Nearly half of all refugees are children, and almost one in three children living outside their country of birth is a refugee . These numbers encompass children whose refugee status has been formally confirmed, as well as children in refugee-like situations.
133-485: In addition to facing the direct threat of violence resulting from conflict, forcibly displaced children also face various health risks, including: disease outbreaks and long-term psychological trauma , inadequate access to water and sanitation, nutritious food, health care [6] and regular vaccination schedules. Refugee children , particularly those without documentation and those who travel alone, are also vulnerable to abuse and exploitation. Although many communities around
266-598: A terrorist attack . Short-term reactions such as psychological shock and psychological denial are typically followed. Long-term reactions and effects include bipolar disorder , uncontrollable flashbacks , panic attacks , insomnia , nightmare disorder, difficulties with interpersonal relationships , and post-traumatic stress disorder (PTSD). Physical symptoms including migraines , hyperventilation, hyperhidrosis, and nausea are often developed. As subjective experiences differ between individuals, people react to similar events differently. Most people who experience
399-441: A broader view of health problems than biomedical models. Evidence suggests that a minority of people who experience severe trauma in adulthood will experience enduring personality change. Personality changes include guilt, distrust, impulsiveness, aggression, avoidance, obsessive behaviour, emotional numbness, loss of interest, hopelessness and altered self-perception. A number of psychotherapy approaches have been designed with
532-501: A client to experience and process through their trauma safely and effectively. As "trauma" adopted a more widely defined scope, traumatology as a field developed a more interdisciplinary approach. This is in part due to the field's diverse professional representation including: psychologists, medical professionals, and lawyers. As a result, findings in this field are adapted for various applications, from individual psychiatric treatments to sociological large-scale trauma management. While
665-904: A few common aspects. There is frequently a violation of the person's core assumptions about the world and their human rights , putting the person in a state of extreme confusion and insecurity. This is seen when institutions depended upon for survival violate, humiliate, betray , or cause major losses or separations instead of evoking aspects like positive self worth, safe boundaries and personal freedom. Psychologically traumatic experiences often involve physical trauma that threatens one's survival and sense of security. Typical causes and dangers of psychological trauma include harassment ; embarrassment ; abandonment; abusive relationships; rejection; co-dependence; physical assault; sexual abuse ; partner battery; employment discrimination ; police brutality ; judicial corruption and misconduct ; bullying ; paternalism ; domestic violence ; indoctrination ; being
798-412: A few refugee camps that can present danger to refugee children and families by housing members of armed forces. Also, at a few refugee camps, militia forces may try to recruit and abduct children. The third stage, host country experiences, is the integration of refugees into the social, political, economic, and cultural framework of the host country society. The post-migration period involves adaptation to
931-531: A forced migration to a foreign country, and the beginning of the process of refugee status determination. A review of refugee children in high-income countries showed PTSD prevalence ranging 19–54%, with an average prevalence of 36%. Refugee children are extremely vulnerable during migration and resettlement, and may experience long-term pathological effects, due to "disrupted development time". Psychoanalysts of refugee health have proposed that refugee children experience mourning for their culture and countries, despite
1064-421: A general description of Freud's understanding of trauma, which varied significantly over the course of Freud's career: "An event in the subject's life, defined by its intensity, by the subject's incapacity to respond adequately to it and by the upheaval and long-lasting effects that it brings about in the psychical organization". The French psychoanalyst Jacques Lacan claimed that what he called " The Real " had
1197-428: A greater capacity to adopt their host country's language and cultural practices, they are often used as linguistic intermediaries between service providers and their parents. This may result in increased tension in family dynamics where culturally sensitive roles are reversed. Traditional family dynamics in refugee families disturbed by cultural adaptation tend to destabilize important cultural norms , which can create
1330-413: A greater risk of exhibiting psychiatric symptoms of mental illnesses following traumatic stress. Unaccompanied refugee children display more behavioral problems and emotional distress than refugee children with caretakers. Parental well-being plays a crucial role in enabling resettled refugees to transition into a new society. If a child is separated from his/her caretakers during the process of resettlement,
1463-459: A greater sense of belongingness. These outcomes are protective against the devastating impacts of psychological trauma. All psychological traumas originate from stress, a physiological response to an unpleasant stimulus. Long-term stress increases the risk of poor mental health and mental disorders, which can be attributed to secretion of glucocorticoids for a long period of time. Such prolonged exposure causes many physiological dysfunctions such as
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#17328521528441596-425: A high prevalence of infectious disease . Measles has been a major cause of child deaths in refugee camps and among internally displaced people ; measles also exacerbates malnutrition and vitamin A deficiency. Some countries, such as Kenya, have developed preventive, detective, and curative programs to specifically target measles within the refugee children population. Kenya has reached over 20 million children with
1729-453: A hostage or being kidnapped can also cause psychological trauma. Long-term exposure to situations such as extreme poverty or other forms of abuse , such as verbal abuse , exist independently of physical trauma but still generate psychological trauma. Some theories suggest childhood trauma can increase one's risk for mental disorders including post-traumatic stress disorder (PTSD), depression, and substance abuse. Childhood adversity
1862-638: A lack of wastewater networks and sanitation systems are common. Hardships of a refugee camp may also contribute to symptoms following a refugee child's discharge from a camp. A small number of Cuban refugee children and adolescents, who were detained in a refugee camp, were assessed months after their release, and it was found that 57 percent of the youth exhibited moderate to severe posttraumatic stress disorder (PTSD) symptoms. Unaccompanied girls at refugee camps may also face harassment or assault from camp guards and fellow male refugees. In addition to having poor infrastructure and limited support services, there are
1995-424: A larger extent than boys, are vulnerable to sexual exploitation and abuse, both of which can have far-reaching effects on their physical and mental health. Third country resettlement refers to the transfer of refugees from the country they have fled to another country that is more suitable to their needs and that has agreed to grant them permanent settlement. Currently the number of places available for resettlement
2128-531: A limited amount of education, and those held in interrogation centers receive no education at all. In two of the prisons visited by Defense for Children International Palestine, education was found to be limited to two hours a week. It has also been reported that child administrative detainees in Palestine do not receive sufficient food to meet their daily nutritional requirements. Documented cases of child detention are available for more than 100 countries, ranging from
