25/06/ ,200 Asylum-seeking Children arrived in UK with Family in 2015 (Refugee Council briefing 2016)

Transcription

1 Therapeutic Interventions for Refugee Children: Recommendations and Challenges Dr Kim Ehntholt Clinical Psychologist Traumatic Stress Clinic, Camden and Islington NHS Foundation Trust, London Asylum Seekers in the EU (House of Lords EU Committee 2 nd Report 2016) 7,200 Asylum-seeking Children arrived in UK with Family in 2015 (Refugee Council briefing 2016) 1

2 UASC Statistics (Refugee Council briefing 2016) an individual under the age of 18, who is separated from both parents and is not being cared for by an adult who, by law or custom, is responsible for doing so (UNHCR, 1994) from Eritrea, Afghanistan, Albania, Iran, Vietnam, Iraq, Syria, Sudan Common Symptoms of Emotional Distress in Refugee Children Sad, depressed, tearful Worried, anxious Clingy, separation anxiety Behaviour problems Sleep problems Appears tired Poor concentration Difficulties learning new language Nocturnal enuresis Headaches & stomach pain Lack of appetite Peer problems, e.g. few friends, bullied Post Traumatic Stress Disorder (PTSD), e.g. flashbacks, avoidance of reminders, easily startled by loud sounds Mental Health Needs of Young Refugees 40% report PTSD, depression & anxiety (Hodes, 2000) 1/3 Central American refugees met criteria for PTSD (Arroyo & Eth, 1985), 50% prevalence in adolescent Cambodian refugees (Kinzie et al., 1986) High rates of depression & anxiety in children exposed to war (Mghir et al., 1995; Zivcic, 1993) Psychiatric symptoms & disorders persistent (Sack, et al., 1999) 2

3 Clinical interview Good interpreter Assessment Tools for diagnosis use Structured Clinical Interviews Translated self-report measures do exist For children ( PTSD, depression, anxiety measures & manual For parents, Strengths and Difficulties Questionnaire behavioral rating ( For UASC, depression, anxiety, PTSD and stressful life events measures developed by Tammy Bean ( Phased Model of Intervention (NICE, 2005) Establish safety and trust Traumafocused Therapy/ Intervention Reintegration Phase One Phase Two Phase Three Interventions for Refugee Children Exposed to Trauma & Loss EMDR Trauma-focused CBT NET/Kidnet Writing for Recovery Grief Teaching Recovery Techniques 3

4 EMDR Uses bilateral stimulation when processing memories Client is asked to conjure up an image of their traumatic events while the therapist simultaneously moves their finger in front of the client s eyes is a rhythmic, lateral motion Involves a combination of both exposure and distraction or dual attention as it is called Case series (Oras, Cancela de Ezpeleta & Ahmad, 2004) CBT Child case vignettes (Vickers, 2005) Adult refugees (Otto et al., 2003; Paunovic & Ost, 2001; Snodgrass et al., 1993) Trauma & Grief-focused manual-based CBT group 20 sessions for Bosnian adolescents in school setting (Layne et al, 2001) Trauma & Grief focused, psychoed & relaxation techniques, 12 week group, individual & family sessions for Kosovan adolescents (Mohlen et al, 2005) Narrative Exposure Therapy (Schauer, Neuner, & Elbert, 2005) NET = CBT + testimonial Short-term treatment based on principles of CBT but using an adapted narrative approach multiple traumas & can t identify 1 worst event Lifeline with flowers & stones Carried out an RCT in a refugee camp with adult refugees (Neuner et al, 2004) & KIDNET case series with 6 adol Somalis (Onyut et al, 2005) 4

5 Writing for Recovery manual (Pennebaker, van Emmerik, Neuner, Dyregrov,Yule & Raundalen, 2005; aimed at adolescents exposed to or bereaved through war and disaster based on Pennebaker s work that writing down feelings about an emotional experience can help reduce distressing reactions & improve health adolescents meet 2x a day for three consecutive days, writing lasts for only 15 mins so 90 mins in total Positive results with young Iraqi & Afghani refugees Grief manual (Yule, Dyregrov, Straume & Kraus; childrenandwar.org) aims to help groups of children with bereavement reactions following a loss that results from war or large-scale disasters enormous variations exist in mourning rituals & beliefs the manual is being carefully evaluated by professionals from many different cultures to minimise causing offence Teaching Recovery Techniques (TRT) (Smith, Dyregrov, Yule, Perrin, Gjestad & Gupta, 2000; Manualised group intervention for children Parallel group sessions for parents/carers aims to give children better coping strategies so they feel more in control of their reactions & can benefit from the support of their families and opportunities in school For 8+ years best with groups of <15 children Successful in Sri Lanka, Iran, Turkey, Greece, China & the UK 5

6 Content of the 5 Sessions of TRT Focus on Intrusive symptoms Psychoeducation re PTSD & normalising reactions Imagery techniques Dual attention techniques (similar to EMDR) Managing frightening dreams Discuss/draw traumatic events Arousal symptoms Discuss connection between thoughts & physical sensations Progressive relaxation & Imagery Sleep hygiene Positive/coping self-statements Pleasurable activity scheduling Avoidance symptoms Introduced graded exposure Practiced imaginal exposure Encouraged to draw, write & talk about upsetting wartime events Encouraged to look to the future What makes Interventions Difficult? Challenges in Treatment Lack of stability Worries re asylum application/ deportation Fears for family in home country Poor accommodation Poverty Ongoing trauma Communication barriers Traumatised parents Parents without a daytime occupation Social isolation Missing family members Lack of case/ social workers Challenges due to UK Immigration System 6

7 Challenges related to UASC 10,000 missing in the EU vulnerable to smugglers traffickers & organised crime Poor registration process Disregard for Best interest of the child principle Lack of Trust in Government Authorities Family Reunification not being facilitated Age disputes/ assessments Temporary Protection until 17 ½ years old Challenges for Professionals Vicarious traumatisation Burnout/ Compassion Fatigue Requires Supervision Clear boundaries Peer support Work-life balance Self-care References Treatment Ehntholt, K.A. & Yule, W. (2006). Practitioner Review: Assessment and Treatment of Refugee Children and Adolescents who have experienced War-related Trauma. Journal of Child Psychology and Psychiatry, 47(12), Ehntholt, K.A., Smith, P., & Yule, W. (2005). School-based Cognitive- Behavioural Therapy Group Intervention for Refugee Children who have Experienced War-related Trauma. Clinical Child Psychology and Psychiatry, 10(2), Detention Lorek, A. Ehntholt, K., et al. (2009). The Mental and physical health difficulties of children held within immigration detention: A pilot study, Child Abuse & Neglect, 33, Robjant, K., Hassan, R. & Katona, C. (2009). Mental health implications of detaining asylum seekers: systematic review. The British Journal of Psychiatry, 194,