original article

Responses to conflict, family loss and flight: posttraumatic stress 11 3

Results The study revealed lower PTSD rates than measured among URMs in previous studies. Girls were more likely to develop PTSD. PTSD was significantly correlated with single war-related traumatic events. The depression score for the sample was above the clinical cut-off value.

Conclusions Trauma-specific psychopathology was less severe than reported in other studies. These find-ings could be explained by concepts of resilience. Other implications, such as response bias, are discussed.

Keywords Posttraumatic stress disorder · Coping strate-gies · African unaccompanied refugee minors

Reaktionen auf Konflikte, Verlust von Familienangehörigen und Flucht: Posttraumatische Belastungsstörung bei unbegleiteten, minderjährigen Flüchtlingen aus Afrika

ZusammenfassungAnliegen Unbegleitete minderjährige Flüchtlinge sind oftmals als Patienten vorstellig in kinder- und jugend-psychiatrischen Einrichtungen. Neben vorhandenen sprachlichen Barrieren existieren in der Literatur wenige Daten zu dieser heterogenen Patientenpopulation. Vor-liegende Studie fokussiert die aus Afrika stammenden, unbegleiteten, minderjährigen Flüchtlinge (URMs) in Österreich und untersucht das Vorhandensein etwaiger psychischer Störungen, insbesondere jener einer post-traumatischen Belastungsstörung (PTBS) und etwai-ger begleitender Symptome und Komorbiditäten. Auch werden in diesem Zusammenhang Coping-Strategien erfasst.

Methode Bei den insgesamt 41 afrikanischen URMs, die innerhalb von Österreich rekrutiert werden konnten, wurden neben „UCLA PTSD Index und Inventare“ auch

AbstractObjective To investigate African unaccompanied refugee minors (URMs) living in Austria for posttraumatic stress disorder (PTSD) prevalence and related symptoms, comorbidity, demographics and coping strategies.

Method “UCLA PTSD Index and inventories” and “Scales for Children Afflicted by War and Persecution (SCWP)” were used to assess 41 African URMs.

NeuropsychiatrDOI 10.1007/s40211-013-0094-2

Responses to conflict, family loss and flight: posttraumatic stress disorder among unaccompanied refugee minors from Africa

Sabine Völkl-Kernstock · Niranjan Karnik · Michaela Mitterer-Asadi · Elisabeth Granditsch · Hans Steiner · Max H. Friedrich · Julia Huemer

I have passed a lot, but, you know, I don’t want to tell anyone because it’s a lot… (Z., 16 years, Somalian unaccompanied refugee minor).

J. Huemer () · S. Völkl-Kernstock · M. Mitterer-Asadi · M. H. Friedrich Department of Child and Adolescent Psychiatry,Medical University of Vienna, Waehringer Guertel 18-20,1090 Vienna, Austriae-mail: julia.huemer@meduniwien.ac.at

S. Völkl-Kernstocke-mail: sabine.voelkl-kernstock@meduniwien.ac.at

M. Mitterer-Asadie-mail: michaela.mitterer@gmail.com

N. KarnikDepartment of Psychiatry, Rush University, 1645 West Jackson Avenue, Suite 600, Chicago, IL 60612, USAe-mail: niranjan_karnik@rush.edu

E. GranditschRohrbach Hospital, Krankenhausstraße 1,4150 Rohrbach, Austriae-mail: e.t.granditsch@gmx.at

H. SteinerDepartment of Psychiatry and Behavioral Sciences,Stanford University School of Medicine, Child Psychiatry and Child Development, 401 Quarry Road,Stanford, CA 94305-5719, USAe-mail: steiner@stanford.edu

Received: 3 October 2013 / Accepted: 2 December 2013© Springer-Verlag Wien 2013

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2 Responses to conflict, family loss and flight: posttraumatic stress 1 3

symptoms correlated significantly with state depression and anxiety scores. Thirdly, a correlation between coun-try of origin and reasons for flight was assumed, taking into consideration the current sociopolitical situation in specific African countries. In addition to the mentioned exploratory hypotheses, the authors aimed at descrip-tively assessing relevant sociodemographic and trauma-related variables.

