Fifteen years of detaining children who seek asylum in Australia - evidence and consequences

Health of children who experienced Australian immigration detention

BACKGROUND

Australian immigration policy resulted in large numbers of children being held in locked detention. We examined the physical and mental health of children and families who experienced immigration detention.

METHODS

Retrospective audit of medical records of children exposed to immigration detention attending the Royal Children's Hospital Immigrant Health Service, Melbourne, Australia, from January 2012 -December 2021. We extracted data on demographics, detention duration and location, symptoms, physical and mental health diagnoses and care provided.

RESULTS

277 children had directly (n = 239) or indirectly via parents (n = 38) experienced locked detention, including 79 children in families detained on Nauru or Manus Island. Of 239 detained children, 31 were infants born in locked detention. Median duration of locked detention was 12 months (IQR 5-19 months). Children were detained on Nauru/Manus Island (n = 47/239) for a median of 51 (IQR 29-60) months compared to 7 (IQR 4-16) months for those held in Australia/Australian territories (n = 192/239). Overall, 60% (167/277) of children had a nutritional deficiency, and 75% (207/277) had a concern relating to development, including 10% (27/277) with autism spectrum disorder and 9% (26/277) with intellectual disability. 62% (171/277) children had mental health concerns, including anxiety, depression and behavioural disturbances and 54% (150/277) had parents with mental illness. Children and parents detained on Nauru had a significantly higher prevalence of all mental health concerns compared with those held in Australian detention centres.

CONCLUSION

This study provides clinical evidence of adverse impacts of held detention on children's physical and mental health and wellbeing. Policymakers must recognise the consequences of detention, and avoid detaining children and families.

Moral injury related to immigration detention on Nauru: a qualitative study

BACKGROUND

Immigration detention is associated with detrimental mental health outcomes but little is known about the underlying psychological processes. Moral injury, the experience of transgression of moral beliefs, may play an important role.

OBJECTIVE

Our aim was to explore moral injury appraisals and associated mental health outcomes related to immigration detention on Nauru.

METHODS

In this retrospective study, we conducted in-depth interviews with 13 individuals who had sought refuge in Australia and, due to arriving by boat, had been transferred to immigration detention on Nauru. At the time of the study, they lived in Australia following medical transfer. We used reflexive thematic analysis to develop themes from the data.

RESULTS

Major themes included 1) how participants' home country experience and the expectation to get protection led them to seek safety in Australia; 2) how they experienced deprivation, lack of agency, violence, and dehumanization after arrival, with the Australian government seen as the driving force behind these experiences; and 3) how these experiences led to feeling irreparably damaged. The participant statement 'In my country they torture your body but in Australia they kill your mind.' conveyed these three key themes in our analysis.

CONCLUSION

Our findings suggest that moral injury may be one of the processes by which mandatory immigration detention can cause harm. Although refugees returned to Australia from offshore detention may benefit from interventions that specifically target moral injury, collective steps are needed to diminish deterioration of refugee mental health. Our results highlight the potentially deleterious mental health impact of experiencing multiple subtle and substantial transgressions of one's moral frameworks. Policy makers should incorporate moral injury considerations to prevent eroding refugee mental health.

Mental health consequences of detaining children and families who seek asylum: a scoping review

Almost 80 million people globally are forcibly displaced. A small number reach wealthy western countries and seek asylum. Over half are children. Wealthy reception countries have increasingly adopted restrictive reception practices including immigration detention. There is an expanding literature on the mental health impacts of immigration detention for adults, but less about children. This scoping review identified 22 studies of children detained by 6 countries (Australia, Canada, Hong Kong, Netherlands, the UK and the US) through searches of Medline, PsychINFO, Emcare, CINAHL and Scopus data bases for the period January 1992-May 2019. The results are presented thematically. There is quantitative data about the mental health of children and parents who are detained and qualitative evidence includes the words and drawings of detained children. The papers are predominantly small cross-sectional studies using mixed methodologies with convenience samples. Despite weaknesses in individual studies the review provides a rich and consistent picture of the experience and impact of immigration detention on children's wellbeing, parental mental health and parenting. Displaced children are exposed to peri-migration trauma and loss compounded by further adversity while held detained. There are high rates of distress, mental disorder, physical health and developmental problems in children aged from infancy to adolescence which persist after resettlement. Restrictive detention is a particularly adverse reception experience and children and parents should not be detained or separated for immigration purposes. The findings have implications for policy and practice. Clinicians and researchers have a role in advocacy for reception polices that support the wellbeing of accompanied and unaccompanied children who seek asylum.

