‘This doctor,I not trust him,I’m not safe’: The perceptions of mental health and services by unaccompanied refugee adolescents

Abstract

Background:

Unaccompanied refugee adolescents are a small but clinically significant group. This group is vulnerable with physical and psychiatric needs which are often not met. There are several barriers to providing care for this group, originating with the refugees but also due to service provision.

Aims:

The aim of this research is to appreciate the views and perceptions that unaccompanied minors hold about mental health and services.

Method:

Fifteen unaccompanied adolescents engaged with mental health services were interviewed, and thematic analysis was employed to explore relevant issues.

Discussion:

Their views reflected a range of opinions on mental health and the treatments they received, but many held negative attitudes toward mental health and had a lack of trust in services. This could be explained by their descriptions of their experiences within their home country of psychiatric care, their experiences of being a refugee/asylum-seeker or cultural differences.

Conclusion:

We argue it is important to engage this group in the development of policy and practice in child mental health, and in developing services.

Keywords

Refugee adolescents mental health stigma qualitative perceptions

Introduction

Globally, there are approximately 12 million refugees and asylum-seekers, and in 2012, there were 193,510 refugees and 17,170 asylum-seekers in the United Kingdom (United Nations High Commissioner for Refugees (UNHCR, 2012)). It is recognised that approximately half of the world’s refugees are adolescents, with unaccompanied refugee/asylum-seeking adolescents being defined as those under the age of 18 years, separated from parents and attached to no significant adult (Thomas & Byford, 2003). In 2011, 6% of UK applications were from unaccompanied asylum-seeking adolescents (Refugee Council, 2012), with 11% being under the age of 14 years, 29% aged 14–15 years and 60% aged 16–17 years (Home Office, 2004). Hence, the majority of this group falls within the adolescent range.

Our understanding of refugees and their service needs remains fragmented due to a lack of evidence (Cox, 2011), but research suggests that this group is at high risk of developing mental health problems due to their previous experiences (Fazel, Wheeler, & Danesh, 2005). They are likely to need mental health services (Huemer & Vostanis, 2010), but struggle to get their needs met (Ellis, Miller, Baldwin, & Abdi, 2011). While the reasons are unclear, several factors implicated include the communities’ stigma of mental health (Lustig et al., 2004), their own attitudes and mistrust of authority (Ellis et al., 2011). Additionally, appropriate services may be unavailable or insufficient for their needs (Vostanis, 2010).

Unaccompanied asylum-seeking/refugee adolescents are an especially vulnerable group due to their social/personal circumstances and the lack of responsible adults safeguarding their interests (Thomas & Byford, 2003). Unaccompanied refugee adolescents, in particular, have greater psychiatric morbidity than the general population (Huemer et al., 2009), and up to 47% suffer severe symptoms of anxiety, depression and posttraumatic stress (Derluyn & Broekaert, 2007). This is important as the cumulative exposure to traumatic events is associated with a range of negative psychological outcomes (Fazel, Reed, Panter-Brick, & Stein, 2012; Thabet, Karim, & Vostanis, 2006), but despite this, the mental health trajectories of this group remain diverse (Ellis et al., 2011).

The stress faced by these young people includes involuntary displacement from their home (Ellis, Kia-Keating, Yusef, Lincoln, & Nur, 2007) and can also be a consequence of discrimination and resettlement (Montgomery & Foldspang, 2008). A ‘triple stigma’ can arise from (1) associations with their refugee/asylum-seeking status, (2) mental health problems and (3) resultant from their unaccompanied situation.

Understanding the perspective of unaccompanied refugee/asylum-seeking adolescents with regard to services is essential so that they can be tailored to meet their specific needs (Rutter, 2003). In contemporary practice, these young people may receive the appropriate treatments, but there are concerns that there is sometimes a failure to consider the distress experienced and the adversities encountered (Ehnholt & Yule, 2006). Even within available services, treatments such as psychological therapies need to be adapted, as application of an unaltered Western model of treatment can be meaningless for them (Lynch, 2001). Therefore, refugee/asylum-seeking adolescents can affect service design and delivery, and this article seeks to explore their perspectives.

