Children in detention
The Effect Of Detention Centres On The Health Of Children
MAPW Position Paper adopted May 2002
Since 1989, refugees seeking asylum in Australia who have arrived by boat in Northern waters have been detained by the Commonwealth Government in breach of international human rights standards. Australia is a signatory to the 1951 UN Refugee Convention, the Universal Declaration of Human Rights, the Convention on the Rights of the Child and the International Covenant on Civil and Political Rights. Prolonged mandatory detention breaches many articles of these conventions. Eg Australia, by its current policies, breaches at least 13 articles of the Convention on the Rights of the Child. (appendix 1)
There are five detention centres in Australia. They are run by Australasian Correctional Management and Australian Protective Services, who are contracted by the Department of Immigration, carrying out orders of the Minister of Immigration, the Hon Phillip Ruddock. The numbers of detainees varies over time, usually numbering between one and two thousand. Of these about one third are children. In comparison, the number of people in Australia in breach of visa or Immigration laws was 60,103 as at 30 June 2001 and the total number of refugees world wide in 1999 was estimated by UNHCR at 21 milllion.
1.2 Health status of asylum seekers
Research suggests that asylum seekers and refugees (including children) have a range of illnesses which require health and medical treatment.
A recent audit[i] of 102 community-based asylum seekers attending a general practice clinic in Sydney found a range of illnesses, and concluded that a significant proportion of those asylum seekers required specialist care. The most frequent presenting problems were infectious and respiratory. Although no children presented with psychological problems many were fearful when examined. Few had received adequate health and medical services.
Another study[ii] of 40 asylum seekers attending a charitable organisation in Sydney which provides education and support for asylum seekers, suggested that most were suffering from psychological and physical symptoms sufficiently serious to warrant medical assessment. Thirty reported exposure to premigration trauma, 10 had been subjected to torture, 10 reported gastrointestinal disease, nine musculoskeletal complaints, six gynaecological problems and one had an infectious disease (hepatitis).
Smith has described the similarity between the health of asylum seekers and that of refugees resettled in Australia from overseas.[iii] Their general health problems are complex and compounded by the socioeconomic disadvantage they experience in Australia. Likewise in the United Kingdom, studies have found that many of the diverse and manifold health needs of asylum seekers overlap with those of “deprived or excluded groups, ethnic minorities or new entrants to the country”.[iv]
International studies assessing the health needs of refugees also conclude that refugees have a range of health and medical illnesses. In the United Kingdom one in six refugees has a physical health problem severe enough to affect their life and two thirds have experienced anxiety or depression.[v] Not surprisingly, a past history of torture, or the feelings of insecurity experience by refugees, amplify and extend the duration of the illnesses.[vi] In addition, post migration factors such as discrimination, lack of social support and unemployment have been identified as major contributors to anxiety and depression in refugees.[vii] Children, in particular, appear to suffer prolonged psychological distress after resettlement.[viii]
Some asylum seekers present with physical sequelae of torture or other violent trauma which may not have received adequate medical attention in their countries of origin. These sequelae include malunited fractures, osteomyelitis, epilepsy or deaifness from head injuries, or non-specific musculoskeletal pain or weakness.[ix] In rape victims, in addition to the psychological sequelae of rape, there may be a risk of HIV or other sexually transmitted diseases.
The incidence of infectious and nutritional diseases varies between refugee groups according to their country of origin.[x] The presence of HIV, hepatitis A and B, tuberculosis and immunisable diseases is a major public health concern.[xi] However, severe parasitic and intestinal infections are also common. Helicobacter pylori infection is particularly common in refugees from developing countries or in those who have spent time in refugee camps.[xii]
According to the RACGP, in addition to the range of complaints similar to those of the rest of the Australian population, the following health problems are likely to be common amongst refugees:
- psychological issues such as post traumatic stress disorder, anxiety, depression and psychosomatic disorders
- direct physical consequences of torture such as musculoskeletal pain or deaifness
- under recognised and under managed hypertension, diabetes and chronic pain
- poor oral health, a result of poor nutrition and diet, lack of fluoride water, poor dental hygiene practices and limited dental care in the past
- infectious diseases including TB and intestinal parasites
- delayed growth or development in children
Summary: The research done both here and overseas shows that prolonged detention contributes to further psychological and physical health problems for the individuals concerned.
