sou · GUB3114 · 2007-01-01 00:00:00 — In the problem of asylum-seeking children who were suddenly transformed from being healthily (more or less) alive to being living-dead increased between 2003 and 2005. The people working with the children used the theories of psychiatry and their own many years of experience in the psychiatric care of asylum-seeking families/children to try to explain what had caused the situation. They applied three levels of analysis: the indivdual, the family and the system (context). We know that children look to their parents to read how their life should be interpreted. They notice much more how their parents feel than what their parents Often children assume a certain role to help the parents feel better. When the problem grew we became confused. Why did so many children show an identical pattern of symptoms? It was a new syndrome ocurring in a large group and in a short time. Our theory was that many families saw that the only way to stay in was to present an illness. As the number of children with with- drawal syndrome increased and the symptoms became more intensive, the situa- tion turned into a major problem. We had never before during 15–20 years of asylum-seeking psychiatry experienced such a new syndrome in such large groups, explained. An increasing number of families turned to paediatric care because of the alarming intensity of their childs symptoms. In the hospital many children devel- oped severe withdrawal behaviour very quickly and required tube feeding. No form of somatic treatment could reduce the symptoms. The patients were then transferred to the psychiatric in-patient unit, but even here the treatment could not reduce the symptoms. The situation became more and more critical as the number of children with severe symptoms increased. The only way the children could recovere was if the family was granted a Permanent Permit (Swedish acronym PUT). But very few families were granted a PUT. The families were suffering and expressed no idea of hope; they didnt believe that anything at all positive was in store for them in the future. It became a ght between paediatric and psychiatric experts. The child- and adolescent psychiatric care choose out-patient treatment for these children, whereas paediatric care preferred hospitalisation. The media became deeply involved; perhaps this was the reason why so many cases developed in such a short time, continued. In 2005 a new out-patient system was introduced in . The idea was to coordinate child and adolescent psychiatric care with paediatric care and adult psychiatric care. The aim was to support the families so that their children would not have to be hospitalised. We supported the parents, stimulated them to participate in everyday life; for example, to take walks outside the home. We wanted to help parents feel that they could take charge of their situation. We also helped the parents to take care of their childs nursing process. It was a very intense model designed to give maxi- mum support. In the beginning of 2005, 30 children in showed severe withdrawal behaviour. In of the same year the number had risen to 50, and in had 70 children with severe withdrawal behaviour. By 2006 the number had declined to 34 children. Of the 70 families in Novem- ber, 36 had received the PUT. When the families got the PUT, we could see the rst signs of recovery. For some, it took a few days or weeks, but the average time of recovery was three to six months. A group showed no signs of recovery. Our general experience is that a PUT is a condition for recovery. We could also see, however, that a period of intensive treatment, with support given to both the parents and the children in combination with changed expectations from the staff, can result in signs of some progress towards recovery without a PUT, stated. The following is a summery of the general discussion that followed after the presentations. To make the discussion more comprehensible for the reader, the comments have been structured along thematic lines. The feeling of fear Is the fear of returning home cited by many families real, or is it somewhat exagger- ated? The moderator, , from , noted that we must be really careful not to ignore the fact that children have the ability to think, reect and act. stated in her introduction that: To work with asylum-seeking children and their families is very challenging and affects you deeply. Many others as well as I myself have been deeply involved in the situation of individual children. from the Psychiatry stressed that there is always a mix of explanations to any given situa- tion. He believed that it was too simplistic to talk about fear as being either realistic or exaggerated; rather, it has to do with the children relating to what their parents say. He described a situation in which a child hears the same story all day long, lying in a semi-dark apartment, with the mother weeping in bed and the father standing out on the balcony smoking. The only thing the child hears about is the danger of returning. Children relate to what the parents say. They are also afraid of losing one or both parents. In many cases, the child starts to develop the symptoms when the mother gets ill. Children interpret reality through their parents. So it is not so much the fear of returning to the real world, but rather to the world the parents have described, he concluded. Could the fact that many children come from post-totalitarian countries be one explanation, asked: Could that have resulted in a tendency to give up in the face of the public authorities? It might explain the deep hopelessness many parents show. This could also be a signal to the children that there is a danger. I dont think that the children have experienced real danger, but when parents signal danger, children are deeply affected and therefore believe that they are in a dangerous situation. Yelena Vinogradova protested at what she called a very stereotype image