Blog

Report: An Emotional Health and Wellbeing Specialist Early Intervention Framework

By Dr. Ana Draper

In July 2016, A Parliamentary Select Committee report entitled Children in Crisis: Unaccompanied Migrant Children in the EU makes the statement: ‘All we can know for certainty is that the number of unaccompanied children in the EU runs to many tens of thousands and has grown significantly in recent years’. From this uncertainty a very specific figure of 3,043 asylum applications from unaccompanied minors were made in the UK, an increase of 56% from 2014. Most of these children have arrived in Kent and passed through reception centres in the county before being rapidly dispersed either into foster care or supported living arrangements. It is from the experience of working therapeutically with these children that the recommendations in this paper are being made.

What is outlined here is a model of the early interventions that the Unaccompanied Asylum Seeking Children (UASC) project in Kent recommends as necessary in order to create a resilience model that provide crucial foundations for the long term wellbeing of children to Post Traumatic Stress Disorder (PTSD), depression and anxiety. The long term effects of such early intervention are vast in scope from the rescuing and humanising of individuals who have already had significant loss and trauma in their lives to providing a shield against future radicalisation and the nurturing of people who are assets to the UK.

Embedded in the philosophy of this early intervention framework is also the creation of a culture of welcome to these children within the structures of bureaucratic disorientation in which they find themselves. This last point is especially pertinent given the observation in the Parliamentary report, that UASCs are faced with a pervasive ‘culture of disbelief’ and suspicion in the EU countries in which they arrive, including from ‘border force and immigration officials, law enforcement and social services’. A contributor to the report stated ‘ we received a wealth of evidence on these symptoms of the prevailing disbelief, most of it relating to the UK’. In a post Brexit Britain where it seems that a certain (ill-founded) legitimacy has been given to the voice of hostility and racism, it is essential that those who are hosting UASCs whether in reception centres or post-dispersal, are equipped to provide, not just friendship and welcome, but the tools by which UASCs can find both their feet and their hope.

The importance of early intervention in enabling resilience is well documented and it is important to recognise the reality of a situation where, because of the programme of dispersal, there can be limited time in which to affect therapeutic measures. However, we stress that the interventions recommended here are likely to have huge beneficial effects beyond the relatively short term nature of their implementation. From the work in dispersal and reception centres in Kent we think that there needs to be a change in emphasis on the way in which the ‘trauma’ that UASCs have suffered from is approached and regarded.

Since much existing research and evidence has been focussed on symptoms of PTSD, PTSD itself has perhaps become an assured and expected outcome. By this we mean that it is often taken for granted by health professionals and support workers that all UASCs will be suffering PTSD. There is evidence that this may be the case for a proportion, and yet not a majority of cases. However, we argue that such an assumption potentially becomes a ‘catch all’ compartmentalising diagnosis. The irony then is that the very assumption of PTSD, which itself should lead to specific treatment and interventions, becomes a function of, if not ignoring, then at least ‘putting aside’ the problem. By assuming that PTSD is present, there is a concomitant assumption that the only cure is the ‘magic’ of specialist professionals who have a scarcity in availability and therefore there is a wait for anything to be done. The experience of relating to and talking with the UASCs in Kent reception centres shows that the children have incredibly traumatic experiences in their lives. In fact, these are so far off the scale sometimes that the diagnosis that they suffer PTSD is almost inadequate. It would be easy to assume that all these children are traumatised and will most probably require specialist interventions over time. However, symptoms that present themselves at the time of the child’s arrival in the UK system can be regarded in a more contextual manner that can be addressed simply and immediately and thereby provide the foundations of wellbeing and resilience from which the deeper traumas can be dealt with over time. The ethos should be of ‘caring vigilance’ whereby carers and professionals watch, wait and see what presents over both the short and long terms. Many young people, particularly if they have had strong, healthy attachments in their lives and good early years are extremely resilient. Each child has his/ her own history and resilience potential and the provision of early intervention steps will enable those with strong resilience potential to begin to rebuild their lives and potentially thrive, whilst those who are more vulnerable will become identifiable and therefore suitably cared for.

The suggestion that a short term history should be dealt with first is backed up, if obliquely, by another witness to the Parliamentary report: ‘Some unaccompanied children have pointed out that on their journey they have been focused entirely on survival, the journey and arrival, and when they get to their destination country they are entirely depleted, but then of course they have to face a whole new set of challenges, so we have to be mindful of all they have gone through.’ When a child arrives in the reception centres in Kent, they are often in the midst of an extraordinary journey (because of dispersal and the asylum process, we cannot say the journey is over), one which may have involved being trafficked, hunted, starved, sleep deprived, witnessing death and close escapes with death for the child themselves. This is the immediate experience in the child’s life that they bring to the UK. The proximity of the experience requires a hyper vigilance to the effects of that experience. Therefore the disrupted and non-existence sleep patterns that many children exhibit, for example, may derive from the fact they have spent many months living an essentially nocturnal existence as they attempt to cross through Europe at night, in their ‘focus on immediate survival’.

