the DSM5’s Cultural Formulation Interview clarifies the cultural context of illness as a means of improving diagnostic assessment, treatment, and clinical management. The Cultural Formulation Interview also highlights the role of health disparities, economic inequalities, racism, discrimination, misunderstandings, and misdiagnosis in caring for our patients. As psychiatrists, we promised to serve children in need, whether foreign born or lifelong residents, immigrants or refugees. That is a pledge worth remembering now more than ever. & Accepted July 31, 2017. Dr. Adam is with University of MissourieColumbia. Disclosure: Dr. Adam reports no biomedical financial interests or potential conflicts of interest. Correspondence to Balkozar Adam, MD, Department of Psychiatry, University of Missouri Columbia, 3 Hospital Drive, Columbia, MO 65201; e-mail: [email protected] 0890-8567/$36.00/ª2017 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2017.07.785
REFERENCES 1. United Nations High Commissioner for Refugees. Figures at a glance. http://www.unhcr.org/en-us/figures-at-a-glance.html. Accessed July 1, 2017. 2. Syria envoy claims 400,000 have died in Syria conflict. United Nations Radio. http://www.unmultimedia.org/radio/english/2016/04/syriaenvoy-claims-400000-have-died-in-syria-conflict/#.WVfmVITyvIU. Published April 22, 2016. Accessed July 1, 2017. 3. Lichtblau E. U.S. hate crimes surge 6%, fueled by attacks on Muslims. New York Times. https://www.nytimes.com/2016/11/15/us/politics/ fbi-hate-crimes-muslims.html. Published November 14, 2016. Accessed July 25, 2017. 4. AACAP. AACAP releases statement on immigration executive orders. http://www.aacap.org/AACAP/Press/Press_Releases/2017/ Immigration_Executive_Orders.aspx. Accessed July 01, 2017. 5. Lustig SL, Kia-Keating M, Grant Knight W, et al. Review of child and adolescent refugee mental health. J Am Acad Child Adolesc Psychiatry. 2004;43:24-36. 6. Betancourt TS, Newnham EA, Birman D, Lee R, Ellis BH, Layne CM. Comparing trauma exposure, mental health needs, and service utilization
7.
8.
9.
10. 11.
12.
across clinical samples of refugee, immigrant, and U.S.-origin children. J Trauma Stress. 2017;30:209-218. Heidi Ellis B, Lincoln AK, Charney ME, Ford-Paz R, Benson M, Strunin L. Mental health service utilization of somali adolescents: religion, community, and school as gateways to healing. Transcult Psychiatry. 2010;47: 789-811. Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. J Clin Psychiatry. 2001;62(suppl 13):22-228. discussion 29-30. Huemer J, Karnik NS, Voelkl-Kernstock S, et al. Mental health issues in unaccompanied refugee minors. Child Adolesc Psychiatry Ment Health. 2009;3:13. Thabet AA, Vostanis P. Post-traumatic stress disorder reactions in children of war: a longitudinal study. Child Abuse Negl. 2000;24:291-298. Pumariega AJ, Rothe E, Mian A, et al. Practice parameter for cultural competence in child and adolescent psychiatric practice. J Am Acad Child Adolesc Psychiatry. 2013;52:1101-1115. Draguns JG. Problems of defining and comparing abnormal behavior across cultures. Ann N Y Acad Sci. 1977;285:664-675.
