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The “Lost Boys of Sudan” Functional and Behavioral Health of Unaccompanied Refugee Minors Resettled in the United States

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The “Lost Boys of Sudan” Functional and Behavioral Health of Unaccompanied Refugee Minors Resettled in the United States ARTICLE The “Lost Boys of Sudan” Functional and Behavioral Health of Unaccompanied Refugee Minors Resettled in the United States Paul L. Geltman, MD; Wanda Grant-Knight, PhD; Supriya D. Mehta, PhD; Christine Lloyd-Travaglini, MPH; Stuart Lustig, MD; Jeanne M. Landgraf, MA; Paul H. Wise, MD Objective: To assess the functional and behavioral health Results: Twenty percent of the minors had a diagnosis of unaccompanied Sudanese refugee minors approxi- of posttraumatic stress disorder and were more likely to mately 1 year after resettlement in the United States. have lower (worse) scores on all the Child Health Ques- tionnaire subscales. Low functional and behavioral health Design: A descriptive survey. scores were seen mainly in functioning in the home and in subjective health ratings. Social isolation and history Setting: Local refugee foster care programs affiliated with of personal injury were associated with posttraumatic the US Unaccompanied Refugee Minors Program. stress disorder. Participants: A total of 304 Sudanese refugee minors Conclusions: Unaccompanied Sudanese minors have enrolled in the US Unaccompanied Refugee Minors Pro- done well in general. The minors function well in school gram. and in activities; however, behavioral and emotional prob- lems manifest in their home lives and emotional states. Main Outcome Measures: Health outcomes were as- The subset of children with traumatic symptoms had char- sessed using the Harvard Trauma Questionnaire and the acteristics that may distinguish them from their peers and Child Health Questionnaire. Outcomes included the di- that may inform future resettlement services for unac- agnosis of posttraumatic stress disorder and scores on all companied minors in the United States. Child Health Questionnaire subscales and global single- item assessments. Arch Pediatr Adolesc Med. 2005;159:585-591 URING THE PAST 30 YEARS, lence and deprivation. Similar levels of dis- much research has been tress have been found in other refugee conducted regarding the populations, such as Guatemalans,7 Af- health status and psycho- ghanis,8 and Somalis.9 Refugee children Author Affiliations: logical outcomes of refu- who are not accompanied by parents or Departments of Pediatrics Dgees, particularly Asian refugees. In Thai other adult biological family members (Dr Geltman) and Emergency refugee camps, Cambodian adolescents when resettled in other countries also seem Medicine (Dr Mehta), Boston were found to have high levels of emo- to be at particularly high risk for distress- University School of Medicine, tional distress related to their experi- related symptoms and are less likely to re- Boston, Mass; Department of ences with violence.1 Longitudinal stud- ceive psychological care.10 A study11 of Pediatrics, Rehabilitation 2,3 Institute of Chicago, Chicago, ies of Cambodian refugee adolescents in former unaccompanied Vietnamese chil- Ill (Dr Grant-Knight); Data the United States also found significant lev- dren repatriated to Vietnam suggested that Coordination Center, Boston els of psychological distress, school fail- a broad range of factors contributed to their University School of Public ure, and posttraumatic stress disorder emotional and behavioral problems. Health (Ms Lloyd-Travaglini); (PTSD). Significantly traumatized chil- In 2000, the United States began the re- Department of Psychiatry, dren in the former Yugoslavia were also settlement of unaccompanied Sudanese Harvard Medical School, Boston found to experience an extremely high refugee minors from the Kakuma refugee (Dr Lustig); HealthAct Inc, prevalence of PTSD.4 In contrast, Bosnian camp in Kenya, a group labeled the “Lost Boston (Ms Landgraf); and child refugees in the United States were Boys of Sudan” by the news media. In the Department of Pediatrics, found to have relatively lower-than- late 1980s, war forced these very young Stanford University School of expected rates of PTSD and depression.5 children to flee their burning villages as Medicine and the Centers for 6 Health Policy and Primary Care However, another study of Bosnian refu- their parents and families were often killed. Outcomes Research, Stanford gees reported that 77% of the children had They reportedly witnessed significant University, Stanford, Calif experienced behavioral symptoms attrib- atrocities, such as immediate family mem- (Dr Wise). uted to specific exposures to war vio- bers being stabbed or mutilated.12 Seek- (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 159, JUNE 2005 WWW.ARCHPEDIATRICS.COM 585 Downloaded from www.archpediatrics.com , on July 25, 2005 ©2005 American Medical Association. All