Adaptative Skills and Global Functioning of Unaccompanied Migrant Minors in Europe: A Systematised Review

Abstract

Objectives:

This systematised review aimed to examine European literature reporting data about adaptative skills and global external functioning of unaccompanied minors (UAMs).

Methods:

We conducted a systematised screening of four databases (APA PsycINFO Ovid, Medline Ovid ALL, Embase.com and Web Of Science Core Collection) using a research strategy including social, scholarly and behavioural abilities as well as externalising problems associated with the target population of UAMs. Thirty articles were included using pre-defined inclusion and exclusion criteria.

Results:

Our review showed that despite high levels of internalising disorders, socio-behavioural and educational adjustment of UAMs remained positive. It demonstrated how this population displays a strong desire for academic success and prosocial behaviours instead of aggressivity in everyday life. Nevertheless, our review drew attention to the strong tendency of UAMs to internalise their disorders and display chronic distress and problematic behaviours which increased with time spent in the host country.

Conclusion:

Our study draws attention to the risk of underestimating the real mental health needs of refugees, due to preserved external functioning combined with significant settlement pressures.

Introduction

In the context of migration, the United Nations Committee on the rights of the child defines unaccompanied minors as children “who have been separated from both parents and other relatives and are not being cared for by an adult who, by law or custom, is responsible for doing so.” Concerning mental health, the prevalence of depression, anxiety and posttraumatic stress disorder (PTSD) is high among UAMs and persists over time. Although the population of UAMs is very heterogeneous between the studies, the higher mental health risk than in adult and accompanied minor (AM) refugees is well established [1]. The prevalence of PTSD among UAMs in Europe has been evaluated at between 19% and 52.7%, with a median of 35.5% [2]. A Swedish study comparing 710,170 native minors to 33,501 UAMs showed an 8-fold higher risk of PTSD in the second group [3].

UAMs are more exposed to traumatic life events because of their younger age and lack of parental protection. They also face high levels of psychosocial and administrative insecurity, particularly during the transition to adulthood [4]. Psychosocial stress factors contribute to the persistence and worsening of their disorders [5]. Even with the support of healthcare professionals, UAMs still face important social pressures regarding their independence and transition to adulthood which can hinder their adaptation and global functioning in a new country.

Adaptative skills are defined by the American Psychology Association (APA) as “abilities that enable one to meet new challenges, such as the ability to adjust to a new environment and to learn new things.” They also involve “self-management, such as the ability to control one’s impulses.” [6] Hence, in children, adaptative skills may be represented by the presence or absence of externalised disorders, academic and educational achievement as well as interpersonal skills. We therefore used these concepts as a framework for our search strategy.

While studies of externalising disorders (irritability, aggressive behaviours, poor peer relations, etc.) in UAMs report heterogenous prevalence rates [7–11], many studies describe a tendency in youth with immigrant backgrounds [12–14], particularly UAMs, to internalise their emotional problems and mental health needs. These results suggest the possible existence of a specific form of “external resilience” among young refugees and migrants [15–18].

Secondly, evidence suggests that academic achievement may be negatively linked with the presence of PTSD or depression in the general population [19–21]. However, this is not always confirmed in studies of refugee populations. Some studies report a higher risk of school problems among refugees [22, 23], while others observe a particular form of resilience to these problems [24–26]. Furthermore, the adaptative skills examined in these studies usually include other spheres of social and professional life [14, 24], suggesting a high level of general functioning in this population.

Explaining these findings requires taking into account social issues relating to the hosting and integration of refugees, as well as screening and access to mental healthcare. For refugees facing administrative insecurity, the negative consequences of externalised distress are significant. Conversely, access to care and screening of emotional distress are hampered when troubles are internalised.

This systematised review aims thus to clarify the adaptative skills of UAMs in European host countries and particularly social, academic and learning capacities as well as prevalence of externalising disorders and global functioning difficulties.

