Table Of ContentUMEÅ UNIVERSITY MEDICAL DISSERTATIONS
New Series No 1213 - ISSN 0346-6612 - ISBN 978-91-7264-651-3
Child and Adolescent Psychiatry, Department of Clinical Sciences
Epidemiology and Public Health Sciences, Department of Public Health and Clinical Medicine
Umeå University, Sweden
Living in the present with the past:
mental health of Bosnian refugee children in Sweden
AKADEMISK AVHANDLING
som med vederbörligt tillstånd av Rektorsämbetet vid
Umeå universitet för avläggande av medicine doktorsexamen
kommer att offentligt försvaras i Sal B, 9 tr, Tandläkarhögskolan
fredagen den 14 november 2008 kl 09.00
av
Stephen Goldin
Fakultetsopponent:
Adj Professor Anders Hjern,
Epidemiologiskt centrum, Socialstyrelsen
Umeå 2008
Living in the present with the past:
mental health of Bosnian refugee children in Sweden
Stephen Goldin, 2008
Child and Adolescent Psychiatry, Department of Clinical Sciences
Epidemiology and Public Health Sciences, Department of Public Health and
Clinical Medicine
Umeå University, Sweden
New Series No 1213 - ISSN 0346-6612 - ISBN 978-91-7264-651-3
ABSTRACT
The negative impact of war on child mental health has been repeatedly
documented. Still, the majority of children exposed to ethnic and political
violence show no signs of clinical disorder. In Western countries of exile, these
findings have prompted a variety of attempts to evaluate refugee children, in
the hope of identifying and offering support to those children “at risk”. This
study critically examines one such attempt. The aims are fourfold: 1. to
describe the range and pattern of child trauma-stress exposure and mental
health reactions as captured on clinician semi-structured interview; 2. to
critically compare clinician assessment with independent parent, child and
teacher reports; 3. to identify factors of potential risk or protective import for
child mental health; 4. to draw clinical implications: from whom and by what
means can children at risk be reasonably identified?
The target of our study was the entire population of Bosnian-Serbian-Croatian
speaking child refugee families assigned to Umeå and surrounding
municipalities during 1994-95. Fifty families, containing 90 children aged one
month to 20 years, were included in the study. Assessment occurred in two
phases. First, a semi-structured interview was conducted that inquired broadly
as to the child’s family background, trauma-stress exposure, emotional-
behavioral problems, patterns of family functioning, and future hopes. Second,
standardized self-report questionnaires were administered, separately to parent
and child, to provide alternative appraisal of the child’s war exposure, mental
health symptoms, coping strategies, and social network. Teacher evaluation of
child cognitive-social functioning as well as emotional-behavioral problems
was also obtained.
Clinician semi-structured interview revealed the child’s pre-war period as
preponderantly good, and provided richly detailed narratives of child exposure
during war and resettlement that clustered into a limited number of type-
stories. Independent parent assessment captured the same broad strokes of
child war exposure; but both approaches – fixed questionnaire and semi-
structured interview – showed specific areas of blindness. Teenage self-report
offered a disparate but equally rich account of war exposure, while that of
primary school child was significantly less detailed.
Nearly half of the study children (48%) were identified on clinician interview
with one or more mental health problem “demanding further attention”.
Depressiveness was the single most prevalent symptom (31%), followed by
posttraumatic reactions (23%) and anxiety-regressiveness (15%). Independent
symptom appraisal by parent and primary school child was largely concordant
with that of clinician, while teenagers made similar assessment as to who was
in distress, but defined the nature of that distress differently. Teacher report
stood apart, identifying fewer inward emotional problems and asserting the
cognitive-social competence of the vast majority of study children.
Trauma-stress exposure during both war and resettlement presented as an
unequivocal risk to mental health, but accounted for only part of outcome
variance. Additional factors of strong import related broadly to “living in the
present”. Parent impairment of daily routines, child dissatisfaction with school
and an ongoing quarrelsome relationship presented as risk factors. Protection
was associated with parent maintenance of a warm family climate and of
concrete physical-emotional caring, child social ties to physically present
others, including teacher; and above all, a family sense of hope for the future.
Results support the general robustness of our semi-structured approach.
Exploring the child’s present well-being in narrative relation to past and
future, our assessment captured and gave meaning to the complexity of child
exposure and behavior. At the same time, independent parent and child
appraisals provided an additional richness to the retelling and evaluation of
child experience. Particularly the apartness of teacher report underscores the
need to incorporate an outside-world vantage point in the process of risk
assessment.