of her country: Many people ask us, how do people survive in your country? But please, dont imagine that we live in a country where everybody is afraid to go outside. This stereotype image of works as an obstacle to the rebuilding of our country. The problem of parental behaviour in is not about our totalitarian past. During Soviet time 15 years ago, we had a very strong education system; children participated in a wide range of activities. Everything was available and free of charge for children. Another aspect of fear is the feeling of failure – having to return home when asylum has not been granted. Or as from Norwegian Directorate of Immigration remarked: There are push factors and pull factors in migration. But how does society meet people when they come back and they have not succeeded? Yelena Vinogradova answered by giving a different example: Imagine that you have sold everything you own and go to , realising that you have spent every- thing on paying for the journey. How would you feel if you were then forced to return? So the feeling is not so much about the danger of coming back, but about the failure of having to return home when everything has been spent. from Swedish Save the Children stressed the childs own perspec- tive on the situation and the individual reactions to fear: It is important to see that all children are different. When you are involved with asylum-seekers, you have to remember that you are dealing with human rights. We need to be more educated in human rights. We talk about children and their way of seeing trauma, when we talk to them about going home. We talk about violence in the society. From their perspective it is dangerous, she commented. from Kosovo compared the present situation with that in her region after the war: Im an activist in the defence of the rights of the child. But being professional in my work doesnt mean that I deny children their rights. Some have had a very hard time in their country of origin, but others have not. In 1999, 600,000 people ed to ; when the war was over they returned home. Most of them have horrible stories to tell, but it is not traumatic to send someone back to his or her country of origin. Nevertheless, we do have some very difcult cases, like when children who were born and raised in are suddenly expelled to Kosovo, a country where they have no rst-hand experience of living. It is known that you can be re-traumatised when you return back, said, and continued, But if you were not traumatised in the war, you cant be re-traumatised. It might be the case for some of the children, but from reading the report it seems to me that very few have experienced real trauma. from was also puzzled about how the symptoms had developed in : In we had one million internally displaces persons, but I never heard of anything like this. We had atrocities, such as children who saw their parents being burned alive in front of them, but it did not create this kind of syndrome. So I do not understand what has happened with the children here in , if they, according to the report, didnt already have mental health problems in . Another aspect, continued, that could contribute to the explana- tion is the role of the extended family in . When people migrate with just the mother and father they become separated from the whole of the good environment at home: it was the grandmother and not the mother who took care of the chil- dren. Now they are left with only their parents. the children do not want to recover and thereby live only with their parents. The situation for minorities from asked why so many Uigurs came to . Do they have special information channels to get informa- tion about ? Burul Makenbaeva replied: After the Soviet Union collapsed, we have seen the rise of a migration industry with a number of companies doing business. Many families looking for a better life use this service. Historically, Uigurs have been more ready to move. The minority has a closer relationship to the land because traditionally they own their own land. Uigurs are creative people. have a great history. They are good musicians, chefs and they own and operate many restaurants. Yelena Vinogradova added that in the northern part of there is a large Uigur population and a strong movement for independence. We have information about the arrest of terrorists; nobody knows where but the people who were arrested were Uigur. also stressed the importance of distinguishing between the situation for the Uigur population in and their situation in Central : In the situation is complicated, with uprisings and severe repression. But in we have not seen any case of Chinese Uigur developing the same symp- toms as the Uigur from the Central Asian countries, although Central Asian Uigurs dont risk the same fate as Chinese Uigurs should they have to return. Differences between the Nordic countries In practice it does not take an appreciably longer time in to reach a decision in normal asylum-seeking cases than it does in or . However, the waiting period for asylum-seekers may be longer in due to the countrys more exible rules for new applications. believes that a big difference between and is the reception centres. In there were six families with children displaying severe withdrawal behaviour. Two of them were immediately sent back to their countries of origin. In one case the child became well on the day they left, at the very moment they considered the game to be over. Two other families returned to . One of them came to with their child in a wheel chair. They did not like the stay so they returned to after 1–2 weeks, leaving the wheelchair behind. At our camp the child was laughing and playing around. Three weeks later we received a call from , asking us to return the wheelchair, as it was needed once again by the same family. What did we do that was so different from ? A big difference between and is that we looked to the child, not the family. From the minute the families