Material and methods

Participants

A total of 41 URMs participated in the study. Age ranged from 15 to 18 years, with 35 participants being male and six being female. The majority of subjects came from Gambia, Somalia, and Nigeria; the three countries rep-resented the largest number of asylum-seeking URMs in Austria at the time of the assessment (Table 1). After complete description of the study to the subjects, written informed consent was obtained. In terms of their legal status, URMs were unthreatened by immediate deporta-tion, as all of them had pending procedures for granting the right of asylum.

Inclusion criteria were as follows: (1) female or male African refugee minors residing in Austria in URMs resi-dential accommodations and being currently unthreat-ened by prompt deportation, (2) those unaccompanied by parents or close relatives and 15–18 years of age, and (3) those having sufficient knowledge of English language.

Somalia, Gambia, and Nigeria do not only represent entirely different sociodemographic and geographic structures. The reasons for URMs leaving their home country are similarly diverse. While Somali URMs have been threatened by the war, which we believed to be more traumatogenic, there are largely economic, political, and religious reasons for flight in Nigeria and Gambia.

„Scales for Children Afflicted by War and Persecution (SCWP)“ als Untersuchungsinstrumente eingesetzt.

Ergebnisse Im Vergleich mit vorhandenen Daten in der Literatur zeigten sich in vorliegender Studie nied-rigere PTBS Werte. Die Vulnerabilität für PTBS war für Mädchen erhöht. Die Diagnose einer PTBS stand in einem signifikanten Zusammenhang mit einmali-gen kriegsbezogenen traumatischen Ereignissen. Die Depressions-Skala für das Sample befand sich über den klinischen Cut-off Werten.

Schlussfolgerungen Die traumaspezifische Psycho-pathologie war unterhalb der in anderen Studien auf-gezeigten Werte. Diese Ergebnisse könnten durch eine mögliche erhöhte Resilienz erklärt werden. Weiterfüh-rende Erklärungsmodelle werden diskutiert.

Schlüsselwörter Posttraumatische Belastungsstörung  · Coping Strategien  · Afrikanische unbegleitete minder-jährige Flüchtlinge

Introduction

Of the total population under the United Nations High Commissioner for Refugees (UNHCR) (31.7  million), nearly 44 % are younger than 18 years, and 10 % of them are younger than 5 years [1]. Unaccompanied refugee minors, URMs (also referred to as “unaccompanied chil-dren”), are children younger than 18 years who have been separated from both parents and are not being cared for by an adult [2]. UNHCR’s founding mandate defines refugees as people who are outside their country and cannot return owing to a well-founded fear of perse-cution because of their race, religion, nationality, politi-cal opinion, or membership of a particular social group. When people flee their own country and seek sanctuary in another state, they often have to apply for “asylum”—the right to be recognized as bona fide refugees and receive legal protection and material assistance [1]. Sev-eral studies have revealed that adolescent, war-affected refugees are at increased risk of developing mental health problems and that among these, posttraumatic stress reactions are the most extensively investigated, with prevalence ranges from 37 to 52 % [3], when compared with peers [4]. Trauma severity is a significant predictor of trauma response [5]. Several studies also describe URMs as a highly vulnerable group [6], showing significantly higher frequencies of psychopathology when compared with accompanied refugee minors, with prevalence rates for posttraumatic stress disorder (PTSD) ranging up to 84 % [7]. These adolescents need to be further examined, especially in terms of studying the impacts of cumulative trauma [5]. The present study investigated African URMs who currently live in Austria. Firstly, based on previ-ous studies, the authors assumed that there would be a higher prevalence rate of PTSD symptoms among URMs compared with reported rates among accompanied ref-ugee minors. Secondly, it was hypothesized that PTSD

Table 1 Demographic features

N Percentage

Age N = 40. Age in years: 16.95 (SD = 0.815)

