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Support for unaccompanied children and youth – effects, experiences and perceptions

A systematic review and assessment of social and ethical aspects

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identifies and presents available scientific evidence to support policy and decision making, including the development of national guidelines, at other government agencies. In consultation with professional experts, SBU staff generates supporting documentation to address the various questions that have been posed.

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Published: Report no: 294 Registration no: SBU 2017/94 ISBN: 978-91-88437-36-5 https://www.sbu.se/294e

According to Swedish law, the term unaccompanied children designates asylum-seekers under 18 years of age, who on arrival in the host country have been separated from their parents, or from another adult who could be regarded as acting in place of the parents, or those who after arrival are without any such parental substitute.

  • Our systematic review of the scientific literature failed to identify any controlled studies investigating or comparing the effects of different sup­­portive interventions for unaccompanied children and youth.
  • Our systematic review of research which in var­ious ways highlights the experiences and per­­cep­tions of unaccompanied children and youth with respect to factors which facilitate, or hinder, their social integration, physical and mental health and ability to function, has res­ulted in seven comprehensive themes (third level themes*)
    • Security and control: A basic prerequisite. Unaccompanied children and youth have experienced trauma and loss, which in com­bi­nation with uncertainty about the future, im­plies a lack of basic security, control and safety. This has a pronounced effect on every­­day life and influ­ences wellbeing and the abil­ity to cope with daily issues and dif­fi­cul­ties, and the ability to envisage their future.
    • The new country: Both opportunities and difficulties. Unaccompanied children and youth express a strong motivation to receive an education, to adapt to the new country and take advantage of the opportunities available. At the same time, they describe structural and social barriers as well as difficulties related to finding themselves in an unfamiliar cultural and social context. Altogether this can hinder a positive devel­op­ment in terms of health, integration and ability to function.
    • Coping with difficulties: A balance of vari­ous strategies. Coping strategies (strategies for managing difficulties by thoughts and behavior), such as avoidance, flight and posi­tive thinking, can have a positive function, but can sometimes also be a barrier to health, inte­gration and abil­ity to function. Religion can be perceived as meaning­ful for wellbeing and the ability to manage difficulties.
    • The daily environment: Supportive relation­ships, influence in accommodation and access to school and activities are important. Unaccompanied children and youth claim that support, good relationships and having influence in accommodation and mealtimes in accomodation are important, regardless of the type of accommo­dation. School is per­ceived as important for learning, wellbeing and relationships. The importance of support and advice from adults at school and in relation to the school and education is em­phas­ized. With respect to the school as a place for developing relationships with people of similar age, both positive and negative experiences are described. Leisure activ­ities are described as important for wellbeing, for build­ing social relationships and creating a meaningful environment.
    • Relationships: Support and guidance from adults are meaningful, contact with those of the same age is important but also difficult. Unac­com­panied children and youth emphasize the importance of guidance, support and continuity and the opportunity to have some influence and independence regarding their relationships with adults. Relationships with those of similar age are considered to be important but also difficult. Relationships with their biological family implies not only missing them but also support. The quality of the relationship with the biological family may promote or hamper wellbeing and development.
    • Social services and health and medical care: Varying perceptions and experi­ences of support and need. Unaccompanied children and youth acknow­ledge the importance of basic support from social services, but con­sider the support provided to be inad­equate. They express varying perceptions and ex­peri­ences of psychological support from the health services.
    • Identity and belonging: Reconciling the past, the present and the future. Unaccom­panied children and youth strive both to retain their language and culture of origin and to adapt to the new country, while at the same time trying to maintain their relation­ships with people in their country of origin and to support them. They can find it a struggle to determine where they belong. Religion can be a means of creating con­tinu­ity with previous experiences.

 

* The third level’s themes have been formulated in such a way as to disclose the core findings. These themes have been used to arrange and present the results in a simple and easily readable way and are condensed from all the themes at level two, regardless of the strength of the evidence.

Aim

The aim of the report is two-fold: To conduct a sys­tematic review in order to investigate the scientifically documented effects of different supportive interventions, from social services, health services and schools, on the experiences and perceptions of unaccompanied children and youth, with respect to what facilitates or hinders their social integration, mental and phys­ical health and ability to function. Relevant ethical and social aspects have also been analyzed.