Methods

Search Strategy

A literature search of four bibliographic databases, Embase.com, Ovid MEDLINE(R) ALL, APA PsycINFO Ovid and Web of Science Core Collection, was conducted in September 2022. All searches were carried through without restrictions of language or date. Additional records were identified through backward citation tracking and Google Scholar. The detailed search strategies, keywords, and index terms are presented in Table 1.

In constructing the research equation, we explored the population of UAMs in relation to their adaptative skills.

We included as key words, education and school performance, social abilities and behaviour problems. Resilience, acculturation and coping were also included as these terms are specific to the adaptative issues faced by UAMs in a foreign environment without the concrete and symbolic protection of adults.

Study Inclusion Criteria

The inclusion criteria were peer-reviewed studies (A) published between 2005 and 2022; (B) at least partly observational and quantitative, with the exclusion of case reports (n < 10); (C) related to European data which permitted higher specificity (although we are aware that the asylum aspects and living conditions of refugees may vary even in this small geographical area); (D) published in English or French; (E) related to education, externalised disorders, social relationships and global adaptation of UAMs in European host countries. We decided to include qualitative literature reviews as our study aimed to draw an overview of the current knowledge on the adaptative skills and global functioning of UAMs. As milestones of previous research, reviews can indeed be of great help for a comprehensive understanding of earlier qualitative findings and trends.

Population Inclusion Criteria

The studied populations had to be (A) children aged above 13 years; (B) described as unaccompanied refugees or migrants in the host country (studies relating to young adult refugees or migrants who arrived as UAMs in the host country but reached the age of majority during or just before the start of the study were also included. If no clear distinction was made between UAMs and AMs, the study was excluded); (C) forcibly displaced. We carefully checked the definition used by the studies that mentioned the term “migrant” as this can be very widely used. Thus, only papers referring to children not represented by an adult representative in the host country were included. As the term of unaccompanied minors is related to the situation of in the host country, we did not take into consideration the migration journey (alone or accompanied).

Results

Our search strategy identified 1,050 articles. After eliminating duplicates, 778 articles were examined by title and abstract using the pre-defined inclusion and exclusion criteria. Deduplication of references exported from the databases was performed in Endnote 20 (Clarivate Analytics, United States).

Twenty-seven articles were included using the search equation, and three additional studies were found by citation tracking and informal Google Scholar research. The PRISMA flow chart (Figure 1) summarises the selection process.

FIGURE 1

Study Characteristics

Of the 30 studies, four were literature reviews, 12 used cross-sectional data with no control group, eight used cross-sectional data with a control group, four used longitudinal data with no control group, and two used retrospective data. Three of the studies were mixed (with qualitative and quantitative data).

Host countries in which research was conducted were as follows: Norway (n = 7), Belgium (n = 4), Austria (n = 4), the Netherlands (n = 3), Italy (n = 3), Spain (n = 2), Sweden (n = 1), Germany (n = 1) and the United Kingdom (n = 1). Literature reviews reported European and (partly) American data. Publication dates ranged from 2006 to 2022.

The size of the population examined ranged from 19 to 22,803 individuals. Control/comparison groups were mostly native-born youth (n = 5) or accompanied minors and immigrants (n = 3). One study compared two different groups of UAMs and one study compared UAMs to other children living in child care facilities.

In Norway, five of the reviewed studies were part of a single research program conducted by the Norwegian Institute of Public Health and included approximately 2,200 UAMs (or youth who arrived as such) and thus used highly similar data. The two other Norwegian studies used the same sample of UAMs. In the Netherlands, three studies were based on the same sample of 900 UAMs with different control groups (AMs, young migrants and social workers). In Austria, the three reviewed articles examined the same sample of 41 African UAMs between 15 and 18 years old.

In terms of measurement methods, self-report questionnaires for UAMs were mostly used (n = 24). Clinical data and structured interviews (n = 3) were also employed. A national register was used in the retrospective study.

Four studies collected data on the perceptions of interested parties (guardians, legal representatives, teachers) with regard to the UAM’s psychosocial health.