2. Impact of detention on children
Current practices of detention of infants and children are likely to have both immediate and larger‑term effects on children’s development, psychological and emotional health. Children in these situations are exposed to multiple stressors including:
- behavioural and psychological distress in adults,
- dislocation from protective social groups and structures,
- witnessing violence and self‑harm, and
- separation from attachment figures.
These stressors, in combination with prior exposure to conflict and community breakdown, immediately place these children at risk for the development of Post‑Traumatic Stress Disorder (PTSD) and the longer‑term consequences of this.
There is a body of scientific literature pointing out that infants and children are vulnerable to the effects of stress and trauma and may develop severe PTSD symptoms.[xiii],[xiv] These symptoms are common within the first month of trauma and have been found to occur in many situations including child maltreatment,[xv] violence exposure[xvi] and natural disasters. Rates of PTSD in children traumatized by maltreatment are similar to those of children traumatized by war and homicide.
In a study of Cambodian adolescents three years after survival of the Pol Pot regime, 50% had persistent symptoms of PTSD, depression and anxiety.[xvii] PTSD may become chronic and factors such as lack of supportive adults and attachment figures, inadequate mental health services and ongoing trauma can all contribute to persistent symptoms.[xviii]
Recent research focuses on the developmental implications of early trauma on neurobiological and psychological development.[xix] Childhood trauma has been shown to produce alterations of biological stress systems and adverse effects on brain development.[xx] These are significant in that these changes are associated with ongoing vulnerability to stress and are risk factors for the development of a range of mental health problems including mood disorders, conduct disorders and substance abuse.
Early trauma, including exposure to adult distress and self‑harming behaviours, separation from attachment figures and cultural dislocation, constitute significant stressors for children and are likely to be of a magnitude to effect neurobiological development. Research suggests that these effects are persistent and related to ongoing symptoms. There are no effective interventions available to reverse these charges which points to the importance of prevention of traumatic exposure in vulnerable groups such as infants and children.
Maintenance of attachment relationships and enabling adults to support traumatized children have been found to protect children from development of chronic PTSD.[xxi] Secure attachment relationships are known to increase children’s resilience and have capacity to manage stress. Children with secure attachment relationships are less vulnerable to the effects of trauma and are able to use their attachment figures for support in processing and resolving traumatic events. Unresolved traumatic experiences are related to chronic PTSD symptoms and mental health problems.
In young children, disruptions of attachment relationships, such as removal from a primary carer or multiple changes of carer, are severe stressors and may produce immediate symptoms of distress and behavioural disturbance. Responses to loss of attachment figure have been extensively documented and include stages of separation protest, despair and eventual disengagement or withdrawal.[xxii] Research in Attachment Theory has supported the original hypotheses that attachment disruption and attachment trauma may effect children’s ongoing capacity to form reciprocal emotional relationships and is linked to disruptions in personality development.[xxiii] Children with Disorganized Attachment relationships, (often the result of maltreatment or mental disorder in carers) are at risk of development of conduct and emotional problems.[xxiv]
Children currently held in detention centres have been exposed to serious psychological distress in adults, adult self‑harming behaviours and have experienced cultural dislocation and community trauma. In these circumstances it is likely that many will develop PTSD and that this may become chronic with effects on development. Any additional loss of adult support and attachment disruption is likely to increase symptom severity and contribute to ongoing psychopathology. Furthermore, children may be kept in detention for long periods of time if their parents are assessed as not being refugees.
The length of time in an institution, and quality of institutional care has a major impact on the potential for long-term recovery of children.[xxv] The longer the length of time in institutional care, the less likely children are to recover from trauma. The quality of institutional care is affected by the institution’s management – institutions with well trained, well supported staff whose hours are reasonable, who have reasonable breaks and regular inservice are less likely to create abusive environments for children institutions.
Based on this literature the specific concerns regarding children in detention centres are that they are exposed to severe adult distress and traumatic behaviours such as self‑harm, and that there are inadequate supports for children who may be experiencing acute and ongoing effects of trauma. Furthermore, there are few appropriate mental health supports adult carers to enable them to protect children in distress.
Given the evidence of ongoing trauma to children in detention, there is inconsistency between mandatory reporting of child abuse and the existence of children in mandatory detention in Australia.
3. MAPW calls on the Commonwealth Government to:
- End mandatory detention for children and their families
- · Provide full medical assessment and on going adequate medical treatment to all refugees and asylum seekers
- · Provide education to children and job retraining for adults at least equal to the standard enjoyed by Australian citizens, understanding the special needs of this group of people.