Background

From 2014 until 2017 the number of unaccompanied children and youth arriving in Sweden has varied: from 1,336 in the year 2017 to 35,369 in the year 2015. During the same period the proportion of girls has been about 20%, except for 8% in 2015. Most of the newly-arrived unaccompanied children and youth are teenage boys.

Unaccompanied children and youth are a heterogeneous group with respect to such factors as their reasons for fleeing, their age, living conditions at home, level of education, socioeconomic standard and cultural and religious background. This means that individual needs and expectations can influence both the choice of supportive interventions and the anticip­ated outcome of such interventions.

Various agencies are involved in their reception. The Swedish Migration Agency is responsible, among other things, for assessing the need for protection and the decision to grant a residence permit. The Swedish Migration Agency also determines which local author­ity is to be responsible for reception of the applicant and arranges for reimbursement to the local council. The local authority has the main responsibility for the practical reception of unaccompanied children and youth with respect to accommodation, daily care, special support where indicated, appointment of a guard­ian and school attendance. The county councils and regional councils are responsible for health, medical and dental care.

Method

The supporting scientific evidence has been compiled on the basis of a systematic review of the research lit­erature, involving searching and critical scrutiny and the findings have been collated in accordance with the method described in SBU’s manual. The work has been based on unambiguous questions and inclusion and exclusion criteria. A broad search of the literature was undertaken through a number of databases. This was followed by assessments of the relevance and qual­ity of the studies. The results of these studies were collated. Finally, an assessment was made of confidence in the available scientific evidence. For qualitative synthesis, the evidence-grading system CERQual was applied, disclosing to what extent confidence in the results is negatively affected by methodological flaws in the included studies; the extent to which the data are relevant to Swedish conditions, how coherent the data are and whether the data are adequately comprehensive. A description of ethical and social aspects has been undertaken with the aid of a preliminary version of guidelines for integrating ethical aspects in evaluation of social studies. These guidelines have been compiled by SBU.

Results

Interventions directed towards unaccompanied children and youth

Our systematic review of the scientific literature failed to identify any studies which met our inclusion criteria. Nor did we find any well-conducted, controlled studies which investigated or compared the effects of different interventions for unaccompanied children and youth.

Experiences and perceptions in the new country

Our systematic review of research into the experi­ences and perceptions of unaccompanied children and youth with respect to factors which enhance or hinder positive development is based on 29 articles published between 2004 and 2017. Five articles concern unaccompanied children and youth in Sweden, 3 are from other Nordic countries, 15 from other European countries and 6 are from USA. The mater­ial comprises a total of 519 subjects, 136 of whom are girls. Afghanistan is the predominant country of origin in the studies, while other countries include, for example, Somalia, Eritrea, Sudan and Nigeria. The results are presented in Table 1.

Ethical and social factors

Our systematic review of the literature failed to ident­i­fy any controlled studies which investigated or compared the effects of different supportive interventions for unaccompanied children and youth. There is a need for quantitative research methods which in an ethically acceptable way can improve our knowledge of the effects of interventions in this specific group. The selection of interventions intended to support unaccompanied children and youth in­volves consid­eration of particular ethical issues, and this requires that those responsible handle these questions with awareness and consistency. Moreover, the fact that unaccompanied children and youth are not only refugees but arrive on their own, without the support of a responsible adult, means that respon­sible decisions need to be made. There may also be other particular issues which further complicate decision-making, for example the effects of trauma, neglected or comprom­ised somatic health, social exclusion, isolation and vulnerability, sociocultural turbulence, attitudes to government officials, uncertainty about the processes of asylum and integration, conflicts with respect to goals, and lack of co-ordination between various au­thor­ities involved.