In terms of socio-demographic features, excluding the literature reviews, the overall number of UAMs in the reviewed studies reached approximately 25,000 UAMs. However, this was highly influenced by the Swedish retrospective study of 22,000 UAMs. Age was mainly between 15 and 18 years and male UAMs were over-represented in all studies. Globally, the most represented countries of origin were Afghanistan, Iraq (approximately 6700 UAMs put together), Somalia (approximately 2700 UAMs) and other African countries (nearly 2000 UAMs). Studies included in literature reviews had similar socio-demographic profiles.

The characteristics and results of the reviewed studies are detailed in Table 2.

Education and School Performance

Regarding education, we took in consideration studies that reported data about school success as well as educational pathways and environment of UAMs. Grades, motivation and self-management at school, achieving higher education (university) and safe employment as well as aspirations are examples of variables that were reported in the reviewed studies to describe experiences of UAMs in educational settings.

In total, UAMs’ educational environment and performance were addressed in 13 of the included records. Several authors found that UAMs were disadvantaged in terms of attaining higher education and safe employment [27, 42, 46]. In spite of this trend, a high capacity for resilience was also described in the same studies, with UAMs showing similar performances to other youth in social care [27] or using alternative paths to achieve their educational and professional goals [42, 46].

According to some authors, UAMs expressed their resilience (defined in 2 studies as “competence under stress” and “utilizing resources and behaviours to overcome challenges and maintain and achieve wellbeing” [51, 52]) through high levels of motivation and aspirations [29, 44], regardless of their trauma experiences and levels of psychopathology [37, 42].

One study showed education and employment to be the second-highest pre-migration and the highest post-migration aspiration in Afghan UAMs [45]. Another study showed that UAMs’ school satisfaction was better than that of the general population [32].

Protective factors for the academic achievement of UAMs were analysed in one systematic literature review [30]. The authors separated resilience from risk factors according to five “socio-ecological” levels: the child (individual characteristics), micro and meso-systems (socio-administrative, individual and community support), exosystems (employment and finances) and macrosystems (migration policy, community). Globally, micro and mesosystemic influences (i.e., supportive or unsupportive parents and teachers, supportive friends or disruptive classmates) were shown to be the most important resilience factors among the UAM population. Furthermore, the European evidence drew particular attention to specific disadvantaged sub-groups of UAMs: UAMs with mental or physical health issues [30, 53], young UAM mothers, UAMs who have lived in detention and UAMs with unknown or pending asylum status [30].

Two studies highlighted the ability of UAMs to successfully use efficient educational resources quickly after arrival [43, 44].

One Austrian study found that because of their need for self-sufficiency, UAMs were less likely to be involved in university education than their AM peers [44].

Finally, concerning the school environment, two studies found that UAMs’ mental health needs were often underestimated and under-reported by teachers (same authors and same population) [40, 47].

Social and Interpersonal Skills

We used the APA definition for interpersonal skill which is an “aptitude enabling a person to carry on effective interactions and relationships with others, such as the ability to communicate thought and feeling or to assume appropriate social responsibilities” [6]. In our review, we also included studies reporting data on aggressive behaviours, antisocial functioning or conduct disorders as they are part of interacting with others.

Nine studies addressed the social and interpersonal skills of UAMs, as well as the prevalence of violent or aggressive behaviours. One study addressed the social functioning of 41 African UAMs resettled in Austria [33]. High levels of repressive defensiveness (“extreme self-restraint or suppression of egoistic desires”) and restraint (“impulse control, suppression of aggression, consideration of others and responsibility”) were observed. In another study based on the same sample of UAMs, a low level of interpersonal violence was found [34]. In a German study of 49 men who were former UAMs, family violence (in the premigration period) predicted more aggressive actions, whereas exposure to organised violence (war, torture) had no impact on the occurrence of such acts nor on appetitive aggression (a propensity to “violence-related enjoyment”) [8]. Furthermore, the severity of posttraumatic stress symptoms did not influence aggressivity and the number of violent acts committed [8].