Methods

Participants

The adolescents and their carers were referred to a specialist child and adolescent mental health service (CAMHS) for ‘looked-after’ children following problems encountered at ‘home’ or school. They were recruited through Local Authorities from Central England (Table 1). A total of 15 adolescents aged 15–18 years and their carers consented (carers’ data represented elsewhere). Participants were mostly male, typically from Afghanistan, but also from Iran, Somalia and Eritrea. All had English as a second language, and while an interpreter was available for all, most chose to speak for themselves.

Table 1.

Table of participants.

Number	Gender	Age in years	Nature of the mental health problem	Country of origin	Immigration status
1	M	18	Depression, Self-harm	Afghanistan	Refugee
2	M	15	PTSD, Anxiety	Iran	Asylum seeking
3	M	17	PTSD, Depression, Anxiety	Afghanistan	Asylum seeking
4	M	17	Self-harm, Adjustment reaction	Afghanistan	Refugee
5 (Declined)	F	18	PTSD, Substance misuse	Somalia	Refugee
6	F	17	PTSD, Depression, Self-harm	Eritrea	Asylum seeking
7	M	15	Learning difficulties, Dissociative disorder, PTSD	Afghanistan	Asylum seeking
8	M	17	Psychosis	Somalia	Refugee
9	M	16	Self-harm, PTSD, Anxiety	Afghanistan	Asylum seeking
10	M	17	PTSD, Depression	Afghanistan	Refugee
11	M	16	Self-harm, Adjustment reaction	Iran	Refugee
12	M	17	Self-harm	Afghanistan	Asylum seeking
13	M	18	Depression, Adjustment reaction	Afghanistan	Asylum seeking
14	M	15	Depression, Self-harm, Substance misuse	Afghanistan	Asylum seeking
15	M	18	PTSD, Self-harm	Afghanistan	Refugee
16	M	18	PTSD, Impaired sleep	Afghanistan	Refugee

PTSD: posttraumatic stress disorder.

Data collection

Face-to-face semi-structured interviews were audio-recorded to allow an exploration of issues from the participant’s perspective. Interviewing continued until data saturation was achieved (O’Reilly & Parker, 2013a).

Data analysis

Data were analysed using thematic analysis, allowing meaning to be drawn from data through the emergence of patterns (Boyatzis, 1998). Data were transcribed verbatim and independently coded to improve reliability. Categories were examined systematically to identify core issues to address the aims of the research. Due to the language difficulties, some questions required rephrasing, and some answers initially lacked coherence or were fragmented. Therefore, the representation of these answers as direct quotations is fragmented in places.

Ethics

Ethical approval was obtained through the National Research Ethics Service (NRES, UK).

Analysis

In relation to mental health, four themes emerged: descriptions of mental health, mental health and asylum-seeking/refugee status, experiences of using services and opinions of treatments.

Theme 1: Descriptions of mental health

Adolescents’ definitions of mental health were variable. Some were able to describe mental health along classical Western lines; however, others defined it differently, denying any problems, using a physical explanation of their symptoms or using fairly negative/pejorative language:

1. Mental health, means when some people’s not happy. (Respondent 6)

2. I think I was before going mental very in mind, my brain wasn’t working seriously. (Respondent 13)

Although there were language difficulties, some respondents were able to relate their mental health directly to their emotions, ‘not happy’. These descriptions were fairly clear and would enable services to understand them. While some were able to clearly articulate their problems, others described their problems in more abstract ways. This may have been simply due to linguistic issues or may reflect particular cultural views. Attributing the condition to the ‘mind’ or ‘brain’ allowed them make sense of their experiences and demonstrates a significant degree of insight.

Many of the adolescents denied having mental health problems, even on direct questioning, despite engagement with services. These participants tended to describe physical symptoms as the cause:

3. He says I’m not (.) I am ill because I’ve got a headache and my eyes hurt. (Respondent 7: interpreter)

4. I don’t have any (.)uh (.) I mean I’m not um (.) mental problem (.) I go (.) I saw the bad dream I didn’t sleep then sometimes. (Respondent 6)

These respondents are using alternative descriptions for their mental state. For example, Respondent 7 attributed their ill health to parts of their body, rather than directly to emotions. The interviewer sought clarification, but he was clear that he had no mental health problem. This denial of mental health problems was also shared by Respondent 6: ‘I’m not mental problem’.