Thank you to the Alliance of Professionals Concerned about the Health of Asylum Seekers and their Children and Ms Victoria Toulkidis (Senior Policy Officer at the Royal Australasian College of Physicians) who made a substantial contribution to the text and who provided most of the references.
McMaster D Melbourne University Press 2001 Asylum Seekers Australia’s Response to Refugees
Silove D & Steel Z (1998) Psychiatry Research and Teaching Unit The University of NSW The Mental Health and Well-being of On Shore Asylum Seekers in Australia.
[i] Harris MF and Telfer BL. The health needs of asylum seekers living in the community. Med J Aust 2001; 175(3): 589-592.
[ii] Sinnerbrink I, Silove DM, Manicavasagar VL, Steel Z, Field A. Asylum seekers: general health status and problems with access to health care. Medical Journal of Australia 1996; 165: 634-637.
[iii] Smith M. Desperately Seeking Asylum: The Plight of Asylum Seekers in Australia. New Doctor 74, Summer 2000-2001: 21-23.
[iv] Bardsley M and Storkey M. Estimating the numbers of refugees in London. Journal of Public Health Medicine. Vol. 22, No. 3, pp. 406-412.
[v] Carey Wood J, Duke K, Karn V, Marshall T. The settlement of refugees in Britain. London; HMSO, 1995. (Home Office research study 141).
[vi] Sundquist J and Johannson SE. The influence of exile and repatriation on mental and physical health. A population-based study. Soc Psychiatry Psychiatry Epidemiology 1996; 31: 21-8.
[vii] Pernice R, Brook J. Refugees' and immigrants mental health: association of demographic and post-immigration factors. J Social Psychology 1996: 136: 511-20.
[viii] Hjern A, Angel B, Jeppson O. Political Violence, family stress and mental health of refugee children in exile. Scand J Soc Med 1998; 26: 18-25.
[ix] Burnett A, Peel M. The health of survivors of torture and organised violence. British Medical Journal 2001, 322 (7286): 606-609.
[x] Jones D, Gill, Paramjit S. Refugees and primary care: tackling the inequalities. BMJ, 1998; 317: 1444-1446.
[xi] Burnett A, Peel M. Asylum seekers and refugees in Britain. BMJ 2001; 322 (7285): 544-547.
[xii] Walker PF and Jaranson J. Refugee and immigrant health care. Medical Clinics of North America. 1999; 83: 1103-1120.
[xiii] Blank A.S. (1993). The longitudinal course of posttraumatic stress disorder. In J.R.T. Davidson and E.B. Foa (Eds.), Posttraumatic Stress Disorder: DSM‑IV and Beyond. Americani Psychiatric Press, Washington, DC. pp. 3‑22
[xiv] Pynoos R.S, & Eth, S. (1985). Witnessing acts of personal violence. In S. Eth & R.S. Pynoos (Eds.), Post‑traumatic Stress in Children. Americani Psychiatric Press, Washington, DC. pp 17‑43.
[xv] Mannarino, A.P., Cohen, J. A., & Berman, S. R. (1994). The relationship between preabuse factors and psychological symptomatology in sexually abused girls. Child Abuse & Neglect, 18, 63‑71.
[xvi] Pynoos, R. S., & Nader, K. (1989). Children’s memory and proximity to violence. Journal of the Americani Academy of Child & Adolescent Psychiatry, 28, 236‑241
[xvii] Kinzie, J. D., Sack, W., Angell, R., & Clarke, G. (1989). A three year follow‑up of Cambodian young people traumatized as children. Journal of the Americani Academy of Child and Adolescent Psychiatry, 28, 501‑504.
[xviii] De Bellis M.D. (2001) Developmental traumatology: The psychobiological development of maltreated children its implications for research, treatment, and policy. Development and Psychopathology. pp 539‑564.
[xix] De Bellis, M.D., Keshavan, M., Clark, D.B., Casey., B. J., Giedd, J., Boring, A.M., Frustaci, K., and Ryan, N.D. (1999). A.E. Bennett Research Award. Developmental traumatology part II: Brain development. Bioloical Psychiatry, 45, 1271‑1284.
[xx] De Bellis, M.D., and Putnam, F.W. (1994). The psychobiology of childhood maltreatment. In Child and Adolescent Psychiatric Clinics of North America, 3, 663‑677.