Peer relationships were assessed in two Italian studies [7, 38]. Scores of peer-related problems were found to be at increased levels or in the borderline range (compared to clinical scores and native youth). Despite this, studies addressing prosocial behaviour and socialisation (through self-reported questionnaires) showed that UAMs usually scored in the normal range of these variables, and sometimes better than AM youth [7, 36, 44].

Long term outcomes in communication and social skills of UAMs living in Spain for 9 months were reported as worse than those of UAMs who resettled more recently [43]. This is in line with Norwegian data showing more avoidance in UAMs as time goes by since resettlement [50]. The authors of this last study noted higher avoidance behaviours among male UAMs and lower avoidance behaviours among UAMs who reported being in touch with an adult confidant [50].

Externalising Disorders

In opposition to internalising disorders defined as a psychiatric condition involving “overinhibited or internally focused symptoms” such as anxiety disorders, fear, and depression, externalising disorders refer to a spectrum of disinhibition and external behaviours such as aggressivity, delinquency, conduct problems, oppositionality, hyperactivity and attention problems [54].

From an epidemiological perspective, it is worth questioning the prevalence of externalising disorders as UAMs have been shown to internalise mental health issues. Seventeen reviewed studies covered the prevalence, expression and evolution of externalising disorders in UAMs. Externalisation and behavioural problems have frequently been compared to internalisation and emotional disorders. As mentioned in the introduction, UAMs’ “external functioning” is less likely to be impaired than their “internal functioning” [5, 10, 32, 33, 38].

Reviewed epidemiological studies comparing the prevalence of externalising disorders in UAMs vs. AMs and native youth are listed in Table 3.

The overall result is a lower, although sometimes identical, prevalence of externalising disorders in UAMs compared to control groups. In an Italian study of a small sample of UAMs who had experienced violence, behavioural problems as measured by scores on the Strength and Difficulties Questionnaire remained below normative clinical scores [38]. It is noteworthy that the only study that showed a higher prevalence of externalising disorders among UAMs was based only on problems perceived by caregivers and social workers [41].

The findings of the reviewed studies (which show high methodological similarities) are heterogenous concerning the link between past trauma and externalising disorders. Past trauma did not influence the prevalence of these disorders or the socialisation and acculturation processes in four studies [10, 35, 36, 49] while they did in tree others [31, 47].

Surprisingly, two studies highlighted an increase in the prevalence of behavioural disorders which are part of the externalisation spectrum, with time spent by UAMs in the host country [31, 35]. A more recent work showed a similar increase in behavioural disorders in UAMs especially when they had contact with their parents [39].

Some authors reviewed the European literature with an interest in substance abuse and criminality among UAMs. They reported the same trends as in our work concerning the prevalence of externalising disorders among UAMs and AMs [28]. The authors failed to show a clear picture concerning substance use among UAMs but highlighted that post-migration risk factors were likely to increase drug consumption and criminality in this population [28].

Global Functioning and Long Term Adaptation

Several studies included in our review addressed the short and long term functionality of UAMs in view of the high prevalence of mental health conditions/disorders (or the high level of psychopathology). Global functioning is defined by the World Health Organisation (WHO) as “the positive features of the relationship between a health condition and the environmental and personal context of the individual” [55]. It can thus be related to functioning in different areas of life and can be measured with different scales.

Despite some contrasting results, our review showed that the overall good functioning of UAMs in educational and social spheres is likely to apply to other areas. In a Norwegian cross-sectional UAM study, one-third of those with PTSD were not impacted in their functioning, while 20% reported significantly impaired functioning [10].

Furthermore, despite high levels of depressive disorders, longitudinal study showed no influence of depression on UAMs’ acculturation (assimilation of culture in the host country) [48]. However, several of the reviewed articles showed that in the long-term disorders present on arrival were likely to become chronic [29, 39, 48–50]. In some studies, externalising disorders that were initially absent were likely to develop with more time spent in the host country [28, 31, 50].