In addition to using physical descriptions or denial, some used terminology that would be considered politically incorrect in Western culture:

5. I don’t want anyone say [A] is crazy. And I was very crazy actually because I try twice kill myself, I try hung myself. I cut myself, I really was crazy. (Respondent 11)

6. I say no I don’t want to go hospital to be with the mentals or that kind of people. (Respondent 1)

7. My friend tell me they can give you an injection and they send you in the crazy hospital. (Respondent 9)

Even when they acknowledged they had mental health problems, they still expressed negative attitudes towards mental health, both for themselves and others. It is not unusual for young people to use negative concepts to describe mental health (O’Reilly, Taylor, & Vostanis, 2009). This is demonstrated by the phrases ‘mentals’, ‘crazy’ or ‘that kind of people’, which together with the concept of a ‘crazy hospital’ positions those with mental illnesses as a socially excluded group. Evidently, the labelling of mental health problems from their perspective is synonymous with being removed from society and incarcerated.

Theme 2: Mental health associated with asylum-seeking/refugee status

Commonly, mental health problems were associated with their experiences of being asylum-seekers/refugees. These experiences tended to be grouped into their own personal encounters, fears for their families’ welfare and worries about immigration status:

8. Cuz I had a difficult journey and you know for me it was difficult to cope or live alone. (Respondent 10)

9. I’m seventeen, I’m alone, I’m scared. (Respondent 14)

It is well documented that many asylum-seeking/refugee young people encounter further trauma or abuse during their journey, as well as fears of deportation (Huemer & Vostanis, 2010). This has potential to impact on mental health which is oriented to by the respondents who report that they are ‘alone’. In addition to these stresses, some respondents report having considerable anxiety about the welfare of their families/communities left behind:

10. I’m here I don’t know my family about (.) worry about my family. (Respondent 3)

11. I was thinking about my family so that’s why I was sad. (Respondent 14)

These responses are entirely appropriate to being unaccompanied minors who have been separated from their homes. Other respondents describe the hostile environments in the countries of origin, which contrasts with their experience of those in the host country:

12. And my mum feel now died, I feel she died, now is (?), now my mum is live …. My brother died. He got gunshot, someone kill him, my uncle dead. And my uncle dead, three uncle dead, my father died. (Respondent 8)

13. I see lots of problems in my age when I was in Afghanistan so from age ten I been seeing people die in front of me I’ve seen people killing each other in front of me (.) dead bodies in front of me. (Respondent 1)

Although the experiences of these respondents have been extreme, it is difficult to ascertain the relative impact of these events on their mental health or whether the subsequent dislocation and integration into a new environment may have been more significant. Potentially, it is a cumulative effect and therefore care needs to be taken when interpreting multiple layers of events. Most individuals described multiple traumas which could have contributed to their problems. Obviously, in addition to the dislocation from their home country, there remains uncertainty around the immigration process which may affect their mental health.

Theme 3: Experiences of using services

The respondents talked about their experiences of services in the United Kingdom, but also care provided in their home country. Despite this engagement with UK services, there was a general distrust of them. Some of this appears to have a cultural element feeling different from the host population:

14. English people and doctor people, you don’t understand me anything at all for me. (Respondent 8)

15. Because in here everything is different in England. It’s like England is very healthy for everybody, like hospitals, doctor, family, anyone but, no, in Iran I don’t think is like someone like, if I have problem, I don’t think it’s like someone like help me, is only my parent or someone else. (Respondent 11)

Both respondents felt that the cultural differences impacted on services’ understanding of them, which may have implications in creating an optimal environment for any service delivery. Complicating matters further appear to be a more fundamental distrust of health services:

16. This doctor, I not trust him, I’m not safe. (Respondent 8)

17. I didn’t say to anything about my problem, I didn’t tell it to anybody, you know, because I don’t trust anybody. (Respondent 9)

Considering the traumatic events and possible exploitation of these young people, mistrust is entirely understandable and continues to act as a protective mechanism. However, this is another barrier for the adequate engagement with services. This mistrust can translate into feeling ‘not safe’. Mental health services perceive themselves as trustworthy, but trust is clearly an important issue for these young people, and Respondent 16 reports that this is necessary if they are to receive the help they need:

18. Trust is the most important thing, so what I would suggest to [names service] is, I really appreciated their help, at that time I did really needed help to be honest with you, ’cos I was in a very big mess …………… If you keep things to yourself obviously it will never ever help you. (Respondent 16)