[xxi] Pfefferbaum, B. (1997). Postraumatic stress disorder in children: A review of the past 10 years. Journal of the Americani Academy of Child & Adolescent Psychiatry. 36, 11, pp. 1503‑1511
[xxii] Cassidy J (1999). The nature of the child’s ties. In J.Cassidy and P.Shaver, Handbook of Attachment: Theory, Research, and Clinical Applications. The Guilford Press, New York. pp 3‑20.
[xxiii] Kobak R. (1999). The emotional dynamics of disruptions in attachment relationships: Implications for theory, research, and clinical intervention. In J.Cassidy and P. Shaver, Handbook of Attachment: Theory, Research, and Clinical Applications. The Guilford Press, New York. pp 21‑43.
[xxiv] Greenberg M.T. (1999). Attachment and psychopathology in childhood. In J.Cassidy and P Shaver, Handbook of Attachment: Theory, Research, and Clinical Applications. The Guilford Press, New York. pp 469‑496.
[xxv] Armstrong K. The impact of traumatic childhood experiences on children’s lives, with particular reference to traumatised children raised in institutional settings. Aboriginal and Islander Health Worker Journal 1999; 23(2): pp 14-20.
Australia ratified the United Nations’ Convention of the Rights of the Child (Convention) in 1990.
Australia’s current policy in relation to asylum seekers places children (either accompanied or unaccompanied) in detention centres. The outcomes of this policy result in breaches to Australia’s obligations under the Convention as follows:
- Article 3(3) “States Parties shall ensure that the institutions, services and facilities responsible for the care or protection of children shall conform with the standards established by competent authorities, particularly in the areas of safety, health, in the number and suitability of their staff, as well as competent supervision.”
- Article 6(2) “States Parties shall ensure to the maximum extent possible the survival and development of the child.”
- Article 9(1) “States Parties shall ensure that a child shall not be separated from his or her parents against their will, except when competent authorities subject to judicial review determine, in accordance with applicable law and procedures, that such separation is necessary for the best interests of the child. Such determination may be necessary in a particular case such as one involving abuse or neglect of the child by the parents, or one where the parents are living separately and a decision must be made as to the child's place of residence.”
- Article 9(3) “States Parties shall respect the right of the child who is separated from one or both parents to maintain personal relations and direct contact with both parents on a regular basis, except if it is contrary to the child's best interests.”
- Article 13(1) “The child shall have the right to freedom of expression; this right shall include freedom to seek, receive and impart information and ideas of all kinds, regardless of frontiers, either orally, in writing or in print, in the form of art, or through any other media of the child's choice.”
- Article 19(1) “States Parties shall take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has the care of the child.”
- Article 22(1) States Parties shall take appropriate measures to ensure that a child who is seeking refugee status or who is considered a refugee in accordance with applicable international or domestic law and procedures shall, whether unaccompanied or accompanied by his or her parents or by any other person, receive appropriate protection and humanitarian assistance in the enjoyment of applicable rights set forth in the present Convention and in other international human rights or humanitarian instruments to which the said States are Parties.”
- Article 24(1) “States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.”
- Article 28(1) “States Parties recognize the right of every child to a standard of living adequate for the child's physical, mental, spiritual, moral and social development.”
- Article 31(1) “States Parties recognize the right of the child to rest and leisure, to engage in play and recreational activities appropriate to the age of the child and to participate freely in cultural life and the arts.”
- Article 37(b) “No child shall be deprived of his or her liberty unlawfully or arbitrarily. The arrest, detention or imprisonment of a child shall be in conformity with the law and shall be used only as a measure of last resort and for the shortest appropriate period of time”
- Article 37(c) “Every child deprived of liberty shall be treated with humanity and respect for the inherent dignity of the human person, and in a manner which takes into account the needs of persons of his or her age. In particular, every child deprived of liberty shall be separated from adults unless it is considered in the child's best interest not to do so and shall have the right to maintain contact with his or her family through correspondence and visits, save in exceptional circumstances”
- Article 37(d) “Every child deprived of his or her liberty shall have the right to prompt access to legal and other appropriate assistance, as well as the right to challenge the legality of the deprivation of his or her liberty before a court or other competent, independent and impartial authority, and to a prompt decision on any such action.
- Article 39 “States Parties shall take all appropriate measures to promote physical and psychological recovery and social reintegration of a child victim of: any form of neglect, exploitation, or abuse; torture or any other form of cruel, inhuman or degrading treatment or punishment; or armed conflicts. Such recovery and reintegration shall take place in an environment which fosters the health, self-respect and dignity of the child.”