1. Introduction

Violence against children in all forms is a violation of children’s rights and an enormous child health issue [1]. The magnitude and impact of forced migration among children is one such example of violence, associated with physical, sexual, and psychological trauma. The number of children on the move has grown at an unprecedented rate. In 2021, there were 37 million displaced children worldwide including 14 million refugees and 23 million internally displaced children [2]. In Europe, this included 23,255 unaccompanied minors seeking asylum, which is a 72% increase compared with 2020 (13,550) [3]. Most recently, there has been major dislocation of children from Ukraine and Afghanistan. The 2021 withdrawal of U.S. forces from Afghanistan has resulted in Afghan families choosing to separate to get as many members of their families as possible to safety. More than 1500 children have come to the United States unaccompanied [4]. In addition, following the Russian invasion of Ukraine in 2022, 1.1 million children have migrated to neighboring European countries, with an additional 2.5 million internally displaced inside Ukraine [5]. In addition, thousands of Ukrainian child have been forcibly deported to Russia for illegal adoption for Russian families [6]. Post-traumatic stress disorder (PTSD) is prevalent among refugee minors, and its negative effects on daily life have been thoroughly studied [7]. Though there have been studies that have focused on PTSD in unaccompanied refugee minors (URM), they have frequently been cross-sectional, small, qualitative in nature, and/or have used convenience samples. A URM is defined as “a person who is under the age of 18 and who is separated from both parents and is not being cared for by an adult who by law or custom has the responsibility to do so” [8]. Displacement in all forms puts a child at a high risk of separation from parents. In 2019, only 27% of children surveyed upon arrival in Europe via the Mediterranean had traveled with family [9]. Loss of connection to a caregiver is a developmental crisis for many children amid adversity. Furthermore, in 2017, over 94 refugees arriving in Europe reported indicators of potential trafficking and exploitation during their journey, with children’s reports of these incidents higher than adults [10]. Given how essential a stable family is for a child, it is not surprising that PTSD rates are higher in children who have undergone displacement than in those exposed to similar traumas without the loss of parents and a stable social world [11]. Given the increased instability of unaccompanied children and the subsequent mental health problems that occur, this paper aims to review the literature regarding PTSD in unaccompanied refugee and asylum-seeking minors, focusing on the prevalence of PTSD, protective and exacerbating factors of developing PTSD, and potentially effective interventions. Even when an unaccompanied refugee minor is able to safely relocate to a new country, the resettlement process may expose them to adverse outcomes of racism, islamophobia, and xenophobia [12]. 

There are several interventions that have demonstrated to be effective. These include trauma-focused cognitive behavioral therapy (TF-CBT); My Way (“Mein Weg”), a TF-CBT and group-processing mixed therapy; teaching recovery techniques (TRT); expressive arts intervention (EXIT); and narrative exposure therapy for children (KIDNET). Each is briefly described below.

Trauma-focused cognitive behavioral therapy (TF-CBT) is considered one of the most widely studied and effective treatment of post-traumatic stress disorder for school-aged children and adolescents ^[13][54]. Gutermann et al., in a meta-analysis of 135 studies, found that TF-CBT was the most effective and yielded the highest mean effect sizes regarding treatment of those who have experienced trauma ^[14][55]. In regard to URM, Uterhitzenberger and Rossner, in a pilot study, found that TF-CBT was feasible and effective in reducing PTSD in severely traumatized in an unaccompanied refugee minor girl ^[15][56]. TF-CBT included the following eight components under the PRACTICE acronym: psychoeducation and parenting skills, relaxation, affective modulation, cognitive processing, trauma narrative, in vivo exposure, conjoint child/caregiver sessions, and enhanced safety and future skills. The individual participated in 12 sessions of TF-CBT from a treatment manual, with PTSD symptoms decreasing in a significantly and remaining stable for 6 months. However, since it was a case report of a single individual, one must be cautious on generalizing the results. The same authors conducted a second pilot with six URM with similar positive outcomes ^[16][57]. More recently, Chipalo conducted a systematic review of the effectiveness of TF-CBT in reducing trauma symptoms among refugee children and found that in four peer review studies TF-CBT were deemed effective ^[17][58]. Despite the promising results of TF-CBT with URM, future additional studies need to be conducted to provide more empirical support for its effectiveness and generalizability to for treatment of PTSD with unaccompanied refugee youth.

