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June 2017

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CC BY-NC 4.0

Authors:

Marianne Jakobsen

Norwegian Centre for Violence and Traumatic Stress Studies

Melinda Ashley Meyer DeMott

European Graduate School

Trond Heir

University of Oslo

Available via license: CC BY-NC 4.0

Content may be subject to copyright.

For peer review only

Mental health of unaccompanied refugee minors during the

asylum process: an observational cohort study

Journal:

BMJ Open

Manuscript ID

bmjopen-2016-015157

Article Type:

Research

Date Submitted by the Author:

17-Nov-2016

Complete List of Authors:

Jakobsen, Marianne; Norwegian Centre for Violence and Traumatic Stress

Studies,

Meyer DeMott, Melinda; Norwegian Centre for Violence and Traumatic

Sress Studies

Wentzel-Larsen, Tore; Norwegian Centre of Violence and Traumatic Stress

Studies,

Heir, Trond; Norwegian Centre for Violence and Traumatic Stress Studies;

University of Oslo, Institute of Clinical Medicine

Primary Subject

Heading:

Public health

Secondary Subject Heading:

Mental health

Keywords:

Refugee, Adolescent, Unaccompanied minor, Follow-up study, Norway

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Mental health of unaccompanied refugee minors during the

asylum process: an observational cohort study

Authors: Marianne Jakobsen

, Melinda A. Meyer DeMott

, Tore Wentzel-Larsen

1,3

Trond Heir

1,2

Norwegian Centre for Violence and Traumatic Stress Studies.

Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway.

Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway.

Correspondence to: Marianne Jakobsen, Norwegian Centre for Violence and Traumatic

Stress Studies, NCVTSS, Pb 181 Nydalen, 0409 Oslo, Norway

Email:marianne.jakobsen@nkvts.no

Word count: 3503

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ABSTRACT

Objectives: To examine the mental health of unaccompanied refugee minors (UM)

prospectively during the asylum-seeking process, with a focus on specific stages in the

asylum-process, such as age assessment, placement in a supportive or non-supportive facility,

and final decision on the asylum applications.

Design: A two and a half year follow-up study of UM seeking asylum in Norway. Data were

collected within three weeks (n=138), and at 4 months (n=101), 15 months (n=84) and 26

months (n=69) after arrival.

Setting: Initially in an observation and orientation centre for unaccompanied asylum-seeking

adolescents, and subsequently wherever the UM were located in other refugee-facilities in

Norway.

Participants: Male UM from Afghanistan, Somalia and Iran, with self-reported age 15-18.

Main outcome measures: Mental health symptoms assessed by Hopkins Symptom

Checklist-25, and Harvard Trauma Questionnaire.

Results: At the group level the young asylum seekers reported high levels of psychological

distress on arrival, and symptom levels that stayed relatively unchanged over time.

According to age-assessment procedures 56% of the population was not recognized as minors.

Subsequent placement in a low- support facility was associated with higher levels of

psychological distress in the follow-up period. Those who were placed in a reception centre

for adults had higher levels of psychological distress symptoms both after 15 months and 26

months compared to the remaining participants who were placed in reception centers for

youth. Refusal of asylum was highly associated with higher levels of psychological distress.

Conclusions: Mental health trajectory of young asylum-seekers appears to be negatively

affected by low support and refusal of asylum.

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Strenghts and limitations of this study.

x.Strengths include a longitudinal design, with first assessment within three weeks after

arrival to the host country, and repeated measures.

x. Use of computer-based assessment with audio-translations throughout the study.

x.Selection of participants was limited to the most common nationality groups arriving in

Norway at the time of inclusion.

x.High attrition rate due to the fact that asylum seekers tend to move between and within

countries, and that many were told to leave the country.

INTRODUCTION

In 2015 more than 88 700 unaccompanied minors (UM) fled to Europe

, putting considerable

pressure on these countries to provide the necessary resources needed. Separated children that

are no longer protected by parents or other caregivers, usually have to be under the age of 18

in order to be given the special protection and care that is granted unaccompanied refugee

minors. In the countries of origin for UM the civil registration service of their country often

function poorly, and birth certificates can be lost, thrown away or falsified.

The scientific

basis for assessing age is controversial, in that these tests only determine physical maturity,

and are most uncertain from the age of 15 to 21, where natural variation is at its greatest.