2261-961: A measles and rubella immunization campaign carried out at the national level in May 2016. In 2017 the Kenya Ministry of Health even reported a routine vaccination coverage of 95 percent in the Dadaab refugee camp . As of April 2017, in response to the first confirmed cases of measles in the camp, UNICEF and UNHCR have collaborated with the Kenya Ministry of Health to swiftly implement an integrated measles vaccination program in Dadaab. The campaign, which has been targeting children aged six to 14 years, also includes screening, treatment referrals for cases of malnutrition, vitamin A supplementation, and deworming. Diarrhea, acute watery diarrhea, and cholera can also put children's lives at risk. Countries, such as Bangladesh, have identified
2394-441: A new culture and re-defining one's identity and place in the new society. This stress can be exacerbated when the children arrive in the host country and are expected to adapt quickly to a new setting. It is only a minority of refugees who travel into new host countries and who are allowed to start a new life there. Most refugees are living in refugee camps or urban centres waiting to be able to return home. For those who are starting
2527-460: A new life in a new country there are two options: Asylum seekers are people who have formally applied for asylum in another country and who are still waiting for a decision on their status. Once they have received a positive response from the host government, they will legally be considered as refugees. Refugees, like citizens of the host country, have the rights to education, health, and social services, whereas asylum seekers do not. For instance,
2660-493: A new setting. Traditionally, the mental health of children experiencing conflict is understood in terms of either post-traumatic stress disorder (PTSD) or toxic stress. Prolonged and constant exposure to stress and uncertainty, characteristic of a war environment may result in toxic stress that children express with a change in behavior that may include anxiety, self-harm, aggressiveness or suicide. A 2017 study conducted in Syria by Save
2793-490: A new society. Differences between parental and host country values can create a rift between the refugee child and his/her new society. Less exposure to stigmatization lowers the risk of refugee children developing PTSD. Cognitive and structural barriers make it difficult to determine the medical service utilization rates and patterns of refugee children. A better understanding of these barriers will help improve mental healthcare access for refugee children and their families. It
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#17328521528442926-638: A part of the child's identity , making reintegration difficult once he or she is removed from the unstable environment. Examples of children's pre-migration experiences: In general, children may also cross borders for economic reasons, such as to escape poverty and social deprivation, or some children may do so to join other family members already settled in another State. But it is the involuntary nature of refugees' departure that distinguishes them from other migrant groups who have not undergone forced displacement. Refugees , and even more so their children, are neither psychologically nor pragmatically prepared for
3059-539: A person with a traumatic disorder to engage in disruptive behaviors or self-destructive coping mechanisms, often without being fully aware of the nature or causes of their own actions. Panic attacks are an example of a psychosomatic response to such emotional triggers. Consequently, intense feelings of anger may frequently surface, sometimes in inappropriate or unexpected situations, as danger may always seem to be present due to re-experiencing past events. Upsetting memories such as images, thoughts, or flashbacks may haunt
3192-414: A pioneer of modern psychodynamic perspective, also argues that social relations can help people recover from trauma, but specifically refers to attachment theory and the attachment dynamic of the therapeutic relationship. Fosha argues that the sense of emotional safety and co-regulation that occurs in a psychodynamically oriented therapeutic relationship acts as the secure attachment that is necessary to allow
3325-480: A potentially traumatic event do not become psychologically traumatized, though they may be distressed and experience suffering. Some will develop PTSD after exposure to a traumatic event, or series of events. This discrepancy in risk rate can be attributed to protective factors some individuals have, that enable them to cope with difficult events, including temperamental and environmental factors, such as resilience and willingness to seek help. Psychotraumatology
3458-610: A prevalence of depression of 3–30%, with an average prevalence of 18%. However, other large-scale community surveys have found that the rate of psychiatric disorder among immigrant youth is not higher than that of native-born children. Nonetheless, experiments have shown that these adverse outcomes can be prevented through adequate protective factors, such as social support and intimacy. Additionally, effective adaptation strategies, such as absorption in work and creation of pseudofamilies, have led to successful coping in refugees. Many refugee populations, particularly Southeast Asian, undergo
3591-602: A range of rights, such as the right to physical and mental health, privacy, education, and leisure. And many countries do not have a legal time limit for detention, leaving some children incarcerated for indeterminate time periods. Some children are even detained together with adults and subjected to a harsher, adult-based treatment and regimen. In North Africa , children travelling without legal status are frequently subjected to extended periods of immigration detention. Children held in administrative detention in Palestine only receive
3724-439: A recording of an event, even if distressing, does not cause trauma; however, an exception is made to the diagnostic criteria for work-related exposures. Vicarious trauma affects workers who witness their clients' trauma. It is more likely to occur in situations where trauma-related work is the norm rather than the exception. Listening with empathy to the clients generates feeling, and seeing oneself in clients' trauma may compound
3857-448: A refugee's understanding of mental illness and available healthcare. Other factors that delay refugees from seeking medical help are: A broad spectrum of translation services are available to all refugees, but only a small number of those services are government-sponsored. Community health organizations provide a majority of translation services, but there are a shortage of funds and available programs. Since children and adolescents have
3990-433: A rift between parent and child. These difficulties cause an increase of depression, anxiety and other mental health concerns in culturally-adapted adolescent refugees. Relying on other family members or community members has equally problematic results where relatives and community members unintentionally exclude or include details relevant to comprehensive care. Healthcare practitioners are also hesitant to rely on members of
4123-456: A secondary migration to larger communities of kinfolk from their countries of origin, which serve as social support networks for refugees. Research has shown that family reunification, formation of new social groups, community groups, and social services and professional support have contributed to successful resettlement of refugees. Refugees can be stigmatized if they encounter mental health deficiencies prior to and during their resettlement into
Refugee children - Misplaced Pages Continue
4256-435: A trauma reminder, also called a trauma trigger . These can produce uncomfortable and even painful feelings. Re-experiencing can damage people's sense of safety, self, self-efficacy , as well as their ability to regulate emotions and navigate relationships. They may turn to psychoactive drugs , including alcohol , to try to escape or dampen the feelings. These triggers cause flashbacks, which are dissociative experiences where