JOURNAL 804
www.jaacap.org
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 10 OCTOBER 2017
W
ar, violence, and persecution have led to unprecedented numbers of people forced out of their homes. The number of refugees worldwide has topped 22 million, many of whom are children.1 In Syria alone nearly 5 million have fled to escape constant attacks and devastating bombings. There is no end in sight for the Syrian civil war that broke out in 2011 and has killed more than 400,000 people.2 Child psychiatrists in the United States have a long history of treating refugees. We are already starting to feel the ripple effect of the current refugee crisis, which is exacerbated by the recent presidential executive orders. Federal judges have refused to uphold parts of the orders, but confusion, fear, and xenophobia remain. Increased Islamophobia and hate crimes have rocked many of the communities where these children are expected to relocate.3 Several organizations released statements after the executive orders that warned of the added risk of stress, trauma, anxiety, bullying, and stigma to an already vulnerable population.4 They referenced the lasting effects on a child’s brain and what happens when a child feels unwanted. Numerous studies went into further detail describing the tremendous stress endured by refugee children, including witnessing murders or mass killings, fighting in armed conflicts, or working in labor camps.5 It is our professional and moral obligation to advocate for the safety and treatment of these children. Their hardships began long before they entered our borders and will stay with them long after. A recent study found that refugee youth experienced greater trauma, such as community violence and loss, than immigrant and US-origin youth, and that refugees can benefit from specialized mental health services and public policies.6 I recently treated a Syrian teenage refugee who eluded death by hiding in a bathroom. His childhood was marked by dead bodies and a stream of funerals for relatives. He evaded terrorists who wanted to recruit him and soldiers who wanted to draft him. These groups would kill him if he resisted. On one occasion, soldiers came to his house under cover of night searching for any antigovernment sympathizers. His father was not home at the time, and as the oldest male person in the house, he carried the weight of his family’s survival. The family sought refuge in a relative’s home, but the relative’s home was burned down, and the family was displaced once again. When I saw him, he had been in the United States for a few months. He had not attended school in years, and he JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 10 OCTOBER 2017
MD
faced poverty and discrimination as a refugee. His elementary school had been attacked, and when the family escaped to another country, they could not afford the bus fare to send him to school. He wrestled with feelings of gratitude and guilt. Why did he survive when so many others didn’t? He didn’t speak English, and he started working a custodial job to help support his family. He was numb and detached. Although he worked, he remained in a state of shock and suffered from severe denial. His family was more concerned about his lack of school attendance than his depression or posttraumatic stress disorder (PTSD) because they viewed education as the key to a successful future. The stigma of mental illness made the family reluctant to seek treatment. The refugee worker assigned to the case encouraged treatment and provided transportation. A car was a luxury the family did not have; so was medical insurance. Because access to insurance remains a problem for refugees and non-refugees alike, providers should be aware of untreated trauma. Many refugees wait months or longer to see a psychiatrist. In addition, one study that looked at a group of Somali refugee adolescents found a low rate of use of mental health services, meaning those who need services often are not getting them.7 Research also indicates that patients, including refugees and immigrants, with depression and anxiety can present with somatic symptoms.8 As with all populations, refugees are not monolithic. For example, unaccompanied refugee minors were shown to have higher levels of PTSD symptoms than accompanied refugees.9 Overall, children of war experienced high levels of PTSD. The absence of stressors was found to decrease PTSD symptoms over time.10 Clinicians have a small but growing number of options to help them in their quest to provide culturally sensitive care. The American Academy of Child and Adolescent Psychiatry’s (AACAP) Practice Parameter for Cultural Competence is a valuable tool.11 It explores cultural values and beliefs, noting that although many support children and their families in times of difficulty, some can act as barriers to mental health care. It is our job as psychiatrists to know the difference. The case of the Syrian refugee illustrates the impact of culture on refugees’ mental health. As child and adolescent psychiatrists, we listen to our patients, hear their pain, diagnose their symptoms, and treat their illnesses. However, many refugees are hesitant to seek help. Instead, they are quick to attribute their mental health issues to temporary lapses, religious tests, or spiritual penance.12 Being cognizant