97.6

Gender Male: 35; Female: 6 85.4; 14.6

Country of origin

Gambia 14 34.1

Somalia 11 26.8

Nigeria 8 19.5

Guinea-Bissau 2 4.9

Mali, Eritrea, Kenya, Niger, Ghana, Algeria

Each country: N = 1 2.4

SD standard deviation

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Responses to conflict, family loss and flight: posttraumatic stress 31 3

2. Scales for Children Afflicted by War and Persecution (SCWP) [10] is a questionnaire that provides informa-tion about demographic features and analyzes the experiences in the home country and during the flight. It also contains a depression, anxiety, and somatiza-tion scale. The test–retest reliability (r = 0.80) and the consistency (α = 0.86) of the depression scale were reported as rather high. The cut-off score for clinical diagnosis was set at 13. The SCWP anxiety scale has a consistency between 0.83 and 0.85; the cut-off score for clinical diagnosis is 18. The SCWP somatization scale has an internal consistency of α = 0.90, with a mean of 19.02 and a standard deviation of 17.06. As suggested by Walker [10], the cut-off score should be set at the first standard deviation.

3. The clinical utility of UCLA Trauma Reminder Inven-tory, UCLA/Brigham Young Expanded Grief Inven-tory, and UCLA Trauma Exposure Profile [8] has been detailed in the original publication referenced. Based on face validity, the authors believed that these instru-ments might shed light on the experiences of URMs.

There are few studies in the present field that have focused on African study populations and African norms of mental health services [11], thus explaining the lack of culturally appropriate measures.

Statistics

All statistical analyses were conducted using the Statis-tical Package for the Social Sciences Version 15. Group comparisons of categorical variables were carried out by means of Pearson’s chi-square tests, and those of con-tinuous variables were performed by means of t-tests for independent samples. In addition, relationships between continuous data were analyzed using Pearson’s correlation coefficients. The error type I was set at 0.05.

Results

Prevalence of PTSD

The prevalence of PTSD was assessed with the UCLA PTSD Index for DSM-IV. The results revealed that 17 % (of N = 41) fulfilled the full criteria and 29.3 % met the par-tial criteria for PTSD (meaning that there is a likely risk of having or developing PTSD).

PTSD comorbidity

When correlating PTSD scores with anxiety, somatiza-tion, and depression scales, a medium positive correla-tion between anxiety scale and full PTSD diagnosis was found (p = 0.029). The mean depression scale was 14.50, which is greater than the mentioned cut-off-score of 13.

Human subjects and recruitment

The present study was approved by the ethics committee of the Medical University of Vienna. With the help of a non-governmental organization that provides counsel-ing for migrants and refugees, all those residing in URMs residential accommodations under the responsibility of the Austrian Public Welfare System were asked to par-ticipate in the study. The study and its instruments were presented to administrators in charge of each participat-ing institution, and their oral consent was obtained. The questionnaires were distributed and checked for com-pleteness by trained personnel, who also offered instruc-tions and guidance throughout the assessment.

Study procedure

The adolescents were assessed on successive days. The administration of the entire testing procedure took sev-eral hours each day. The sequence of test administration was maintained throughout the assessments. We paid close attention to evidence of fatigue and exhaustion and worked clinically to restore motivation and continuity. We also sought to minimize similarities of the assess-ment with police interviews or interviews in the course of asylum seeking, emphasizing the clinical nature of inter-actions and confidentiality guaranteed by the study pro-tocol. We kept the interviewer’s level of clinical training high (all doctorate-level trainees with specialty training in Child and Adolescent Psychiatry, trilingual in English, German, and French), anticipating that considerable clinical skill would be needed to handle the subjects’ concerns and suspicions as to why all the questions were asked.

Of a possible total of 15 residential institutions, 8 agreed to participate and had youth who fulfilled inclusion crite-ria. A total of 64 URMs were eligible to participate in the study, and of these, 36 % (N = 23) refused to take part or did not succeed in completing the questionnaires.

