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Mental health needs of child asylum seekers and refugees

November 2018

Position statement 52


Summary

The RANZCP opposes immigration policies that are detrimental to the mental health of child asylum seekers and refugees.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) presents this position statement to affirm its opposition to immigration policies that are detrimental to the mental health of child asylum seekers and refugees. The RANZCP opposes the routine, prolonged and indefinite detention of asylum seekers under the policy of mandatory detention. Children and their families are particularly vulnerable, especially unaccompanied minors. In the RANZCP’s view, detention should only ever be used as a last resort, with the child’s best interests in mind and for the shortest possible length of time.

Key messages

  •  All children have the right to equal access to healthcare regardless of their immigration status.
  • Child asylum seekers and refugees are at higher risk of mental illness and post-traumatic symptoms as a result of experiences from before their migration, during their journey and after their arrival.
  • Many child asylums seekers and refugees have severe mental health problems that require specialist treatment which may be unavailable in detention or offshore settings.
  • Prolonged detention can have severe and detrimental effects on the mental health of child asylum seekers and refugees, particularly when it occurs in isolated locations, with poor access to health and social services, and with prolonged uncertainty of asylum seeker claims.
  • Mental disorders in child and adolescent detainees should be managed outside the detention environment because continued exposure to traumatic stress associated with detention will adversely impact recovery.
  • Transfers to facilitate specialist treatment should be arranged as quickly as possible to minimise distress and worsening health.
  • Wherever possible, children should be managed in community settings with primary caregivers, and should not be separated from them. For all children, attachment is central to well-being and recovery.
  • In the RANZCP’s view, the practice of detaining children should only occur as a last resort, for the shortest possible time and with decisions informed by the best interests of the child.

Background

Immigration policies can present a range of obstacles to securing the mental health needs of child asylum seekers and refugees, including issues associated with access to health and education services, contact with caregivers and certainty regarding the processing of their claims.

Under current Australian law, asylum seekers who arrive by boat are placed in mandatory detention until their claim for asylum has been processed and their refugee status determined. Current law also prevents even those asylum seekers found to be refugees from settling in Australia, further prolonging uncertainty.

Australia’s policy of mandatory detention was introduced in 1992 and has been maintained in various forms by successive governments. Under the Migration Act 1958 (Commonwealth) there is no time limit on detention. The Migration Act contains a principle that a minor shall only be detained as a measure of last resort. It has, however, been a source of significant concern that, despite this, children and their families and unaccompanied minors continue to be subject to routine, prolonged and sometimes indefinite detention, with only temporary protection granted even when refugee status has been confirmed.

The Minister for Home Affairs is responsible for the implementation of current policies and is also the legal guardian for asylum seeker unaccompanied minors. The RANZCP regards this as a problematic conflict of interest. The Minister’s responsibility to act in the best interests of the child is often incompatible with the treatment of asylum seekers, including children (Corbett et al., 2014; RANZCP, 2014; AHRC, 2014a).

Detention of children contravenes responsibilities under the United Nations Convention on the Rights of the Child, ratified by Australia in 1990. Specifically, it fails to uphold:

  • Article 3(1): The best interests of the child must be a primary consideration in all actions concerning children
  • Article 37(b): Detention must be a measure of last resort and for the shortest appropriate period of time; children must not be deprived of liberty unlawfully or arbitrarily
  • Article 37(a),(c): Children in detention have the right to be treated with humanity and respect for the inherent dignity of the person
  • Article 6(2), 39: Children have the right to enjoy, to the maximum extent possible, development and recovery from past trauma
  • Article 22(1): Asylum-seeking and refugee children are entitled to appropriate protection and assistance (UNCRC, 1989).

As at 31 July 2018, there were five children in onshore detention facilities, 12 children in the Nauru Regional Processing Centre, 176 children in community detention and 2,835 children in the community on a bridging visa (Department of Home Affairs, 2018). Although this represents an improvement from three years ago, the fact that there are any children in this situation is of significant concern. As at October 2014, the average length of time for a child in immigration detention was 14 months (AHRC, 2014). This is comparable to the average length of time for all people in immigration detention which was just under 15 months (556 days) as of July 2018 (Department of Home Affairs, 2018).

Evidence

There is now a large body of evidence showing that immigration detention policies can be harmful. Uncertainty of asylum claims and prolonged detention, particularly in isolated locations with poor access to health and social services can have severe and detrimental effects. Any forced separation is highly stressful for children and can cause lifelong trauma, as well as an increased risk of other mental illnesses, such as depression, anxiety, and posttraumatic stress disorder (PTSD).

