Living in the present with the past : mental health of Bosnian refugee children in Sweden

Sammanfattning: 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.