arrived they had 24-hour supervision by a nurse. We did not let the mother and child have much interaction without the nurse being present. We believe that this method has been a success. Another thing I noticed about your system in is the lack of trust between healthcare authorities and immigra- tion authorities. In we work very closely together. We quickly built a network so that no one acted alone, he said, adding: Yet another difference between and is the media debate. It becomes a big problem when people who have great authority in healthcare are not discussing healthcare, but rather migration issues. from The Danish Red Cross could also see differ- ences between the Danish and the Swedish system. In the asylum-seeking process has nothing to do with the care, which is run by the Red Cross independ- ently. Our system is not better, but it might have a few answers to your situation. In , all asylum-seekers live in centres, like institutions. In many ways this is not good, but it could have some positive effects for the children. The centres have kindergartens and schools. They are not so much in touch with normal society, but newcomers never nd themselves in the minority; the teachers know who they are. The negative side is that after 3–4 years of living in the centres, it is difcult for the children to move on and learn more, she said. All staff members in the centres in have the same idea of how to meet the children. So if children move from one centre to another, they will be accorded the same treatment and reception. In the centres, the network around the children is very tight. If a child is observed to be having problems, the professional network will discuss and initiate support in the school and healthcare. thats why we havent seen this in . And yet, we have been very aware of the symptoms you have here, added. , the moderator, reminded everybody that in the 1990s also in many asylum-seekers were living in centres. At that time we did not have the problems we are discussing today. With the present system in , the asylum-seeking families are left much on their own. They live separated from other families. Perhaps this is one key to our understanding the problem, she remarked. agreed: The change in our system from centres to individual living is good in intention, but it is not entirely good for the children. We can also see that the syndrome has happened only to children arriving together with their families; we have no cases among children who came alone to . But they, on the other hand, live together with others. also emphasised the need for a multiple analysis: This problem emerged in . We must investigate what happened here, in the families, in society, in the healthcare system and in the media. There is not one explanation, but many; we need to get the whole picture. from stressed the importance of not ignoring the political dimension: I represent the bad guy in society. Our politicians have decided on our immigration policy and we have been assigned to uphold it. We have also signed the Convention and it is our mission to achieve a balance between these two sides. It is easy for me to sit here and point ngers at the media, social welfare, NGOs and others, but in fact we all have our roles to play. , whose task is to evaluate how has handled its reception mission, continued with a reection on the reception system in : I have found that there are things we could improve within our present system. Some of you have pointed at the problems in , with individual living and a scattered organisation for support in the large city. That can be part of the answer, but not all of it. Because the rst cases did not appear in , but at a reception centre in northern , where there was good co-operation among the public authorities. And yet, they had many cases. So this is a very complex problem – and we all have to look at ourselves. added: Another thing that surprises me a lot is the asylum- seeking process and that you consider denying permanent residency to be a trauma. Each country has its own set of rules and it is very important that people know this so that they understand what will happen if they are refused. Sometimes you do harm, even when your intentions are very good. But being an immigrant doesnt mean you are ill. It means you have a reason not to stay in your own country. Is life in too good? So then, why do only children from certain countries develop the symptom, and why only in ? believes that a simplistic and naive perspective has dominated the discussion in during the last two years: Are only those coming to in danger in their countries of origin? Appar- ently those coming to are in no danger, as asylum-seekers there do not need a PUT to stay healthy. In fact, I think we are too good; we are naive when we project our own fears on these families. We should overcome our own obstacles. Im not a doctor, but what kind of physical disease is this that needs a political medicine – PUT? from repeated that she did not believe the political situation in her home country was a cause. The answer lies with those who have made migration a protable business: For sure, we are a developing country, but all countries have human rights problems, even the . But people are not moving from the because of rights violations. Migration is a very good business for some companies and individuals. You contact them and you can choose in which country you would like to seek asylum. has a good social system and in people are told that everything will work out for them in . That is why they are so shocked when they are rejected here, she said, adding: It is very nice that you in are so kind to people from our country, but there are other ways to solve the problem. In the healthcare system is not so terrible as you might have heard from the families. If you would like to give them treatment, you could pay for it in , where people could live in their normal surroundings. , from the Immigration and