This chapter of the submission examines evidence regarding the effects of detention on the immediate and long-term mental health of children and adolescents. No systematic research on the mental health effects of detention in Australia is available. However there is a vast body of knowledge, based on research, which underpins the conclusions drawn.
The developmental needs of children and adolescents are well understood. The psychological effects of traumatic events and environments akin to the detention environment in Australia are also known.
This chapter concludes that detention has an adverse immediate and long-term effect on children and adolescents, the extent of which depends on the degree of exposure to traumatic events preceding arrival in Australia; the length of detention; the level of violence and self-damaging behaviours witnessed or experienced in detention; the opportunities for play and meaningful activity; the degree of emotional support and protection provided by parents/ care-givers; the behaviour and attitudes of detention staff, including management; and the quality of health, mental health and educational services.
Post-detention circumstances also vary, but the temporary nature of protection offered those who are released, and the absolute restriction on future family reunion, subject children and their family members to continuing uncertainty and loss. Such circumstances can only be considered as extremely adverse for vulnerable children and particularly so for unaccompanied minors.
With so many causal factors operating to determine mental health, a wide range of effects has to be expected, from extreme self-degradation and destructive behaviours towards self and/or others, which can persist for years, to reasonable adaptation. The weight of evidence indicates that the detention environment will do harm because, at minimum, children have been dislocated and have in most cases lived under oppressive regimes, making them vulnerable and sensitive to hostile and harsh conditions in a new environment; the detention environment is monotonous, confining, and depriving of freedom, and the detention regime undermines the capacity of the family, where present, to protect and support their children.
INTRODUCTION...............................................................................................................................................................................
Aim of this submission and about its authors...............................................................................................
Methodological issues....................................................................................................................................................
Content outline of mental health submission..............................................................................................
MENTAL HEALTH NEEDS OF CHILDREN AND ADOLESCENTS.........................................................................................
Normal development........................................................................................................................................................
The effects of trauma.....................................................................................................................................................
Factors jeopardizing the mental health of children in detention
PRE-DETENTION EXPERIENCES...................................................................................................................................................
Deleterious ASPECTS of Detention AND their Consequences for the Mental Health of children.
THE EXPERIENCE OF CHILDREN............................................................................................................................................
THE EXPERIENCE OF FAMILIES.............................................................................................................................................
THE EXPERIENCE OF UNACCOMPANIED MINORS...........................................................................................................................
POST-DETENTION EXPERIENCES.............................................................................................................................................
The post -detention environment and its consequences for asylum seekers and TPV holders
Adequacy of Mental Health Services for Children and Adolescents in Detention and Following Detention
In detention.............................................................................................................................................................................
Post-detention......................................................................................................................................................................
Post-detention services for refugees....................................................................................................................................
Access to public mental health services
Conclusion....................................................................................................................................................................................
This submission to the HREOC Inquiry into children in detention examines evidence regarding the psychological well-being of these children and adolescents, and addresses the question of whether detention is deleterious to their mental health.
The submission has been prepared by the Mental Health Group of KIDS (Kids in Detention Story). The group is made up of professionals who deal with the mental health of children, and includes psychiatrists, psychologists, and social workers. Many of these people work with refugees and/or victims of trauma.
In preparing this submission, many sources of evidence have been used. These include former detention centre staff, people with direct experience of being held in detention, and clinicians working with people in detention. It also draws upon the authors’ clinical experience, as well as research and relevant literature.
Early in the process of gathering information, it became clear to the authors that a definitive exploration of the effects of detention on children and adolescents seeking asylum in Australia was not possible. The mandatory detention of children in immigration detention centres is unique to Australia, and therefore little scientific material is available from overseas. Further, in the local context, systematic research into effects has not been carried out because of a number of difficulties in accessing primary material. Firstly, current government policy limits contact with people in detention and research has been disallowed. Secondly, refugees who have been in detention are concerned that talking about their experiences may jeopardise their claim to eventual refugee status. Thirdly, detention centre staff who are currently employed in the detention centres are concerned about losing their jobs.
Finally, even if direct access to detainees were possible, the authors have serious ethical and clinical issues to consider regarding the well-being of detainees. Interviews about personal responses to, and experiences of, detention may provoke considerable distress and expectations about assistance, which cannot be adequately addressed.
In spite of these limitations, some members of the mental health group have had extensive experience, including direct contact with many children and their parents who are currently in, or have been in detention. In addition, several members of the group have interviewed a number of workers employed in a variety of capacities in the detention centres. Information has been obtained with the informed consent of all those providing interview material.
In order to ensure confidentiality, we have removed the names of our sources, except in those cases where a professional informant has given explicit consent to include potentially identifying information.
For the reasons outlined above, we cannot draw upon systematic and comprehensive research about the impact of Australian detention centres on the mental health of children and adolescents. Nevertheless, it is the view of the authors that there is sufficient knowledge about the psychological needs of children and adolescents, and the conditions to which they are subjected, to draw strong conclusions about the effects of detention.
The submission begins with a brief description of the mental health needs of children and adolescents and the fundamental conditions which are needed to lay the foundations for normal development. The next section describes the nature of pre-detention experiences which have an impact on children and adolescents, and the conditions in detention which affect them and their families, in both the short and long term. Types of experiences that are deleterious to mental health are outlined. The influence of the post-detention environment is then considered. This is followed by a discussion of the adequacy of mental health services available to detainees in detention and on release.
Children and adolescents have needs which are particular to their age and are distinct from those of adults. The way in which needs are met at various stages of their development lays the foundation for future development in cognitive, social and emotional domains. Authors such as Bowlby[1] (1980), and Erikson[2] (1950), have shown that children’s future lives and contributions to society are profoundly influenced by their earlier experiences. It is beyond the scope of this submission to provide a detailed overview of a child’s development, but the aim of the following outline is to alert the reader to the importance of the quality of parenting/care-giving, and the broader social environment, in influencing the course of development.
An infant until the age of two years relies for its well-being on the nurturing of its parents or care-givers. Physical needs are paramount, but it is also the stage of life when trust in others and the ability for emotional regulation develops. There is a burgeoning research literature that shows that the quality of care-giving influences the development of brain functioning.[3] [4]Deprivation of emotional needs for comfort, and disruption of the attachment relationship between caregiver and infant, are known to have long term effects.[5] The younger the child when multiple traumas occur, the greater the negative impact later in life.[6]
The stage of life from 18 months to 3.5 years is the period in which autonomy develops. Autonomy refers both to physical independence and the capacity to explore and master the environment away from primary attachment figures, who are normally the parents. Where the external environment is insecure, hostile, restrictive and unpredictable, and when attachment figures are unable to moderate the influence of an uncertain environment, children’s developing autonomy is impaired.
Further development of initiative and independent mastery continue over the life span, but the period from 4 years to 12 years is recognised to be the stage when self-esteem and the development of conscience are particularly vulnerable to environmental influences. Punitive care-givers, or other authority figures such as teachers and custodians, can readily establish a tendency to excessive guilt, shame and a sense of unworthiness and unlovability. Even without punitive caregivers, children tend to see themselves as the cause of wrong outcomes, and they take undue blame. Continued impairment of initiative, independence and mastery produce a sense of failure and sense of continued dependence.
Adolescence is normally associated with the period 12 to 18 years. However it is conventional in the refugee literature to extend it to at least 21 years, in recognition of the fact that reaching this stage of development is often delayed as a result of earlier experiences. The adolescent faces many developmental changes in all spheres of functioning. Those changes produce challenges, which must be met for the adolescent to achieve true adult maturity.
Changes take place in the capacity to reason. This is the period when the adolescent develops the ability to think abstractly, and to consider multiple perspectives. Consequently adult motives are scrutinised and new systems of explanation for events are generated.
Sexual and social development and norms of behaviour also occur in this period. Adolescents are particularly attuned to understanding what is good and bad about behaviour. Identity formation is a major task of adolescence and different roles are actively explored. Adolescents are especially prone to being influenced by peers and adults who guide which roles they “should” undertake.