Health professionals confront the intentional harms of indefinite immigration detention: an Australian overview, evaluation of alternative responses and proposed strategy

Purpose

Indefinite immigration detention causes well-documented harms to mental health, and international condemnation and resistance leave it undisrupted. Health care is non-independent from immigration control, compromising clinical ethics. Attempts to establish protected, independent clinical review and subvert the system via advocacy and political engagement have had limited success.

The purpose of this study is to examine the following: how indefinite detention for deterrence (exemplified by Australia) injures asylum-seekers; how international legal authorities confirm Australia’s cruel, inhuman and degrading treatment; how detention compromises health-care ethics and hurts health professionals; to weigh arguments for and against boycotting immigration detention; and to discover how health professionals might address these harms, achieving significant change.

Design/methodology/approach

Secondary data analyses and ethical argumentation were employed.

Findings

Australian Governments fully understand and accept policy-based injuries. They purposefully dispense cruel, inhuman and degrading treatment and intend suffering that causes measurable harms for arriving asylum-seekers exercising their right under Australian law. Health professionals are ethically conflicted, not wanting to abandon patients yet constrained. Indefinite detention prevents them from alleviating sufferings and invites collusion, potentially strengthening harms; thwarts scientific inquiry and evidence-based interventions; and endangers their health whether they resist, leave or remain. Governments have primary responsibility for detained asylum-seekers’ health care. Health professional organisations should negotiate the minimum requirements for their members’ participation to ensure independence, and prevent conflicts of interest and inadvertent collaboration with and enabling systemic harms.

Originality/value

Australia’s aggressive approach may become normalised, without its illegality being determined. Health professional colleges uniting over conditions of participation would foreground ethics and pressure governments internationally over this contagious and inexcusable policy.

Asylum seeking children and adolescents in Australian immigration detention on Nauru: a longitudinal cohort study

INTRODUCTION

Immigration detention has a profound and negative impact on the physical health, mental health, development and social-emotional well-being of children, adolescents and their families. Australian clinicians will report results from detailed health and well-being assessments of asylum seeking children and adolescents who have experienced prolonged immigration detention.

METHODS AND ANALYSIS

This is a national, multicentre study with a longitudinal cohort design that will document health and well-being outcomes of the children and adolescents who have been detained in offshore detention on the remote island of Nauru. Outcome measures will be reported from the time arrival in Australia and repeated over a 5-year follow-up period. Measures include demographics, residency history and refugee status, physical health and well-being outcomes (including mental health, development and social-emotional well-being), clinical service utilisation and psychosocial risk and protective factors for health and well-being (eg, adverse childhood experiences). Longitudinal follow-up will capture outcomes over a 5-year period after arrival in Australia. Analysis will be undertaken to explore baseline risk and protective factors, with regression analyses to assess their impact on health and well-being outcomes. To understand how children's outcomes change over time, multilevel regression analysis will be utilised. Structural equation modelling will be conducted to explore the correlation between baseline factors, mediational factors and outcomes to assess trajectories over time.

ETHICS AND DISSEMINATION

This research project was approved by the Sydney Children's Hospitals Network Human Research Ethics Committee. Subsequent site-specific approvals have been approved in 5 of the 11 governing bodies where the clinical consultations took place. In order to ensure this research is relevant and sensitive to the needs of the cohort, our research team includes an asylum seeker who has spent time in Australian immigration detention. Results will be presented at conferences and published in peer-reviewed Medline-indexed journals.