The

consequences for many young asylum seekers assessed to be 18 years or older is that they will

no longer be considered as minors, and therefore not receive special protection in accordance

with the United Nations.

Most studies investigating UM mental health have a cross-sectional design with a selection of

youths with different levels of legal recognition and different durations of time in exile.

These studies show consistently that individual factors such as exposure to violence and other

traumatic events prior to migration, correspond to elevated symptoms of psychological

distress.

In some studies the negative effects of exile related stressors are also described

, yet

they focus on youths with varying time in exile. There are different asylum-procedures within

the different countries

, and most UM endure some uncertainty before their legal status is

defined. Most countries provide some form of shelter for UM while they are waiting for their

case to be processed, but conditions vary greatly. Positive health effects have been shown to

be associated with receiving a permanent residence permit

, but this process may take months

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and sometimes years. The impact of different levels of social support that UM are offered,

especially after the first stage of reception and registration, have not been studied in detail.

The aim of our study was to examine UM`s mental health during the asylum-seeking process,

and more specifically whether the official age assessed, level of support, and the outcome of

the asylum application were associated with UM`s mental health at different stages of the

asylum seeking process.

METHODS

Participants and procedures

The sample in this study was a male convenience sample recruited from an observation and

orientation centre for unaccompanied asylum-seeking adolescents between ages 15 and 18

years, which was the only one in Norway at this time. In this reception centre, all UMs who

claimed to be in this age group stayed for the first weeks while asylum interviews and age-

assessment procedures were performed. A research assistant kept track of all new arrivals, and

each time our testing capacity allowed us to include some new participants, she was instructed

to invite the ones who had arrived most recently. The study was conducted between

September 2009 and March 2011. Altogether, the inclusion periods for this project were 12

weeks in 2009, 8 weeks in 2010, and 21 weeks in 2011. During these time periods young

asylum seekers came mainly from Afghanistan and Somalia. According to the statistics unit at

the Norwegian Directorate of Immigration, 406 male UM from these language groups arrived

in Norway during the inclusion periods. Unaccompanied males with self-reported age of 15 to

18, that had just arrived, were contacted by the research assistant. Altogether, 216

adolescents were asked to participate, and 209 returned the informed consent and attended the

study. Some participants were included in an Expressive Arts intervention group (n=71), that

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is not part of the present study. The remaining 138 are the focus of this article. More about the

whole project can be found on our home pages

Information to participants included statements that participation would not impact the

chances to stay in the country. Only one contact attempt was made for each individual, and no

payment was offered.

Participants followed the normal procedures in the asylum process. In Norway all UMs

receive assistance from a multi-disciplinary professional staff (educators, social workers,

psychologists, physicians, and nurses) in the first reception centre while waiting for their

“official-age” to be assigned. Those defined as 18 or older can be moved to adult housing

where less professional assistance is provided. The asylum-seekers considered to be from 15

to 18 years are moved to specialized youth centres, with staff available 24 hours, every day.

The youngest children stay in even more specialized orphanages. There are some exceptions

to this pattern, according to variable housing capacity some 18-year old asylum-seekers are

allowed to stay in the youth centres for some time. The youth centres are located all over

Norway, and have language classes for all inhabitants. Food is prepared and served by the

staff, and there are staff members available day and night. Most centres have recreational

activities, and they give individualised support and medical follow-up if needed. In an adult

centre, the asylum-seekers are left to themselves most of the time. They buy and cook their

own food, have no school or other scheduled activities, and have no guardians or staff

members to ask for advice.

The first screening procedure was conducted within the first three weeks, and later repeated at

4 months (n=101), 15 months (n=84) and 26 months (n=69) after arrival. At the last

assessment the population was almost halved, mainly because many of the informants were

transported out of the country, or had disappeared from the different living facilities.

Measures

Demographic data was registered with the aid of interpreters at the initial assessment. We

asked for self-reported age, literacy, years of school attendance, and whether their parents

were still alive, deceased, or if participants had lost touch with their parents and did not know.

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Later we registered the results of official age-assessments, especially which participants who

were thought to be at least 18 years of age. We also determined the level of care offered

according to placement in asylum centres for either adults or for youth. Before the last

assessment we registered the legal status, as participants were either given time-limited or

permanent permission to stay, or were refused legal residence in the country.

