Living in the Shadows: Trauma science puts immigrants under the microscope

Be they Bosnian, Cambodian or Haitian, people leaving their countries as refugees often show signs of trauma, through post-traumatic stress disorder, depression and other mental health problems.

The findings are consistent in repeated studies, regardless of the population under the microscope. And the work provided one of the underpinnings for our ongoing Living in the Shadows series.

The percentage of people suffering from mental health effects and the possible causes do vary, though. Over a few posts I will explore the science around the connection between immigration and trauma. I have tried to link to free copies of the journal articles I mention, but note that many journals charge for access.

Let’s start with one of the common experiences that leads to people being refugees: war. One of the most frequently cited studies in this area is a piece written by Dr. Richard Goldstein from the Departments of Social Medicine and Pediatrics at Harvard Medical School.

During the war in Bosnia that lasted more than three years in the mid-1990s, Goldstein oversaw a survey of children age 6 through 12 living in 25 centers for displaced persons in the city of Zenica, Bosnia-Hercegovina. All told, he was able to gather information from 364 children. Interestingly, less than 2% of the children said they had suffered a physical injury related to the war, while 92% of them said they had experienced life-threatening shelling. Here’s what Goldstein found:

All the children surveyed exhibited symptoms of significant distress. … Ninety-four percent of the children met the criteria of PTSD, and all reported symptoms satisfying the element in the diagnosis of reexperiencing traumatic events, 96.4% the element of avoidance of associated stimuli, and 99.4% the element of increased arousal. The mere presence of loud noises or military personnel would make the children feel as if they were once again amidst hostilities. They were unwilling or, in more severe cases, unable to play with other children and startled easily.

Let’s just pause on that for a second. These were children at the age when playing is supposed to be a central part of their lives and yet, “[t]hey were unwilling or, in more severe cases, unable to play with other children and startled easily.”

What was underlying those symptoms of distress? Goldstein found:

Two thirds of the children reported feeling guilty that they were responsible for the troubles in their family. More than half of the children showed extreme pessimism regarding their future when they reported that they believed they would never be happy, and 37.7% felt that life was not worth living.

Goldstein’s study continues to be regularly cited in trauma research. In 2005, JAMA Pediatrics published a paper about the “Lost Boys of Sudan” by Dr. Paul Geltman with the Department of Pediatrics at Boston University School of Medicine and colleagues. The researchers focused on Sudanese children in foster care programs affiliated with the U.S. Unaccompanied Refugee Minors Program (URMP) at 10 sites throughout the country.

All told, they were able to gather 304 questionnaires. They then analyzed the questionnaires and drew conclusions. Note that, depending on how many kids answered certain questions, the rates that the researchers were able to establish varied. For example, 241 children answered questions that allowed researchers to conclude that 20% (or 48 of 241) scored in the diagnostic range for post-traumatic stress disorder (PTSD).  The researchers also wrote:

Fifty-eight percent of 284 youths reported frequent “recurrent thoughts of the most hurtful event.” Other questions with high prevalences of frequent symptoms were “feeling as though the event was happening again” (40%), recurrent nightmares (38%), feeling on guard (37%), sudden emotional responses when reminded of the event (37%), avoiding activities that remind them of the hurtful event (36%), and avoiding thoughts associated with the hurtful event (32%).

There was also something interesting – and is it too much to say “hopeful” – in Geltman’s paper and others on the topic. “Comparing their health at the time of the study with that on arrival in the United States, 54% of the youths rated their health as much better; 24%, somewhat better; 17%, about the same; 2%, somewhat worse; and 2%, much worse,” Geltman wrote.

So that means that more 78% said that their health had improved since arriving in the United States. Perhaps we should expect as much given the resources we have in the United States, but this runs counter to a frequent narrative: that immigrants arrive in the United States only to see their health deteriorate. This is one of the reasons that the Living in the Shadows series is trying to explain the many ways that immigrants experience health and the health system.

Be sure to follow @immighealth for all the latest updates on the series.

Image by United Nations Photo via Flickr