rights reserved. ing refuge in Ethiopia, an estimated 25 000 children and thus could facilitate participation and completion of the study. trekked hundreds of miles across the savannah and des- Although not experienced as research staff, the URMP staff mem- ert. Along the way, hyenas and lions stalked, injured, and bers were instructed not to assist the Sudanese minors in com- killed many of the youth. In 1991, the Ethiopian gov- pleting questions or to offer clarifications to questions (except as ernment expelled the Sudanese refugees, with many flee- described further in the “Instruments” subsection). ing to Kenya in the face of attacks from soldiers and helicopter gunships. In these migrations, the children INSTRUMENTS forded rivers, in which many drowned, nearly drowned, or were killed by crocodiles. Once in Kenya, thousands Staff conducted interviews with either small groups or individu- of the Sudanese refugees registered at the Kakuma camp, als. Youths wrote their own answers on their individual ques- where they lived in small groups sharing a shelter and tionnaire packets and then were allowed to seal the packets in resources or with foster families. Most received some an envelope. Consequently, the setting should not have influ- limited but voluntary education and other assistance, enced responses owing to concerns about staff involvement or although violence, hunger, and inadequate living con- awareness of responses. All participating youths spoke and read ditions remained substantial problems.12 English, although with varying levels of proficiency. All instru- In this study we examined the functional and behav- ments were written and administered in English. Because youths ioral health status of this group of young Sudanese refu- were from several different ethnic and linguistic groups, it was not possible to conduct the study in the primary language of the gees approximately 1 year after their arrival in the United refugees without excluding those from minority ethnic and lin- States. Our focus was directed at the extent to which their guistic groups. A staff member simultaneously read the ques- experiences of psychologically traumatic events, refu- tions out loud while the youths also read the questions and com- gee resettlement, and demographics were associated with pleted their answers on their copies. This strategy had been used clinical symptoms, psychosocial functioning, and gen- in a pilot workshop conducted by the investigators with 1 local eral health status. This effort was undertaken to assess program and was effective in increasing comprehension and the programmatic needs of initiatives to relocate unac- completion of measures as the youths’ spoken English fluency was generally better than their written fluency. The strategy has companied refugee children to the United States and to 13 provide insight into the clinical and psychosocial expres- also been used in previously published research. sion of early traumatic experiences in children who seek The pilot workshop used 2 of the instruments later used in the study: the Harvard Trauma Questionnaire (HTQ) and the refuge in unfamiliar cultural settings. Ways of Coping instrument. The workshop also used focus groups to gather information about the youths’ experiences and METHODS responses. Other instruments in the pilot workshop included the Youth Self Report. Researchers used feedback from partici- pants, staff, and foster parents in planning this study. In par- PARTICIPANTS ticular, many of the youths found that the Youth Self Report’s concepts were too colloquial, culturally inappropriate, or a poor We surveyed a convenience sample of the 476 Sudanese mi- match to their maturity level. Feedback from focus groups also nors in refugee foster care programs affiliated with the US Un- allowed prioritization of important background variables in- accompanied Refugee Minors Program (URMP). All 476 Su- cluded in this study. Feedback from foster parents was impor- danese minors, who arrived in the United States in late 2000 tant in understanding the youths’ responses to the assessment through early 2001 through the URMP, were eligible to enroll process and the parents’ understanding of key background and in the study. Local URMP staff solicited the participation of the behavioral issues. youths and obtained informed consent. Staff attested to the It was the consensus of the researchers and program staff youths’ comprehension and agreement to participate. The study that youth would not be willing to devote multiple sessions or was conducted from February 2002 through July 2002 in col- more than 2 hours to the study. Therefore, brevity of the in- laboration with the URMP lead agencies, contracted by the US struments was important. This time constraint prevented us from Department of State: the Lutheran Immigration and Refugee conducting comprehensive evaluations with multiple or longer Service and
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