Exposure

Serious Life Events checklist (SLE), was developed by Tammy Bean and colleagues

order to assess if an adolescent meet the criteria A1 (experienced a traumatic event) in the

DSM-IV, for a diagnosis of PTSD. It is a self-report questionnaire which asks whether or not

the participant has experienced twelve different kinds of traumatic events, such as separation

from family, natural disaster, war and physical or sexual abuse. The instrument was scored by

answering yes or no on each item.

Psychological distress

Hopkins Symptom Checklist-25 (HSCL-25)

is a self-administered questionnaire designed to

measure anxiety and depression. It has been validated in various clinical and community

samples.

13,14

The HSCL-37 A version is an extension of the HSCL-25, and has also been

applied in a number of refugee studies with minors.

15,16

The additional 12 items measuring

externalizing behavior are not included in this paper. Each item was scored with 1 (not

bothered) to 4 (extremely bothered).

Post Traumatic Symptom Score (PTSS)

The Harvard Trauma Questionnaire

is a comprehensive instrument that was developed to

assess potentially traumatic experiences and post-traumatic symptoms in various cultural

contexts. Its psychometric properties were first established in a highly traumatized, clinical

population, but it has also been evaluated with a larger community sample, and with asylum

seeking adolescents

6, 18

. The HTQ part IV, comprises 30 symptom items, among which the

first 16 items measure “The symptoms of PTSD” according to the DSM–IV.

These 16 items

are scored with 1 (not at all) to 4 (extremely).

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Computer-based assessment

The chosen psychometric measurements were combined into a single questionnaire using the

program MultiCASI

. The questionnaires were filled in by the participants themselves, in

their native languages, Dari, Pashto, Farsi or Somali, using laptops with touch-screen function.

Translations had been attained from earlier projects, and were controlled by independent,

native speaking, interpreters before they were added to the questionnaire. The items appeared

one after the other on the screen, together with answering alternatives. All text had a sound-

file connected to it that started as soon as the item appeared on the screen. The test could be

used with any level of reading competence, and the sound of each item could be activated by

touch, as many times as necessary. Items could be skipped and left unanswered, but would

then be repeated once more towards the end of the questionnaire. The first introduction to the

computer based self-screening was done shortly after arrival, with one language group at the

time. An interpreter was present together with maximum five participants, as they were

instructed in how to use the touch screen. They were encouraged to ask clarifying questions as

they went on with answering the items, all in the same room, with earphones on, in order not

to disturb each other. During the following waves of data collection the same questionnaire

was used and translating services were not necessary. The results were transported digitally to

the SPSS files.

Data analysis

Differences in HSCL and PTSS between 0, 4, 15 and 26 months were assessed by linear

mixed effects models by categorical time, including an inter-individual random effect.

Relationships between HSCL, and PTSS at each time point ≥ 4 months and characteristics

known at that time point were assessed by unadjusted and linear regression. Specifically,

covariates were being literate, parents deceased, number of adverse events and age assessed as

≥18 years at 4 months. At 15 months, being placed in a reception center for adults or youth,

was included, and at 26 months also asylum status; permanent, time limited or refusal of

asylum. Nonresponse analysis during follow up (4 to 26 months) used a generalized

estimating equations (GEE) logistic regression by time and baseline HSCL score, reading

ability, category for parents alive and number of serious life events. For descriptive analyses

we used the SPSS version 22 for Windows. Beyond this, data was analyzed using R (The R

Foundation for Statistical Computing, Vienna, Austria) with the R package nlme for mixed

effects models and gee for GEE analyses

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Table 1. Baseline characteristics of male unaccompanied refugee minors at arrival in Norway. Figures

are given as number (%) when others not specified.