A comprehensive understanding of the influence of the detention environment on children depends on an appreciation of the developmental needs of children and adolescents outlined above. It depends also on the recognition that the social environment has the power to produce change, for better and worse. Effects on children and adolescents will depend on a number of factors:
§ The age of the child or adolescent
§ The extent to which their development has been disrupted by pre-arrival experiences, such as exposure to violence and disruption to relationships
§ The length of detention and the quality of that environment
§ The extent of exposure to violence whilst in detention, both direct and indirect
§ The extent to which their family is intact
§ The extent to which parents retain their capacity to nurture and protect whilst in detention
The following description of the course of development by Garbarino and colleagues[7], who are recognised leaders in the field of the effects of violence on children, highlights the legacy of failing to take responsibility for the adverse effects of the environment on children.
“ In the developmental process, the child forms a picture or draws a map of the world and his or her place in it. As children draw these maps, they move forward on the paths they believe exist. If a child’s map of the world depicts people and places as hostile, and the child as an insignificant speck relegated to one small corner, we must expect troubled development of one sort or another: a life of suspicion, low self-esteem, self-denigration, and perhaps violence and rage. We can also expect a diminution of cognitive development and impediments to academic achievement and in-school behaviour”
In order to understand the impact of violence and traumatic events on a child or adolescent’s development, the age of the child, as well as the extent of exposure to those events, must be taken into account. The following section describes the effects of traumatic events, highlighting age-specific effects.
There is no simple relationship between a particular event or cause, and effect. The impact of detention depends on previous experiences, personal and family vulnerabilities and strengths. The children and adolescents who are detained are already at risk by virtue of dislocation and separation from relatives and friends. The detention environment, a close examination of which can be found in the following section, can only exacerbate the deleterious effects of previous experiences. The detention environment itself is a stressful one. It is a traumatic environment, particularly when prolonged.
Pynoos, Steinberg and Wraith in a textbook review[8] noted a wide range of frequently encountered deleterious effects following traumatic stress in children of various ages, both in the short and the long term. Importantly, they also note that the longer children remain in environments where they are exposed to violence, the greater the risks of significant effects on developmental achievements. They emphasise that for all ages, “in violent environments, each successive exposure may cause acute traumatic reactions from which there is only incomplete recovery, potentially increasing the risk of significant deviation in developmental trajectory.”
Not only are children especially vulnerable at the time of traumatic events, but on the whole, enduring psychosocial ill effects of trauma are much more prominent in children than adults, ever more so in the younger groups.[9] “The DSM-IV64 PTSD field trials found that associated features of PTSD, such as difficulties with regulation of affect and alterations in self-concept, were most prominent in adults who report being traumatized before age 4 years.”65 Davidson and Smith (1990)[10] report that individuals who experienced an initial trauma before the age of eleven, were three times more likely than those who experienced their first trauma as teens to develop psychiatric symptoms. Limited coping resources may render children more vulnerable to indirect stressors than adults.
When basic developmental needs are not met, or seriously disrupted, psychological symptoms and disorders are likely to occur. These manifest differently at each developmental stage: children are affected by traumatic events according to their level of cognitive and emotional development.
Age specific effects of traumatic events
| Infants | failure to thrive, basic trust does not develop, searching for protective figure |
| Preschool children | difficulties with regulation of affect, separation anxiety, re-enactment of traumatic events |
| School-age children | attentional disturbances, extreme internalising and externalising behaviours, impaired skill acquisition, omen formation (look for omens to predict future disasters) |
| Adolescents | substance abuse, sexual acting-out, anti-social behaviour, suicidal ideation, identity disturbance, depression, |
Intense anxiety, fear, feelings of helplessness, and the symptoms of posttraumatic stress disorder, can develop and persist for a long time after a traumatic event or events. The experience of helplessness, rather than the ostensibly horrific nature of an event, is the critical factor in determining the severity of the trauma reaction.[11] There are many ways in which anxiety manifests itself and they occur at all ages:
· Intrusive and recurrent distressing recollections of the traumatic event, including nightmares, flashbacks and in children, repetitive reenactments in play
· Impairment in the ability to think, concentrate and remember
· Conditioned fear response to reminders, places, things and people’s behaviour leading to avoiding fearful situations and emotional withdrawal
· Generalised fear not directly related to trauma such as fear of strangers or fear of being alone
· Hypervigilance or watchfulness
· Regressed behaviours such as bedwetting in children
· Startle responses to sudden changes in the environment
· Reduced capacity to manage frustration and tension
· Emotional numbing and detachment
· Psychosomatic complaints
The effects of anxiety are disturbing and reinforce feelings of helplessness. Children and adolescents try to cope in various ways, some of which are adaptive in the short-term but maladaptive in the long term. Some children and adolescents predominantly react with withdrawal and passivity, manifesting as lack of spontaneity, constriction of play/social activities, and inability to learn. Others predominantly react with aggression, disruptive behaviour and restlessness to deal with frustration and stress.
The connection with others and the world is usually dramatically altered as a result of trauma. Grief is common with manifestations in numbing, pining or yearning for a missing or dead relative/friend. Anxiety is associated with grief, as are emptiness, apathy, despair and anger. Attachment behaviour in relationships is altered leading to increased dependency, clinging behaviour or fierce self-sufficiency, guardedness and withdrawal. The quality of relationships is also affected, renewed loss is feared impairing the development of new relationships. Depression can develop in children and adolescents with symptoms of pessimism, loss of interest, sleep disturbance, appetite disturbance, poor concentration, self-degradation, hopelessness and suicidal thoughts and plans.
Guilt and shame are common consequences for children and adolescents exposed to traumatic events. They imagine that they should have been able to do something to avert violence or other traumatic events, even when nothing could have been done. Such thoughts can become a preoccupation. One of the most profound effects of guilt is that it can inhibit the experience of pleasure of any kind. This can lead in some cases to complete withdrawal, exacerbated by the need to hide due to shame. Self-blame is extremely common, and self-destructive behaviour can occur as an effort to expiate guilt through self-punishment. Shame can also lead to aggression towards others that can disguise feelings of aggression towards oneself. Defiance is also a typical defence against shame.
Other effects are less visible, trauma affecting at an existential level perceptions of the self and the adult world. Notions of good and bad, trust in others and the future can be irrevocably changed, affecting fundamental values about the self and life itself. Children and adolescents are particularly susceptible to having their moral development truncated as a result of their exposure to violence.
Adolescents commonly become depressed in reaction to loss and bewilderment about the cruel behaviour of adults. They may withdraw into passive hopelessness, or take impetuous action fuelled by a sense of invulnerability, a feature which is typical of their age. They may use self-destructive and antisocial acts and behaviours as a way to distract themselves from anxiety and a loss of faith in the world. Other responses include anorexia, self-mutilation, belligerence, ascetic withdrawal, or the adoption of a premature adult role. The adolescent’s process of identity formation is greatly affected and fails to develop.
Compared to adults, adolescents are at increased risk of PTSD[12] and other adult type disorders. In addition, trauma at this developmental stage may affect adolescents’ abilities to integrate past, present, and future expectations into a lasting sense of identity. This may develop into identity confusion, aggression, deliberate risk taking, and an inability to form stable relationships.[13]
The context in which children and adolescents reach the shores of a country and seek asylum must be understood in order to comprehend the potential cumulative impact of a detention environment on them.
Most people in the remote detention centres come from Afghanistan and Iraq. Most, until the time of writing, were indeed granted refugee status66 . It is reasonable to deduce that most children and adults in those detention centres seeking asylum have been exposed to traumatic events, albeit to varying degrees.
Such events would include internal displacement and attendant hardship, civil war, sudden disappearance of family members, death of family members, knowledge of executions and torture, damage and destruction to homes, witnessing of atrocities and murders, and separation from and loss of loved ones. Some children and adolescents would have been directly targeted for persecution and experienced direct physical and psychological injuries.
Countries such as Afghanistan and Iraq are known to have had, or still have, regimes that impose political oppression with harsh punishments such as torture and death. These punishments are used as methods of control through terror. Repressive regimes cultivate a climate of fear to suppress opposition, and both children and adolescents would have lived under such conditions for varying lengths of time.