4389-426: A traumatic quality external to symbolization. As an object of anxiety, Lacan maintained that The Real is "the essential object which isn't an object any longer, but this something faced with which all words cease and all categories fail, the object of anxiety par excellence ". Fred Alford, citing the work of object relations theorist Donald Winnicott , uses the concept of inner other, and internal representation of
4522-544: A triggering mechanism resulting in an individual's inability to cope with the stress of certain events." Often, psychological aspects of trauma are overlooked even by health professionals: "If clinicians fail to look through a trauma lens and to conceptualize client problems as related possibly to current or past trauma, they may fail to see that trauma victims, young and old, organize much of their lives around repetitive patterns of reliving and warding off traumatic memories, reminders, and affects." Biopsychosocial models offer
4655-621: A year after an initial screening than non-refugee children of the same age and living in the same communities. A study analyzing the medical records of former refugees residing in Rochester, New York, between 1980 and 2012 demonstrated that former child refugees may be at increased risk of obesity , type 2 diabetes , and hypertension following resettlement. Many Afghan children lack access to urban diagnosis centers in Pakistan; those who do have access have been found to have various types of cancer. It
4788-516: A year-long cholera vaccination campaign in October 2017, targeting all children in the camps. At health centers in the refugee camps, UNICEF has been screening for potential cholera cases and providing oral rehydration salts. Community-based health workers are also going around the camps to share information on the risks of acute watery diarrhea, the cholera vaccination campaign, and the importance and necessity of good hygiene practices. During all points of
4921-464: Is aimed more at correcting or minimizing the damage of a stressful event. A passive response is often characterized by an emotional numbness or ignorance of a stressor. There is also a distinction between trauma induced by recent situations and long-term trauma which may have been buried in the unconscious from past situations such as child abuse . Trauma is sometimes overcome through healing; in some cases this can be achieved by recreating or revisiting
5054-631: Is also estimated that, within Turkey's Syrian refugee population, 60 to 100 children are diagnosed with cancer each year. Overall, the incidence rate of pediatric cancers among Turkey's Syrian refugee population was similar to that of Turkish children. The study additionally noted, however, that most refugee children affected by cancer were diagnosed when the tumor was already at an advanced stage. This could indicate that refugee children and their families often face obstacles such as poor prognoses, language barriers, financial problems, and social problems in adapting to
5187-611: Is another mental health disorder with symptoms similar to that of psychological trauma, such as hyper-vigilance and intrusive thoughts . Research has indicated that individuals who have experienced a traumatic event have been known to use symptoms of obsessive- compulsive disorder, such as compulsive checking of safety, as a way to mitigate the symptoms associated with trauma. In time, emotional exhaustion may set in, leading to distraction, and clear thinking may be difficult or impossible. Emotional detachment , as well as dissociation or "numbing out" can frequently occur. Dissociating from
5320-492: Is another type of cognitive behavioral therapy that focuses on learning safe coping skills for co-occurring PTSD and substance use problems. While some sources highlight Seeking Safety as effective with strong research support, others have suggested that it did not lead to improvements beyond usual treatment. A review from 2014 showed that a combination of treatments involving dialectical behavior therapy (DBT), often used for borderline personality disorder, and exposure therapy
5453-482: Is associated with neuroticism during adulthood. Parts of the brain in a growing child are developing in a sequential and hierarchical order, from least complex to most complex. The brain's neurons change in response to the constant external signals and stimulation, receiving and storing new information. This allows the brain to continually respond to its surroundings and promote survival. The five traditional signals (sight, hearing, taste, smell, and touch) contribute to
Refugee children - Misplaced Pages Continue
5586-403: Is effective in reducing PTSD and depression symptoms, and it increases the likelihood of patients no longer meeting the criteria for PTSD. There is a large body of empirical support for the use of cognitive behavioral therapy for the treatment of trauma-related symptoms, including post-traumatic stress disorder . Institute of Medicine guidelines identify cognitive behavioral therapies as
5719-522: Is guaranteed to unaccompanied refugee minors until they reach the age of majority or until they are reunited with their families. Some European nations have established programs to support the resettlement and integration of refugee children. The European countries admitting the most refugee children in 2016 via resettlement were the United Kingdom (2,525 refugee children), Norway (1,930), Sweden (915), and Germany (595). Together, these accounted for 66% of
5852-495: Is highly effective in treating psychological trauma. If, however, psychological trauma has caused dissociative disorders or complex PTSD , the trauma model approach (also known as phase-oriented treatment of structural dissociation) has been proven to work better than the simple cognitive approach. Studies funded by pharmaceuticals have also shown that medications such as the new anti-depressants are effective when used in combination with other psychological approaches. At present,
5985-614: Is important for children to access healthcare for the following reasons: Early interventions and treatments, Prevention of Childhood illnesses, Health tracking. Many refugees develop a mistrust of authority figures due to repressive governments in their country of origin. Fear of authority and a lack of awareness regarding mental health issues prevent refugee children and their families from seeking medical help. Certain cultures use informal support systems and self-care strategies to cope with their mental illnesses, rather than rely upon biomedicine. Language and cultural differences also complicate
6118-690: Is important to note the presence of possible avoidance responses. Avoidance responses may involve the absence of expected activation or emotional reactivity as well as the use of avoidance mechanisms (e.g., substance use, effortful avoidance of cues associated with the event, dissociation). In addition to monitoring activation and avoidance responses, clinicians carefully observe the individual's strengths or difficulties with affect regulation (i.e., affect tolerance and affect modulation). Such difficulties may be evidenced by mood swings, brief yet intense depressive episodes , or self-mutilation . The information gathered through observation of affect regulation will guide
6251-458: Is in the best interests of both the child and the parent(s). Trauma is hard to speak of by those that experience it. The event in question might recur to them in a dream or another medium, but it is rare for them to speak of it. Trauma can be caused by human-made, technological and natural disasters, including war, abuse, violence, vehicle collisions, or medical emergencies. An individual's response to psychological trauma can be varied based on
6384-583: Is insufficient physical and material security in some camps. Certain groups of refugees, such as LGBTI refugees and women at high risk of gender-based violence, especially cannot be sufficiently protected from other refugees in the camps. Or it could simply be the fact that the state or territory where refugees fled to does not run refugee camps (e.g. Syria or Egypt). Some refugees leave camps in search of better economic opportunities in urban centres and to avoid being dependent on aid rations. Some even move back and forth between urban centres and refugee camps to get