N = 138

Age, self-reported

Mean years (SD)

Range

16.22 (0.84)

15 - 18

Age, assessed by authorities

Mean years(SD)

Range

18.22 (2.27)

15 - 28

Nationality

Afghan

Somalian

Iranian

102 (73.9)

32 (23.2)

4 (2.9)

Literacy, self-reported 50 (36.8)

Loss of parent

Father

Mother

Both

Unknown

85(62.9)

29(21.5)

25(18.5)

16(11.9)

Psychological distress (N=199)

Mean HSCL (SD)

Caseness (n>2.0)

2.03 (0.58)

92 (46.2)

Posttraumatic stress (N=198)

Mean PTSS (SD)

Caseness (n>2.0)

2.19 (0.58)

130 (64.4)

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Results

Three fourths of the population came from Afghanistan, while the remaining came from

Somalia and Iran (table 1). There were no significant differences between the countries of

origin and the variables included in this article. A minority (36%) were able to read in their

own language. Mean number of serious life-time events experienced was 6.3 (SD 2.3), range

1-11. Most of the participants (96%) had experienced at least one of the serious life events

listed. The most frequently reported experiences were life threatening events (82%), physical

abuse (78%), and loss of a close relative (78%). The official age assessment found a mean age

of 18.4 years (SD 2.4), range 15-28, which meant that 72 (56%) participants were considered

to be adults. Of this “adult”group, 36 participants were allowed to stay at the care centres for

adolescents, while the rest had to move to centres for adults. None of the participants received

psychiatric treatment during the study.Overall there were no significant changes in the level

of symptoms within the study period (p≥.084), neither for HSCL(Table 2) nor for PTSS.

Table 2. Mixed effect coefficients (MEC) for time modelling the course of psychological distress (HSCL)

and posttraumatic stress (PTSS) in unaccompanied refugee minors after arrival in host country.

HSCL

PTSS

MEC

95% CI

MEC

95% CI

Time

.136

.725

4 mo vs 0 mo

0.04

0.09, 0.16

.557

0.02

12, 0.15

.811

15 mo vs 0 mo

0.14

0.01,0.27

.037

0.03

0.11, 0.17

.671

26 mo vs 0 mo

0.02

0.16, 0.13

.831

0.06

0.21, 0.09

.441

HSCL : Hopkins symptom checklist

PTSS : Posttraumatic stress symptom checklist

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Tables 3-5 show the associations between variables of interest, and symptoms of

psychological distress at different test points. Outcome of age assessment, which was known

shortly after the first assessment, had no significant association with psychological distress at

4 months (table 3). However, those who were estimated to be 18 years or older, had higher

levels of symptoms at 15 months (table 4) and at 26 months (table 5), but not when adjusted

for the outcome of the asylum-applications at the 26 month assessment.

Table 3. Regression coefficients for literacy, pre-migration bereavement, serious life-events and post-

migration age assessment, related to course of psychological distress (HSCL) in young male asylum

seekers 4 months after arrival in host country; unadjusted and adjusted results.

Unadjusted

Adjusted

Coef. 95% CI P Coef. 95% CI P

Being literate 0.348 0.115,0.581 .004

0.262

0.006, 0.518

.045

Parents deceased

Unknown vs both alive

One dead vs both alive

Both dead vs both alive

0.175

0.146

-0.172

-0.232,0.581

-0.166,0.457

-0.564,0.219

.245

.396

.355

.384

0.146

0.182

-0.053

-0.254, 0.545

-0.119, 0.483

-0.442, 0.337

.457

.472

.234

Adverse events

0.066

0.015,0.116

.012

0.046

0.006, 0.098

.084

Age assessed ≥18 years 0.126 -0.118,0.370

.308

0.068 -0.191, 0.326

.604

HSCL: Hopkins symptom checklist

Adjusted for whether subjects participated in initial 5 week expressive arts group-intervention

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Table 4. Regression coefficients for literacy, pre-migration bereavement, serious life-events and post-

migration age assessment, in addition to asylum-seeker facilities, related to course of psychological distress

(HSCL) in young male asylum seekers 15 months after arrival in host country; unadjusted and adjusted

results.

Unadjusted

Adjusted

Coef.

95% CI

Coef.

95% CI

Being literate

0.054

254,0.363

.727

0.008

0.296, 0.313

.957

Parents deceased

Unknown vs both alive

One dead vs both alive

Both dead vs both alive

0.240

0.253

0.581

-0.278,0.757

-0.141,0.646

0.097,1.065

.134

.359

.206

.019

0.346

0.317

0.626

-0.133, 0.825

-0.051, 0.684

0.157, 1.094

.073

.154

.090

.010

Adverse events

0.039

0.030,0.107

.262

0.054

0.010, 0.119

.099

Age

assessed

≥18 years

0.522

0.238,0.805

<0.001

0.375

0.058, 0.692

.021

Adult reception center

0.464

0.136,0.792

.006

0.354

011, 0.695

.043

HSCL: Hopkins symptom checklist

Adjusted for whether subjects participated in initial 5 week expressive arts group-intervention

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Table 5. Regression coefficients for literacy, pre-migration bereavement, serious life-events and post-

migration age assessment, asylum-seeker facilities, in addition to asylum-status, related to course of

psychological distress (HSCL) in young male asylum seekers 26 months after arrival in host country;

unadjusted and adjusted results.