Case 1
An English Language Centre teacher recounted the experiences of a young adolescent student whose father had been imprisoned and tortured overseas. The student was also detained in order to influence the father’s confession. The teacher recounts that the child was also tortured. Subsequently, the student described to the teacher that detention in Australia had been difficult but he was unable to speak in more detail.
Access to basic needs of food and shelter has also been precarious for refugees and their children. As well, many children and adolescents arriving in Australia by boat have been exposed to perilous journeys.
Case 2
One worker described the palpability of grief in the family she visited as part of her counselling work. They had lost many of their extended family in a boat that had sunk before reaching Australia. They also heard in detail about how a parent had tried to save his children but failed and watched them drown.
The countries of origin of people in city based detention centres such as Villawood in Sydney, and Maribyrnong in Melbourne, are far more diverse, and the rates of approval for refugee status far less than that for the remote centres. (insert figure form legal group)
It is therefore very difficult to know to what extent traumatic events have characterised their pre-arrival experiences. Nevertheless, for the young, the dislocation and inevitable separation from family, friends and homeland are indisputable facts. The extent to which dislocation and separation are traumatic events would depend on the degree to which those disrupted connections represent disruptions to core attachment relationships. This would also be influenced by the number of family members with whom they arrive.
It is important to recognise that some children may have been well protected from violence and other threatening events in their country of origin by their families. For those children, incarceration in a detention centre could well be their first experience of restricted freedom and hardship.
Relevant research has shown that a range of pre-migration experiences has been implicated in the psychological well-being of refugees. Pre-migration variables that have been found to correlate with later psychological disorder in adults include combat exposure, incarceration, death of or separation from family members, danger during flight from country, poor physical health status and rural background.[14] Some of these studies included older adolescents in their samples. The pre-migration experiences of younger children have received less attention,[15] but the predictors of psychological disorder in adults are likely to affect the well-being of children insofar as their parents are disabled by those experiences (the generational transmission of trauma is discussed below).
There is no reason to believe that the level of pre-migration risk factors is less amongst detained asylum seekers than in the refugee populations these results have been derived from. In fact there is some evidence to the contrary. One study, a survey of Tamil asylum seekers in the Maribyrnong Detention Centre[16] found that the detainees had experienced over twice the level of exposure to war related trauma compared to Tamil asylum seekers living in the community.
If the vulnerabilities of detainees are at least as great as refugee compatriots in the community, their initial 'settlement' experience, that of detention, is arguably considerably more unfavourable than the settlement environment of off-shore refugees.
The psychological effects of detention cannot be understood without considering the child who is detained, the child's family, the specific features of the detention environment, and the duration of detention. While definitive research is yet to be conducted, clinical experience indicates that detained children are likely to suffer adverse psychological effects when one or more risk factors are present.
A child who has suffered pre-migration trauma, who has been exposed to traumatic events within detention, whose attachment to parents is insecure or disrupted, or who is detained for a protracted period, is at great risk of psychological harm. While pre-existing vulnerability increases the risk of harm, there is however little doubt that detention, especially when protracted, can cause psychological disturbance in both children and adults who were not especially vulnerable prior to detention. This section explores how detention undermines a child's psychological health.
Australia's detention centres vary physically, both according to their internal design and their surrounding environment; however detainees and detention staff describe both urban and rural centres as austere and prison-like.[17] While the appearance of the detention centres may provoke a range of reactions in the general population, there is little doubt that detained asylum seekers experience the detention centres as prisons. "What have I done to be kept in prison" is a common plea of the detained asylum seeker; it is a question parents put to health workers and children put to their parents.
Despite their differences, all centres create a monotonous environment. In terms of sensory experience, the environment provides children with a limited range of stimulation. Particularly for young children, the environment is institutional and homogeneous from visual, aural and tactile perspectives. It is both bland and harsh: visual uniformity is combined with the discordant sounds of institutional life - the public address system, televisions on at all hours, raised voices reverberating against hard surfaces. 17 Such a physical environment does not foster children's capacity for sustained attention and self-directed play, nor their ability to creatively engage with novel stimuli.
Case 3
An ethno-specific pre-school worker volunteered that children have not learnt how to play. She has found that normally playgroups and childcare help children to learn how to play, they improve their behaviour, and they also learn how to communicate with other children. She says of the detention centres that the children just play with rocks.
Case 4
A former health worker at a detention centre said "The Centre was a very barren place. There was little joy there, few areas for infants to play safely and not much grass. There weren’t many toys. Kids played with sticks, there were a couple of kites people made. There were only 1-2 balls for soccer."
Fulfilling the basic elements of everyday life poses many problems for detainees. Times for eating are restricted. In some detention centres detainees are expected to state their “number” in order to obtain food. Food options are limited, often not culturally appropriate, and detainees frequently report finding meals unpalatable.
Many asylum seekers, including children, suffer from sleep disturbance due to previous trauma or depressed mood. The detention environment exacerbates disorders of sleep in a number of ways. The lack of daily routine and of opportunities for physical exercise are not conducive to good sleep. There are relatively few daily activities marking the passage of time in detention, and a consequence of this is that it is not uncommon for detainees to experience a reversal of their waking and sleeping times.17
Detainees often report that their sleeping arrangements do not feel secure. The impersonal and unfamiliar rooms can cause disorientation when a detainee wakes from a disturbed sleep. Parents have reported that they don't go to sleep with a sense that their children are safe. There have been reports that torches have been shone in the faces of sleeping detainees for the purposes of night time identification.17 This is a practice that is obviously intrusive for any person, but particularly disturbing for asylum seekers who have been imprisoned or who are traumatized, and suffer from exaggerated startle reactions.
Life in detention lacks normal structure and predictability. For both adults and children, there is paucity of access to activities of daily living which provide opportunities for productive participation, or even minor experiences of achievement. Areas for children and adolescents' undisturbed play are limited. Children under school age have no formal social or educational facilities available, and some children over twelve are not attending schools.
For children of all ages, opportunities for exploration of the physical environment are very restricted. The physical and emotional challenges that a normal physical environment provides for a young child, by means of which cognitive development is stimulated, are largely absent in detention. Similarly, the child's social environment is both impoverished and disorganized.
In smaller centres there are sometimes no peers who share the child's language. Where relationships are formed, they can be severed by the removal without warning of detainees who may be deported, released or moved to other centres. There is no community structure within which peer relationships are contextualized, regulated, and given enduring value. Observers have consistently noted the obstacles to the formation of stable relationships in a milieu in which tensions often run high, and in which people of varying ages and diverse backgrounds are thrown together.[18]
Self evidently, children's relationships with detention staff are an important feature of their social experience. However, detention staff's rapid rotation through some centres precludes the development of ongoing relationships between staff and detainees. Reports of the quality of relationships that detainees have with detention staff are variable. Clearly staff work in very difficult circumstances, and their training is limited in regard to a population that is culturally diverse, that includes children of all ages, and children and adults who are mentally unwell.
Some detention staff have received training from torture and trauma services which aims to increase awareness of detainees’ circumstances and needs. However this training 'competes' with a political climate, sometimes allegedly encouraged by the centres management,17 [19] that views detainees as 'alien' and undeserving of humane understanding. The treatment of detainees can vary greatly: detainees speak of having experienced both humane attitudes and overt and covert intimidation.17 [20] [21]
Irrespective of the individual detention staff's attitudes however, the nature of the work will tend to bring them into conflict with detainees, including children and especially adolescents. This is simply because on a day to day basis they regulate and enforce a regime of captivity that detainees' experience as oppressive.
Case 5
A person who had been a visitor to a detention centre stated that children had spoken to him about a conflict that had occurred between some children and officers. The punitive consequences set by the officers carried a damaging effect on the children after release from detention.
Case 6
The opinion of a worker who has observed detention officers, is that for some officers the tension associated with working with children in detention has an impact on themselves as parents. In order to minimise this impact, she believed that some officers tried to distance themselves from the children in detention by referring to the children by their numbers and through minimising direct contact with the children.