Table 1 Experiences and perceptions for unaccompanied children and youth.
Level 3 theme and the themes included in Level 2. A decision has been made as to whether the experience is facilitating (+), inhibiting (–) or both (+/–). Confidence in the scientific evidence has been assessed for all the level 2 themes according to CERQual and is designated as strong (⊕⊕⊕⊕), moderate ⊕⊕⊕◯, low (⊕⊕◯◯) or very low (⊕◯◯◯).
Perceived as facilitating (+) or inhibiting (–) (SBU:s interpretation) Theme at Level two Confidence in the scientific evidence according to CERQual
Security and control: A basic prerequisite
– Unaccompanied children and youth describe trauma, dislocation and loss, and struggle to understand these experiences. ⊕⊕⊕◯
– Unaccompanied children and youth consider that earlier trauma and their unsettled status profoundly affect their daily lives and lead to emotional problems, loss of control, lack of self-confidence and inability to foresee their future. ⊕⊕⊕◯
– Unaccompanied children and youth perceive that being categorized as an asylum seeker is associated with feelings of exclusion, loss of status and identity. ⊕⊕⊕◯
– Unaccompanied children and youth consider the asylum process to be unjust, disrespectful and hard to grasp. ⊕⊕◯◯
+/– Unaccompanied children and youth consider security, hope and a structured daily life to be important for their ability to cope. ⊕⊕◯◯
+/– Unaccompanied children and youth consider that a friendly reception on arrival is important for their sense of security. ⊕◯◯◯
The new country: Both opportunities and difficulties
+ Unaccompanied children and youth express strong motivation to receive an education and adapt to the new society. ⊕⊕⊕◯
– Unaccompanied children and youth perceive that cultural differences regarding eye contact with adults can lead to misunderstanding. ⊕⊕⊕◯
+/– Unaccompanied children and youth struggle with different cultures and religious contexts and/or have adapted their religious practice to their new circumstances. ⊕⊕⊕◯
+/– Unaccompanied children and youth consider that educational and vocational choices are affected by economic and social factors and by barriers within the education system. ⊕⊕⊕◯
– Unaccompanied children and youth state that they have experienced discrimination. ⊕⊕◯◯
– Unaccompanied children and youth express concern that interpreters might not translate their statements properly. ⊕◯◯◯
Coping with difficulties: A balance of various strategies
+ Unaccompanied children and youth describe different coping strategies such as avoidance, escape, positive thinking, gaining control and comparing present and past life-situations. ⊕⊕⊕◯
+ Unaccompanied children and youth describe religious faith as important for their wellbeing and as a means of coping with challenging experiences. ⊕⊕⊕◯
– Unaccompanied children and youth report that problems dealing with past and present conditions can lead to excessive consumption of alcohol. ⊕⊕◯◯
– Unaccompanied children and youth perceive that avoidance of past memories creates a dilemma in the long term. ⊕⊕◯◯
The daily environment: Supportive relationships, influence in accommodation and access to school and activities are important
Daily environment: Accommodation
+/– Unaccompanied children and youth express such feelings as isolation, loneliness and mistrust but also support and trust, regardless of type of accommodation. ⊕⊕⊕◯
+/– Unaccompanied children and youth describe mixed experiences of sharing group housing with their unaccompanied peers. ⊕⊕⊕◯
+/– Unaccompanied children and youth express different degrees of closeness, attachment and distance in their relationships in foster homes. ⊕⊕⊕◯
+/– Unaccompanied children and youth express frustration over restricted autonomy and would like influence in and contribute to everyday routines in group housing and foster homes. ⊕⊕⊕◯
+/– Unaccompanied children and youth perceive food and meals to be significant for their wellbeing and sense of inclusion. ⊕⊕⊕◯
– Unaccompanied children and youth describe a variety of difficulties in relationships with their foster parents. ⊕⊕◯◯
+ Unaccompanied children and youth state that close relationships/family-like conditions are important for them to feel ”at home” ⊕⊕◯◯
+/– Unaccompanied children and youth reported leaving foster homes despite positive relationships with their foster parents. ⊕◯◯◯
+/– Unaccompanied children and youth have mixed feelings about group housing in rural locations. ⊕◯◯◯
Daily environment: School
+/– Unaccompanied children and youth experience both difficulties and support in peer relationships at school. ⊕⊕⊕◯
+ Unaccompanied children and youth emphasize the importance of guidance, care and support from adults, for enhancing school performance and for understanding norms and values. ⊕⊕⊕◯
+/– Unaccompanied children and youth consider that school promotes mental health and wellbeing, but also that mental health problems have a negative effect on their ability to function at school. ⊕⊕◯◯