Detention in particular is detrimental to development and mental health and has the potential to cause long-term damage to social and emotional functioning (Mares, 2016; HREOC, 2004; AHRC, 2014). It is on the basis of this evidence that the RANZCP opposes the mandatory detention of children. The 2014 report by the Australian Human Rights Commission, The Forgotten Children: National Inquiry into Children in Immigration Detention, identifies significant concerns for the plight of children in these conditions (AHRC, 2014a). The report notes that 34% of children in detention centres had serious mental health disorders, compared with 2% in the Australian population (AHRC, 2014). High rates of serious mental health disorders were also noted a decade earlier in the report A Last Resort? (HREOC, 2004).

Risks to the mental health, well-being and development of children are the result of a combination of pre-migration experiences, the detention environment, uncertainty around visa outcomes, living in a closed environment, witnessing violence and the incapacity of their parents/guardians to provide appropriate care and protection often due to their own declining mental health. Furthermore, women giving birth in detention are particularly at risk of post-natal depression or anxiety and attachment difficulties with their infants. Children held in detention have reduced access to education and social development, including limited access to play groups, toys, games and schooling (RANZCP, 2014). Immigration detention is an environment of both high threat and neglect.

Children detained for long periods of time are at higher risk of suffering mental illness and post-traumatic symptoms including anxiety, distress, sleep and behavioural disturbances, bed-wetting, suicidal ideation and self-destructive behaviour including attempted and actual self-harm (Mares, 2016; HREOC, 2004). Children and adolescents in detention are 12 times more likely to self-harm and 10 times more likely to attempt suicide than Australian children who are not detained, with suicide attempts documented even in very young children in detention (Steel et al., 2004). Between January 2013 and March 2014 there were 128 reported actual self-harm incidents among children in closed immigration detention facilities in Australia (AHRC, 2014).

The detention centre environment is inadequate with respect to developmental opportunities, cognitive and educational facilities and support for parenting. Infants and young children born in detention are particularly vulnerable and show signs of developmental compromise (AHRC, 2014). The specialist services required to treat children with the severe mental health problems common among child asylum seekers and refugees are generally unavailable in detention settings or offshore locations such as Nauru. In such cases, specialist care may be urgently required and transfers to a location where ongoing and adequate specialist care is available should be facilitated in a timely manner.

It is not only psychiatrists who are concerned about the health and welfare of children and their families in immigration detention. In a 2014 survey of paediatricians in Australia, over 80% of respondents reported that they agreed with the Australian Medical Association’s assertion that ‘detention of asylum seeker children and their families is a form of child abuse’ (Corbett et al., 2014).

In summary, the RANZCP remains extremely concerned that highly vulnerable children are living in conditions known to be damaging to their mental health, well-being and development, particularly when more humanitarian solutions, such as community detention, exist. In all circumstances, the human rights and dignity of all should be honoured. Citizenship status must not be a barrier to early childhood education, acceptable living conditions, appropriate means of support, adequate healthcare and access to child protection measures.

Increasingly, medical practitioners employed in immigration detention centres are speaking out about ethical dilemmas of concern to them. These include the ethics of providing medical care in an environment that is in and of itself causing harm, as well as the challenge of meeting conflicting obligations to patients, employers contracted to provide services and the Department of Home Affairs. There is growing discourse around how best to provide care to these vulnerable children and families in traumatising environments, whether ethical professional practice is possible, and whether or not a professional boycott is appropriate (Newman, 2016; Sanggaran et al., 2014).

Recommendations

It is the position of the RANZCP that the practice of detaining children should only occur as a last resort, for the shortest possible period of time and with the decision informed by the best interests of the child (for example, to enable the most essential health and safety checks). In order to support the health and wellbeing of child asylum seekers and refugees, the RANZCP calls for all children and their families who are seeking asylum to be allowed to live in the community, while their claims for refugee status are being processed, with those found to be refugees offered ongoing protection or speedy resettlement.