Case 7
A lawyer stated overhearing a detention officer comment about the detainees and about what should happen to them, in what the lawyer considered a derogatory way.
Environments that create uncertainty and lack of control contribute to the development of a range of mental health problems.[22] [23]The current detention regime produces helplessness in a myriad of ways. Centres control daily life: when and where a detainee can eat, sleep, and see visitors.
From studies of prisons, one would expect considerable variation in the way rules are enforced[24]. For example, rules regarding access to visitors appear to vary, with some detainees reporting apparent attempts to discourage visits by imposing arbitrary rules. An example given was the denial of visitors' permission to visit a detainee because they didn't spell the detainee's name correctly.17 Small features of daily life are experienced by detainees as controlled in petty and arbitrary ways. For instance, in one centre the number of non -religious books that a detainee can keep in his or her room is limited to two. There are rules regarding the size of articles the centre allows as gifts that detainees are permitted to receive, and the number of pieces of fruit that can be given to them. 17 19
Case 8
A worker described a theme that recurred in groups she ran for refugee children and in groups for their parents. When name tags were used in the group they were spontaneously associated with Australian detention centre identification numbers. Experiences volunteered by group participants regarding these numbers were; that people in detention were known as a number, that to collect food you had to call out a number, and at night if a torch was shone in your face you had to call out your number.
Case 9
Another worker told of parents’ efforts to protect their families from the dehumanising effect of being known as a number. For example, these efforts included refusal to comply with directives around presentation of ID tags by individual family members, particularly the children, at meal times. The worker described the response of some officers was to castigate the parents in order to get compliance.
Case 10
A lawyer who represents detainees reported that children have begun to identify themselves by numbers instead of by names and families. When asked “What’s your name?” the children respond by saying their number. In the opinion of the lawyer, the result is that children have become institutionalised and stripped of their identity.
Such control of the minutiae of daily life compounds the experience of helplessness when the detainee confronts the larger context of their current existence. Their detention is indefinite, and the process whereby they may achieve asylum is complex, and often not understood. Fears of repatriation are often intense. 17 [25] [26] The well-being of family members who remain in the country of origin or in transit is often unknown, and this is very often a source of overwhelming apprehension.
Adults and adolescents experience these fears directly, younger children register them both directly and through their parents' distress and helplessness. In the midst of such uncertainty, parents find that they cannot control the environment in which their children live. Detainees' lack of control of their larger circumstances and immediate physical environment converge to create in both parents and their children a profound sense of powerlessness.
What are the psychological consequences of such conditions of daily life? One must emphasize again that no systematic research has been conducted on the mental status of detainees, but clinicians' experience and some small scale studies provide strong indications as to how detainees fare psychologically.
First of all there is a consistent observation by experienced clinicians that detainees, both adults and children, deteriorate psychologically with time25 2617 19 Many become passive, withdrawn and apathetic, and develop a low-grade depression. Concentration and cognitive functions are affected, and this interferes with the ability to engage in the limited amount of purposeful activities that are available such as English classes. Others experience severe exacerbations of pre-existing problems, post-traumatic stress disorder, unresolved grief reactions and major depression. Sometimes vulnerable detainees develop psychotic disorders.17 Children often regress to earlier stages of functioning.
Case 11
A lawyer from a detention centre reported that on the set days for the release of the detainees, some very young children developed rituals which expressed their expectations of release. When these expectations were not met their hopes grew fainter and they became more despondent.
Case 12
A detention centre worker described with distress her observations of an older child who had regressed to a much earlier developmental stage as a result of witnessing a riot.
Case 13
The opinion of a lawyer who visits the detention centres is that there had been a general deterioration of physical and mental health in the child and adolescent population in detention. He states that they present as having regressed speech, withdrawn behaviour, dark rings around their eyes from poor sleep, and avoidance of eye contact. When the lawyer asked whether they would see the doctor the children expressed an expectation that the doctor would not help and all they would be told is to drink more water, rest, and have a Panadol.
One of the few studies of detainees in Australia examined the mental state of detained Tamil asylum seekers. It found that these individuals, who were detained in the Maribyrnong centre, 'exhibited significantly higher levels of depression, posttraumatic stress, anxiety, panic, and physical symptoms, compared to Tamil asylum seekers, refugees and immigrants living in the community'.16 A recent report[27] noted that a wide variety of behavioural disturbances are present in detained children, which include
"separation anxiety, disruptive conduct, nocturnal enuresis, sleep disturbances, nightmares and night terrors, sleep-walking, and impaired cognitive development. At the most severe end of the spectrum...mutism, stereotypic behaviours, and refusal to eat or drink".
The report also noted that "children of parents who reach [a] tertiary depressive stage appear to be particularly vulnerable to developing a range of psychological disorders”, an observation others confirm 19.
There have been frequent reports of behavioural disturbances in detained adolescents, manifesting as violent or self-harming acts. This behaviour has to be understood developmentally and in relation to the existence of violence within the detention environment. Children do not have the capacity to comprehend their environment in terms of justice, but adolescents have “moral antennae”. They scrutinise adults for their fairness and react strongly to unfairness. Research has shown that children exposed to inescapable violence over years develop the belief in adolescence that revenge is the best way to obtain justice.[28] The potential for retributive justice, combined with identification with the aggressor, which is another way to deal with chronic feelings of helplessness, can lead to the perpetration of violent acts.
Although the Australian detention environment is not responsible for earlier exposure to violence, the bewilderment detention creates can precipitate the desire to avenge previous injustices where previous exposure to violence has been great. Where aggressive behaviour is legitimised by family, peers or other influential figures, the probability of acting out against others increases.
In fact, rather than feeling outwardly violent, most young people carry their feelings of unfairness and frustration within and are vulnerable to acting against themselves. Self- harm and suicide can become the only way out. Tatz (1999) analysing the causes of Aboriginal youth suicide, calls for understanding such behaviour in terms of a long history of powerlessness and existential crisis rather than in terms of mental disorder[29]. He quotes the French writer Albert Camus who wrote “people are simply tired and have had a gutful of the hypocrisy of life, the meaninglessness of life, the purposelessness of life, and they see no horizon, and they see no means of altering such horizons as they have.”
This quote captures the meaning of existential despair which can lead to suicidal behaviour. It highlights the predicament of young people in detention, as well as adults, a predicament borne of history as well as of harsh current circumstance. The existence among adolescent asylum seekers of existential despair and consequent aggressive and suicidal behaviour is consistent with the literature that has examined detained youth. Toch[30] (1992) found that 7.7% of 1054 young offenders in an institution had injured themselves during their stays which averaged 17 months. Self-injury has been described as a sub-culture in young-offender institutions.[31]
A simple summary of the causes of suicide amongst young people in custodial settings, including remand, is offered by Liebling (1992)31 and echoes the view of Tatz:
“It is the combined effects of feelings of hopelessness, their current situation and the fact that they cannot generate solutions to that situation that propel the young prisoner towards suicide.”
Humiliation and the degradation associated with anonymity further fuel passivity, self- harm and violent protest. Such reactions are common amongst refugee survivors of torture and trauma, as a legacy of the violence done to their bodies or to the sanctity of their values. Experiences of children in detention may continue a corrosion, begun in their home countries, of their moral and spiritual fibre. Violence may become normalized. Children may see relationships as precarious, themselves as helpless, and they may distrust the future.[32] Particularly among older children recovering from trauma, intense rage is often experienced, combined with poor impulse control. Impulsive anger is a common component of post-trauma reactions.
When children are detained, renewed feelings of helplessness and injustice will inevitably provoke attempts to exert some control, at least in some detainees. In a normal environment attempts at control can be adaptive and can manifest in responses such as creating a hospitable home environment, and acquiring skills. Where options for adaptive control are unavailable, various behaviours emerge such as passivity, submission, withdrawal, excessive help-seeking behaviour, self-harm and in some instances violent protest. These are all attempts to escape from the emotional states described above. They are also a form of communication.
Case 14
A counsellor working with a young person heard that he had been caught up in a riot when tear gas was used. He is traumatised by the memory of believing that his mother had been killed during the riot when she fell unconscious during it.