It is perhaps unsurprising therefore that the general perspective of mental health services was negative with many children reporting that they did not like attending their appointments and that the interventions were unhelpful:

19. When I’m in the meeting I’m like one minute is one hour (.) I don’t like (laughs). (Respondent 3)

20. I lost my family I had a lot of problem (.) …. I was telling her a lot of things ……… but she didn’t help me. (Respondent 6)

21. They ask you one question, they ask you one word like ten times, they keep asking. They know everything but she just keep asking, I said I can’t do this. If you are keep doing this … end of 2012 you’re going to kill me, I said I’m going to do it. (Respondent 2)

It is not uncommon for children generally to disengage with interventions or show some form of resistance to mental healthcare (O’Reilly & Parker, 2013b). This can be problematic for service providers who are charged with safeguarding and promoting mental well-being in these populations. This is further compounded by the feeling that services fail in their duty to provide help for these individuals. Obviously, care needs to be taken when working with these young people, as their views about mental health services may only worsen if they feel their problems are becoming more intense. These young people have responded in a negative way to what is seen in contemporary practice which includes a full assessment and clarification of the problems in detail. This by definition requires a great deal of questioning and characterises psychiatric practice. Although the respondents typically were negative about engaging with services and tended to dislike attending, some were able to see benefits:

22. Well coming here the doctor helped me and the doctor tell me the reason (.) I was happy about the reason that is the most important thing for me. (Respondent 9)

23. He says I’ve seen Doctor [X] twice (.) he has been very helpful (.) he always help us (.) he’s thanking him. (Respondent 7: interpreter)

This does, however, have to be contextualised against the rest of the narratives in these interviews where the individuals, particularly Respondent 7, denied having any mental health difficulties but appears thankful that he has been helped. There are clearly some contradictions in their accounts of their involvement with services. To contextualise the experiences within a Western health service, it is useful to explore their experiences of services in the country of origin.

The respondents were able to describe what their experiences or perceptions of mental health services were in their home countries. In general, the adolescents described health services as limited or absent. There was also distrust of the professionals involved in these services, which may partially account for the limited trust of refugee services:

24. They different yeah (.) they is different (.) no-one like a feel sick or something in my country give a tablet or something. (Respondent 4)

25. No CAMHS there (.) there is a hospital if he there is a you know some people trust that some people not trust that. (Respondent 9)

The sample represents different countries of origin with different notions of mental health and treatments. In addition to not trusting services or experiencing treatment lacking in any psychological support, one respondent described an unpalatable view of their experience of a mental health hospital, and another talked about the limited knowledge that appears to exist about mental health:

26. I went to see one hospital in Afghanistan I was really young (.) I was (.) they’re usually kids going to see mentals problem (.) mental people (.) there’s just like a prison they put in there and they’re just inside the cage fighting with others (.) they’re just like making fun of people. (Respondent 1)

27. Yeah, in Afghanistan in winter if you got money, you go to hospital, if you don’t have money then go on street, sleep on street. Sleep on street and go crazy, innit. (Respondent 4)

28. But there’s one thing is good about Afghanistan is the service is good if you’ve got the money, everything will go through, you know, straight away but in England you don’t pay. (Respondent 12)

The descriptions of the hospital being ‘like a prison’ and the comparison of the environment to ‘cage fighting’ is an unpleasant visual image. The experience is that the label of mental illness invites mockery or incarceration. It is unsurprising, therefore, that young people feel uncomfortable admitting they have mental health issues or engaging with treatments. The State-funded services available in the United Kingdom contrast considerably with the descriptions of healthcare in Afghanistan. The economic aspects of healthcare limit what available resources are accessible by the population, with health declining when it cannot be afforded: ‘sleep on the street and go crazy’. Even if initial treatment is possible, the ongoing costs become unviable.