Key words: child and adolescent, refugee, war, traumatic events, mental
health, PTSD, risk factors, social network, family, coping, multiple informants
UMEÅ UNIVERSITY MEDICAL DISSERTATIONS
New Series No 1213 - ISSN 0346-6612 - ISBN 978-91-7264-651-3
Child and Adolescent Psychiatry, Department of Clinical Sciences
Epidemiology and Public Health Sciences, Department of Public Health and Clinical Medicine
Umeå University, Sweden
Living in the present with the past:
mental health of Bosnian refugee children in Sweden
Stephen Goldin
Umeå 2008
Cover:
the soldier hits my mother
she holds me in her arms
Bosnian boy, 6-years old
•
Copyright Stephen Goldin 2008
Division of Child and Adolescent Psychiatry
Department of Clinical Sciences
Umeå University
SE-901 87 UMEÅ
Sweden
ISBN 978-91-7264-651-3
Printed in Sweden by Print & Media, Umeå 2008
Kärlek lever av
att kärlek se
till Ulla och Simon
•
ABSTRACT
The negative impact of war on child mental health has been repeatedly
documented. Still, the majority of children exposed to ethnic and political
violence show no signs of clinical disorder. In Western countries of exile, these
findings have prompted a variety of attempts to evaluate refugee children, in
the hope of identifying and offering support to those children “at risk”. This
study critically examines one such attempt. The aims are fourfold: 1. to
describe the range and pattern of child trauma-stress exposure and mental
health reactions as captured on clinician semi-structured interview; 2. to
critically compare clinician assessment with independent parent, child and
teacher reports; 3. to identify factors of potential risk or protective import for
child mental health; 4. to draw clinical implications: from whom and by what
means can children at risk be reasonably identified?
The target of our study was the entire population of Bosnian-Serbian-Croatian
speaking child refugee families assigned to Umeå and surrounding
municipalities during 1994-95. Fifty families, containing 90 children aged one
month to 20 years, were included in the study. Assessment occurred in two
phases. First, a semi-structured interview was conducted that inquired broadly
as to the child’s family background, trauma-stress exposure, emotional-
behavioral problems, patterns of family functioning, and future hopes. Second,
standardized self-report questionnaires were administered, separately to parent
and child, to provide alternative appraisal of the child’s war exposure, mental
health symptoms, coping strategies, and social network. Teacher evaluation of
child cognitive-social functioning as well as emotional-behavioral problems
was also obtained.
Clinician semi-structured interview revealed the child’s pre-war period as
preponderantly good, and provided richly detailed narratives of child exposure
during war and resettlement that clustered into a limited number of type-
stories. Independent parent assessment captured the same broad strokes of
child war exposure; but both approaches – fixed questionnaire and semi-
structured interview – showed specific areas of blindness. Teenage self-report
offered a disparate but equally rich account of war exposure, while that of
primary school child was significantly less detailed.
Nearly half of the study children (48%) were identified on clinician interview
with one or more mental health problem “demanding further attention”.
Depressiveness was the single most prevalent symptom (31%), followed by
posttraumatic reactions (23%) and anxiety-regressiveness (15%). Independent
symptom appraisal by parent and primary school child was largely concordant
with that of clinician, while teenagers made similar assessment as to who was
in distress, but defined the nature of that distress differently. Teacher report
stood apart, identifying fewer inward emotional problems and asserting the
cognitive-social competence of the vast majority of study children.
Trauma-stress exposure during both war and resettlement presented as an
unequivocal risk to mental health, but accounted for only part of outcome
variance. Additional factors of strong import related broadly to “living in the
present”. Parent impairment of daily routines, child dissatisfaction with school
and an ongoing quarrelsome relationship presented as risk factors. Protection
was associated with parent maintenance of a warm family climate and of
concrete physical-emotional caring, child social ties to physically present
others, including teacher; and above all, a family sense of hope for the future.
Results support the general robustness of our semi-structured approach.
Exploring the child’s present well-being in narrative relation to past and
future, our assessment captured and gave meaning to the complexity of child
exposure and behavior. At the same time, independent parent and child
appraisals provided an additional richness to the retelling and evaluation of
child experience. Particularly the apartness of teacher report underscores the
need to incorporate an outside-world vantage point in the process of risk
assessment.
Key words: child and adolescent, refugee, war, traumatic events, mental
health, PTSD, risk factors, social network, family, coping, multiple informants
•