Discussion

This systematised review contributes to the current state of knowledge on adaptative skills and global functioning of UAMs. It appeared that in the European context, the adaptative capacities of UAMs are largely preserved despite a high prevalence of PTSD, depression and anxiety. These results illustrate a type of resilience with preserved functional capacities and strong motivation to succeed in academic and social life. As pointed out by several authors, UAMs suffer from largely internalised disorders, which creates a gap between the emotional distress they experience in their private lives and the resilient behaviours they express in the social spheres.

The few longitudinal studies involving UAMs make this observation even more complex by showing a gradual decline in adaptative behaviour related to the length of time spent in the host country. This issue should be addressed in further longitudinal studies.

Scholarly and Social Resilience Among UAMs

It was clear in our review that UAMs show particular resilience in facing the challenges of migration and the settlement process. This has been the subject of many European qualitative studies, which are not included in our review [56–58]. Different contextual and societal factors may explain these results. First, it seems obvious that UAMs are likely to undergo particular pressure to integrate and excel in educational, professional and social domains. Successful integration can lead to better social inclusion in the host country [27, 59], the ability to support oneself [42, 58] and, in some cases, to provide for the needs of the family in the home country [57]. While facing chaotic life circumstances resulting from migration, insecurity in the asylum process and a future that may seem doomed, UAMs might consider academic and social achievement as a way to control their life and an important resilience strategy [60, 61].

This great maturity of UAMs in scholarly and social spheres of functioning is described by one study as part of an “adultomorphic behaviour” they adopt in response to the absence of parents [7]. During and after migration, these young people may be forced to adopt such behaviour to provide for their needs without any adult protection. Furthermore, as a way to take up the space left by the absence of parents UAMs may engage in the creation of more social connections and integrate quicker than their AM peers [44].

Nevertheless, as some authors mentioned, a selection effect in the great resilience of the UAM population in Europe is highly probable. Those who make it to Europe may represent a particularly resilient population, explaining their strong ability to cope with the difficulties of post-migration life [32]. This same effect could also be observed concerning violent behaviours in youth who have experienced organised violence [8]. According to these authors, the studied sample of refugees could be a selection of individuals who rejected war, with those who stayed behind being more likely to have adapted to the violent environment and consequently developed violent behaviours [8].

Externalising Disorders in the Migration Context

Studies conducted in host countries mostly showed preserved external functioning and an equal or lower level of social and behavioural disorders than in AMs [11] and natives [5, 7, 9, 32, 33, 40].

Reviewed articles suggest low association between UAMs’ psychopathologies and school motivation, aspirations and social skills [37, 42]. Nevertheless, this finding must be carefully interpreted as it could lead to underestimating the real mental health needs of this population. This tendency was especially noted in studies comparing self-reported and perceived (by an adult in charge) mental health needs of UAMs [40, 47]. Indeed, high levels of unmet needs were alarming and may contribute to the chronification of disorders already present from the moment of arrival [47–50].

Although we might expect time spent in the host country to have a positive effect, the few longitudinal studies reported here surprisingly showed higher levels of chronic disorders that altered previously acquired good social functioning. Socio-behavioural problems, even when they were absent at the time of arrival, appeared or worsened with the length of stay in the host country [31]. Peer influence, in that context, could either be a protective or a risk factor [31, 39] and should be addressed in further studies.

However, it is reasonable to assume that the approach of age of adulthood may explain new behavioural problems as it implies a greater risk for UAMs to be sent back. They may be exposed to a feeling of loss of control [31], and present reactive behaviours in that context. From another point of view, this situation of insecurity could also lead UAMs to conceal their disorders to meet the social and administrative requirements imposed by the asylum process [32].

Good global functioning, which was described in the educational, professional and social spheres, as well as the initial low level of externalising disorders, should then be carefully considered. The legal and administrative contexts in which UAMs find themselves are likely to be a source of stress and anxiety, maintaining emotional difficulties at a high and stable level or causing more externalising disorders [7, 28, 31, 33, 35, 62].

Thus, our review draws particular attention to the post-migration risk factors that UAMs face while resettling in a new country. By only focusing on their pre- or peri-migration background, mental health professionals may miss a whole sphere of influence on the overall experience of UAMs [28].