To ensure that supportive, caring and non-traumatising early experiences for asylum seeker children and adolescents are provided, the following recommendations are made:

  • Australia’s immigration detention laws, policies and practice should be amended to comply with the Convention on the Rights of the Child. In particular children should be processed within 7 hours in order to reduce the likelihood of mental distress or disorders. This should be applied to both onshore and offshore Australian detention facilities.
  • Comprehensive assessment of child asylum seekers in detention should examine the roles of environmental deprivation, the availability of parental emotional support and the effects of traumatic exposure in contributing to clinical disorder.
  • Children, especially young children, should be removed from detention together with their families as soon as possible.
  • The protection and strengthening of the child’s attachment relationship(s) is central to promoting wellbeing and recovery and children should be managed in community settings with primary caregivers wherever possible. However, if this is not possible, there needs to be an assessment of the impact of family separation and the availability of alternate attachment figures. Adolescents may be better able to tolerate separation from family if placed with appropriate community supports acceptable to the young person and their family.
  • Mental disorders in child and adolescent detainees should be assessed by child and adolescent psychiatrists or mental health specialists and, wherever indicated, should be managed outside the detention environment as continued exposure to traumatic stress associated with detention impacts adversely on recovery. Children with serious mental disorders should be referred for specialist assessment and comprehensive trauma-informed care, including evidence-based treatment where indicated. This may require transfer to centres where specialist services are available.
  • Psychiatrists and other clinicians consulting to, or working in, detention centres should be supported to act in accordance with international ethical guidelines for medical practitioners, as well as RANZCP guidelines (RANZCP, 2016), and adhere to these in a way that advocates for the human rights of the child at all times.
  • Child asylum seekers and refugees at risk of abuse, neglect or developmental harm should be reported to and provided support from child protection authorities, independent of their visa status.
  • Health workers, professional medical bodies and other relevant parties should continue to maintain a robust, transparent discussion of the ethical, clinical practice and education and training issues regarding treating child asylum seekers and refugees.

Further reading

This statement should be read in conjunction with
►  Position Statement 46: The provision of mental health services for asylum seekers and refugees 
► Professional Practice Guideline 12: Guidance for psychiatrists working in Australian immigration detention centres [PDF; 121 KB]

Australia (1958) Act No. 62 of 1958, Migration Act 1958 – Volume 1. 8 October.

Australian Human Rights Commission (2011) Immigration detention in Leonora – Summary of observations from visit to immigration detention facility in Leonora. Available at: https://www.humanrights.gov.au/publications/2011-immigration-detention-leonora (accessed 28 August 2014).

Australian Human Rights Commission (2014) The Forgotten Children: National Inquiry into Children in Immigration Detention, November. Sydney, Australia.

Corbett E, Gunasekera H, Maycock A, Isaacs D (2014) Australia’s treatment of refugee and asylum seeker children: the views of Australian paediatricians. Medical Journal of Australia 201(7): 393–8.

Department of Home Affairs (2018) Immigration Detention and Community Statistics: Summary. Available at: https://www.homeaffairs.gov.au/ReportsandPublications/Documents/statistics/immigration-detention-statistics-july-18.pdf (accessed 22 October 2018).

Human Rights and Equal Opportunity Commission (2004) A Last Resort? Report of the National Inquiry into Children in Immigration Detention. Sydney, Australia.

Mares S (2016) The Mental Health of Children and Parents Detained on Christmas Island: Secondary Analysis of an Australian Human Rights Commission Data Set. Health & Human Rights: An International Journal 18(2): 219–32.

Newman L (2016). Asylum seekers and refugees – how should psychiatry respond? Australasian Psychiatry 24(1): 5–7.

Royal Australian and New Zealand College of Psychiatrists (2014) Australian Human Rights Commission National Inquiry into Children in Immigration Detention. Available at: https://www.ranzcp.org/Files/Resources/Submissions/RANZCP-SUBM-AHRC-Children-Detention.aspx (accessed 29 September 2014).

Royal Australian and New Zealand College of Psychiatrists (2016) Professional Practice Guideline 12: Guidance for psychiatrists working in Australian immigration detention centres. Available at: https://www.ranzcp.org/Files/Resources/College_Statements/Practice_Guidelines/PPG-12-Guidance-for-psychiatrists-working-in-Austr.aspx (accessed 22 August 2018)

Sanggaran J, Ferguson G, Haire B (2014) Ethical challenges for doctors working in immigration detention. Medical Journal of Australia 201(7): 377–8.

Steel Z, Momartin S, Bateman C, Hafshejani A, Silove D, Everson N, Salehi J K, Roy K, Dudley M, Newman L, Blick B, Mares S, Raman S, Everett (2004) Psychiatric status of asylum seeker families held for a protacted period in a remote detention centre in Australia. Australian and New Zealand Journal of Public Health 28(6): 427–36.

United Nations General Assembly (1989) Convention on the Rights of the Child. 20 November, United Nations, Treaty Series, vol. 1577, p. 3. Available at: http://www.refworld.org/docid/3ae6b38f0.html (accessed 28 August 2014).


Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.