Unadjusted Adjusted

Coef.

95% CI

Coef.

95% CI

Being literate

0.025

305,0.355

.881

0.040

0.322, 0.242

.777

Parents deceased

Unknown vs both alive

One dead vs both alive

Both dead vs both alive

0.591

0.261

0.670

0.021,1.162

-0.130,0.652

0.160,1.180

.043

.042

.187

.011

0.562

0.384

0.532

0.076, 1.047

0.049, 0.719

0.088, 0.976

.038

.024

.025

.020

Adverse events

0.059

0.126,

0.008

.083

0.041

0.097,0.016

.155

Age assessed ≥18 years

0.392

0.086

,0.

697

.013

0.070

0.428, 0.288

.696

Adult reception center

0.717

0.372,1.063

<.001

272

0.169,0.712

.222

Asylum status

(vs acceptance)

Time-limited asylum

Refusal of asylum

-0.035

0.787

-0.391,0.320

0.402,1.172

<.001

.844

<.001

-0.103

0.590

-0.498, 0.292

0.122, 1.059

.017

.602

.015

HSCL: Hopkins symptom checklist

Adjusted for whether subjects participated in initial 5 week expressive arts group-intervention

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One third of the participants were placed in a reception centre for adults. Figure 1 shows the

trajectories of psychological distress for participants placed in a reception centre for adults or

for youth. Those who were placed in a reception centre for adults had higher levels of

psychological distress symptoms both at 15 months (table 4) and 26 months (table 5)

compared to the remaining participants who were placed in reception centres for youth.

However, when adjusted for the outcome of the asylum application at the 26 month

assessment, the difference was not significant.

Final decision on the asylum claims was given between the last two test points. Refusal was

highly associated with higher levels of psychological distress. Achieving time limited

residence permission was not significantly different compared to permanent asylum (table 5).

Trajectories of psychological distress for those who received refusal or acceptance of their

asylum application are illustrated graphically in figure 2. Refusal was related to the official

determined age of the asylum seeker. Among the participants who were considered to be 18

or more, 52 out of 72(72.2%) were refused, compared to 15 out of 59(25.4%) among the

participants who were considered to be under 18 (7 missing).

The symptom scores of the PTSS (not illustrated in the tables) showed a similar association as

the HSCL-scores, with higher levels of PTSD-symptoms for those placed in a reception center

for adults at 15 months (adjusted difference 0.34, 95% CI 0.06 to 0.63, p=0.017), as well as

higher symptom scores for those who received a negative result for the asylum application at

26 months (adjusted difference 0.60, 95% CI 0.24 to 0.95, p=0.001).

Loss to follow-up was not significantly related to initial levels of distress. Also, none of the

baseline covariates were significantly related to nonresponse.

DISCUSSION

The present study is a follow-up of unaccompanied refugee minors with four waves of

assessment from within three weeks after arrival to more than two years spent in the host

country. At the group level the young asylum seekers reported high levels of psychological

distress on arrival, and symptom levels that stayed relatively unchanged over time. A low

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level of support during the asylum process and a negative outcome of the asylum application

were associated with higher levels of psychological distress.

Determination of the legal status of the asylum seekers involved age assessment procedures,

with x-rays and dental examinations for all participants in this study. This resulted in a

considerable gap between self reported age and the official age estimates designated by the

immigration authorities. On the basis of these examinations 55% of the asylum seekers were

considered to be at least the age of 18, and thus did not achieve a UM status. They risked

being moved to a facility for adults, with low levels of support and care, and limited access to

education and leisure activities. Also, the likelihood of being granted asylum was related to

age, as illustrated by the numbers of children and adults in our study who got refusal of their

claims.