Paediatric asylum seekers in Western Australia: Identification of adversity and complex needs through comprehensive refugee health assessment

AIM

Asylum seekers (ASs) report high rates of trauma and difficulty accessing health and educational services. This study aims to ascertain the needs of paediatric ASs managed by the tertiary Western Australian paediatric Refugee Health Service (RHS), including demographic features, the range of health and psychosocial issues and ongoing management challenges.

METHODS

An audit of multidisciplinary RHS assessments, health records and hospital admissions for new AS patients (<16 years) between July 2012 and June 2016 was undertaken.

RESULTS

Records for 110 ASs were reviewed (mean age 6 years, standard deviation 4.72 years). Multiple issues (medical, psychological, developmental, educational) were identified after the first tertiary assessment (median 4, interquartile range (IQR) 3-6) compared to referral sources (median 1, IQR 0-2, P < 0.001). The median number of issues per child at audit completion was 6 (IQR 4-7, P < 0.001). Multiple refugee adverse childhood experiences were identified, with all experiencing >3 (median 4, IQR 4-5). Most had detention experience (107/110, 97.2%), family separation (91/108, 84%) and interrupted education (41/46, 89.2%). The median duration of detention was 7 months (IQR 3-12.5 months) at time of initial review across multiple sites (median 2, IQR 1-3 locations). High rates of hospital interaction were evident, with 45.4% requiring hospital admission and 36% presenting to the emergency department. The median number of outpatient appointments attended per child was 5 (IQR 2-8). Parental and child mental health concerns were identified in 53.6 and 46.3%, respectively.

CONCLUSIONS

Paediatric ASs have complex trauma backgrounds with exposure to multiple adverse events within disrupted family units. The majority of Western Australian ASs assessed demonstrated negative health or education sequelae compounded by detention not previously identified prior to comprehensive paediatric review. Our data support the urgent removal of ASs from held detention. Ongoing holistic assessment and management engaging multidisciplinary trauma-informed paediatric refugee services to optimise health and well-being is recommended.

Practitioner Review: Mental health problems of refugee children and adolescents and their management

BACKGROUND

Since 2010, the numbers of refugees have increased and around half are under 18 years of age. It is known that experience of organised violence, displacement and resettlement increases the risk for psychiatric disorders and psychosocial impairment. This review integrates recent research into the risk and protective factors for psychopathology with service and treatment issues.

METHODS

We draw on and critically evaluate key systematic reviews in the selected areas, innovative robust studies and relevant government reports.

RESULTS

Many refugee children show resilience and function well, even in the face of substantial adversities. The most robust findings for psychopathology are that PTSD, and posttraumatic and depressive symptoms are found at higher prevalence in those who have been exposed to war experiences. Their severity may decrease over time with resettlement, but PTSD in the most exposed may show higher continuity. More severe psychiatric disorders including psychosis may also occur. Service delivery needs to take into account socioeconomic and cultural influences but, given the high level of unmet need even in high-income countries, stepped care delivery is required. The evaluation of psychological interventions, often delivered in group settings, suggests that they can be effective for many distressed children; however, for the more impaired, a greater range of disorder-specific therapies will be required.

CONCLUSIONS

Child and adolescent mental health clinicians and service providers need to be aware of the specific needs of this population and systems for service delivery. There are significant knowledge gaps in understanding risk and vulnerability, service delivery and treatment effectiveness.

New developments in the mental health of refugee children and adolescents

The increase in refugees globally since 2010 and the arrival of many into Europe since 2015, around 50% of whom are under 18 years, have been the stimulus to greater investigation and publications regarding their mental health. This clinical review summarises selected themes in the field as described in the published literature since 2016. The themes include refugee statistics, premigration and postmigration experiences, psychopathology focusing on parent-child relationships, unaccompanied refugee minors and associations between resettlement, acculturation and mental health. Some important reviews and studies are discussed that address service and treatment provision. While there has been a recent increase in research in this field, more is needed into the course of psychopathology, protective factors and the promotion of integration into resettlement countries, as well as models of service delivery and treatment effectiveness.

