sou · GUB3114 · 2007-01-01 00:00:00 — In this process knowledge from the childrens countries of origin is a necessary contribution. This is the rst paragraph of the invitation to the international workshop on asylum-seeking children with severe withdrawal behaviour that was held in on 4th to 5th 2006. The purpose of the workshop was to move one step further in understanding the situation and, of course, in knowing how to meet the childrens needs in the best way. This document is the result of the workshop. The material has been edited for English language usage to make it more comprehensible. The aim has not been to all the participants behind a joint declaration, but rather to highlight the issue from different perspectives. It is our view that all the participants, in one way or another, have helped us gain knowledge and thus further enhance our under- standing of this very complex issue. We hope that this workshop report will stimulate the ongoing dialogue between the public authorities and organisations that are working to support the children and their families. In particular we hope that the knowledge and experience of the experts from , , , , , , and will inspire further contacts and exchange of knowledge and experience. The perspectives, experiences and knowledge put forward in this workshop are important contributions to our ongoing national coordination mission. The purpose of this was to enhance our understanding of the situation of asylum-seeking children in with severe withdrawal behav- iour, and how to meet the childrens needs. In order to broaden the perspective experts from the childrens countries of origin were invited to share their experi- ences and knowledge. This, together with the results of the in-depth study Asy- lum-seeking Children with Severe Withdrawal Behaviour – Trauma, Culture, Asylum Process and short presentations made by , and the Child and Adolescent Psychiatry in , formed the basis for reection and discussion during the one and a half day long workshop. The participants represented public authorities, interest organisations, non-governmen- tal organisations, healthcare and social services institutions from all across . Of the ve invited child experts from , , , and , four represented local non-governmental organisations working with healthcare and child welfare and one represented a university clinic centre. Also participating were experts from , and . The discussion can be summarised as follows: Co-operation between various public authorities around the child and family is of vital importance for giving the best support. This has been a factor for success in , and also in where cooperation and consensus about how to treat and support the child and family is believed to be an important reason for stopping the epidemic. Lack of respect and distrust between public authorities, healthcare and migration authorities stands out as a troublesome situation that does not promote the childrens health. The medias role in this was also a subject for discussion. The Swedish reception system for asylum-seekers is based on integration in the ordinary Swedish welfare systems and society. This means, for example, that many asylum-seekers arrange their own housing arrangements, use the public healthcare system and their children go to ordinary schools. In the larger cities it is more difcult to nd a place to live, which has resulted in families having to change domicile often. In and most asylum-seekers live in centres where they have access to special healthcare facilities and schooling for their children. Contrary to it is not the migration authority that is in charge of the reception centres, but rather municipalities and/or NGOs. The discussion focused on differences between the systems and the childrens need of continuity and predictability. To be denied permanent in is very hard for the children and their families. Many families fear, for different reasons, to return to their country of origin. One of the factors that make it difcult to return is that many families have invested all their assets in the migration to . When residency in is denied, all their assets are exhausted but they have had a taste of another life; it is then very hard to repatriate. One question is how to help children nd a way to handle this situation, preferably early in the asylum-seeking process. Another question is if we need more cooperation with the countries of origin to facilitate the familys repatriation. Many experts report that private companies in the asylum-seeking families countries of origin do business on peoples to leave their country. The information that these companies give is one-sided and often misleading. They raise false hopes and expectations, promise permanent residency in the host country and in some cases advise the migrants in detail on how to act when they arrive. Is there some way to get around this problem? The role of the Child- and Adolescent Psychiatry (CAP) in the asylum- seeking process needs to be discussed and claried. When working very close with the families, it is hard to be reective/objective and not take sides and become an activist for the family. A crucial issue is that it is the responsibility of the CAP to make out a health certicate for the asylum-seeker. With the new asylum-seeking process introduced in 2006, the question arises of whether this situation should be handled differently. , political advisor to , the Swedish Minister for Migration and Asylum Policy, welcomed the participants with the hope that they would contribute to a better understanding of the situation. The minister ap- pointed as national coordinator in 2004, with the mission to information and conduct investigations. But the initiative was more than just another study: It was rather an activist approach with the mission to bring together various stakeholders and experts for concerted action and at the same time to encourage new methods and networks in , said. saw several explanations to the decrease in the number of children with severe withdrawal behaviour. Better knowledge among professionals working with the children is one important explanation. He also pointed out the presidential decision by the government in 2005 that claried to migration authori- ties how to decide in asylum cases. Between the 15th of last year and the 30th of this year, we have had a temporary asylum law which granted permanent permits to a large number of families. Most of the children recovered after permanent residency was granted, stated. Background to the current situation , Research Leader and author of the report Asylum-seeking Children with Severe Withdrawal Behaviour – Trauma, Culture, Asylum Process (SOU 2006: 49), presented a background to the current situation. The following is a short summary of his presentation. Until 2005 there was research on the situation of children with severe with- drawal behaviour, only a short mapping had been done and there were a few reports from doctors and psychiatrics. So the rst task for the national coordinator was to dene and limit the problem. This resulted in the rst report Asylum-seeking Children with Severe Withdrawal Behaviour – Status of Knowledge and Survey. The basis of the rst report was a study on the number of children, their symptoms, family situation, and also a mapping of the research that had been done so far. Totally 424 asylum-seeking children were reported to have been treated by the child and adolescent psychiatry from 2003 until . It was important for us to see if any other country had reported the phenom- enon. We decided to contact experts in other European countries that receive asylum-seekers. A short questionnaire was sent to seven European countries and to more than 70 organisations. The questionnaire had to include a description of the symptoms, otherwise the respondents would not have understood the question. We received negative answers from all the countries – the phenomenon was unknown in Europe. Science is still unable to explain why the phenomenon of asylum-seeking children with severe withdrawal behaviour appeared in in the early 2000s and then developed into an epidemic-like condition in 2005, explained. After the rst report it was urgent to take the analysis a step further with an in-depth study. The new report consists of three parts based on these three questions: Why did the problem occur only in and rst in the 2000s? Why are only asylum-seeking children from certain areas in the world affected? What has contributed to the incidence of the problem – traumatising events in the home countries, the asylum process in or other factors? The rst part of the study examines the political and social contexts of the coun- tries/regions from which the absolute majority of asylum-seeking children with severe withdrawal behaviour have come in recent years. The second part is a comparative study of the asylum-seeking process in , and . The third and last part is a study of the childrens/families experience of and societys view of the problem. The report includes a new survey of the numbers of asylum-seeking children who show severe withdrawal behaviour. The new updated survey shows a clear downward trend in the number of asylum-seeking children with severe withdrawal behaviour. In 2005 our survey identied 178 asylum-seeking children with severe withdrawal behaviour. At the beginning of 2006, 65 asylum-seeking children with these symptoms were treated by child and adolescent psychiatric services. time, a further 82 children, former asylum-seekers who had been granted permits, were being considered for treatment. A follow-up in showed that this gure had fallen in less than a month to 59. The childrens recovery almost always took place after a permit had been issued. Conclusion from the report The study has found no relation between the events or the culture in the countries/ regions whose citizens are overrepresented in the statistics and the incidence of severe withdrawal behaviour among asylum-seeking children from these countries/ regions. has any information emerged showing that severe withdrawal behav- iour had been observed in children at risk in these countries, neither during nor after war nor among internal refugees in refugee camps. A comparison between the asylum-seeking process in the three Nordic coun- tries shows that asylum policy is in no way more rigid nor more restrictive than that of the other Nordic countries, taking three factors into account (see futher in the report). In practice, it does not take appreciably longer time in to reach a decision in normal asylum cases than it does in the other Nordic countries. The waiting period for asylum cases can at times be longer in due, for example, to the countrys more exible rules for new applications. Other circumstances that prolong the waiting period are, for example, the lack of a passport or equivalent (91 per cent of the cases) and that it takes time to transform a rejected application to an approved one. The study has not been able to nd any evidence that trauma (apart from possibly in individual cases) could be the explanation for the asylum-seeking childrens withdrawal symptoms in . The culture in the childrens countries of origin may be described as holistic, where a predominante idea is that a person must be willing to sacrice his or her life, happiness and own interests in favour of those of the family, and where chil- dren from an early age are socialised in the idea that they are rst and foremost members of the family and only thereafter individuals. However, culture can explain certain behaviours or individual peoples attitudes, but it can never be the only explanation for a social phenomenon such as asylum-seeking children exhibit- ing severe withdrawal behaviour. No general explanations can be offered for the emergence of the phenomenon. The following circumstances may, however, alone or in combination, explain indi- vidual cases of children with severe withdrawal behaviour: the asylum-seeking process and ambiguous attitude when processing decisions to reject applications in asylum cases; traumatic or stressful events in the country of origin, in other countries of asylum and in ; the childs previous state of mental health; the parents capacity to care for the child; and cultural patterns of thought and behaviour. The problem is complex and requires therefore a multifactor explanatory model. An extract from the presentation at the workshop: , Director of , , gave a brief overview of the situation in her country: is the largest country in South Caucasus with a population of 8 million people; of them 2 million are under 14 years of age. The ofcial unemploy- ment rate is , NGOs say . is an oil-producing country and should have good possibilities for development. A mayor problem is the corrupt system. In 1988 and until the cease-re was signed in 1994, Armenia and Azerbai- jan were in armed conict over Nagorno-Karabakh. The conict has greatly impacted the development of the country. lost nearly of its territory and has had to support some 1 million refugees and internally displaced people (IDP). Furthermore, after the war most Armenians left . There are also many refugees coming from Chechnya, and other countries into Azervaijan. Many children from Chechnya have experienced much worse atrocities than what you have heard about from the families seeking asylum in . Still they dont show the same withdrawal behaviour, remarked. Psychiatric treatment in is not so bad, according to . The main outpatient clinic for children is in the capital . The problem is that the clinic is for neurological as well as psychiatric disorders. Among internally displaced children (IDP Children) we can see psychological Some of the symptoms are fear, anxiety, aggressive and auto-aggres- sive behaviour, low self-esteem, depression, insomnia and nightmares. Many children have a low self-esteem. I visited one camp; it was at Christmas-time. The children said: is not going to visit us, he only visits local children, not us, because were IDP. The education system in is very authoritarian and the same goes for the relations within the family. Violence against children is not recognised and there is no child policy in the country. Parents can inuence, manage and abuse children, and we believe that this could also inuence what happens here in . But at the same time, I dont see any link between our culture and what happened in . is not a country where it is dangerous to be politically . The television is under government control but we have opposition newspapers and opposition parties. People are not afraid to speak out. There is no prejudice against mothers living alone with their children. Two million men are in working. The problem you encounter in is social and economic, not cultural, she continued. An extract from the presentation at the workshop: Yelena Vinogradova, Program Director of the Accord, gave a brief overview of the situation in , a large country (4 times the size of ) with 15 million habitants. Twenty-six per cent of the population in is under 15 years of age. School enrolment is high and there is ethnic diversity with many minorities. Representatives of more than 130 nationalities live in . Fifty-seven per cent of the population are Kazakhs. During the years 1995-1999, the general feeling was of a country on the verge of collapse, but did not have any ethnic conicts, no war. Now many ethnic Russians, Koreans and Germans are returning to to start businesses. When somebody tells you that he or she was a victim of violence or political issue, it can be true. Perhaps one or another family can be affected by the situa- tion; for example, neighbours might not accept you because you are from another ethnic group. But there is no systematic discrimination against Uigurs or other ethnic groups, Yelena Vinogradova explained. In fact, people would have difculty telling who comes from which group. Or as Yelena put it while showing workshop members a photo of a group of teenagers: Take a look at this picture; its from my sons school. Can you tell me who is Kazak, who is Uigur, who is of German origin? No, and no one else would be able to do so either, she remarked, stating further that the current migration problem in has nothing to do with the relations among the various ethnic groups in . An extract from the presentation at the workshop: Burul Makenbaeva, Executive Director of the NGO Mental Health and Society in Bishkek, , gave a picture of a multicultural society with more than eight ethnic groups. There is a high level of corruption and strong migration trends in , both within the country and to countries abroad, mostly to , , and . lacks the large oil reserves that some of the neighbour- ing countries possess. There have been some campaigns to turn public attention to the rights of the child. Democracy is not very well developed, but several NGOs monitor the human rights situation. There is discussion of the need to reform the constitutional system. In post-totalitarian countries, many social policies are top-down. We do not have enough capacity to work from bottom-up. Another problem is the low capac- ity of the civil society, Burul explained. The Uigur tribe has historically collaborated with the Kazak tribe, seeking protection from the strong Chinese empire. In this, has been an ally. Uigurs and other communities are developing their own identities. The Islamic inuence is growing. People speak their native languages in the family but not in school. In general, there are no serious ethnic conicts in the country. Before I came here I met with Uigur leaders. They say that they have the same problems as other ethnic groups, such as corruption, complaints about the educational system, Burul said. There is a National Mental Health Policy with a National Mental Programme since 2001. ratied in 2005. However, since 1998 there has been a reduction of mental health profession- als working with children. There is only one adolescent centre for the whole country. The treatment is free of charge, but that is not enough. An extract from the presentation at the workshop: , Manager within the NGO Amity in , gave an introduc- tion to the situation in . As the federation is now being divided into two countries, her presentation concerned only. Of a population of 7.5 million, or 1.5 million are below 18 years. Ten per cent of the population live below the poverty line, and many young people have already left the country due to the economic and social situation. The refugee situation started in 1992 with the wars in former . In 1999 a new wave of refugees arrived, this time from Kosovo. The people constitute a large group among the refugees. Many refugees and internally displaced persons have difculty adapting to the new situation; there are problems in meeting basic needs and psychosocial problems as well. The most vulnerable children are those who have lost one or both parents, or those with families that have been divided due to ethnic reasons. In the population there have also been some specic problems. The have a nomadic way of life with a tendency towards emphasising group acceptance. They enter marriage at age 14-15 and they live in multigenerational households. The structure is highly patriarchal. At the same time, they have healthy inner resources for survival. It is important to help children to t in with their peers from the domestic population. It is also important to work with the parents, as they do not understand the necessity for integration. The way of bringing up their children gives the children a wide scope of freedom; children are treated like small adults. But it is freedom with responsibil- ity. For example, the children are expected to contribute to the familys income or to take care of younger brothers and . It is possible that this has given them an extra responsibility to ensure that the family will be granted in , and that this, in turn, has resulted in the behaviour you can see, explained. An extract from the presentation at the workshop: , Head of Child and at Univer- sity , explained that when she returned to Kosovo in 1999 there was no child psychiatry at all in the country. Now there is a mental health clinic in Kosovo. The government talks about giving priority to the health of the young population, but there is no budget for mental health work with children. Everyone who has lived through the war years in Kosovo is traumatised in one way or another. Initially, many NGOs and other donors were working in the coun- Now the donors are phasing out. One principle for her work is to make use of best practices from other countries and to work with other entities in Kosovo, for example with the primary health care. Among the important aspects to take into consideration, mentioned the following: Transition (status, economy, politics, values, nuclear family etc) Conicts (society, individual, new values) We think of ourselves as a group, but now the norms are changing and we are becoming more individualistic. Traditionally, families in Kosovo have been strong, relying on the extended family, but when the social structure changes to the nuclear family, we lack the infrastructure to support the families in this process. We are working a lot with adolescents who nd themselves caught between the new and the old and who face many problems of adjustment. clinical experience is that children in the Kosovo culture express their distress through physical illness. She believes that the syndrome in is more a learnt behaviour than a disorder. We have Kosovo refugees in many countries, so maybe there is something in that makes them develop such a syndrome only there; maybe you have a law that supports such a syndrome? Yes – if you are very ill you can stay – so we have found the solution! I may sound ironic, but I believe that this has very much to do with what you experience in . Also, people believe in . You have a very good structure and a long reputation for receiving refugees. the loss people are facing in is bigger when they do not get accepted. They are not only losing the possibility to stay, but also their belief in as heaven, she concluded. , Director at of , presented an overview of the role of the board: is a government agency under the . The Boards overall aim is to promote good health and social welfare, a high quality care on equal terms for the entire population. issues guidance to the health and social service professions on standards of professional conduct and ethics. Based on experiences presented at an expert hearing in 2005, the board published in October 2005 a guidance about asylum-seeking children with severe withdrawal behaviour. The guidance is written both for politicians and personnel in county councils and the municipalities (in healthcare and the social services). highlighted one problem that was taken into account when formu- lating the guidance; namely, that many families move around in during the asylum-seeking process. This is one reason a coordinator is needed. In the guidance we focus on how to prevent and how to discover early these children. We suggested that each child and family have a coordinator. The coordina- tor would be responsible for the continuity of the professional support with networks around the child. If the family moved within , the coordinator would nd a new coordinator at the new place so that the needs of the children can still be fullled. Also, we point out that there is the duty for all personnel in the Health and Social services to report on the situation if they nd that a child is being harmed or injured. It is our experience that earlier this reporting was not so good, explained. , Head of Child- and Adolescent Psychiatry (CAP) in , gave a presentation of the situation in capital city.