Theme 4: Opinions of treatments

In addition to the views expressed regarding the cultural background and services provided within the United Kingdom, the unaccompanied adolescents did have views on the actual treatments that they received. The general treatment modality within CAMHS is psychotherapeutic in nature relying on talk, with medication utilised when this approach has failed, the symptoms are severe or when the condition responds only to medication. This therapeutic approach appeared very different to the a priori expectations of the young people. Three broad issues emerged: views on talking therapies, risks of re-traumatisation and medication:

29. CAMHS is somebody talking to you on that, now I know what it is, somebody talking to you, if you have any problem, you can talk to the doctor. (Respondent 9)

30. That doesn’t helps me (.) that makes me more hard because um the all the time I was talking about the past (.) so every time I went there (.) reminding me after I went home again (.) same depression and same problems. (Respondent 1)

Opinions on talking therapies were mixed with some appreciating the value of therapy, while others are more negative about this modality. These negative views are particularly relevant as many of the adolescents reported that reliving the experiences during treatment opened them to re-traumatisation, making their problems feel worse. Although this may be distressing for the young people, sometimes this is part of the therapeutic process which is something that needs explaining to them. However, in addition to this, it should be appreciated that their immigration status and unaccompanied position may reinforce their feelings of distress, thus affecting the therapy.

Given their viewpoints on mental health problems, it is common for the respondents to request medication for psychiatric conditions. Some respondents saw the drug treatments as a positive aspect of their care:

31. I have medication, not medication that time, when you have medication get better. (Respondent 8)

32. Giving me some medicines to keep my low up so that was a bit helping me (.) ………. so I went back home (.) take the medicines and took it and I felt back normal. (Respondent 1)

The full quotation from Respondent 1 described an incident where he forgot to take medication for a week and the subsequent negative effects. This illustrated a positive view of medication as it made him ‘normal’. However, many adolescents failed to understand the reasons for medication, and others sought it as treatment, particularly if they thought their symptoms had a physical origin. This lack of clarity does raise issues of informed consent which needs to be considered carefully in practice.

Discussion

Conflict in many parts of the world has led to an increase in refugees. Increased recognition that refugees have significant physical health, social and mental health needs has meant a development of services for them. Services need to be appropriate to the requirements of this population and recognise their specific requirements. The voices of unaccompanied minors need to be acknowledged in these developments as they are a particularly vulnerable group.

An understanding of the concept of mental health is often essential in ensuring engagement with treatment. These concepts were unfamiliar to some of these adolescents, and many reported negative views of mental health. Nonetheless, their negative perceptions of mental health are not entirely different from adolescents living in Western cultures (O’Reilly et al., 2009). These adolescents either denied them or reconstituted them as physical problems. The participant’s understanding did appear to be concomitant with their age; however, there were a number of influences upon this. This may be a reflection of their language difficulties (Lustig et al., 2004), may be an echo of the cultural attitudes of their home environment (Lynch, 2001) or their experiences of services back home. Describing mental health is notoriously difficult, and most adolescents typically think in terms of mental illness, rather than being mentally healthy (Svirydzenka, Bone, & Dogra, 2014).

While there were reported positive experiences, there was general mistrust of services, particularly doctors. These adolescents appeared cautious of services for several reasons, including professionals identified as representatives of the state, and/or fear of deportation (Ellis et al., 2011). Consequently, mental health and legal issues can be perceived as intertwined, despite the differences being explained to them. In our sample, the level of trust did not appear dependent upon their immigration status. However, this was a limited cross-section of this population. Thus, the mistrust of strangers could be viewed as protective, originating from their adverse experiences or culture. Trust is inherently a relational concept, which lies between people and events, people and organisations, and people (Gilson, 2003). Ultimately, therefore, trust involves a degree of risk derived from the individual’s uncertainty of the intentions, motives and future actions of others on whom they are dependent (Kramer, 1999). Our respondents reported finding the host country unfamiliar, which can affect trust, thus creating a further impediment to engagement. Furthermore, the unfamiliar language and limited independent communication may have had some effect. In many cultures, there is a mistrust of people outside of the family unit, and their current situation precludes them from accessing the support of their families, which they may have accessed if distressed in their home country. Although not universal, some adolescents in Western cultures have also been shown to lack trust in services which would support or enhance their mental health (Flisher et al., 1997; Wilson & Deane, 2001). The views of the unaccompanied minors should be seen in this context; however, their mistrust does seem to be of a greater degree.