Similarly, the apparent ‘eating disorders’ and digestive problems the UASCs exhibit may be a result of the fact that during the journey of survival, the child has been malnourished or semi starved. The following are some of the issues that affect USAC:

  • Poor sleep (a lack of sleep or disturbed sleep)
  • Vivid flashbacks • Intrusive thoughts & images • Nightmares or sleep terrors • Lack of concentration
  • Hyper vigilance • Poor emotional regulation
  • Poor understanding of nutrition
  • Deliberate self-harm • Irritable and aggressive behaviour
  • Issues with cultural acclimatisation
  • Intense distress at symbolic or real reminders of trauma
  • Physical manifestations: trembling, sweating, pain and nausea
  • Self-destructive behaviours or recklessness
  • Disordered eating and related re-feeding symptoms

All of these symptomatic behaviours can be usefully regarded in their first presentation as being normal responses to the most recent, trying and exhausting experiences in the lives of the child. They should be seen as contextual and not abnormal responses and they should also been seen holistically as interconnecting with each other. If a child experiences nightmares, this can be regarded as a normal and in fact positive sign that some normal processes are happening towards the resolving of the trauma. This traumatised child can be supported in the short term with regards sleep patterns/nutrition so that a certain stability is attained as quickly as possible whilst understanding that longer term PTSD may manifest at a later date. The short term work advocated here will allow for more effective interventions on any deeper issues that may appear by equipping the child with a stable place from which to work.

Four areas of early intervention we believe need to be addressed:

  • Sleep
  • Nutrition and re-feeding
  • Trauma and bilateral movement
  • Hope and aspiration

Sleep

In the Kent reception centres, observations of the sleep patterns of UASCs showed that the majority of them would sleep during the day and were unable to sleep at night. This created problems at the very simple level of the routines that the reception centres were trying to establish, but one may not wonder that a child who has not slept at all during the night, is unable to turn up for skills training at 9 am. Thus a very simple negative patter is established whereby the lack of sleep leads directly to the child missing out on some vital elements of being able to function in their new environment. The GP who provides a service to young people in reception centres reported that 100% of the UASC he sees, report disordered sleep patterns in the consultations with him.

In 2013, Israel Bronstein and Paul Montgomery examined the sleeping patterns of Afghan UASCs in which they state: “Within this group of children, sleep problems should not only be considered as symptoms of possible PTSD but as problems themselves, given they can lead to a range of daily functional impairments in memory, concentration, attention, motor performance, academic performance, and behaviour. In children specifically, sleep problems may influence cognitive and behavioural functions and lead to increased fatigue, sleepiness and slower reaction times”

All of this is also exhibited amidst the population of the Kent reception centres where staff also reported that many young people would sleep in groups with the light on, having learned to do this to protect each other. In order to attempt to reset the sleeping patterns of the young people, sleeping hygiene education and packs have been developed, as well as a formulation to reset the circadian rhythms.

When UASC were asked if the sleep packs had helped one week after using them at a reception centre, they stood up, clapping and cheering to demonstrate the difference this intervention had made. When clinicians have used this as part of a therapeutic formulation and intervention, the feedback is positive, with young people stating often a marked difference in the scoring from 0 to 10 in their ability to sleep.

That said, there is a need to undertake further research into this intervention into disordered sleeping with UASC.

Nutrition and Feeding

The problems surrounding UASCs and nutrition are interlinked with the issues of broken sleep patterns – and are not dissimilar to an intense form of jet lag including symptoms of indigestion, constipation, diarrhoea, nausea, lack of appetite, anxiety, disorientation, irritability and memory problems. On top of this reception staff have reported that many young people ate very little and struggled to manage food. Many exhibit the physical symptoms of semi-starvation such as gastro-intestinal discomfort, dizziness, oedema, reduced strength, headaches, hyper-sensitivity to noise and light. Some of these children would also exhibit behaviours such as binge -eating and purging, self-harm, a loss of interest in the future, depression and an abnormal fascination with food which are indicative of eating disorders. Again, semi-starvation is linked to the experience of the arduous journey the UASCs have just undergone and there is a requirement to support their emotional health and wellbeing during the re-feeding phase of their recovery. The GP who sees children in the reception centre also stated that gastric discomfort in a variety of forms is also reported by most of the UASC in the consultations he gives.

It is important that a general practitioner supports children experiencing gastric distress as part of the re-feeding process who can support with medication that deal with physical symptoms such as gastric reflux and constipation. On the main, most UASC are underweight and an initial weight that can be monitored is also good practice and will support an aspect of understanding in respect of the re-feeding process.

A re-feeding diet of small meals every 2/3 hours is also important to support the digestion process and also the body’s ability to reacclimatise to being fed on a regular basis. A healthy diet needs to be followed that avoids foods that rapidly increase the blood sugar such as sweets and cakes, as hypoglycaemia is a likely by-product of such foods.