Case 15
A nurse reported that on her return to a detention centre for a further period of employment she noticed a "dramatic change" in children's behaviours that included withdrawal, sullenness, oppositional and aggressive behaviour, anxiety, and bedwetting. During her time away from the centre, there had been a riot. The nurse also described how a young child appeared afraid that the officers would harm her father. The nurse observed that the effects of loss for the children are heightened when further separations occur, such as when other children who are friends are released or transferred from the detention centre.
Case 16
A lawyer from a detention centre reported that he knew of at least two early adolescent children who had purposefully cut themselves in an attempt to make a statement about their experience of detention and their need to be released. The lawyer also reported knowing of a younger child who had also self harmed.
To the vulnerabilities and circumstances already identified as invoking self harm or aggression amongst detained adolescents, must be added the fact that the detention environment exposes children to specific forms of violence. There are of course now many accounts of acts of violence occurring in most of the centres between detainees, and between detainees and authorities. The prevalence of physical or sexual abuse is yet to be fully investigated, but one commentator opines that
“l have no doubt that … child sexual abuse has happened. And l think that if we look at the environment that has been established there, [in detention centres] where you are putting people of different ethnic backgrounds, you’re putting people who might be criminals or those genuinely seeking asylum here in our country, and you put children into that mix as well, then the imbalance of power means that there’s going to be abuses occur.” [33]
Case 17
Although the details cannot be provided, a worker described how a mother took extraordinary action to ensure her young daughter’s genitalia was physically repulsive in order to minimise the risk of sexual assault by male detainees.
Case 18
A former health worker expressed concern about the vulnerability of children and adolescents in detention. A number of young adolescents described a sense of fear about being assaulted sexually. The worker believed that there was under-reporting of threats of sexual assault in detention.
Case 19
A lawyer at a detention centre reported that adolescent girls were afraid of walking alone around the compounds for fear of sexual assault.
Children are witnesses to and are caught up in riots, hunger strikes, and self-harming and suicidal behaviours. Exposure to the suicidal behaviour of others is associated with an increased risk of suicide or suicidal behaviour. This effect seems to be particularly strong for children, who are much more susceptible to the effects of suggestibility, identification and modeling.
Case 20
A counsellor reported that her client, a father of a young adolescent, described how his son who was exposed to riots while in detention in Australia, was very frightened and even now, months later, has nightmares related to the riot.
It is not uncommon for detained asylum seekers to assert that detention is as bad or worse than the persecution they have suffered in their country of origin.17 Prima facie, given that the persecution suffered is often quite horrific, such statements can appear as exaggerations or even self-serving hyperbole. However, one can understand that, on the contrary, such statements reflect sincerely expressed beliefs.
Firstly, it is necessary to take into account the extent to which the asylum seekers' emotional resources and resilience have been sapped by their survival of persecution and loss. This can include loss of family, friends, possessions and culture, in effect, virtually their whole world.
Secondly, there is the degree to which detention departs from the asylum seeker's hopes and expectations of a safe and peaceful place in which to recover and find 'asylum'. Instead yet another ordeal commences for them. Confronted by this reality, detained adults and older children feel exhausted, their hopes crushed. 17 Younger children feel the loss of hope in their parents and older siblings. They may, owing to their level of cognitive development, interpret the situation highly egocentrically and blame themselves for their family's predicament. Alternatively they may begin to believe ‘that their parents have done something wrong and that is why they are being locked up and punished’.18
Case 21
The comments by a lawyer from a detention centre reflected that children experience detention as a prison, and that their time there is like a sentence for crimes they do not comprehend.
Detention's effects on children cannot be considered in isolation from the effects on family members. There is an intimate relationship between children's psychological states and the well-being of their parents. This is a robust finding across various populations. For instance, increased incidence of a wide range of psychological difficulties has been found in studies of children of holocaust survivors.[34] A survey of children of Australian Vietnam veterans found that they suffer three times the suicide rates of a comparable community sample.[35] A review of studies examining children of depressed parents found that depression in parents was associated with problems of adjustment and diagnosable disorders, particularly depression, in their children.[36] Reduced parental responsiveness - constricted affect, withdrawal, and less effortful interaction - are likely to be implicated in this effect, but contextual conditions (such as family stress or marital discord) may also contribute.[37]
Fundamental to children’s needs is a family environment which creates secure attachments and developmentally appropriate engagement with the external world. Bowpitt stated that "parents’ ability to assist traumatised children may be hampered by their unawareness of children’s exposure to specific events; underestimation of children’s distress; parents’ inability to cope with their own distress; and the ‘conspiracy of silence associated with overwhelming trauma".[38] Many studies have highlighted the significance of parental capacity to protect children affected by trauma.[39] [40] [41] [42] [43] [44] [45] Parents who are themselves traumatised may become aggressive, perpetuating a lack of safety.8 18 32
Pynoos et al,8 noted that “Post-trauma disturbances in parental responsiveness, and impairment in parental role function, are a major source of secondary stress for children”. Children are very sensitive to their parent’s emotional state and this directly influences their sense of well being. Research indicates that a child is able to detect parental distress from one year of age. [46]
Observations in detention centres in Australia are consistent with the literature. There are many clinical reports of parents, owing to increasingly severe depressive and anxiety states over the course of their detention, becoming unable to adequately care for their children.17 19 All of the key service providers interviewed by Maksimovic et al (2001) in their study of children in detention indicated that children do not receive sufficient support from their own parents, as they themselves are experiencing high levels of stress or clinically diagnosed depression.18
Detention challenges the integrity of the family unit in a fundamental way. Prior to detention, the relationship between parent and child is likely to have been shaken by exposure to violence and dislocation. The family grouping in detention has already been stripped of its extended network of family and community supports. In its weakened state, the family, sometimes comprising only a mother and her children, must attempt to maintain a semblance of normal family life in an environment over which they have little control.
However every aspect of normality is confronted. Daily routines with which families are familiar cannot be sustained because of the regimentation of the detention centre. The inability of parents to be able to acquire food outside prescribed times means that they are unable to respond to the needs of their children in the most basic sense.
Parents are also unable to protect their children from exposure to a vast array of events from which they would normally shield them. There is nowhere for parents to close the door to create a membrane around the family unit. The possibilities for privacy and intimacy are very limited. A study by Raundelen[47] emphasised that parents’ inability to protect their children from dangers leads to children feeling betrayed. A study by McCallin[48] found that accompanied children in the detention centres could not rely on their parents to provide care and safety: “[t]he children feel that their parents are powerless in the face of the stronger, organised elements within the camps.”
Case 22
A client of a counsellor had been out of detention for well over a year but repeatedly related the impact of not being able to take any food from the dining room which she felt she needed for her health while breast feeding. She was distressed about feeling forced to “steal” some food which was subsequently taken from her.
Case 23
A lawyer from a detention centre recounted the difficulty for some mothers to determine what they fed their children because they could not get special baby food after their child had reached a certain age as it was expected they would then eat solids.
Not only do parents have to deal with their own sense of powerlessness, but they have to live with the knowledge that their own children see them as impotent and unable to provide protection, discipline and guidance. As a consequence parents can feel humiliated and demoralized. Children sometimes develop a precocious awareness of their parents' distress. They are at increased psychological risk when they continuously suppress verbal or emotional expression to avoid upsetting the traumatised parent, withdraw, are ignored or scapegoated, over-identify with the traumatised parent or take on parental roles and responsibilities.
Parents often attempt valiantly to protect their children from the distress they themselves experience, sometimes successfully, but at other times in vain. 19
Case 24
A clinician who works with a number of parents released from detention describes the cumulative effect on parents of trying to cope in an unsupportive environment and being concerned that their children are affected by their own distress. The clinician further describes how powerless parents feel at being unable to protect their children from exposure to violent events within the detention centre that can result in the child developing psychological symptoms that remain for some time.
The evidence regarding the effects of detention in Australia on families is clinical and anecdotal, but the observations all run in the same direction. It is therefore reasonable to conclude that detention undermines family life and the ability of parents to adequately provide for their children. The detention environment would challenge the integrity of the most stable family, quite apart from families that have been uprooted and dispersed, often in tragic circumstances.