In child mental health, the predominant modality of treatment remains the ‘talking’ therapies, and alongside these modalities has been an increased use of medication, despite their effectiveness not being fully evaluated (Lustig et al., 2004). Many of the respondents found engaging with talking treatment difficult, and they deemed pharmacological treatments more acceptable. This may reflect cultural experiences, where mental healthcare was limited or absent and treatment was different or a different understanding of illness. Explanatory models of illness have a very strong cultural basis, and while talking therapies have a well-established framework within a Westernised healthcare system, this is not universal globally. Talking therapies can also be challenging, due to linguistic limitations (even when using interpreters) due to the loss of the subtle nuances of communication. Consequently, psychiatric intervention may be deferred until their language has improved (Huemer & Vostanis, 2010). This is a decision that needs to be balanced against the risk. Even with appropriate medication, some respondents lacked clarity regarding their treatment. This does raise concerns around informed consent as they should understand their treatments.

Although the unaccompanied adolescents were either of refugee status or asylum-seeking, they had been within the United Kingdom for different lengths of time, but they had all been under a specialist mental health service for at least 6 months. It is difficult to quantify the effects of acculturation (the process of cultural change), assimilation (adaption of cultural attitudes of the prevailing group) and peer group influences on these young people and therefore whether this process had influenced their understanding of the Western health model. This variability does obviously pose challenges for services, which supports the need for specialist clinicians who understand these needs. Fortunately, in this situation, the assessments and therapies were provided by such professionals.

The findings from this study have implications for ethics and services. Services should have the flexibility and accessibility to engage the child, and mental health input should always be integrated with welfare, education and physical health services, thus encouraging consistency and acknowledging the ‘therapeutic’ role of those involved. Their access and engagement can be also improved by utilising the mediation of people who have already gained their trust (Davies & Webb, 2000). Importantly, in addition to history of trauma, the impact of the current psychosocial adjustment and uncertainty over the future are also considerations. Ideally, foster carers would need specific training on the issues facing these adolescents or if possible have a shared cultural background; however, finding foster placements or group accommodation which can meet these needs is difficult, and this was reflected in our sample.

Ultimately, professionals still have the power to decide what services will be accessible particularly for those who actively choose to decline treatment. Young people can feel that their voice is not given due credence (LeFrançois, 2007), and this is particularly problematic for unaccompanied asylum-seeking/refugee adolescents. They may prefer to resist the indigenous pathways to care and decline treatments, or may view the service as intrinsic to their refugee application, rather than as a mental health intervention. It is important to strike a balance between respecting their rights to make decisions and protecting them from long-term health consequences.

This population remains under-represented in research, and there are inherent difficulties in accessing them. The sample itself is ostensibly small but is nonetheless representative of the population and reflects the quality criteria for sampling adequacy for the method (O’Reilly & Parker, 2013a). The representative group is in the 15- to 18-years range and is potentially self-selected by the group members’ ability to endure the refugee process unaccompanied. Although there were linguistic difficulties, the adolescents were able to express pertinent views from which to draw conclusions. Future research may focus on younger children or consider a wider range of countries of origin as many of the adolescents in our study were from Afghanistan, to obtain a broader range of perspectives and understanding. It may also be useful to obtain data from other localities within the United Kingdom, but our data has transferability. At present, there is limited published literature on the perceptions of mental health services in British adolescence, particularly in relation to issues such as trust, and further work would be beneficial. Larger quantitative studies may help to inform service design or government policy with the aim of developing interventions which will facilitate care.

Footnotes

Acknowledgements

We would like to thank the young people who consented to participate in this study. We also extend thanks to the social workers and clinical professionals who made access possible. Finally, we thank Claire Bone for her comments on earlier drafts.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

References

Boyatzis

(1998). Transforming qualitative information: Thematic analysis and code development. London, England: SAGE.

Cox

(2011). Issues in safeguarding refugee and asylum-seeking children and young people: Research and practice. Child Abuse Review, 20, 341–360.

Davies

Webb

(2000). Promoting the psychological well-being of refugee children. Clinical Child Psychology and Psychiatry, 5, 541–554.

Derluyn

Broekaert

(2007). Different perspectives on emotional and behavioural problems in unaccompanied refugee adolescents. Ethnicity and Health, 12, 141–162.

Ehnholt

Yule

(2006). Practitioner review: Assessment and treatment of refugee children and adolescents who have experienced war-related trauma. Journal of Child Psychology and Psychiatry, 47, 1197–1210.