+ Unaccompanied children and youth appreciate the learning process in school, in which they are expected to contribute actively, with their own reflections. ⊕⊕◯◯
Daily environment: Leisure time
+ Unaccompanied children and youth consider that leisuretime activities are an aid to distraction, social interaction and participation and to the restoration of meaning and coherence. ⊕⊕⊕◯
Relationships: Support and guidance from adults are meaningful, contact with those of the same age is important but also difficult
Relationships: Adults
+ Unaccompanied children and youth express the need for and the importance of social support from adults (e.g. legal guardians, foster parents, housing staff, teachers and social workers). ⊕⊕⊕◯
– Unaccompanied children and youth perceive a lack of continuity in relationships with adults. ⊕◯◯◯
+ After leaving foster care, unaccompanied children and youth experience a lack of friendly or parent-like relationships with foster parents. ⊕◯◯◯
– Unaccompanied children and youth feel betwixt and between: they assume adult responsibility, but are treated like children. ⊕◯◯◯
+/– Unaccompanied children and youth describe their relationship with their legal guardian as formal. ⊕◯◯◯
+/– Unaccompanied children and youth emphasize the importance of the initial encounter. ⊕◯◯◯
Relationship: Those of the same age
+/– Unaccompanied children and youth consider friendship to be important but not uncomplicated. ⊕⊕⊕◯
+/– Unaccompanied children and youth express a desire to develop social relationships with young people in the local community, but experience difficulties in making contact. ⊕⊕⊕◯
Relationships: Biological family
+ Unaccompanied children and youth consider that their biological families have a positive influence. ⊕⊕⊕◯
– Unaccompanied children and youth state that they miss contact/closer contact with and support from their biological family; they struggle to re-establish and maintain contact. ⊕⊕⊕◯
Social services and health and medical care: Varying perceptions and experiences of support and need
+/– Unaccompanied children and youth stress the importance of social services for meeting basic needs, but also report inadequacies in and dissatisfaction with the contact. ⊕⊕⊕◯
+/– Unaccompanied children and youth express mainly negative views on mental health issues. ⊕⊕⊕◯
– Unaccompanied children and youth describe both negative and positive experiences of mental health care and are generally distrustful of the health care services. ⊕⊕◯◯
– Unaccompanied children and youth report exploitation and neglect in the host country. ⊕⊕◯◯
+/– Unaccompanied children and youth consider that they have limited access to reproductive health services and education. ⊕⊕◯◯
Identity and belonging: Reconciling the past, the present and the future
+/– Unaccompanied children and youth stress the importance of having the opportunity to preserve their mother tongue and to learn the language of the host country. ⊕⊕⊕◯
– Unaccompanied children and youth describe trauma, dislocation and loss, and struggle to understand these experiences. ⊕⊕◯◯
– Unaccompanied children and youth consider that earlier trauma and their unsettled status profoundly affect their daily lives and lead to emotional problems, loss of control, lack of self-confidence and inability to foresee their future. ⊕◯◯◯
– Unaccompanied children and youth perceive that being categorized as an asylum seeker is associated with feelings of exclusion, loss of status and identity. ⊕◯◯◯
– Unaccompanied children and youth consider the asylum process to be unjust, disrespectful and hard to grasp. ⊕◯◯◯
+/– Unaccompanied children and youth consider security, hope and a structured daily life to be important for their ability to cope. ⊕◯◯◯
+/– Unaccompanied children and youth consider that a friendly reception on arrival is important for their sense of security. ⊕◯◯◯

Full report in Swedish

Project group

Experts

  • Henry Ascher (MD, PhD, Professor in Public Health)
  • Åsa Backlund (Senior Lecturer, PhD in Social Work)
  • Titti Mattsson (Professor of Public Law)
  • Christian Munthe (Professor of Practical Philosophy)

SBU

  • Pernilla Östlund (Project Manager)
  • Göran Bertilsson (Assistant Project Manager)
  • Gunilla Fahlström (Assistant Project Manager)
  • Kickan Håkanson (Project Administrator)
  • Ann Kristine Jonsson (Information Specialist)
  • Knut Sundell (Assistant Project Manager)

Flow charts

Figure 4.1 Included studies with quantitative design

Quantitative studies: At start 2986 abstracts, 113 read in full, but all were excluded

Figure 5.1 Included studies with qualitative design, experiences and perceptions

Qualitative studies, experiences and perceptions. At start 1009 abstracts, 146 read in full text, 48 were relevant but 28 ha dmoderate risk of bias, 19 high risk, 1 with low risk of bias

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