6517-593: Is less than the number needed for children for whom resettlement would be most appropriate. Some nations have prioritized children at risk as a category for resettlement: The United States established its Unaccompanied Refugee Minor Program in 1980 to support unaccompanied children for resettlement. The Office of Refugee Resettlement (ORR) by the Department of Homeland Security currently works with state and local service providers to provide unaccompanied refugee children with resettlement and foster care services. This service
6650-420: Is the study of psychological trauma. People who experience trauma often have problems and difficulties afterwards. The severity of these symptoms depends on the person, the types of trauma involved, and the support and treatment they receive from others. The range of reactions to trauma can be wide and varied, and differ in severity from person to person. After a traumatic experience, a person may re-experience
6783-745: The Syrian Arab Republic had forced 4.9 million Syrians out of the country, half of which were children. The same report found that, by the end of 2015, more than ten years of armed conflict in Afghanistan had forced 2.7 million Afghans beyond the country's borders; half of the refugees from Afghanistan were children. During times of war, in addition to being exposed to violence, many children are abducted and forced to become soldiers. According to an estimate, 12,000 refugee children have been recruited into armed groups within South Sudan. War itself often becomes
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#17328521528446916-450: The 1890s that psychological trauma was the origin of all instances of the mental illness known as hysteria . Charcot's "traumatic hysteria" often manifested as paralysis that followed a physical trauma, typically years later after what Charcot described as a period of "incubation". Sigmund Freud , Charcot's student and the father of psychoanalysis , examined the concept of psychological trauma throughout his career. Jean Laplanche has given
7049-516: The Children determined that 84% of all adults and most children considered ongoing bombing and shelling to be the main psychological stressor, while 89% said that children were more fearful as the war progressed, and 80% said that children had become more aggressive. These stressors are leading causes of the symptoms described above, which lead to diagnosis of PTSD and toxic stress, among other mental conditions. These issues may then be further exacerbated by
7182-637: The Convention often serves as the primary basis for refugee status determination, but some countries also utilize other refugee definitions, thus, have granted refugee status not based exclusively on persecution. For instance, the African Union has agreed on a definition at the 1969 Refugee Convention , that also accommodates people affected by external aggression, occupation, foreign domination, and events seriously disturbing public order. South Africa has granted refugee status to Mozambicans and Zimbabweans following
7315-657: The Convention. Somalia and the United States are the only two countries that have not ratified it. The United Nations 1951 Convention on the Status of Refugees is a comprehensive and rigid legal code regarding the rights of refugees at an international level and it also defines under which conditions a person should be considered as a refugee and thus be given these rights. The Convention provides protection to forcibly displaced persons who have experienced persecution or torture in their home countries. For countries that have ratified it,
7448-619: The Pacific labour trafficking is more prevalent. Many unaccompanied children fleeing from conflict zones in Moldova , Romania , Ukraine , Nigeria , Sierra Leone , China , Afghanistan or Sri Lanka are forced into sexual exploitation . Especially vulnerable groups include girls belonging to single-parent households, unaccompanied children, children from child-headed households, orphans, girls who were street traders, and girls whose mothers were street traders. While refugee boys have been identified as
7581-414: The U.N. High Commissioner for Refugees show that only half of all refugee children that are elementary school-aged are able to access schooling. Similarly, amongst secondary school-aged children, only 22 percent of children can access schooling. Unfortunately, this culminates in a rate of access to higher education of only one percent amongst all refugees. Additionally, North American schools often do not have
7714-822: The UNHCR prioritizes urban refugees for resettlement over those refugees living in refugee camps . In Kenya, for example, only refugees living in Nairobi are submitted for resettlement places, and not those refugees living in the refugee camp site of Kakuma or Dadaab . However, Kenya's national refugee policy requires all refugees to live in camps, though this requirement is not strongly enforced. Reasons for living in urban settings rather than in refugee camps could be specific medical care needs that cannot be provided for in camps, poor and uncertain conditions in camps, or higher than average educational achievements and aspirations, as camps do not provide many higher education opportunities. There
7847-460: The activities are play genogram, sand worlds, coloring feelings, self and kinetic family drawing, symbol work, dramatic-puppet play, story telling, Briere's TSCC, etc. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines trauma as the symptoms that occur following exposure to an event (i.e., traumatic event) that involves actual or threatened death, serious injury, or sexual violence. This exposure could come in
7980-421: The actual and potential cultural factors informing their interactions with refugee patients. Culturally competent care tends to prioritize the social and cultural determinants contributing to health, but the traditional Western biomedical model of care often fails to acknowledge these determinants. To provide culturally competent care to refugees, mental healthcare providers should demonstrate some understanding of
8113-540: The actual efficacy of yoga in reducing the effects of trauma needs more exploration. In health and social care settings, a trauma informed approach means that care is underpinned by understandings of trauma and its far-reaching implications. Trauma is widespread. For example, 26% of participants in the Adverse Childhood Experiences (ACEs) study were survivors of one ACE and 12.5% were survivors of four or more ACEs. A trauma-informed approach acknowledges
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#17328521528448246-895: The application process. In Australia , for instance, unaccompanied children, who usually do not have any kind of legal assistance, must prove beyond any reasonable doubt that they are in need of the country's protection. Many children do not have the necessary documents for legal entry into a host country, often avoiding officials due to fear of being caught and deported to their home countries. Without documented status, unaccompanied children often face challenges in acquiring education and healthcare in many countries. These factors make them particularly vulnerable to hunger, homelessness, and sexual and labor exploitation. Displaced youth, both male and female, are vulnerable to recruitment into armed groups. Unaccompanied children may also resort to dangerous jobs to meet their own survival needs. Some may also engage in criminal activity or drug and alcohol abuse. Girls, to
8379-483: The assessing clinician may proceed by inquiring about both the traumatic event and the outcomes experienced (e.g., post-traumatic symptoms, dissociation, substance abuse , somatic symptoms, psychotic reactions). Such inquiry occurs within the context of established rapport and is completed in an empathic, sensitive, and supportive manner. The clinician may also inquire about possible relational disturbance, such as alertness to interpersonal danger, abandonment issues , and
8512-570: The asylum process. They are minors who are separated from their families once they reach the host country, or minors who decide to travel from their home countries to a foreign country without a parent or guardian. More children are traveling alone, with nearly 100,000 unaccompanied children in 2015 filing claims for asylum in 78 countries. Bhabha (2004) argues that it is more challenging for unaccompanied children than adults to gain asylum, as unaccompanied children are usually unable to find appropriate legal representation and stand up for themselves during