Adaption and Resilience: Post-migration Period and Paradoxes

Our review contributes to the field of knowledge of adaptative and global functioning of UAMs in Europe. We showed that UAMs displayed a specific form of resilience in terms of academic, social and externalising behaviours. These results have been discussed in the previous chapters but it is worth considering them in the light of the status of UAMs in host countries. In Western societies, this status is at the border of several concepts. On the one hand, an UAM is considered as a child whose “best interests,” should be protected (as defined by the United Nations Convention on the Rights of the Child); on the other, as an asylum seeker subject to the relevant decision-making processes. Public institutions are likely to exert indirect pressure on UAMs by requiring them to adapt quickly and effectively, as they risk being sent back on reaching adulthood. This paradox between reception and integration pressure, as well as between child protection and asylum procedures, was raised by several authors and experts in this domain [62–64] and may explain our results.

The high marginalisation of UAMs should be set in the context of the insufficient support they receive in the host country [62] and the good level of functioning they must adopt by hiding their disorders and meeting the challenges of integration. In one review, it was demonstrated that the same study can show a UAM to be “vulnerable” [65], resilient [66] or both at the same time [29]. This strengthens the tension between precariousness and perseverance which is specific to this group.

In sum, the lack of knowledge or denial of these paradoxical issues by public institutions, represents a significant danger to the wellbeing of UAMs on reaching adulthood.

Limitations

First, because Europe is a large geographical area, it is not possible to generalise any migration policy, resettlement context or access to care for UAMs. The conclusions of this review should thereby be considered carefully. Nevertheless, the studies reviewed focused on the Western and Northern European countries which are host to a large majority of the UAMs in Europe.

Studies of UAMs display high heterogeneity in the populations selected, selection procedures (most samples are unrepresentative convenience samples), sample sizes and diagnostic procedures (interview, various self and hetero-reported scales).

UAMs typically come from different countries and cultures, which may have influenced the findings, especially when self-report questionnaires were used. UAMs from different cultural backgrounds are likely to differ in their perceptions of difficulties and the socio-administrative context they are facing. Furthermore, the diversity of languages and causes of migration are other factors that may influenced the results of this review. Therefore, it would be too simplistic to consider that the journey of UAMs in our Western societies can be perfectly predicted and categorised.

According to some authors, self-report questionnaires may introduce potential selection bias by underestimating externalising disorders. This is what sometimes called the social desirability bias [30], which can be amplified in the context of administrative insecurity, such as asylum status, and can lead UAMs to hide externalising disorders [32, 63]. Furthermore, regarding the term “externalising disorders,” it should be noted that the selected studies seldom analysed the subtypes of this broad category within the UAM population.

Finally, this review highlighted the lack of longitudinal studies, which provide the most reliable information on the social and mental health outcomes of UAMs.

Conclusion

This study aimed to conduct a systematised review of adaptative skills and global functioning of UAMs, a population who is subjected to migration, family separation and mental health issues.

Our result showed that UAMs have great motivation at school and high professional aspirations. When presenting mental health disorders, they tend to conceal their dissocial and behavioural manifestations. This is reflected in high scores of socialisation, low levels of externalising disorders and only little or no use of violence.

The high prevalence of anxiety, depression and posttraumatic stress disorders reflects a process of internalisation of mental health issues and can explain this population’s “external life” success. Despite the strong evidence concerning this form of external resilience that leads to a good global adaptation of UAMs, domains of life satisfaction and personal fulfilment remain to be explored. As pointed out in one of our study, resilience is a multidimensional concept that may be independent of mental health issues [16].

Finally, it should be noted that stress and difficulties experienced after settling in the host country may negatively influence mental health in the same way (and sometimes to a greater extent) as pre- and peri-migration risk factors. Post-migration stressors can lead to a chronification of disorders. Findings from longitudinal studies should raise awareness of the development and persistence of mental disorders in UAMs long after their arrival. When meeting these minors in care facilities, particular attention should be paid to dealing with ongoing or new psychosocial stressors and not only to the traumatic elements experienced before arrival [67, 68].

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