Abstract
Background
Recently, we reported a strong, disease-independent relationship between accumulated preadult environmental risks and violent aggression later in life. Risk factors were interchangeable, and migration was among the explored risks. Alarmed by these data, we assessed collected risk load in young ‘healthy’ refugees as a specific subgroup of current migration streams and evaluated first signals of behavioral abnormalities.
Methods
In 9 German refugee centers, n = 133 young refugees, not previously in contact with the health system, were recruited, many of them unaccompanied minors. Risk factors experienced apart from migration/refuge were carefully assessed: Traumatic experiences before/during/after flight (including war, genocide, human trafficking, torture, murder, slavery, terrorist attacks), urbanicity, physical and sexual abuse, problematic alcohol and cannabis use (lifetime). Evaluation comprised physical exam and psychopathology screening.
Findings
Refugees arrived in Germany via Eastern Mediterranean/Balkan route (34.6%), from Africa via Central Mediterranean route (39.1%), by plane (17.3%) or other routes, such as Western Mediterranean or Atlantic (9.0%). Flight reasons were war/expulsion (25.6%), persecution/threats to life (51.9%), economical/others (22.5%). On top of migration/refuge, 42.8% of subjects had ≥3 risk factors; only 4.5% of refugees had no additional risks. Global level of functioning and severity of psychopathology were strongly associated with number of accumulated risks (Jonckheere–Terpstra trend-test: p = 7.61 × 10−7 and p = 3.62 × 10−7, respectively).
Interpretation
Young refugees, arriving in hosting countries with alarming ‘risk burden’, should be considered as highly vulnerable towards development of global functional deficits, behavioral abnormalities, and neuropsychiatric disorders. Rapid proactive integration or sustainable support of those who will return to rebuild their countries are mandatory.
Funding
The Max Planck Society supported this work.
1. Introduction
,
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]. However, studies on accumulation of risk factors, their impact in relation to genetic risk, and their effects on human behavior are sparse. When we started working on preadult accumulation of environmental risk factors, first in schizophrenic individuals, we made several surprising discoveries. Accumulation of ≥3 risk factors before the age of 18 years led to a nearly 10-year earlier onset of schizophrenia; the environmental risk factors were interchangeable, i.e. they could all replace each other, just the number was important; the impact of environmental risk was definitely stronger as compared to any common genetic risk [
,
]. From these robust findings, we moved on to compare extreme groups for exploring potential epigenetic alterations. Whereas epigenetic findings turned out to be minor, we encountered another unexpected observation during this follow-up study, namely that early accumulation of environmental risk was associated with violent aggressive and criminal behavior in adulthood [
]. This finding was obtained in 6 independent samples, including healthy cohorts. Migration, both first and second generation, was again among the environmental risk factors [
]. In fact, even once migrants have settled and formed families, their children, the second generation migrants, have an increased and even more pronounced risk of behavioral abnormalities and mental health problems [
].
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]. Furthermore, the overall number of refugees is highest ever worldwide and likely to increase further [
]. Reports speak about an enormous burden of mental health disorders in young refugees [
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]. Similar information is available for earlier migration/refuge waves, all based on self-reports and questionnaires [
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]. However, data on load of accumulated risks and its consequences are completely lacking.
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]. The present study was designed to start prospectively evaluating across German refugee asylums the accumulated environmental risk load of young migrants, many of them unaccompanied minors, who were not in previous contact with the health system. We demonstrate here a dramatic risk burden of these individuals on top of migration, and its stair-pattern like association with global functional deficits, behavioral abnormalities, and neuropsychiatric disorders. A follow-up study in several years will reveal data on the development of violent aggression, criminality and radicalism or of severe mental illness in this cohort.
3. Results
], relatively low, with cannabis and alcohol amounting to 15% and 7%. Importantly, however, among the consumers of cannabis, 4 unaccompanied male refugees (3%), still minors during the flight, revealed clear and thus far undetected psychotic symptoms, 2 of them with suicidality.
Fig. 2Accumulation of environmental risk factors in young ‘healthy’ flight migrants and their association with level of functioning and psychopathological outcome. (A) Risk accumulation and functional outcome rated by the Global Assessment of Functioning (GAF) scale; note the stair-like decrease in daily life functioning in relation to the amount of negative environmental risk experienced. (B) Risk accumulation and severity of psychopathology, rated as composite score of Clinical Global Impression (CGI), total score of Positive and Negative Syndrome Scale, PANSS, as well as Hamilton and Montgomery–Åsberg Depression Scales; note the stair-like increase in psychopathology with increasing numbers of risks; z-scores adjusted to positive values. Two-sided Kruskal–Wallis H-test and one-sided Jonckheere–Terpstra test for trends (below; italics) presented.