The results from our study is in agreement with other studies that have found that high-

support housing, with sufficient supervision, was associated with lower levels of

psychological symptoms

. Others have also described problems directly connected to the

asylum process, and have registered them as components in a list of post-migration stressors

A weakness with most of these studies, are cross-sectional designs where there are no base-

line measurements. Only a few studies have repeated assessments

where problems directly

connected to the asylum process, such as age-assessment procedures, lack of adequate

housing, low support, etc., have been evaluated. The complexity of factors contributing to the

increasing health risk, make it difficult to draw specific conclusions within the total burden of

stressors.

In all studies with UM, it is likely that there will be some uncertainty concerning the

participants’ true chronological age

. Defined to be overage, in the present study, was not

significantly related to the symptom scores at the 4 month assessment, and there was no

indication that this process was stressful in itself. The age designated by the authorities,

determined what type of housing and level of care that was offered during the remaining

asylum-procedure. This meant that many of the participants had to live in a reception centre

for adults, where they had no guardian, no school, had to cook for themselves, and budget

their benefits. Our findings that this group had higher levels of psychological distress, add

further evidence that living conditions in the asylum seeking period may influence the mental

health of young refugees.

6, 9

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The outcome of the individual asylum applications was revealed to the asylum seekers

between one and two years after the arrival, and the negative impact of refusal was as

expected, since several studies have found that difficulties obtaining legal residence are

associated with a range of psychological problems for this group

. We also know that

longitudinal studies indicate a trend towards reduction of mental health symptoms for

resettled refugees over time.

In a follow-up study of 131 young refugees in Denmark, the

long term effects of pre-migration adversity were mediated by a variety of factors connected

to social life.

Another study suggests positive health effects upon receiving permanent

residence mediated through improved living conditions.

This, in association with our

findings, emphasizes the importance of a supportive post-migration environment for all

refugees with pre-migratory experiences of serious trauma and human rights violations.

Strengths of our study include a longitudinal design, with first assessment within three weeks

after arrival to the host country, and repeated measures. We used computer-based assessment

with the same audio-translations throughout the study, and did not need to use interpreters in

order to complete the psychometric measures at follow-up. Selection of participants was

limited to the most common nationality groups arriving in Norway at the time of inclusion,

and may limit the generalization of our findings. High attrition rate due to the fact that asylum

seekers tend to move between and within countries, and that many were told to leave the

country, may have biased our findings. It is also possible that our research team was not

viewed as independent from the authorities, even though we stressed this fact when we

informed about the project. Finally, we have no data as to whether poor mental health might

have affected the likelihood of asylum. Mental health is generally not an issue in the

processing of asylum applications in Norway. Also, the baseline levels of mental health did

not differ between participants that later received asylum and those who did not.

Implications

Our study shows that young asylum-seekers may spend considerable time in a safe Western

country, without recovering from the distress they have when they arrive in the host country.

A reason for the continuing psychological health problems in this non-clinical group of youth

can possibly be found in the living conditions and the level of care that is provided.

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Adolescence is a challenging transition-period for most people. Fleeing to a foreign country

without parents or other caregivers makes this life-period even more challenging for young

refugees, and puts a considerable responsibility on the receiving countries. The burden of

increasing numbers of asylum-seekers challenges the political intentions of the UN

Convention on the Rights of the Child (CRC) to always give precedence to “the best interest

of the child”.

It is emphasized that safety and dignity in the use of medical assessments

should be applied as a supplement to evaluations of the physical appearance and the

psychological maturity of the child. Needs of vulnerable adolescents and young adults in a

stressful life-situation deserve high priority and should be a main focus regardless of the

outcome of age assessments.

In our society turning 18 is usually considered a transition point from child to adult. Yet with

the limitations of the age determining process we cannot know for certain that this milestone

has been reached. The consequences of this uncertainty can have legal, social and material

implications.

If a child is put under difficult living-conditions, where previous human

support and education is withdrawn, this can have unintended negative effects on these young

individuals transitioning into adulthood. Some child protection services argue that vulnerable

young adults are still in need of support and care after the age of 18

, and need to receive

specialised care into their twenties.

Future studies should focus on how mental health and

resilience evolve over a longer time span, and evaluate specific interventions and appropriate

levels of care for young refugees.

Acknowledgement: Gratitude to Liv Berit Løken for her care and assistance with all aspects

of the data collection. Thanks also to our very skilled interpreters, and to all the young

participants.