The following measures were used:

1. The University of California at Los Angeles (UCLA) PTSD Reaction Index for the Diagnostic and Statisti-cal Manual of Mental Disorders (DSM)-IV (Revision 1) assesses posttraumatic stress symptoms by means of a cut-off value and mirrors the structure of PTSD cri-teria described in DSM-IV [8]. This instrument has good internal consistency, with several reports hav-ing found Cronbach’s alpha in the range of 0.90 [9]. Test–retest reliability ranged from good to excellent, with Pynoos et al. reporting inter-item agreement of 94 % for the DSM-III version [8]. Validity across all the instrument’s versions is suggested by numerous stud-ies that have consistently found higher Reaction Index scores among traumatized samples compared with control subjects, and a clear “dose of exposure” rela-tionship of Reaction Index scores across exposure [8].

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4 Responses to conflict, family loss and flight: posttraumatic stress 1 3

Descriptive assessment of relevant sociodemographic and trauma-related variables

Types of trauma exposures and trauma reminders

The most frequent trauma exposures were caused by community violence, war/political violence, and interpersonal violence (Fig.  1). Frequencies of trauma exposure were correlated with PTSD, showing signifi-cant results for most of the assessed experiences, such as school violence (p = 0.001), drug traffic (p = 0.002), disaster (p = 0.002), fire (p = 0.002), and life-threatening incidents (p = 0.003). Female participants showed signifi-cantly higher scores of avoidance symptoms (Criterion C) related to the traumatic experience than male partici-pants. Girls were also more likely to develop full PTSD than boys (chi-square test, p = 0.038). Boys, in contrast, were more frequently exposed to traumatic events than girls. The UCLA Grief Inventory revealed that 78 % of the participants reported that someone close to them had already died. In 57 % of the reports, the reason for death was violence; in 30 %, an accident; and in 14 %, an illness. Trauma reminders (defined as situations, people, and places that evoke memories of the traumatization itself ) were reported by 46 % of the participants. Of these, 34 % reported “seeing another family” as a trauma reminder.

Whereabouts of family members

When asked about the whereabouts of mother and father, 38 participants gave information about this issue. A total

The mean anxiety scale was 13.56, which is less than the reported cut-off-score. The mean somatization scale was 14.23, which is less than the reported cut-off-score.

Correlation between country of origin and reasons for flight

When asked about the reasons for flight, subjects’ answers largely varied, depending on their country of origin (Table  2). The reasons for flight differed signifi-cantly, depending on the country of origin (p = 0.003).

Table 2 Reasons for flight in different countries

War Politics Reli-

gion

Politics +

Religion

Family Personal

problems

Un-

clear

Gambia 9 3 1 1

Somalia 11

Nigeria 2 4 1 1

Guinea-Bissau

1 1

Mali 1

Eritrea 1

Kenya 1

Niger 1

Ghana 1

Algeria 1

Total (N) 11 16 5 1 5 2 1

Fig. 1 Trauma Exposure Profiles

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Responses to conflict, family loss and flight: posttraumatic stress 51 3

Discussion

Several studies have revealed that adolescent, war-affected refugees are at increased risk of developing mental health problems. PTSD prevalence in these stud-ies ranges from 37 to 52 % [3] when compared with peers [4]. Trauma severity is a significant predictor of trauma response [5]. When looking more specifically at URMs, a relatively small number of papers have investigated psy-chopathology parameters, showing significantly higher frequencies of psychopathology when compared with accompanied refugee minors. In these studies, preva-lence rates for PTSD range between 20 and 84 % [6].

The PTSD assessment in the present study found that 17.1 % of URMs met full criteria and 29.3 % met partial criteria. These scores are lower than those reported in previous studies of refugee minors and URMs. The high percentage of adolescents meeting partial criteria could be due to a relatively higher degree of resilience in this population [11].

PTSD was significantly correlated with single war-related traumatic events. We hypothesized that PTSD diagnosis would correlate with anxiety, depression, and somatization scales assessed by SCWP. This could only be partly confirmed with a medium size effect between anxiety scale and PTSD diagnosis. Furthermore, the depression scale revealed results above the cut-off level for clinical significance. The inconsistent correlation between PTSD diagnosis and depression might indicate a lack of cultural sensitivity of the used questionnaires.