Table 1Effects of accumulated environmental risk on functioning and psychopathology in young refugees
Urbanicity, physical abuse, sexual abuse, problematic alcohol use, cannabis use, traumatic experiences before flight, and traumatic experiences during flight are included in the accumulation model; data are uncorrected means (SD) or n (%); for statistical analysis, Kruskal-Wallis-H or Fisher’s exact test was used. PANSS, Positive and Negative Syndrome Scale; psychopathology composite score consists of scores of Clinical Global Impression, PANSS total, Hamilton Depression Scale, and Montgomery-Åsberg Depression Scale, yielding a Cronbach’s alpha of 0.952; suicidality, individuals with recent suicide attempts. The p values withstanding Bonferroni correction are bolded. *To test for statistical trends, one-sided Cochran-Armitage trend (qualitative traits) or Jonckheere-Terpstra trend (quantitative traits) tests were used. **’Diagnoses’ refer to mental disease diagnoses obtained during exam of refugees, previously considered ‘healthy’ (mainly PTSD).
4. Discussion
In the present investigation, a substantial load of accumulated environmental risk factors became obvious in young ‘healthy’ refugees on top of migration/refuge.
Pre-flight and flight experiences of these young individuals frequently included extreme poverty, genocide, war, experience of terror, torture, persecution for ethnic or religious reasons or sexual orientation, kidnapping, slavery, human trafficking, sexual exploitation, forced labor, physical maltreatment, separation trauma, experiencing or witnessing assaults, massacres, rape and other threats to physical integrity, as well as murder and terrorist attacks.
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], also in the present study, which directly targeted refugees, the deleterious effect of preadult risk accumulation on human behavior, level of functioning and well-being becomes drastically evident. Again, the composition of risk factors, the ‘risk cocktail’, is apparently less relevant for the overall outcome of individuals as compared to the number of accumulated risks, which ultimately determines the result. The harm to the juvenile brain, both psychological and physiological, seems to add up in a venomous fashion on brain functions in the sense of dosis facit venenum. It is thus not too surprising, that there was no appreciable difference in outcome measures, global functioning and psychopathology, dependent on the flight route. It appears that environmental hazards, striking at a vulnerable time of brain development, differ in their initial mechanisms of action on the brain, but likely feed into final common deleterious pathways downstream. Knowledge on hypothetical biological mechanisms underlying this accumulation effect are mainly derived from animal models. Molecular pathways and functions affected seem multifaceted, ranging from neuroendocrine and neurotransmitter systems, neuronal/synaptic plasticity and neurogenesis, to changes in the adaptive immune system and interference with developmental myelination, affecting brain connectivity and network function [
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Coping and help-search strategies are to an essential degree influenced by social status, education, familial, religious, and sociocultural values. We chose mainly individuals with whom communication in German or English was sufficiently possible. This certainly introduced some bias towards higher educational level of included subjects, likely evolving as a protective factor, boosting resilience. Surprisingly, however, we did not see in our sample any appreciable effect of supposed protective factors, e.g. flight alone versus with company, or of being in a close relationship post-flight, on number of accumulated risks or on outcome. This lack of associations may be due to the still relatively small sample size, but strong effects at least are unlikely.
], imposing a clear threat to societal inactivity with regard to integration. Predictable consequences may include a threatening number of subjects that will have developed severe aggression, criminal behavior, and potentially even radicalism, apart from those suffering from severe mental illness.
In fact, also to prevent such consequences, communities and society in general are challenged either to find successful and proactive ways of fast integration in the German/European heritage or to swiftly but sustainably support the potential of those who will return for rebuilding and/or contributing to prosperity and welfare in their native countries. Re-evaluation of still contactable individuals in several years will allow estimating the predictable consequences of societal dormancy, namely a considerable number of high-risk subjects that will have developed violent aggression, criminality and radicalism. Reducing this number should be our common goal.
An important impulse, expected from the present study, is to inform current policies and guidelines and to encourage respective innovative strategies. These include careful initial physical examination, regular health check-ups of refugees and prevention of further risk accumulation. This might be achieved through generation of alternatives to typical refugee accommodations and ghettos, integration from scratch by distributing refugees immediately among other citizens as well as keeping them positively busy. Refugees should be enabled to move away from just being cared-for to self-help plans. A somewhat provocative but ultimately successful idea would be to provide instantaneously jobs/contracts and let them earn their own modest living by supportive work. This requires perhaps modifications of existing legislation, but could then start immediately after the refuge and should be accompanied by regular social worker visits and language training/courses, until the decision of staying or leaving has been made by the authorities. Meanwhile refugees should be free to search in parallel for more adequate jobs with respect to their education or for apprenticeships.
