Premigration

Many events, often long-standing, precede the final decision to leave one’s country. The main factors are political violence, war, genocide, torture, and sexual violence. Women who are victims of sexual violence suffer specific physical (HIV/AIDS, complex gynecological problems, pregnancy) and mental health problems (depression, post-traumatic stress disorder (PTSD)). The lack of appropriate healthcare in the countries from which many migrate (e.g., Arshad et al., 2010; Ebrahim et al., 2010) results in untreated illness. Refugee children are vulnerable to infection, often having had no childhood immunizations or prior medical assessment. Victims of sexual violence will have had no previous health screening. Girls subjected to genital mutilation – 100–140 million girls and women worldwide are forced to undergo genital mutilation (UNICEF, 2013) – will have had no medical follow-up.

Individuals who manage to flee to Western countries are usually those with a foundation of relatively more material and emotional resources, but are often disabled by exposure to multiple trauma, regrets, and guilt at leaving family members behind.

During migration

The journey to safety is usually fraught with multiple dangers at its various stages. Families may become separated or experience further persecution and witness distressing events. Leaving the home country may have only been possible through an agent, with remaining family members left in financial debt to that agent. The journey is risky and many do not make it. Small children, for instance, may have had to be transported in airtight, suffocating containers. Some die. Those who make it, children and adults, are left with survivor guilt and the long-lasting effects of witnessed trauma.

Post-migration

The asylum-seeking process is itself traumatizing and subjectively as difficult to deal with as the stresses that preceded migration. Fear of deportation, poverty, isolation, cultural shock, changing roles in the family, and hostility or racism in the neighborhood and detention center, as well as separation from family, all have an impact on mental health. How an individual responds to these new stressors will depend on early experiences, personal resilience, and the support systems provided by the host country. Newcomers to the UK have to deal with an unwelcoming host community, a lack of English language fluency, and a loss of socioeconomic status. Adults with dependent children (as well as children who are unaccompanied) face the greatest problems.

Refugees often assume that the immigration and health services are one, and so, fearing detention or deportation if they say anything wrong, avoid seeking help for their health problems. Many refugees have no knowledge of the host country or of their legal rights; they do not know what to expect in the future. Legal representation is often difficult to access and may be inadequate. Interpreters may not be available during legal interviews. Lack of a competent interpreter may lead to a negative decision on asylum applications, which could mean that parents, no longer entitled to national asylum-support services under the terms of the Asylum and Immigration Act 2004, can be separated from their children. They report bullying, assault, and racist incidents in detention centers; insufficient time to prepare their cases, and incorrect assessments of their children’s ages that may result in parent–child separation.

Family poverty has negative impacts on health, nutrition, and access to basic living needs, such as appropriate accommodation. Children’s education is disrupted, and may prove unavailable. Local authorities do have a duty to provide services for children in need, but, first, these needs have to be understood and correctly assessed, and the children referred to specific services. Frameworks for the assessment of children in need and of their families do not make any particular reference to the needs of refugee families; there is, in fact, very little information available to health workers about the rights and entitlements of asylum seekers’ families.

Intact families

Families may have been able to flee together, though each member is likely to have gone through a different experience prior to flight. The father may have been imprisoned and tortured; the mother may have experienced harassment or sexual violence. The children may have been bullied at school or may have been unable to attend school altogether. Flight may bring hope and happiness, but also many losses. To admit to difficulties when many are left behind may be impossible, so that emotions are concealed:

Children usually adapt to their surroundings more quickly than parents, and this can create generational communication gaps within the family unit. Children are often given the responsibility of caring for their parents and act as cultural interpreters, a responsibility they may be too young to shoulder. Even intact refugee families, fortunate compared to their peers, find coping difficult.

Separated families

In many cases, children have been left behind; families are broken up; mothers may not know the whereabouts of their children. Children left behind may have been trafficked for the purpose of sexual exploitation, or killed. Mothers may have become single parents faced with the need to look after their children’s welfare alone in new, strange, and uncomfortable situations. Many experience parenting difficulties without knowing how to find help and lack the community support they would have had at home. The idea of talking to strangers about private matters may be culturally unacceptable for many. Adults may neglect their parental role while preoccupied with the asylum process, and depression can subsequently overtake both parents and children. Even when families do reach out for help, immigration caseworkers may not know what do; they may have little knowledge about either mental health or parenting.

Reunited families

Sometimes families are reunited in the new country after a period of separation during which each person has experienced his or her own trauma. Depending on culture and tradition, sharing experiences may be difficult:

Unaccompanied minors

Unaccompanied asylum-seeking minors have to contend with the complexity of the age-assessment process. There is no objective and reliable method for accurately determining age, yet it has major implications for the asylum process and its outcome (Crawley, 2007). If an unaccompanied youth is deemed to be a child, he or she is protected under the Children Act and housed with a foster family. In a study that has become a classic, Keilson (1992/1979) found that, among Jewish children who survived the Holocaust in the Netherlands, it was the family environment of the caregiving families, rather than the severity of the trauma they had experienced, that determined later psychopathology. In the refugee context, this means that what happens after migration, particularly within a family unit, is more important to future mental health than what has preceded it.

According to Crawley (2007), over 60% of asylum-seeking youth assessed as adults in the UK – around 101 over a period of 1 year – were found, after a more detailed assessment, to be children. After such errors, it is little wonder that Majumder et al. (2014) report that these children do not trust mental health workers in host countries and, therefore, do not seek help.

Pregnant women

Women may arrive in the host country pregnant as a result of rape, survival of prostitution, or slave trafficking. These women may not realize they are pregnant and potentially HIV positive until after arrival. Services for pregnant women are often provided by religious groups, but, whatever the quality of services, the process of becoming a mother under such circumstances is fraught with difficulty (O’Shaughnessey et al., 2012). Maternal mortality in this vulnerable group is unacceptably high (Thorogood, 2014).