My Way or (“Mein Weg” in German) is a short-term component-based intervention of TF-CBT combined with a group-processing mixed therapy approach. The cognitive behavioral components compromised psychoeducation, cognitive restructuring, and promoting enhanced safety and future development. The meditation practice included relaxation technique and deep breathing. Pheiffer and Goldbeck conducted a pilot study published in 2017 with 29 Afghan male URMs aged 14–18 years. The pre/post-test comparison indicated a reduction in PTSD symptoms. The intervention demonstrated reduced physiological manifestations of stress, startle response, hypervigilance, sleeping, and attention problems, and anger dysregulation ^[18][59]. The young refugees reported significantly fewer symptoms after taking part in the intervention compared with before the intervention. Improvement was significant in the domains of re-experiencing and avoidance and also in improvement in cognition and mood. In 2019, Pfeiffer and colleagues conducted a randomized, controlled trial with 50 male participants (randomly assigned to the Mein Weg or usual care (UC) group). Both the initial post-treatment and 3-month follow-up assessments showed that the Mein Weg group interventions were more effective in reducing PTSD and depression symptoms ^[19][60].

Teaching recovery techniques (TRT) was developed by The Children and War Foundation, based in the United Kingdom and Norway, and is another manualized intervention based on TF-CBT in a group setting ^[20][61]. TRT is a low-threshold, five-session intervention developed to reduce distressing war- and disaster-related trauma reactions among children and youth. It includes both stress-management skills that help children to better process their trauma-related emotions as well gradual exposure to traumatic experience to assist children in gaining mastery over traumatic reminders. TRT enables normalization to trauma and offers children emotional support by providing them with strategies to cope. Sarkadi and colleagues utilized the CRIES-8 and the Montgomery–Asberg Depression Rating Scale Self-report (MADRS-S) at baseline and post-TCT intervention. At baseline, 83% of URMs were reported to be moderately or severely depressed with 48% experiencing suicidal ideation. Both the PTSD and depression symptoms decreased significantly after intervention ^[21][14]. Saradi et al. initiated a TRT study to evaluate the effect and efficiency of this approach in a randomized, controlled trial ^[22][62]. However, it became evident that revisions to the protocol were needed, especially with regard to the procedures for recruitment and randomization. Upon revision, an adequately powered randomized clinical trial is presently underway ^[23][63]. Recently, Solhaug and colleagues demonstrated that TRT is a potential useful intervention to enhance life satisfaction among URM and can be a measure to support positive development among youth at risk for mental health problems ^[24][64]. Finally, El-Khani and colleagues combined TRT and a parenting education program with preliminary outcome data showing that TRT plus parenting may have the potential to reduce refugee children’s trauma and increase caregivers’ parenting self-efficacy ^[25][65].

DeMott et al. described the use of expressive arts intervention (EXIT) with unaccompanied asylum-seeking children. The approach is based on intermodal expressive arts consisting of music education and music/art/dance therapy to access the “play space”. The objective was to study the long-term effects of short-term, early group intervention. The results demonstrated that EXIT had a beneficial effect on helping minor refugee boys with symptoms of trauma and post-traumatic stress symptoms (PTSS). Improvement was noted in a greater sense of safety, calming, connectedness, self- and community efficacy, and hope. At the end of the follow-up, the EXIT group had a beneficial effect on helping minor refugee boys cope with symptoms of trauma, increase life satisfaction, and develop hope for the future compared to the control group ^[26][66].

KIDNET is a short-term psychotherapeutic approach to the treatment of PTSD for children. It consists of the child and therapist constructing a chronological narrative of the child’s exposure to traumatic stress over the course of 6 to 10 sessions. Ruff et al. demonstrated success in the treatment of refugee children experiencing PTSD symptoms with positive results lasting for over a year ^[27][67]. More recently Peltonen and Kangaslampi (2019) randomly assigned 50 severely traumatized children and adolescents, including 37 refugees, in Finland to KIDNET and treatment-as-usual groups (TAU). KIDNET was significantly more effective than the TAU in reducing PTSD symptoms ^[28][68]. There is presently a rater-blinded, multi-center, randomized, controlled trial comparing KIDNET to treatment as usual within the German general healthcare system ^[29][69].

Finally, it should be noted that there are additional emerging approaches that may prove efficacious with URM, specifically, the extinction of conditioned fear as shown in people suffering from post-traumatic stress disorder (PTSD) and anxiety. Neural oscillatory correlates of such mechanisms appear relevant regarding the development of novel therapeutic approaches such as electrical brain stimulation, vagal nerve stimulation, and deep brain stimulation ^[30][70].