www.jaacap.org
803
ADAM
of this underscores the need for a cultural approach when caring for this population. The first step and the first principle of the Practice Parameter are to identify possible barriers that can stand in the way of treatment. For example, minorities and refugees alike often wait to access services, in part because they fear the “double discrimination” of being a minority and a person with mental illness. Language also can be a critical component to treatment, and as such, it is strongly recommended to conduct the evaluation in the language the child and family are most comfortable. It keeps practitioners from relying on children to translate for their parents, which could “parentify” the child and blur boundaries. It also can decrease the risk of misdiagnosis stemming from misunderstanding. As difficult as it might be for us to admit, we all have our biases. Our cultural biases and stereotypes can interfere with our ability to treat. These tend to be subconscious thoughts that creep into our actions. Don’t shy away from consulting with a colleague who is familiar with the culture or religion of the patient at hand. Awareness of cultural differences in the expression of distress will help us better understand the needs of our diverse patients. Another Practice Parameter principle calls on clinicians to assess for a history of immigration-related loss and trauma. As noted in the case of the Syrian refugee, several issues were related to stress, trauma, acculturation, immigration, and
prejudice. In children and adolescents, such factors can manifest as conduct disorder, sexual acting out, substance abuse, depression, self-harm, sleep dysregulation, and PTSD. In addition to the AACAP’s Practice Parameter, the DSM5’s Cultural Formulation Interview clarifies the cultural context of illness as a means of improving diagnostic assessment, treatment, and clinical management. The Cultural Formulation Interview also highlights the role of health disparities, economic inequalities, racism, discrimination, misunderstandings, and misdiagnosis in caring for our patients. As psychiatrists, we promised to serve children in need, whether foreign born or lifelong residents, immigrants or refugees. That is a pledge worth remembering now more than ever. & Accepted July 31, 2017. Dr. Adam is with University of MissourieColumbia. Disclosure: Dr. Adam reports no biomedical financial interests or potential conflicts of interest. Correspondence to Balkozar Adam, MD, Department of Psychiatry, University of Missouri Columbia, 3 Hospital Drive, Columbia, MO 65201; e-mail: [email protected] 0890-8567/$36.00/ª2017 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2017.07.785
REFERENCES 1. United Nations High Commissioner for Refugees. Figures at a glance. http://www.unhcr.org/en-us/figures-at-a-glance.html. Accessed July 1, 2017. 2. Syria envoy claims 400,000 have died in Syria conflict. United Nations Radio. http://www.unmultimedia.org/radio/english/2016/04/syriaenvoy-claims-400000-have-died-in-syria-conflict/#.WVfmVITyvIU. Published April 22, 2016. Accessed July 1, 2017. 3. Lichtblau E. U.S. hate crimes surge 6%, fueled by attacks on Muslims. New York Times. https://www.nytimes.com/2016/11/15/us/politics/ fbi-hate-crimes-muslims.html. Published November 14, 2016. Accessed July 25, 2017. 4. AACAP. AACAP releases statement on immigration executive orders. http://www.aacap.org/AACAP/Press/Press_Releases/2017/ Immigration_Executive_Orders.aspx. Accessed July 01, 2017. 5. Lustig SL, Kia-Keating M, Grant Knight W, et al. Review of child and adolescent refugee mental health. J Am Acad Child Adolesc Psychiatry. 2004;43:24-36. 6. Betancourt TS, Newnham EA, Birman D, Lee R, Ellis BH, Layne CM. Comparing trauma exposure, mental health needs, and service utilization
7.
8.
9.
10. 11.
12.
across clinical samples of refugee, immigrant, and U.S.-origin children. J Trauma Stress. 2017;30:209-218. Heidi Ellis B, Lincoln AK, Charney ME, Ford-Paz R, Benson M, Strunin L. Mental health service utilization of somali adolescents: religion, community, and school as gateways to healing. Transcult Psychiatry. 2010;47: 789-811. Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. J Clin Psychiatry. 2001;62(suppl 13):22-228. discussion 29-30. Huemer J, Karnik NS, Voelkl-Kernstock S, et al. Mental health issues in unaccompanied refugee minors. Child Adolesc Psychiatry Ment Health. 2009;3:13. Thabet AA, Vostanis P. Post-traumatic stress disorder reactions in children of war: a longitudinal study. Child Abuse Negl. 2000;24:291-298. Pumariega AJ, Rothe E, Mian A, et al. Practice parameter for cultural competence in child and adolescent psychiatric practice. J Am Acad Child Adolesc Psychiatry. 2013;52:1101-1115. Draguns JG. Problems of defining and comparing abnormal behavior across cultures. Ann N Y Acad Sci. 1977;285:664-675.
JOURNAL 804
www.jaacap.org
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 10 OCTOBER 2017