The impact of detention on the social-emotional wellbeing of children seeking asylum: a comparison with community-based children

Accumulating literature demonstrates that immigration detention is harmful to children. However, there is a scarcity of scientifically rigorous and reliable data about the health of children held in detention facilities. The aim of the study was to compare a community-based population of recently arrived refugee children flown into Australia, not detained, resettled in a non-urban area, with a population of children who arrived by boat seeking asylum, detained since arrival. The parent-version of the strength and difficulties questionnaire (SDQ) of children aged 4-15 years was compared in children living in the community with those held in detention. We compared 86 children who had a parent-completed SDQ performed, 38 (44%) in the community group and 48 (56%) in the detention group. The community sample had been living in Australia for 325 days, with no time in detention. The detention sample had been living in detention for a mean of 221 days. The mean age was similar for the community and detention sample at 8.4 years (P = 0.18). In the total sample, children in the detention group had significantly higher SDQ total difficulties scores than children in the community group (P < 0.0001). There was no difference between age groups (P = 0.82). The children in the detention group had, on average, an SDQ total difficulties score that was 12 points higher than children in the community group. Four of the five SDQ subscale scores indicated greater disturbance amongst children in detention (< 0.0001) compared to children living in the community. The detention group had significantly higher scores (P < 0.001) for all except Pro-social scores as compared to Australian norms for the 4-6 and 7-15 years age group. This study presents a rare opportunity to compare the wellbeing of displaced children who were detained following arrival in Australia with those settled in the Australian community since arrival. The community children's scores approximated data from the general Australian childhood population. Children held in detention had significantly more social, emotional and behavioural difficulties than children living in the community, and at levels resembling a clinical cohort. Despite the small sample size, data restrictions and other limitations of the data, statistical significance in differences between the community and detention children is marked and arguably demonstrates the negative impact of post-arrival detention in children who are presumed to have similar levels of pre-arrival adversity. If the objective is to optimise the health and wellbeing of children seeking asylum, removal of post-arrival detention is one of the most powerful interventions available to host countries.

Refugee children's sandplay narratives in immigration detention in Canada

Asylum seeking children arriving in Canada regularly face incarceration in medium-security-style immigration detention centres. Research demonstrates the human cost of detaining migrant children and families and the psychiatric burden linked with such imprisonment. This study aims to understand the lived experiences of children aged 3-13 held in detention. Informed by a qualitative methodology of narrative inquiry, child participants created worlds in the sand and generated stories to express their subjective experience. Results suggest that children's sandplay confirms the traumatic nature of immigration detention while also revealing children's sometimes conflicting understanding of the meaning of detention and their own migration. The results are contextualized by a description of detention conditions and the psychiatric symptoms associated with immigration incarceration. The study highlights the need for more research examining the impact of immigration detention on children's mental health, while also underlining how refugee children's voices provide important direction for policy change.

Refugee children and their health, development and well-being over the first year of settlement: A longitudinal study

AIM

This study aimed to describe refugee children, their families and settlement characteristics, and how their development and social-emotional well-being change over time.

METHODS

We conducted a longitudinal study of 61 refugee children (6 months to 15 years) in an Australian setting, over 2009-2013 and measured child, family and settlement factors as well as physical health, development and social-emotional well-being (Strengths and Difficulties Questionnaire, SDQ).

RESULTS

Questionnaires were completed with parents of 54 (89%) children at year 2 and 52 (100%) at year 3. Forty percent of parents had low levels of education, 30% of fathers were absent on arrival, 13% of children were born in refugee camps and 11% of parents self-disclosed previous trauma. Over time, there was increased parental employment (P = 0.001), improved English proficiency for partners (P = 0.02) and reduced stressful life events in the last 12 months (P = 0.003). At years 2 and 3, parents were studying English (96%; 76%), accessing government financial support (96%; 100%) and primary health care (98%; 87%), and feeling supported by their own (78%; 73%) or the general (69%; 63%) community. Fifteen percent of children had a chronic disease, and 13% were obese and overweight. In pre-school children, 27% had mild developmental problems in year 2; all were normal by year 3. Abnormal SDQ total difficulties scores reduced over time from 13 to 6% of children but this did not reach significance.

CONCLUSION

Most refugee children have developmental and well-being outcomes within the normal range by year 3. However, a minority of children have persistently poor social-emotional outcomes.