The Experience of Unaccompanied Minors
Children and adolescents without parents who are seeking asylum, and are within the detention centres as unaccompanied minors, are in a most vulnerable position. The reality is that young people and children who have left family behind, often lack information about the well-being of family members who are likely to still be in situations that are not safe. This compounds the loss and grief associated with the separations and the uncertainty of the future.
A study by McCallin (1992)48 of children in detention centres in Hong Kong found that unaccompanied and attached children displayed pervasive apathy as a result of the uncertainty of their futures and lack of family support. She states: "Their suffering is essentially "silent", manifested by anxiety and depression, and lack of initiative and confidence in themselves and others."
Within the detention centre, unaccompanied minors do not have the protection of parents to mediate the impact of the reality of centre life. "It would appear that whilst parents cannot shield their children from exposure to actual events, they are able to protect them, to some degree, from the negative effects of their experiences. Children without family support are left to cope with their experiences alone and are thus more vulnerable and at risk." 48
Case 25
A detention centre lawyer reported that a group of unaccompanied minors had joined together and participated in serious action with the intention of protesting against their detention and seeking freedom.
Case 26
A former health worker at a detention centre stated that a number of unaccompanied minors were victims of trauma, or had been caught up in direct fighting. The worker stated that some were very traumatised; they looked confused, were tearful when discussing the war, appeared depressed, and some talked of suicide. Some were unable to play. Some had even seen family members killed. No counselling was provided in detention.
McCallin’s study was undertaken in conditions not dissimilar to those in detention centres in Australia. She described “people are essentially ‘warehoused’ in prison-like facilities…which deny the residents any capacity to engage in normal social and community routines and behaviour…(This) has created a situation of institutional dependency where with time and loss of hope many people become apathetic and depressed. It has also resulted in psychosocial problems such as community protest by means of riots, hunger strikes and self-mutilations, and interpersonal violence characterised by intimidation, robbery and physical and sexual abuse." 48
Children with high levels on the stress scores experienced direct threat to themselves en route (50%) and in detention (52%). The latter events often occur in situations of violence within the centre community — eg demonstrations, hunger strikes, tear-gassing, etc. The study found that the violence experienced by the children "appears to act in a cumulative fashion to exacerbate the effects of isolation and loss that are the daily reality for the unaccompanied and attached children."48 Given that unaccompanied minors in Australian detention centres will have experienced similar events, it is reasonable to infer that the consequences on their psychological state would mirror the findings in the McCallin study.
Other studies of unaccompanied minors in detention centres in Hong Kong, the Philippines, Thailand, Malaysia, Singapore and Indonesia highlight the impact on these children and young people when they are trapped in a situation of uncertainty and powerlessness.[49] [50] They are immobilised by the reality of the conditions in which they live. Even when opportunities to study are available, these young people were unable to take them up.
"Although camps have schools, many children, because they are depressed or distracted by other activities, do not attend; those who go to school receive insufficient education and skills training. The children have little or nothing to do all day. A high percentage of the children distrust authority; they are cynical of the promises of officials and agency workers. They appear to be quite unsettled by the uncertainty of their situation and their fears of what the future holds for them." 49
Children’s lives are not ‘on hold’. Without attention being paid to their particular needs, the cumulative effect of loss of parents and family, being in detention without parental support and nurture, and being vulnerable to the consequences of living in a violent and harsh environment, will almost certainly result in depression and long term psychological damage. In effect their personal integrity suffers and their capacity to recover is diminished.
Given the absence of systematic studies of unaccompanied minors in detention in Australia, it is important to draw lessons from the studies undertaken in detention centres in South East Asia. While there are obviously significant differences between the detention environments, there are fundamental similarities that have a profound impact on the psychological well-being of unaccompanied minors. Some have harmed themselves in detention because of the desperation they have felt about their future.
On release from detention, others have presented with psychosomatic symptoms, expressing their grief about the ongoing separation from the love and nurture of family. Attendance at school may also be spasmodic, reflecting the psychological state of the young person.26 The reasons for leaving home without the protection of parents are experienced as ongoing reminders of their vulnerability both here and in their country of birth. Facing the future on their own can be felt as an overwhelming task and responsibility28.
Case 27
A worker described a situation of an adolescent unaccompanied minor in detention who did not know if his mother had survived, or whether she was dead. While the young man was not allowed to contact his mother during the time he was detained, since release he has spoken regularly with her. He is very close to his mother and lives as he knows she would want him to.
Children’s capacity to adapt and recover from trauma following their pre-detention and detention experiences will depend on their physical and mental state, and resilience at the time of their release. It is also dependent upon the mental health of parents and their capacity to provide an emotionally secure environment for their children. A further important variable is the range of social supports available to the child, adolescent, parents and other care-givers. Ongoing environmental stressors and lack of family and social supports compromise adaptation and recovery from trauma.
Refugee children begin their adaptation to the host society with a range of vulnerabilities. The extent to which these vulnerabilities manifest as psychiatric disorder varies according to pre and post-migration variables. There are a large number of studies, dating from the 1950s with investigations of post WWII refugees, which establish elevated rates of psychological disorder in refugee populations.15 25 [51] The degree to which psychiatric morbidity rates are elevated above community norms, depends on a range of trauma and settlement related variables, and the research methods employed. However, incidence rates of between one to two thirds of the population have been found for some refugee groups.25
Less attention has been given to the study of child refugees. Those studies that do exist, combined with the knowledge now possessed of the long term effects of trauma in non- refugee children, indicate that, amongst traumatized refugee children, psychological problems will be both frequent and enduring in the absence of adequate treatment and care.
In a U.S. community survey, 27% of refugee children, (compared to 2% of non-refugee children) met the criteria of PTSD.38 A large scale Australian study38 of Indochinese, predominantly Vietnamese, children, adolescents and adults, found that on arrival one quarter of the adolescents and one third of young adults had a definite or probable psychological disorder manifest largely in the form of depressive and anxiety symptoms. However within 24 months, the incidence of disorder had decreased significantly.
These results may reflect relatively benign and protective settlement experiences or, alternatively, the timing of the follow up assessment: some long term longitudinal studies of refugees indicate a delayed onset of psychological difficulties.[52] With regard to the duration of post-migration psychological disorders, longitudinal studies of adult refugees have tended to find a reduction of symptomatology over time, although a subset of traumatized individuals, without treatment, develop chronically disabling conditions.25
Child refugees are particularly vulnerable to trauma, and separation from, or loss of, carers. Such experiences can have enduring developmental effects. A study, for example, of the consequences of Jewish children's placement in foster homes in the Netherlands after WWII, found that more than twenty years later issues of loyalty, identity, and mourning continued to affect their psychological well-being.51
Incontrovertibly, while for some refugees the effects of pre-migration trauma can be enduring, the vast majority of immigrants who have settled in Australia through the refugee and humanitarian program have successfully adapted psychologically and socially. With respect to current asylum seekers, the issue of concern is whether successful adaptation will continue to be the rule, at a time when significant obstacles to such success have been erected. While the psychological disorders child detainees develop within detention often persist after the child’s release, recovery is nonetheless possible:
Case 28
A counsellor reported that a close relative of a very young child described how much the child’s behaviour changed once she was released from detention. In detention the little girl had slept poorly, was aggressive, fearful, tearful, highly distressed and unable to focus on activities for any length of time. Once out of detention she slept well, didn't get angry, could play by herself, sits still long enough to have a story read to her, and her attention span has increased.
Post traumatic reactions are now considered disorders of recovery.[53] Whether intensely distressing events such as torture, life threatening experiences, witnessing the death of others, and forced and protracted separation from family members lead to serious psychological disorder depends, in part at least, on the social milieu within which the traumatized individual recovers.
Some authorities suggest that "a variety of current stressors are at least as important as past experiences of violence and torture in causing distress"55. Among asylum seekers it's probable that traumatic experience and post migration stressors act in concert to produce psychological disorders. For instance, Steel et al's study of Tamil asylum seekers in Sydney found that premigration trauma sensitized the asylum seekers to stressors; indeed some stressors were only predictive of disorder when levels of premigration trauma were high.25 A number of stressors in asylum seekers' and refugees' settlement experience have been identified as associated with current distress or predictive of future psychological disorder.