Contributors: M. Jakobsen has had the main responsibility for the drafting and writing of the

article. Heir was, in collaboration with DeMott and Jakobsen, responsible for the literature

review and the conception and design of the article. DeMott and Jakobsen has been

responsible for all phases of the data collection. Data analysis and interpretation of data was

done in cooperation between Jakobsen, Heir and Wentzel-Larsen. All authors have

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contributed to the scientific writing and proof-reading of the article. The paper has been read

and approved by all authors before submission.

Funding: This work was supported by The Norwegian Directorate of Immigration.

Competing interests: None

Ethics approval: Regional Committees for Medical and Health Research Ethics.

Data sharing statement: No additional data are available.

References

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unaccompanied-minor-refugee-boys-in-transit-centers/

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13. Hollifield M, Warner TD, Lian N. Measuring trauma and health status in refugees: a critical

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Adolescents (Hscl-37a): User’s Manual In: Centrum’45. Oegstgeest, 2004.

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. 2016

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Figures

Fig 1. Course of psychological distress (HSCL) during follow up of asylum seekers placed in asylum

centers for adults (n=38) and asylum seekers placed in asylum centers for youth (n=100).

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Fig 2. Course of psychological distress (HSCL) during follow up of asylum seekers who received refusal

of asylum (n=67) and asylum seekers who received residence permission or time limited asylum

(n=64).

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Research checklist

We have gone through the STROBE statement-Checklist list, and have tried to address all items in the

article. We want to make some extra comments to these points:

10 and 13: This study has been conducted in cooperation with Norwegian immigration authorities,

and there were restrictions on where and when we could gain access to the reception centers. The

time periods when we were allowed to register are described in the article. We do not believe these

restrictions impacted the selection of clients, since immigration to Norway happens all through the

year, with very little control by the authorities. The restrictions were based on practical needs for

turnover at the center, and we had to cooperate in order to do any research at all. The study size is

the number of participants we were able to include within the designated time frames. It is hard to

know how many participants we could have reached, since a lot of immigration is illegal, and asylum-

seekers flee from the reception-centers all the time.

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Mental health and the impact of the asylum process: a

longitudinal study of unaccompanied refugee minors.

Journal:

BMJ Open

Manuscript ID

bmjopen-2016-015157.R1

Article Type:

Research

Date Submitted by the Author:

03-Feb-2017

Complete List of Authors:

Jakobsen, Marianne; Norwegian Centre for Violence and Traumatic Stress

Studies,

Meyer DeMott, Melinda; Norwegian Centre for Violence and Traumatic

Sress Studies

Wentzel-Larsen, Tore; Norwegian Centre of Violence and Traumatic Stress

Studies,

Heir, Trond; Norwegian Centre for Violence and Traumatic Stress Studies;

University of Oslo, Institute of Clinical Medicine

Primary Subject

Heading:

Public health

Secondary Subject Heading:

Mental health

Keywords:

Refugee, Adolescent, Unaccompanied minor, Follow-up study, Norway

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Mental health and the impact of the asylum process: a

longitudinal study of unaccompanied refugee minors.

Authors: Marianne Jakobsen

, Melinda A. Meyer DeMott

, Tore Wentzel-Larsen

1,3

Trond Heir

1,2

Norwegian Centre for Violence and Traumatic Stress Studies.

Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway.

Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway.

Correspondence to: Marianne Jakobsen, Norwegian Centre for Violence and Traumatic

Stress Studies, NCVTSS, Pb 181 Nydalen, 0409 Oslo, Norway

Email:marianne.jakobsen@nkvts.no

Word count: 4306

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ABSTRACT

Objectives: To examine the mental health of unaccompanied refugee minors (UM)

prospectively during the asylum-seeking process, with a focus on specific stages in the

asylum-process, such as age assessment, placement in a supportive or non-supportive facility,

and final decision on the asylum applications.

Design: A two and a half year follow-up study of UM seeking asylum in Norway. Data were

collected within three weeks (n=138), and at 4 months (n=101), 15 months (n=84) and 26

months (n=69) after arrival.

Setting: Initially in an observation and orientation centre for unaccompanied asylum-seeking

adolescents, and subsequently wherever the UM were located in other refugee-facilities in

Norway.

Participants: Male UM from Afghanistan, Somalia, Algeria and Iran.