There is also a need to support a UASC’s understanding of their body, the re-feeding process and the emotional dysregulation that is likely to take place. It is also important that carers are aware and can support the young person during this difficult transition.

Trauma and Bilateral Movement

There is a body of literature that shows that sport and physical activity triggers chemicals in the brain that make you feel happier and more relaxed. It also supports your brain to process information, thus learning therefore is enhanced. Physical activity is a distraction from daily stresses and reduces the level of stress hormones secreted and stimulates the production of endorphins, keeping stress and depression at bay. It has been shown to improve the quality of sleep which also has an impact on mood and general outlook.

As per the symptoms described above, many of the UASC would benefit, after an initial period of recovery, in the early days of arrival and assimilation into the UK from sports related activity to reduce the symptoms which can escalate into long term and chronic mental health concerns. Many of the symptoms are suggestive of trauma experiences, which given the right support can be naturally processed by the brain. There is a volume of evidence that shows that bi-lateral movement helps the brain to process and desensitise from traumatic experiences.

To enhance the body’s natural ability to process, there is a need to access sport that is bilateral in movement as a regular activity that a young person can undertake. It is an early intervention strategy that acknowledges that trauma is likely to be present and put protectors in place that enhance not only the body’s natural ability to process and desensitize, but enhances on multiple levels a sense of emotional wellbeing.

A trial is being undertaken in Kent with UASC in supported living and once those results have been reviewed, it is hoped that further research will take place to assess the outcomes of such a formulation.

Hope and Aspirations

What is hope to a UASC, how can we enhance hope stories in a way that these young people can thrive wherever their paths take them? These young people live with constant uncertainty which can heighten a sense of permanent loss and trauma. Hope can be hidden or clouded, it’s not until we un-ravel the young person’s story that we get the full narrative and are able to identify their needs and aspirations. In supporting reception staff and social workers to connect these young people into hopeful narratives; we are tapping into the resources they have from past relationships into present connections linked to the choices they are making about how to go on and live their life in the UK.

An example of this is shown in the transcript of a conversation that took place with a UASC.

Ana: What were you running away from?

J: From the army, as I didn’t want to become a soldier.

Ana: Who else in your family agreed with you?

J: My Mum arranged for me to leave, my brother died and she didn’t want the same thing for me.

Ana: So she wanted to protect you?

J: Yes; she wanted me to have a good life.

Ana: What does a good life look like?

J: To learn, to have a job, to be safe.

Ana: So you hope to learn new things, to get a job and to be safe?

J: Yes.

Ana: So today, how can you make hope real? You know in the choices you have now?

J: I can learn English?

Ana: What would your Mum say if she knew that you are learning English?

J: Good, good, she would be very happy.

Ana: So hope is yours and hers every time you say something in English?

This transcript shows the link to the continuing bonds they have with positive relationships which can be drivers towards making the right steps to things that are likely to shape their success and assimilation. As already stated previous healthy attachments are a known protector to a child’s resilience and linking them through continuing bonds into the present with those attachments is likely to enhance and motivate wellness behavioural patterns.

Early intervention in these four areas as outlined here could have beneficial effects into the long term emotional health and wellbeing of each UASC entering the UK.

The recommendations here have evolved out of Action Research which is a step by step methodology, in which the researcher(s) plan, act, observe and reflect. It is humanistic as it looks to work with and collaborates with those involved and affected to explore the emergent meaning and understanding under observation. In observing the effect of our actions at each stage of the cycle from which change emerges, we have been building a scaffolding of knowledge which allowed us to continuously incorporate findings into subsequent stages of the investigation.

The project team, staff at reception centres, social workers and UASC are all within the observations and actions taking place. Therefore, all those involved, affected and connected are an active part of the research team and relational in nature. Bjorn (1996) and Shotter (1998) refer to participatory action research as multidimensional, dialogical and a fluid form of self-development. These interventions are key things that we have found are required to best help these children, some who have arrived here in some of the most unimaginably tragic circumstances and who may require additional psychological support in the future.

The early intervention steps require further investigation and yet are already showing signs that they will help to reduce the negative impact of the things they have tried to escape from, the journey they have made and the need to wait, watch and see should there be any trauma that needs to be addressed in the future. The early interventions happen within a wider socio-political environment that is laden with misapprehensions, fear and prejudice. A child is not a terrorist (and there is no link between UASCs and terrorism as acknowledged in the Parliamentary report cited earlier). However, if a child who has seen his family murdered by the Taliban and who has subsequently undergone a journey of escape which he has survived against the odds (and we must remember the thousands of children who do not make it here and whose fate is death, sex exploitation, slavery), if that child arrives in a disinterested and hostile UK that makes no attempt to meet any of their basic human needs, is not desperate political radicalisation more of a possibility?

We must think of these children as assets to the nation, they are, after all, by and large brave and extremely capable as they have proved by being able to get here in the first place. The UK needs, ethically and humanely to show these children a face of welcome and the least we can do is meet them at the point of arrival with a supportive plan to help the ongoing asylum passage they will need to make.

Post a comment