A study of young male refugees (aged 16 to 30) in London found that sources of stress included social isolation, the length of time taken to resolve residency status, and language, financial and accommodation difficulties.[54] Schweitzer et al reviewed studies of the post-migration concerns of asylum seekers and refugees and found these included 'separation from one's family, unemployment, poor finance, a lack of access to health and welfare services, and difficulties with the refugee visa application process'.[55] Steel et al found a large number of post-migration stressors were predictive of depression, raised anxiety levels, and PTSD.25 These predictors fell into five categories: the residency determination process; health, welfare and asylum problems; threat to family and friends; adaptation difficulties; and loss of culture and support.
There is a consistency across the research literature as to what the major post migration stressors are, and these findings tally with clinical experience. Some of these stressors are difficult to address, such as fears regarding family whose location is unknown or who remain in perilous circumstances. Other problems, however, are directly related to migration and settlement policy. When one reviews the post migration conditions of life predictive of psychological problems in asylum seekers and refugees, it is apparent that a number of current policy approaches have had, as their unintended consequence, the replication of precisely those conditions.
Case 29
A counsellor seeing a young child released from detention, described that the child believes that when her parents and their friends are talking of forced repatriation to their country of origin they are talking about a return to the detention centre. She thinks her country is the detention centre and is fearful of being returned there.
Parents and temporary unaccompanied adolescents who have been released from detention have multiple settlement tasks; these include finding accommodation and employment, establishing social networks, accessing health services and learning English. However, many Commonwealth-funded settlement services provided to off-shore refugees, whose purpose is to assist settlement and recovery from trauma, are not available to them. The outcome can be a traumatised population having difficulty meeting many important needs.
Asylum seekers released from detention centres with bridging visas may not have access to a work permit or other source of income such as Centrelink or the Asylum Seeker Assistance Scheme. They may not have access to Medicare. This results in those asylum seekers having difficulty obtaining food, clothing, medical care, employment, housing, language skills, and the assistance they require understanding government agencies.
Case 30
A counsellor reported the way her client had described struggling with her difficult past, struggling with the present and having no hope for the future. She described her treatment in Australia as a form of persecution. She felt that authorities in Australia were interested in her previous experiences of persecution so that they could be copied. During detention she lost her sense of hope and now lives in constant fear and uncertainty about her future beyond her three year visa.
The importance of the social environment to people’s mental health is documented in our own National Mental Health Plan (January 1999), and the Victorian Mental Health Promotion Plan (1999-2000). These documents recognise that safety from persecution and discrimination, social connectedness and economic participation, are necessary for good mental health. Given that, as argued above, the mental health of refugee children's parents is highly determinative of children's psychological well-being, it is likely that current Commonwealth government policies are directly affecting children. If the child does not receive the assistance he or she requires, early adaptive failures may set in train a sequence of adverse experiences that consolidate psychological disorder and poor adaptation to the host culture.
Case 31
A family seen by a health worker had been out of detention for only a few months and already had two moves. The worker describes how the husband spends most of the week out looking for more permanent accommodation and for work. He has felt that prejudice regarding the temporary nature of his visa and his ethnicity have made his effort fruitless.
The health worker also reported that there is considerable pressure on the mother as she tries to cope with the behaviour of her young child while being left alone all day while her husband seeks to secure the basic needs of his family. She is isolated and depressed, and her infant screams frequently during the day and has nightmares of detention and the journey by boat.
Case 32
A counsellor reported that her female client, whose mental health deteriorated as a result of being in detention, was released on a bridging visa. Her living arrangements broke down and she and the children became homeless. They are now housed in emergency accommodation. However, post-detention she finds it very difficult to be cooped up and so walks the streets with her children during the daylight hours. Her children have difficulties with fears, their sleep is disturbed and they have nightmares.
There is already evidence that the circumstances experienced by TPV holders are compounding pre-existing psychological difficulties. Health professionals working with refugees have reported that children on TPV or bridging visas experience nightmares, sleep disturbance and eating difficulties. They also noted social withdrawal, expressions of shame, and fear of return to their countries of origin or to the detention centre. Fear of loss of parents or future harm to a parent, depression and anxiety were also reported.19
Case 33
A counsellor of an adolescent boy described how he came to the notice of his teachers as he kept absenting himself from school. Assessment of this child revealed he was not sleeping at night due to his level of fear. He only dared to go to sleep in the morning, and then did not attend school. He described himself as sad and was assessed as depressed.
Case 34
A community worker described two young siblings as “not communicating with other children” and as having no friends at all. At school they play only with one another. The children described to the worker their repeated loss of friends prior to and during detention. She described the children as wanting to know where they would be going (after the three years of the TPV) and being unable to begin making friends. In the mind of the mother, her children’s capacity to develop relationships was suspended.
Case 35
A worker learned from a client that people living in a country town, post-detention, felt rejected by people from their country who held permanent visas. She reported that her client and others felt labelled negatively. Those with TPVs hoped for assistance from permanent residents in the community, practically and in regard to lobbying the government. They felt unsupported and unheard and this led to conflict.
Screening for mental health problems, early intervention for preventing further deterioration, and a supportive environment, are basic requirements in providing for the mental health needs of children and adolescents who may have suffered traumatic experiences prior to detention.13
In the detention environment these conditions are not met. There is no screening to identify and treat trauma reactions soon after arrival, and no attention to early intervention to prevent development of mental health problems. The lack of a friendly, safe environment in which to address mental health issues effectively is the most sorely lacking condition. The effectiveness of mental health interventions is of necessity circumscribed because the conditions contributing to, or exacerbating mental health problems, are intrinsic to the detention environment.
Case 36
A volunteer who visits children in detention reported, “To see kids encircled by razor-wire was chilling. Children need an open environment and freedom to flourish. Entry to the centre is very daunting: you have to go through many locked gates and doors, and then there are the guards in uniform.”
Given the conditions of the detention centres previously described, as an environment in which control and over-control by management promotes wariness and distrust amongst detainees, receptivity to mental health services are diminished. Detainees often do not trust health staff whom they see as employees of management. The result is that mental health problems are minimised by detainees themselves and self referrals are less likely to occur.
Case 37
A worker described the difficulty an older adolescent had in accepting treatment for his psychological symptoms while he was in detention. The young man could not trust the medical staff whom he regarded as part of a system that was contributing to his illness. The worker stated that the young man believed that the system that punished him and made him ill should not also offer him treatment.
Staff at the detention centres, in a position to observe signs of ill mental health and take steps to make a referral, may be reluctant to do so for a number of reasons:
· They are likely to minimise identifying mental health problems if service response options are limited.
· Different understandings of what is a mental health problem can lead to failure to advise appropriate mental health treatment. For example, suicidal acts may be interpreted as manipulative attention seeking behaviour rather than as a sign of severe depression. Failure to go to the dining room may be interpreted as provocative or negative behaviour when it could be the case that the person cannot cope with the noise due to post-traumatic stress disorder.
· Staff would have some "investment" in not recognising everyday difficulties amongst detainees as mental health problems, as this would mean recognising the extent of suffering. There is much less emotional conflict for staff if they are part of a detention regime which is not seen to be holding people, especially children, who are psychologically vulnerable.
This psychological process of minimization may well extend to managers who would also find it stressful to acknowledge that the detention environment contributes to, or produces mental health problems. Budgetary considerations no doubt play a role in the level of services which can be provided and can influence the preparedness to identify the extent of problems.
The provision and/or supervision of treatment by external, independent and qualified consultants would overcome some of the problems caused by minimisation and misinterpretations of behaviour. However, access is a problem. Further, recommendations have been made which are not heeded because they conflict with detention policy. For example, a consultant might recommend that body searches be discontinued as they are deleterious to a detainee’s mental health. If this conflicts with safety procedures the recommendations are likely to be dismissed without discussion.