Ellis

B. H.

Kia-Keating

Yusef

Lincoln

Nur

(2007). Ethical research in refugee communities and the use of community participatory methods. Transcultural Psychiatry, 44, 459–481.

Ellis

B. H.

Miller

Baldwin

Abdi

(2011). New directions in refugee youth mental health services: Overcoming barriers to engagement. Journal of Child and Adolescent Trauma, 4, 69–85.

Fazel

Reed

R. V.

Panter-Brick

Stein

(2012). Mental health of displaced and refugee children resettled in high-income countries: Risk and protective factors. The Lancet, 379, 266–282.

Fazel

Wheeler

Danesh

(2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. The Lancet, 365, 1309–1314.

10.

Flisher

Kramer

Grosser

Algeria

Bird

Bourdon

… Hoven

C. W.

(1997). Correlates of unmet need for mental health services by children and adolescents. Psychological Medicine, 27, 1145–1154.

11.

Gilson

(2003). Trust and the development of health care as a social institution. Social Science & Medicine, 56, 1453–1468.

12.

Home Office. (2004). Asylum statistics 2003. London, England: Author.

13.

Huemer

Karnik

Voelkl-Kernstock

Granditsch

Dervic

Freidich

Steiner

(2009). Mental health issues in unaccompanied refugee adolescents. Child and Adolescent Psychiatry and Mental Health, 3, 13. DOI:10.1186/1753-2000-3-13

14.

Huemer

Vostanis

(2010). Child refugees and refugee families. In Bhugra

Craig

Bhui

(Eds.), Mental health of refugees and asylum-seekers (pp. 225–242). Oxford, UK: Oxford University Press.

15.

Kramer

(1999). Trust and distrust in organizations: Emerging perspectives, enduring questions. American Review of Psychology, 50, 569–598.

16.

LeFrançois

(2007). Children’s participation rights: Voicing opinions in inpatient care. Child and Adolescent Mental Health, 12, 94–97.

17.

Lustig

S. L.

Kia Keating

Knight

W. G.

Geltman

Ellis

Kinzie

J. D.

… Saxe

G. N.

(2004). Review of child and adolescent refugee mental health. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 24–36.

18.

Lynch

M. A.

(2001). Providing health care for refugee children and unaccompanied adolescents. Medicine, Conflict and Survival, 17, 125–130.

19.

Montgomery

Foldspang

(2008). Discrimination, mental problems and social adaptation in young refugees. European Journal of Public Health, 18, 156–161.

20.

O’Reilly

Parker

(2013a). ‘Unsatisfactory Saturation’: A critical exploration of the notion of saturated sample sizes in qualitative research. Qualitative Research, 13, 190–197.

21.

O’Reilly

Parker

(2013b). ‘You can take a horse to water but you can’t make it drink’: Exploring children’s engagement and resistance in family therapy. Contemporary Family Therapy, 35, 491–507.

22.

O’Reilly

Taylor

Vostanis

(2009). ‘Nuts, schiz, psycho’: An exploration of young homeless people’s perceptions and dilemmas of defining mental health. Social Science & Medicine, 68, 1737–1744.

23.

Refugee Council. (2012). Retrieved from http://www.refugeecouncil.org.uk/

24.

Rutter

(2003). Working with refugee children. York, UK: Joseph Rowntree Foundation.

25.

Svirydzenka

Bone

Dogra

(2014). School children’s perspectives on the meaning of mental health. Journal of Public Mental Health, 13, 4–12.

26.

Thabet

Karim

Vostanis

(2006). Trauma exposure in pre-school children in a war zone. British Journal of Psychiatry, 188, 154–158.

27.

Thomas

Byford

(2003). Research with unaccompanied children seeking asylum. British Medical Journal, 327, 1400–1402.

28.

United Nations High Commissioner for Refugees (UNHCR). (2012). Retrieved from http://www.unhcr.org/cgi-bin/texis/vtx/page?page=49e48f166&submit=GO

29.

Vostanis

(2010). Mental health services for children in public care and other vulnerable groups: Implications for international collaboration. Clinical Child Psychology and Psychiatry, 15, 555–571.

30.

Wilson

Deane

(2001). Adolescent opinions about reducing help-seeking barriers and increasing appropriate help engagement. Journal of Educational and Psychological Consultation, 12, 345–364.