8645-565: The border and in refugee camps. Smuggling , in which a smuggler illegally moves a migrant into another country, is a pervasive issue for children travelling both with and without their families. While fleeing their country of origin, many unaccompanied children end up travelling with traffickers who may attempt to exploit them as workers. Including adults, sex trafficking is more prevalent in Europe and Central Asia, whereas in East Asia, South Asia, and
8778-623: The child resettlement admissions to all of Europe. The United Kingdom also established a new initiative in 2016 to support the resettlement of vulnerable refugee children from the Middle East and North Africa, regardless of family separation status. It was reported in February 2017 that this program has been partially suspended by the government; the program would no longer accept refugee youth with "complex needs", such as those with disabilities, until further notice. Refugee children without caretakers have
8911-683: The clinician's decisions regarding the individual's readiness to partake in various therapeutic activities. Though assessment of psychological trauma may be conducted in an unstructured manner, assessment may also involve the use of a structured interview. Such interviews might include the Clinician-Administered PTSD Scale , Acute Stress Disorder Interview, Structured Interview for Disorders of Extreme Stress, Structured Clinical Interview for DSM-IV Dissociative Disorders - Revised, and Brief Interview for post-traumatic Disorders. Lastly, assessment of psychological trauma might include
9044-689: The collapse of their home countries' economies. Other international legal tools for the protection refugee children include two of the Protocols supplementing the United Nations Convention against Transnational Organized Crime which reference child migration: Additionally the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families covers
9177-552: The community because it is breaches confidentiality. A third party present also reduces the willingness of refugees to trust their healthcare practitioners and disclose information. Patients may receive a different translator for each of their follow-up appointments with their mental healthcare providers, which means that refugees need to recount their story via multiple interpreters, further compromising confidentiality. Culturally competent care exists when healthcare providers have received specialized training that helps them to identify
9310-411: The complexity of the interaction between traumatic event occurrence and trauma symptomatology, a person's distress response to aversive details of a traumatic event may involve intense fear or helplessness, but ranges according to the context. In children, trauma symptoms can be manifested in the form of disorganized or agitative behaviors. Trauma can be caused by a wide variety of events, but there are
9443-542: The country or territory where the person fled to. More than 60% of the world's refugee population and 80% of internally displaced persons (IDP) under UNHCR mandate live in urban environments. In 2009, their number was around 5.5 million people. "Urban refugee" is not a recognized legal term in the 1951 Convention relating to the Status of Refugees . However, the UNHCR has adopted a 'Policy on Refugee Protection and Solutions in Urban Areas' in 2009. Urban refugees are among
9576-410: The developing brain structure and its function. Infants and children begin to create internal representations of their external environment, and in particular, key attachment relationships, shortly after birth. Violent and victimizing attachment figures impact infants' and young children's internal representations. The more frequently a specific pattern of brain neurons is activated, the more permanent
9709-526: The environment for danger). Research shows that about 60% of the US population reported as having experienced at least one traumatic symptom in their lives, but only a small proportion actually develops PTSD. There is a correlation between the risk of PTSD and whether or not the act was inflicted deliberately by the offender. Psychological trauma is treated with therapy and, if indicated, psychotropic medications. The term continuous posttraumatic stress disorder (CTSD)
9842-437: The event. Because individuals may not yet be capable of managing this distress, it is necessary to determine how the event can be discussed in such a way that will not "retraumatize" the individual. It is also important to take note of such responses, as these responses may aid the clinician in determining the intensity and severity of possible post traumatic stress as well as the ease with which responses are triggered. Further, it
9975-594: The fact that the war-torn state of their homes is unsafe. This sudden loss of familiarity places children at a greater risk for mental dysfunction. In addition, studies have shown that refugee children show a higher vulnerability to stress when separated from their families. Studies from treatment facilities and small community samples have confirmed that refugee youth are at higher risk for psychopathologic disorders, including post-traumatic stress disorder, depression, conduct disorder, and problems resulting from substance abuse. Refugee children living in high-income countries have
10108-509: The field has adopted a number of diverse methodological approaches, many pose their own limitations in practical application. The experience and outcomes of psychological trauma can be assessed in a number of ways. Within the context of a clinical interview, the risk of imminent danger to the self or others is important to address but is not the focus of assessment. In most cases, it will not be necessary to involve contacting emergency services (e.g., medical, psychiatric, law enforcement) to ensure
10241-451: The form of experiencing the event or witnessing the event, or learning that an extreme violent or accidental event was experienced by a loved one. Trauma symptoms may come in the form of intrusive memories, dreams, or flashbacks; avoidance of reminders of the traumatic event; negative thoughts and feelings; or increased alertness or reactivity. Memories associated with trauma are typically explicit, coherent, and difficult to forget. Due to
10374-454: The general population, with a need for mental healthcare services, are currently accessing care. Adolescent ethnic minorities are less likely to access mental healthcare services than youth in the dominant cultural group. Psychological trauma Psychological trauma (also known as mental trauma , psychiatric trauma , emotional damage , or psychotrauma ) is an emotional response caused by severe distressing events that are outside
10507-409: The high rates of trauma and means that care providers treat every person as if they might be a survivor of trauma. Measurement of the effectiveness of a universal trauma informed approach is in early stages and is largely based in theory and epidemiology. Urban refugee An urban refugee is a refugee who decided or was obliged to settle in an urban area rather than in a refugee camp in
10640-553: The highest to the lowest income nations. Even so, a growing number of countries, including both Panama and Mexico , prohibit the detention of child migrants. And Yemen has adopted a community-driven approach, using small-group alternative care homes for child refugees and asylum-seekers, as a more age-appropriate way of detention. In the United States unaccompanied children are placed in single purpose non-secure "children's shelters" for immigration violations, rather than in juvenile detention facilities. However, this change has not ended
10773-528: The hippocampus, cognitive and affective impairment. This is significant in brain scan studies done regarding higher-order function assessment with children and youth who were in vulnerable environments. Some traumatized people may feel permanently damaged when trauma symptoms do not go away and they do not believe their situation will improve. This can lead to feelings of despair, transient paranoid ideation, loss of self-esteem , profound emptiness , suicidality, and frequently, depression . If important aspects of