Furthermore, the reasons for flight differed signifi-cantly depending on the country of origin, as expected. Apart from that, female URMs showed significantly higher scores for Criterion C on the UCLA PTSD Index (avoidance symptoms) compared with male participants.

In terms of coping strategies, “prayer” and “trying to relax” were most frequently used. Interestingly, as for the assessment of feelings for revenge, the participants mostly avoided to use interpersonal violence as a coping strategy. Whether these findings reflect a certain degree of repression or a concept of reconciliation remains open to discussion. Given that these adolescents were in a for-eign country seeking asylum, it is possible that the social context influenced their choices or answers to these questions.

Strengths and limitations

The current study focused on the assessment of psycho-pathology parameters among a highly specific sample of adolescents from an especially vulnerable background. As mentioned before, very few studies have examined medical and psychiatric needs of URMs so far. Moreover, the present assessment took into consideration different flight backgrounds, ranging from political to religious and economic reasons, as well as coping strategies and trauma-related variables.

of 22 subjects reported their fathers as dead, 11 URMs indicated that their fathers were still in the home coun-try, and for 5 of them, the father’s whereabouts were not known. A total of 16 subjects reported their mothers as dead, 18 said that they were still in their home country, 2 said that they did not know where their mothers were, and 2 indicated “other whereabouts” (Table 3).

Feelings of danger and revenge and coping strategies

When asked for the presence of a current feeling of danger, 74 % URMs answered positively, whereas 21 % claimed the opposite and 5 % were “not sure.” In terms of wishes to return to the home country, 28 % adolescents affirmed the question, 68 % refused to do so, and 5 % were not sure (N = 40). As a reason for the feeling of cur-rent danger, which was perceived by 70.7 % of URMs, 50 % of them named the presence of political violence in the home country, and 39 % named violence through a spe-cific person. In terms of perceived threats to the subjects or their families, the most frequent responses included “political enemy” (32 %), “military” (20 %), and “a dif-ferent clan” (20 %). While 63 % of URMs felt they could forgive their enemy, 38 % did not feel they could do so. A significant portion of participants (47 %) would seek justice through a court, and another 27 % would not seek punishment for their enemy at all.

In terms of coping strategies, prayer proved to be the most helpful and most frequently used mechanism (Table 4). The use of violence, such as hitting someone, turned out to be the least efficient and least used strategy among this study population.

Table 4 Coping strategies

Most common and most efficient

coping strategies

Used often/very

often [N (%)]

Helps a little/very

much [N (%)]

Pray 34 (82.9) 37 (90.2)

Try to relax, stay calm 24 (58.9) 34 (82.9)

Think about it 27 (65.9) 25 (61.0)

TV/music 26 (63.4) 27 (65.9)

Say I’m sorry 25 (61.0) 30 (73.2)

Try to forget about it 21 (51.2) 22 (54.7)

Talk to someone 17 (41.4) 30 (73.2)

Table 3 Whereabouts of mother and father

Whereabouts of Father Mother

N = 38 Percentage N = 38 Percentage

Dead 22 53.7 16 39.0

Still in home country

11 26.8 18 43.9

Do not know 5 12.2 2 4.9

Other reasons 0 0 2 4.9

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6 Responses to conflict, family loss and flight: posttraumatic stress 1 3

variables and whereabouts of family members—call for implications of child protection and welfare agencies to ensure stable and protected surroundings for these adolescents.

AcknowledgmentsWe would like to especially thank Mag. Heinz Fronek (psychologist), staff member of the membership cooper-ation “asylkoordination Österreich,” who has supported this study with his comprehensive knowledge and his thorough insight into the legal and organizational situa-tion in terms of URMs in Austria.

Apart from that, we would like to thank Hubertus Adam, MD, and Fionna Klasen, PhD, for making SCWP available for the current study and for supporting the authors with helpful pieces of advice.

Conflict of interest Völkl-Kernstock S, Karnik N, Mitterer-Asadi M, Gran-ditsch E, Steiner H, Friedrich MH, and Huemer J report no conflict of interest.

References

1. UNHCR. Refugees, asylum-seekers, returnees, internally displaced and stateless persons. 2007. http://www.unhcr.org. Accessed June 2011.