There is provision for counselling services within the detention centres but the counsellors work under considerable pressure. They face the stress of formulating goals which are achievable in the detention centre. Contact with counselling staff indicates that they endeavour to do this, and they do play a critically important support role. At times however they face ethical dilemmas when their professional judgement tells them that only release could avert further deterioration in functioning. They are also in a position to notice when and how psychological harm is being done, but are powerless to change the situation.
The centres are not sufficiently resourced to identify and meet all the mental health needs of child and adolescent detainees. Systematic research of the mental health of children and adolescents in detention is needed to understand the extent of severe problems. There is probably documentation of the prevalence of acting-out behaviours such as aggression, which come to the attention of staff. If this data were available, it could give some indication of the prevalence of such problems. However, it is unlikely that problems presenting as social withdrawal, which are easily overlooked, have been routinely recorded.
There is an immediate need for resources for detention staff trained in child and adolescent mental health who also have expertise in the special problems posed by cross-cultural assessment and treatment. As for any professional team, supervision, secondary consultation and professional development should be available to staff. External mental health and family services could complement and be integrated with the detention mental health team.
In order to contribute to recovery from trauma and torture, several programs have been developed to strengthen families, to accommodate the particular needs of children and adolescents, and to enable professionals who have high contact with children and adolescents to respond to needs.
A mental health service is available through the National Forum for Survivors of Torture and Trauma Services. The Early Health Assessment and Intervention (EHAI) service can provide psycho-educative information, health screening assessments, psycho-social assessments, and short term interventions to those people on TPVs who are settling in Victoria. The same service is available to people on TPVs in all States and Territories.
While this service is available, people do not necessarily access it because of the stressors associated with settling in the community on release from detention. Factors such as insecure or unstable housing, little or no systematic settlement support, the uncertainty about the future, and fragile social support networks, impede the process of referrals (via self or through other workers) to this early intervention service.
Without access to the organisations that exist to provide settlement support and information to new arrivals, those released from detention are unaware of what services are available and how to access them. A consequence is that they remain isolated and disconnected from the Australian community. In addition, anger, disillusionment and suspicion, as well as trauma symptoms, can impact on their capacity to access services such as these.
Children and adolescents do not easily engage with mental health services, but do attend school. Pittaway et al (2001) concluded from their interviews and focus groups with teachers, mental health workers, and with refugee children and parents, that "the school is the perfect forum in which early interventions can be co-ordinated".13 School teachers deal most directly with the range of trauma reactions of children. The normality of the school environment is to be preferred to the ‘threatening’ and stigmatising environment of a mental health service.
Torture and trauma services utilise the school environment to access children and adolescents in order to provide support and interventions. For instance, the VFST works with schools, including teachers, students and parents, through group programs for children, adolescents and parents. Children and young people are more likely to engage with the services offered through such programs than by attending individual sessions with a professional.
Group programs provide an opportunity for children and adolescents to talk about their refugee experiences, to share with others what these experiences mean to them, and to explore the future in a safe caring environment. Parents are also able to talk about their own and their children’s experiences with others in separate parent groups. Professional development is available to teachers and school support staff. In many instances, teachers co-facilitate groups which allow them an opportunity to have a greater understanding of the impact of past events on the child.
A model of intervention that incorporates cultural responsiveness has also been developed by Pittaway et al (2001).13 The model extends beyond the early period of resettlement and requires a staged approach. In the early stages, establishing trust and safety is crucial to break the chain of traumatising factors. In the longer term, secondary mental health problems that may result from resettlement stresses, such as poverty and loss of family, need to be forestalled. As a child’s survival has frequently been due to their parents’ actions, interventions are inclusive of the family.
Because a lack of resources was identified as a key issue, resource manuals were developed to respond to needs identified by teachers and school counsellors. Also developed was a comic for young refugees, a set of three posters and a general brochure. Still needed are comprehensive teaching manuals, culturally appropriate diagnostic and screening tools, and research into family-specific interventions.
While these programs described have been successful, there are not sufficient resources to implement the programs in all the schools where need exists. Nor are there adequate funds to respond to the need for individual attention of children and young people identified through the programs operating in schools.
Interventions with individual children and adolescents and their families, can be provided through both specialist refugee health services and public mental health services. However, there are issues of access to the latter.
A range of studies has shown that adults of non-English speaking background (NESB) have a lower rate of access to public mental health services than adults of English speaking background.52[56][57] This is attributed to factors such as lack of knowledge by NESB groups of mental health services, stigma, fear of government services, differences in conceptualisation of mental illness, and cultural and language barriers to services 56[58].
Data on children from non-English speaking backgrounds who access mental health services are scant. But in a study by Pittaway et al (2001), mainstream and community mental health professionals in New South Wales stated that "refugee children and young people do not access their services".13 An audit, conducted for one month in August 1999, of the cultural background of children attending Child and Adolescent Mental Health Services (CAMHS) found that there was marked under-utilisation of CAMHS by children who came from a home where a language other than English was spoken.[59] Only 10 of the 390 contacts recorded across Victoria might conceivably have been with children from a refugee background, but none were from countries which were the primary sources of refugees at that time.
Interviews with five mental health professionals, in child and youth mental health services, in a region with a high proportion of refugees established that there were no formal or policy barriers to assessing and treating refugee children and young people. However, none recalled assessing or treating more than one refugee child or young person. Other regions also reported that refugee children rarely accessed their services. While child mental health services may not perceive barriers to access, workers who have tried to refer to these services reported that there were long waiting lists at the mental health services. Moreover, the cultural and language barriers to mental health services act as a great deterrent to families.
The professionals interviewed believed that refugee children were not accessing mental health services because their needs were likely to be overlooked. If parents were in crisis, mental health services would focus on providing services to the parents, but the child’s needs might not be assessed. Parents, for their part, may be too preoccupied with settlement problems, or too traumatised themselves, to recognise that their children have a mental health problem. Or they may not conceptualise children’s behaviour within a western mental illness framework.
A central screening issue is that children are reliant on others to make a referral if they need mental health intervention: "the problem is referrals aren’t made". It might be expected that screening of some refugee children would be undertaken by crisis teams, such as Victoria’s outreach-focused Crisis Assessment and Treatment Teams’ (CATTs). Although the primary responsibility of CATTs are to assess and intervene in mental health crises of adults, they also carry responsibility for assessing the welfare and mental state of the children of adult clients, or for assessing children and young people in crisis after hours.
CATT staff acknowledge, however, that they lack expertise and confidence in assessing children, and it was stated that "training on the effects of trauma in children would be useful to teams." The need for training of mental health staff was also endorsed by staff from specialist refugee services, who suggested that child and adolescent mental health professionals are in need of specialist training to help them respond effectively to traumatised refugee children. Lack of expertise in working with refugee children was also reported by mental health workers interviewed by Pittaway et al (2001).13
Primary mental health teams have recently been established in Victoria, consisting of five mental health professionals, linked to each area of mental health service. The purpose of these teams is to improve service provision to people with less serious mental disorders, such as depression and anxiety disorders, including post-traumatic stress disorder. As the teams are small they will provide only a limited direct-care service. Instead they may facilitate treatment by GPs and community health centres. Nevertheless, these teams clearly have the potential to collaborate with other service providers, including schools, to develop community-based early intervention strategies which will benefit traumatised children and their parents, such as are presently provided in some schools by torture and trauma services.
The collaboration between specialist refugee services and mental health services is fundamental to providing effective services.
Case 38
A nurse who worked in a detention centre reported: "The idea was to keep the health budget down. Health is thought of as 'acute' or 'chronic'. Acute health problems are treated to avoid deaths in custody, chronic health problems are not treated… The detainees would say their children are getting sicker and sicker and they are not getting better, and that our medicines do not work.”
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64 DSM refers to the American Psychiatric Association's Diagnostic and Statistical Manual, an authorative listing of diagnostic criteria.
65 David Pelcovitz & Sandra Kaplan, Post-Traumatic Stress Disorder in Children and Adolescents. Child and Adolescent Psychiatric Clinics of North America, Vol 5, No. 2, April 1996 Pp 449-469
66 success rates of refugee applications