10906-404: The host country. Children, particularly those who travel on their own or become separated from their families, are likely to face various forms of violence and exploitation throughout the transmigration period. The experience of traveling from one country to another is much more difficult for women and children, because they are more vulnerable to assaults and exploitation by people they encounter at
11039-418: The individual is less likely to resort to self harm. In these situations it is best to provide a supportive, caring environment and to communicate to the individual that no matter the circumstance, the individual will be taken seriously rather than being treated as delusional. It is vital for the assessor to understand that what is going on in the traumatized person's head is valid and real. If deemed appropriate,
11172-469: The individual to integrate upsetting-distressing material (thoughts, feelings and memories) and to resolve these internally. It also aids in the growth of personal skills like resilience, ego regulation, empathy, etc. Processes involved in trauma therapy are: A number of complementary approaches to trauma treatment have been implicated as well, including yoga and meditation. There has been recent interest in developing trauma-sensitive yoga practices, but
11305-429: The individuals safety; members of the individual's social support network are much more critical. Understanding and accepting the psychological state of an individual is paramount. There are many misconceptions of what it means for a traumatized individual to be in psychological crisis. These are times when an individual is in inordinate amounts of pain and incapable of self-comfort. If treated humanely and respectfully,
11438-629: The internal representation associated with the pattern becomes. This causes sensitization in the brain towards the specific neural network. Because of this sensitization, the neural pattern can be activated by decreasingly less external stimuli. Child abuse tends to have the most complications, with long-term effects out of all forms of trauma, because it occurs during the most sensitive and critical stages of psychological development. It could lead to violent behavior, possibly as extreme as serial murder. For example, Hickey's Trauma-Control Model suggests that " childhood trauma for serial murderers may serve as
11571-582: The introduction and development of proper sanitation habits and facilities as potential solutions to these medical conditions. A 2008 study comparing refugee camps in Bangladesh reported that camps with sanitation facilities had cholera rates of 16%, whereas camps without such facilities had cholera rates that were almost three times higher. In a single week in 2017, 5,011 cases of diarrhea in refugee camps in Cox's Bazar in Bangladesh were reported. In response, UNICEF started
11704-527: The label for this condition after the Vietnam War in which many veterans returned to their respective countries demoralized, and sometimes, addicted to psychoactive substances. The symptoms of PTSD must persist for at least one month for diagnosis to be made. The main symptoms of PTSD consist of four main categories: trauma (i.e. intense fear), reliving (i.e. flashbacks), avoidance behavior (i.e. emotional numbing), and hypervigilance (i.e. continuous scanning of
11837-531: The likelihood that he/she will develop a mental illness increases. This section covers health throughout the different stages of the refugee experience. Refugee children arriving in the United States often come from countries with a high prevalence of undernutrition. Nearly half of a sample of refugee children who arrived to the American state of Washington, the majority of which were from Iraq, Somalia, and Burma, were found to have at least one form of malnutrition. In
11970-464: The lives of children who have undergone a traumatic event. Moral injury is distress such as guilt or shame following a moral transgression. There are many other definitions some based on different models of causality. Moral injury is associated with post-traumatic stress disorder but is distinguished from it. Moral injury is associated with guilt and shame while PTSD is correlated with fear and anxiety . Normally, hearing about or seeing
12103-694: The main victims of exploitation in the labor market, refugee girls aged between 13 and 18 have been the main targets of sexual exploitation. In particular, the number of young Nigerian women and girls brought into Italy for exploitation has been increasing: it was reported that 3,529 Nigerian women, among them underage girls, arrived by sea between January and June 2016. Once they reached Italy, these girls worked under conditions of slavery, for periods typically ranging from three to seven years. Children may be detained in prisons, military facilities, immigration detention centers, welfare centers, or educational facilities. While detained, migrant children are deprived of
12236-582: The majority of refugees and migrants who arrived in Europe in 2015 through mid-2016 were accommodated in overcrowded transit centers and informal settlements, where privacy and access to education and health services were often limited. In some accommodation centers in Germany and Sweden , where asylum seekers stayed until their claims were processed, separate living spaces for women, as well as sex-separated latrines and shower facilities, were unavailable. Unaccompanied children face particular difficulties throughout
12369-518: The most effective treatments for PTSD. Two of these cognitive behavioral therapies, prolonged exposure and cognitive processing therapy , are being disseminated nationally by the Department of Veterans Affairs for the treatment of PTSD. A 2010 Cochrane review found that trauma-focused cognitive behavioral therapy was effective for individuals with acute traumatic stress symptoms when compared to waiting list and supportive counseling. Seeking Safety
12502-536: The most vulnerable groups in low income countries. According to UNHCR, the urban refugee population worldwide is very diverse, comprising a large number of women, children, and older people who have particular protection challenges. The urban refugee population face specific protecting needs attendant to urban environments: they may lack access to services, health, education and are often confronted to xenophobic attitudes in their country of asylum. The overwhelming majority of refugees living in urban areas are to be found in
12635-420: The need for self-protection via interpersonal control. Through discussion of interpersonal relationships, the clinician is better able to assess the individual's ability to enter and sustain a clinical relationship. During assessment, individuals may exhibit activation responses in which reminders of the traumatic event trigger sudden feelings (e.g., distress , anxiety, anger ), memories, or thoughts relating to
12768-431: The next generation, thus making genetics one of the components of psychological trauma. However, some people are born with or later develop protective factors such as genetics that help lower their risk of psychological trauma. The person may not remember what actually happened, while emotions experienced during the trauma may be re-experienced without the person understanding why (see Repressed memory ). This can lead to
12901-494: The normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones generally with death , severe bodily injury , or sexual violence ; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response , but does not produce trauma per se . Examples of distressing events include violence , rape , or
13034-426: The nutrition profiles of refugee children may be explained by the variance in refugees' location and time in transition. Communicable diseases are a pervasive issue faced by refugee children in camps and other temporary settlements. Governments and organizations are working to address a number of them, such as measles, rubella, diarrhea, and cholera. Refugee children often arrive in the United States from countries with
13167-485: The origin of the trauma under more psychologically safe circumstances, such as with a therapist . More recently, awareness of the consequences of climate change is seen as a source of trauma as individuals contemplate future events as well as experience climate change related disasters. Emotional experiences within these contexts are increasing, and collective processing and engagement with these emotions can lead to increased resilience and post-traumatic growth , as well as