Work Permit team at the Minis- try of , also saw the problem as being specic for : The problem is very Swedish. The systems are very much alike in the Nordic countries. The only difference is that has a higher number of asylum- seekers. this is part of the problem. I have been working for 25 years with asylum-seekers. In the beginning we had people who really had political reasons, now they are mostly immigrants. Strategies for prevention and cooping What, then, should be done to prevent this situation from reccurring? What should we do about the families that were not granted a PUT? Yelena Vinogradova argued for a change of focus in the Swedish asylum-seeking process: What I have seen in is that when seeking asylum people are given a lot of information about the asylum-seeking process, the social services and the possibility for young people to go to school – about all the good things in . Its like Welcome to Paradise! But I have seen nothing, correct me if Im wrong, about what should be the familys potential strategy if it is not granted and will have to return home. When families come to , everything is handed to them and their lives become someone elses responsibility. We must think about the young people. What will be their strategy if the family doesnt get a PUT? What will they tell their friends when they go back home? Their parents brought them to ; they left part of their life back home. They need some kind of coping strategy that will prepare them for the return if they do not receive a PUT. suggested that perhaps should help people to become reintegrated. She also saw a need for a stronger cooperation with the countries of origin. Another measure to prevent new cases from developing, sug- gested, could be public awareness campaigns in the countries of origin so that people understand that their applications might be rejected in . , from Child and Adolescent Psychiatry in , emphasised the need to talk to the parents about what is real, and not to medicalise the problem: I think we, the paediatricians and child psychiartists, are the bad guys. We have had poor practices for handling the problem, and have made the phenomenon a and psychiatric problem. All parents want to help their children, but in the process of medicalisation, which they are also a part of, they become afraid – through us. In we learned from a few cases and therefore started group discussions with the parents about what is real. About how to prepare and support their child if they are allowed to stay, and also how to handle the situation if they must return after maybe having spent all they have to get. That is a real crisis! But not a trauma to be treated in psychiatry. But group discussions are, in my experience, very effective. The phenomenon stopped spreading. Residency – the key to recovery? One topic of debate is what role receiving permanent residency, PUT, plays in the recovery. Several of the participants were certain that being granted permanent residency plays a key role in the recovery process. As described it: It begins with PUT; they see the mother become full of hope, and the children understand that the danger is over. An interesting part of this is the role of the media and the public discussion focussed on catastrophe. When people get better, the media is no longer interested. This shows the harmfulness of intense media exposure. However, although granting permanent residency, PUT, seems to play an impor- tant role in the recovery process, it is often very difcult to put an end to the symptoms and return to normality. compared it with working with anorexic patients: Once you have passed a certain point, the way back is much longer than the way in, he explained. , from the Sachsska Childrens Hospital, explained that in their experience most of the children regain their functions very slowly; six months for many of them. It takes a long time, especially to talk again. They are like newborn children. A newborn does not look at you. It takes time to get eye contact with the child. It is like a brain injury that recovers only gradu- ally. I have a very deep respect for the syndrome – when the syndrome started; the pattern is an indication of a severe psychological disorder with loss of neurotical functions, she said. The national report has provided important information on the social back- ground of these children; in the opinion of , it unfortunately does not discuss manipulation and intoxication in a scientic way: To enhance our knowledge about the syndrome, I would like to see a meeting with different actors and experts to discuss national guidelines for the diagnostic examination of these children, she remarked. replied that this is a question for the professions, and has asked the Paediatric and the Child- and Adolos- cent Psychiatic associations to give their members some guidelines. Referring to the situation in presented by , of Save the Children wondered if all the children really had the same symptoms. replied that his research has shown that there is a wide variation of symptoms. put another perspective on permanent residency as a medicine: It is nice to be kind, but this is also a social problem. style-behaviour for life. If Im ill, I can be rewarded, and the pattern is set. That is not humanitarian. from in , stressed the importance of changing our way of working with the children: When the problem escalated in our county, we were very concerned with how we should change our own behaviour. Working with the families in hospitals led to a negative spiral. When we instead started a new way of working with the families, in their homes, it gave positive results. Some children recovered completely with- out a PUT. When we changed our approach in order to strengthen the parents ability, it worked. The children recovered when the parents calmed down. Final words by the moderator In her concluding remarks, the moderator highlighted the difculties facing all those working with the children: