Understanding the mechanisms of transgenerational mental health impacts in refugees
Authors: Grant Sara, Peter Brann
Journal: The Lancet Public Health (2018)

The trauma experienced by refugees has transgenerational mental health impacts.1Silove D Ventevogel P Rees S The contemporary refugee crisis: an overview of mental health challenges.World Psychiatry. 2017; 16: 130-139Crossref PubMed Scopus (306) Google Scholar, 2Fazel M Reed RV Panter-Brick C Stein A Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors.Lancet. 2012; 379: 266-282Summary Full Text Full Text PDF PubMed Scopus (767) Google Scholar A study by Richard Bryant and colleagues3Bryant RA Edwards B Creamer M et al.The effect of post-traumatic stress disorder on refugees' parenting and their children's mental health: a cohort study.Lancet Public Health. 2018; 3: e249-e258Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar in The Lancet Public Health provides evidence about the specific mechanisms by which these impacts might occur. Bryant and colleagues3Bryant RA Edwards B Creamer M et al.The effect of post-traumatic stress disorder on refugees' parenting and their children's mental health: a cohort study.Lancet Public Health. 2018; 3: e249-e258Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar studied more than 400 families who had come to Australia as refugees, primarily from Afghanistan, Iraq, and Iran. They investigated the associations between exposure to trauma, parental post-traumatic stress disorder, parenting style, and children's psychological difficulties. They used path analyses to investigate direct and mediating effects over time. Around a quarter of parents met criteria for likely post-traumatic stress disorder, and children of those parents experienced increased psychological distress. These effects were mediated by harsh parenting style and post-migration stressors. The study provides one of the largest prospective studies of refugee families, and is one of the first studies to investigate the mediating effects of parenting style. Only 6·7% of refugee children scored in the psychological difficulties range on the parent-rated Strength and Difficulties Questionnaire (SDQ).4Goodman R The Strengths and Difficulties Questionnaire: a research note.J Child Psychol Psychiatry. 1997; 38: 581-586Crossref PubMed Scopus (8973) Google Scholar This proportion is lower than the 10·1% estimate for the Australian population5Lawrence D Johnson S Hakefost J et al.Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Commonwealth of Australia, Canberra, ACT2015Google Scholar and estimates of up to 13% in Australian refugee children.6Ziaian T Anstiss Hd Antoniou G Baghurst P Sawyer M Emotional and behavioural problems among refugee children and adolescents living in South Australia.Aust Psychol. 2013; 48: 139-148Crossref Scopus (27) Google Scholar, 7Zwi K Woodland L Williams K et al.Protective factors for social-emotional well-being of refugee children in the first three years of settlement in Australia.Arch Dis Child. 2018; 103: 261-268PubMed Google Scholar However many of the studies5Lawrence D Johnson S Hakefost J et al.Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Commonwealth of Australia, Canberra, ACT2015Google Scholar, 6Ziaian T Anstiss Hd Antoniou G Baghurst P Sawyer M Emotional and behavioural problems among refugee children and adolescents living in South Australia.Aust Psychol. 2013; 48: 139-148Crossref Scopus (27) Google Scholar, 7Zwi K Woodland L Williams K et al.Protective factors for social-emotional well-being of refugee children in the first three years of settlement in Australia.Arch Dis Child. 2018; 103: 261-268PubMed Google Scholar produced these estimates using an SDQ cutoff score of 17, compared with the score of 20 used by Bryant and colleagues. All of these might be underestimates: parents typically under-identify emotional problems compared with adolescent self-reports, and refugee parents might particularly under-report their children's psychological difficulties.6Ziaian T Anstiss Hd Antoniou G Baghurst P Sawyer M Emotional and behavioural problems among refugee children and adolescents living in South Australia.Aust Psychol. 2013; 48: 139-148Crossref Scopus (27) Google Scholar Reduced stressors after resettlement seem to be protective for children's wellbeing7Zwi K Woodland L Williams K et al.Protective factors for social-emotional well-being of refugee children in the first three years of settlement in Australia.Arch Dis Child. 2018; 103: 261-268PubMed Google Scholar and, in this study, no participants had experienced the mandatory detention imposed on some refugees to Australia. The SDQ might also be insensitive to specific psychological impacts of trauma in refugee populations.8Stolk Y Kaplan I Szwarc J Review of the strengths and difficulties questionnaire translated into languages spoken by children and adolescents of refugee background.Int J Methods Psychiatr Res. 2017; 26Crossref PubMed Scopus (26) Google Scholar Silove points out1Silove D Ventevogel P Rees S The contemporary refugee crisis: an overview of mental health challenges.World Psychiatry. 2017; 16: 130-139Crossref PubMed Scopus (306) Google Scholar that the story of refugee mental health should not be seen as uniformly negative. Three quarters of refugee parents in this study did not have post-traumatic stress disorder. This wide spectrum of outcomes underlines the opportunity for effective intervention. Bryant and colleagues' findings highlight particular groups of young people at risk. The greatest differences from population norms occurred in emotional and peer problems, particularly in young women, rather than in conduct problems and hyperactivity. Hence, target areas for intervention could include identification and treatment of parental post-traumatic stress disorder; a focus on protective parenting styles; and strategies for responding to emotional distress and improving peer relationships of children and adolescents, particularly for girls. Health care for refugee families should sit within a broader context. Protective factors for the mental health of refugee children include a strong sense of cultural and ethnic identity, broader community integration, access to opportunities for economic and social participation, and the avoidance of stigma and discrimination.2Fazel M Reed RV Panter-Brick C Stein A Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors.Lancet. 2012; 379: 266-282Summary Full Text Full Text PDF PubMed Scopus (767) Google Scholar, 7Zwi K Woodland L Williams K et al.Protective factors for social-emotional well-being of refugee children in the first three years of settlement in Australia.Arch Dis Child. 2018; 103: 261-268PubMed Google Scholar, 9Correa-Velez I Gifford SM McMichael C The persistence of predictors of wellbeing among refugee youth eight years after resettlement in Melbourne, Australia.Soc Sci Med. 2015; 142: 163-168Crossref PubMed Scopus (73) Google Scholar In many developed countries the two goals of strong cultural identity and broad community integration have sadly become seen as increasingly incompatible. Until recently, Australia's approach to multiculturalism valued the maintenance of a strong ethnic and cultural identity, seeing this as normative and helping to define the broader Australian sense of community.10Soutphommasane T Cultural diversity in leadership: what does it say about Australian multiculturalism?.J Aust Stud. 2017; 41: 287-295Crossref Scopus (4) Google Scholar However, more recent political and social trends have threatened this delicate balance. Finding a compassionate response to the global refugee crisis has caused debate in many developed countries. Ideally, evidence regarding refugee mental health should provide some empirical common ground in these debates. Studies such as that by Bryant and colleagues continue to build the evidence. Mental health problems affecting some refugee families, left untreated, will leave a legacy of individual and transgenerational suffering, community impact, and economic cost. Developed countries such as Australia have the social and financial resources to respond. Do we also have the will to respond to the emerging evidence? For more on population norms see http://www.sdqinfo.com/g0.html For more on population norms see http://www.sdqinfo.com/g0.html We declare no competing interests. The effect of post-traumatic stress disorder on refugees' parenting and their children's mental health: a cohort studyPTSD in refugees is associated with harsh parenting styles, leading to adverse effects on their children's mental health. Programmes to enhance refugee children's mental health should account for PTSD in parents and caregivers, and the parenting behaviours that these children are exposed to. Full-Text PDF Open Access