13300-400: The painful emotion includes numbing all emotion, and the person may seem emotionally flat, preoccupied, distant, or cold. Dissociation includes depersonalisation disorder, dissociative amnesia, dissociative fugue, dissociative identity disorder, etc. Exposure to and re-experiencing trauma can cause neurophysiological changes like slowed myelination, abnormalities in synaptic pruning, shrinking of
13433-550: The patient's background, and a sensitive commitment to relevant cultural manners (for example: privacy, gender dynamics, religious customs, and lack of language skills). The willingness of refugees to access mental healthcare services rests on the degree of cultural sensitivity within the structure of their service provider. The protective influence exercised by adult refugees on their child and adolescent dependents makes it unlikely that young adult-accompanied refugees will access mental healthcare services. Only 10–30 percent of youth in
13566-491: The person feels as though the events are recurring. Flashbacks can range from distraction to complete dissociation or loss of awareness of the current context. Re-experiencing of symptoms is a sign that the body and mind are actively struggling to cope with the traumatic experience. Triggers and cues act as reminders of the trauma and can cause anxiety and other associated emotions. Often the person can be completely unaware of what these triggers are. In many cases, this may lead
13699-470: The person's self and world understanding have been violated, the person may call their own identity into question. Often despite their best efforts, traumatized parents may have difficulty assisting their child with emotion regulation, attribution of meaning, and containment of post-traumatic fear in the wake of the child's traumatization, leading to adverse consequences for the child. In such instances, seeking counselling in appropriate mental health services
13832-426: The person, and nightmares may be frequent. Insomnia may occur as lurking fears and insecurity keep the person vigilant and on the lookout for danger, both day and night. A messy personal financial scene, as well as debt, are common features in trauma-affected people. Trauma does not only cause changes in one's daily functions, but could also lead to morphological changes. Such epigenetic changes can be passed on to
13965-515: The poorest and more conflict-affected regions of the world. Africa and Asia concentrate the highest number of urban refugee populations. Some war-affected countries host a huge number of both urban internally displaced people and refugees in capital cities (such as Kampala or Khartoum ). Urban displaced people also live in the main cities of their country of origin: after protracted exile, many returnees prefer settling back as IDPs in cities and towns of their own country upon return. Since around 2017,
14098-475: The practice of administrative detention entirely. Although there is commitment by the Council of Europe to work toward ending the detention of children for migration control purposes, asylum-seeking and migrant children and families often undergo detention experiences that conflict with international commitments. Some refugee camps operate at levels below acceptable standards of environmental health; overcrowding and
14231-399: The premise of membership of a particular social group, or due to the threat of forced marriage , forced labor , or conscription into armed forces. Others may leave to escape famine or in order to ensure the safety and security of themselves and their families from the destruction of war or internal conflict. A 2016 report by UNICEF found that, by the end of 2015, five years of open conflict in
14364-662: The prevalence rate for overweight amongst refugee children was 18.4%. The prevalence rate of overweight and obesity among refugee children in Rhode Island , increased from 17.3% at initial measurement at first arrival to 35.4% at measurement three years after. But the nutritional profiles of refugee children also often vary by their country of origin. A study involving Syrian refugee children in Jordanian refugee camps found them to be on average more likely overweight than acutely malnourished. The low prevalence of acute malnutrition among them
14497-411: The processes of treatment, confrontation with their sources of trauma plays a crucial role. While debriefing people immediately after a critical incident has not been shown to reduce incidence of PTSD, coming alongside people experiencing trauma in a supportive way has become standard practice. The impact of PTSD on children is to a degree unknown, but education on coping mechanisms have shown to improve
14630-511: The rapid movement and transition resulting from events outside their control. Any direct or witnessed forms of violence and sexual abuse may characterize refugee children's pre-migration experiences. The transmigration period is characterized by the physical relocation of refugees. This process includes the journey between home countries and host countries and often involves time spent in a refugee camp. Children may experience arrest, detention, sexual assault, and torture during their translocation to
14763-501: The refugee experience, refugee children are often at risk of developing several noncommunicable diseases and conditions, such as lead poisoning, obesity, type 2 diabetes, and pediatric cancer. Many refugee children come to their host countries with elevated blood lead levels; others encounter lead hazards once they have resettled. A study published in January 2013 found that the blood lead levels of refugee children who had just arrived to
14896-565: The resources needed to support refugee children. Refugee children often have to handle discrimination, low socioeconomic status, have no family, or come to a setting that clashes with their cultural beliefs leading to behavioral issues teachers are not always prepared for. Extracurricular resources provided to refugee children include supplementary curriculum enrichment resources, videos for the goal or increasing parent and school awareness, informational leaflets and handbooks, as well as ICT based resources, which serve to benefit refugee involvement in
15029-416: The rights of the children of migrant workers in both regular and irregular situations during the entire migration process. Refugee experiences can be categorized into three stages of migration: home country experiences (pre-migration), transit experiences (transmigration), and host country experiences (post-migration). However, the large majority of refugees do not travel into new host countries, but remain in
15162-536: The risk for developing trauma symptoms. Trauma may also result if workers witness situations that happen in the course of their work (e.g. violence in the workplace, reviewing violent video tapes.) Risk increases with exposure and with the absence of help-seeking protective factors and pre-preparation of preventive strategies. Individuals who have a personal history of trauma are also at increased risk for developing vicarious trauma. Vicarious trauma can lead workers to develop more negative views of themselves, others, and
15295-473: The school. The Convention on the Rights of the Child , the most widely ratified human rights treaty in history, includes four articles that are particularly relevant to children involved in or affected by forced displacement: States Parties to the Convention are obliged to uphold the above articles, regardless of a child's migration status. As of November 2005, a total of 192 countries have become States Parties to
15428-663: The selective serotonin reuptake inhibitor (SSRI) antidepressants sertraline (Zoloft) and paroxetine (Paxil) are the only medications that have been approved by the Food and Drug Administration (FDA) in the United States to treat PTSD. Other options for pharmacotherapy include serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants and anti-psychotic medications, though none have been FDA approved. Trauma therapy allows processing trauma-related memories and allows growth towards more adaptive psychological functioning. It helps to develop positive coping instead of negative coping and allows