2. UNHCR. Refugee children: guidelines on protection and care, Geneva. 1994. http://www.unhcr.org. Accessed June 2011.

3. Schaal S, Elbert T. Ten years after the genocide: trauma confrontation and posttraumatic stress in Rwandan ado-lescents. J Trauma Stress. 2006;19(1):95–105.

4. Thabe AA, Abu Tawahina A, et al. Exposure to war trauma and PTSD among parents and children in the Gaza strip. Eur Child Adolesc Psychiatry. 2008;17(4):191–99.

5. Shaw JA. Children exposed to war/terrorism. Clin Child Fam Psychol Rev. 2003;6(4):237–46.

6. Huemer J, Karnik N, et al. Mental health issues in unac-companied refugee minors. Child Adolesc Psychiatry Ment Health. 2009;3(1):13.

7. Wiese EB, Burhorst I. The mental health of asylum-seeking and refugee children and adolescents attending a clinic in the Netherlands. Transcult Psychiatry. 2007;44(4):596–613.

8. Steinberg AM, Brymer MJ, et al. The University of Califor-nia at Los Angeles post-traumatic stress disorder reaction index. Curr Psychiatry Rep. 2006;6(2):96–100.

9. Layne CM, Saltzman WR, et al. Effectiveness of a school-based group psychotherapy program for war-exposed ado-lescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2008;47(9):1048–62.

10. Bayer CP, Klasen F, Adam H. Association of trauma and PTSD symptoms with openness to reconciliation and feel-ings of revenge among former Ugandan and Congolese child soldiers. JAMA. 2007;298(5):555–9.

11. Betancourt TS, Khan KT. The mental health of children affected by armed conflict: protective processes and path-ways to resilience. Int Rev Psychiatry. 2008;20(3):317–28.

12. Plattner B, Karnik N, et al. State and trait emotions in delinquent adolescents. Child Psychiatry Hum Dev. 2007;38(2):155–69.

In contrast, the sample size is relatively small. This is due to the difficult accessibility of URMs. There were problems in establishing appointments, unstable liv-ing circumstances, commitments in terms of legal and organizational aspects, and insecurities with interview settings. Yet, the current study was not designed as an epidemiological assessment and instead was intended as a feasibility project. This fact also explains the absence of a control group in the present assessment. The inclusion criteria focused on adolescents, who could speak English fluently and who could understand the questions easily. This was closely monitored not only in the information session at the beginning but also during the assess-ment itself. Nevertheless, it remains open to discussion whether measures that are common in American and European study procedures are appropriate, reliable, and sufficiently culturally sensitive for the group of URMs.

Clinical conclusions

Generally, there is still a great lack of research and also methodological knowledge in terms of URMs. Future research should put a focus on analyzing stress man-agement, resilience, coping strategies, and long-term outcome [12] among the present study population. Addi-tionally, more focus on research concerning the develop-ment and implementation of culture-sensitive standards and measures is needed; in contrast, the examination and analysis of culture-independent parameters of pro-tective and detrimental factors related to mental health in URMs are of utmost importance for diagnosis and treatment. Eventually, more research is needed to ana-lyze personality and temperament profiles of URMs to understand what makes them succeed in enduring hard-ship and trauma.

In terms of clinical and service-related implications, the mentioned findings particularly point out the need for long-term and multi-method assessments of these youths. Social desirability might affect their answers in a relevant way, an aspect, which might also be of great clinical importance in the course of the legal proce-dures of the asylum-seeking process. Furthermore, treat-ment approaches should take into consideration URMs’ countries of origin and their flight backgrounds, as these might influence the degree and extent of their traumati-zation. In addition, the assessment of coping strategies might help to support processes of recovery in the course of a therapeutic setting.

The mentioned results are also intended to address clinical readers, who increasingly have to deal with the expanding issue of URMs worldwide. By means of a more contextual and individual approach to these youths, peo-ple dealing with URMs, such as residential staff, could improve their quality of care and skills. Finally, the vul-nerable situation these youths are living in—when taking into account the mentioned findings of trauma-related