15561-551: The social world, with which one converses internally and which is generated through interactions with others. He posits that the inner other is damaged by trauma but can be repaired by conversations with others such as therapists. He relates the concept of the inner other to the work of Albert Camus viewing the inner other as that which removes the absurd . Alford notes how trauma damages trust in social relations due to fear of exploitation and argues that culture and social relations can help people recover from trauma. Diana Fosha ,
15694-785: The state of New Hampshire were more than twice as likely to be above 10 μg/dL as the blood lead levels of children born in the United States. Evidence from the Centers for Disease Control and Prevention (CDC) in the United States also found that nearly 30% of 242 refugee children in New Hampshire developed elevated blood lead levels within three to six months of their arrival to the United States, even though their levels were not found to be elevated at initial screening. A more recent study reported that refugee children in Massachusetts were 12 times more likely to have blood lead levels over 20 μg/dL
15827-658: The suppression of the immune system and increase in blood pressure. Not only does it affect the body physiologically, but a morphological change in the hippocampus also takes place. Studies showed that extreme stress early in life can disrupt normal development of hippocampus and impact its functions in adulthood. Studies surely show a correlation between the size of hippocampus and one's susceptibility to stress disorders. In times of war, psychological trauma has been known as shell shock or combat stress reaction . Psychological trauma may cause an acute stress reaction which may lead to post-traumatic stress disorder (PTSD). PTSD emerged as
15960-443: The transmigration stage, living in refugee camps or urban centres waiting to be able to return home. The pre-migration stage refers to home country experiences leading up to and including the decision to flee. Pre-migration experiences include the challenges and threats children face that drive them to seek refuge in another country. Refugee children migrate, either with their families or unaccompanied, due to fear of persecution on
16093-420: The trauma mentally and physically. For example, the sound of a motorcycle engine may cause intrusive thoughts or a sense of re-experiencing a traumatic experience that involved a similar sound e.g. gunfire. Sometimes a benign stimulus (e.g. noise from a motorcycle) may get connected in the mind with the traumatic experience. This process is called traumatic coupling. In this process, the benign stimulus becomes
16226-567: The traumatic events being constantly experienced as if they were happening in the present, preventing the subject from gaining perspective on the experience. This can produce a pattern of prolonged periods of acute arousal punctuated by periods of physical and mental exhaustion . This can lead to mental health disorders like acute stress and anxiety disorder, prolonged grief disorder , somatic symptom disorder , conversion disorders , brief psychotic disorder , borderline personality disorder , adjustment disorder, etc. Obsessive- compulsive disorder
16359-466: The treatment of trauma in mind— EMDR , progressive counting , somatic experiencing , biofeedback , Internal Family Systems Therapy , and sensorimotor psychotherapy, and Emotional Freedom Technique (EFT) etc. Trauma informed care provides a framework for any person in any discipline or context to promote healing, or at least not re-traumatizing. A 2018 systematic review provided moderate evidence that Eye Movement Desensitization and Reprocessing (EMDR)
16492-403: The type of trauma, as well as socio-demographic and background factors. There are several behavioral responses commonly used towards stressors including the proactive, reactive, and passive responses. Proactive responses include attempts to address and correct a stressor before it has a noticeable effect on lifestyle. Reactive responses occur after the stress and possible trauma has occurred and
16625-490: The under five age range refugee children had significantly higher rates of wasting syndrome and stunted growth , as well as a lower prevalence of obesity, in comparison to low-income non-refugee children. However, some time after they arrived in the United States and Australia, many refugee children demonstrated an increasing rate of overnutrition. An Australian study, assessing the nutritional status of 337 sub-Saharan African children aged between three and 12 years, found that
16758-485: The use of self-administered psychological tests. Individual scores on such tests are compared to normative data in order to determine how the individual's level of functioning compares to others in a sample representative of the general population. Psychological testing might include the use of generic tests (e.g., MMPI-2 , MCMI-III , SCL-90-R) to assess non-trauma-specific symptoms as well as difficulties related to personality. In addition, psychological testing might include
16891-431: The use of trauma-specific tests to assess post-traumatic outcomes. Such tests might include the post-traumatic Stress Diagnostic Scale, Davidson Trauma Scale, Detailed Assessment of post-traumatic Stress, Trauma Symptom Inventory, Trauma Symptom Checklist for Children, Traumatic Life Events Questionnaire, and Trauma-related Guilt Inventory. Children are assessed through activities and therapeutic relationship, some of
17024-470: The victim of an alcoholic parent; the threat or the witnessing of violence (particularly in childhood ); life-threatening medical conditions ; and medication-induced trauma. Catastrophic natural disasters such as earthquakes and volcanic eruptions ; large scale transportation accidents; house or domestic fire ; motor collision ; mass interpersonal violence like war ; terrorist attacks or other mass victimization like sex trafficking ; being taken as
17157-543: The world and ourself. Once one has experienced such trauma, it is necessary for an individual to create new assumptions or modify their old ones to recover from the traumatic experience. Therefore, the negative effects of the trauma are simply related to our worldviews, and if we repair these views, we will recover from the trauma. Psychodynamic viewpoints are controversial, but have been shown to have utility therapeutically. French neurologist Jean-Martin Charcot argued in
17290-495: The world as a whole, which can compromise their quality of life and ability to work effectively. Janoff-Bulman, theorises that people generally hold three fundamental assumptions about the world that are built and confirmed over years of experience: the world is benevolent, the world is meaningful, and I am worthy. According to the shattered assumption theory, there are some extreme events that "shatter" an individual's worldviews by severely challenging and breaking assumptions about
17423-610: The world have welcomed them, forcibly displaced children and their families often face discrimination , poverty , and social marginalization in their home, transit, and destination countries. Language barriers and legal barriers in transit and destination countries often bar refugee children and their families from accessing education, healthcare, social protection, and other services. Many countries of destination also lack intercultural supports and policies for social integration. Such threats to safety and well-being are amplified for refugee children with disabilities. Studies done by
17556-551: Was attributed, at least partly, to UNICEF's infant and child feeding interventions, as well as to the distribution of food vouchers by the World Food Programme (WFP). Among newly arrived refugees in Washington state, significantly higher rates of obesity were observed among Iraqi children, whereas higher rates of stunting were found among Burmese and Somali children. The latter also had higher rates of wasting. Such variation in
17689-511: Was introduced into the trauma literature by Gill Straker (1987). It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire, and emergency services. As one of
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