The number of unaccompanied asylum-seeking children (UASC) arriving in Norway the last ten years has varied between 322 (in 2005) and 2500 (in 2009) [1]. Also, the nationalities represented have differed from year to year. European countries received 13.300 asylum claims from UASC in 2011, which is 75% of the worldwide number [2]. Refugee adolescents are known to encounter numerous risk factors that can cause psychological distress, including exposure to violence, and multiple losses [3-5].

Several studies have examined the rates of psychological distress in different samples of refugee children, using self-report instruments, or instruments filled in by parents, teachers or others [6-10]. A large study from Belgium and the Netherlands has revealed higher levels of PTSD symptoms for UASC in comparison to the host populations, and also compared to refugee minors that migrate together with their caregivers [11]. UASC in the same study also reported higher levels of exposure to physical and sexual maltreatment and higher levels of anxiety and depression.

Most studies in this field have used estimates of diagnostic “caseness” based on selfreport instruments filled in by parents, teachers, or the youth themselves; either with “pen and pencil” or with the aid of translators [12]. How to deal with the challenge of whether or not to include illiterate subjects, are usually not discussed in detail. Also, the possible impact of different modes of testing in the same research project; i.e. reading and writing by yourself versus havinganother person read and write for you, is very seldom discussed [13]. Even a renowned analysis of validity problems in the field of transcultural epidemiology does not address this challenge [14].

Other studies have focused on the cross-cultural validity and context relevance of existing screening instruments, seeking adaptation to new settings, while keeping the internal consistency and the construct validity of the scales [15]. Diagnostic evaluations or validation of the appropriate “cutoff” values are often lacking [16].

There are few prevalence studies focusing on young refugees or UASC and to our knowledge none that have used clinical evaluations or diagnostic interviews shortly after migration. On the other hand there is some research with adults, indicating that post-migrational stressors contribute significantly to the psychopathology of refugees [17]. The precise impact of post-migrational stressors can be difficult to determine due to lack of baseline measures or early diagnosis. In addition, this lack of knowledge gives immigration authorities less possibilities to plan for appropriate care when the young refugees arrive. The prevalence of psychiatric morbidity in UASC boys, within four to five months after their arrival in Norway, will be the focus of this study, in addition to self-report screens and demographic data.

This study demonstrates that unaccompanied refugee minors are a very vulnerable group with a high prevalence of psychiatric morbidity. The young men that we interviewed had experienced numerous threatening, horrible and potentially traumatic events, and the most prevalent psychiatric disorder was PTSD. A majority of the youth was bereaved, and lacked the protection and social stability that parents could have offered. In addition to PTSD, high prevalence of depressive and anxiety disorders were found.

To our knowledge, this is the first study on refugee minors that has applied clinical interviews soon after arrival to the host country. Compared to studies that have used this methodological approach in a later phase [28, 29], our findings suggests considerable higher prevalence of both depression and PTSD. Servan-Schreiber, Le Lin and Birmaher, found that 11,5% of Tibetan refugee children (n=61) suffered from PTSD, and the same proportion met criteria for major depression (MDD). Tousignant et al. did not measure PTSD in a group of 203 adolescent refugees from 35 countries, but diagnosed simple phobia in 21%, overanxious disorder in 13% and MDD in 5%. Plausible explanations are different diagnostic approaches as well as refugee populations with different backgrounds. Participants from our study were young men, mainly from Afghanistan and Somalia, parts of the world with a history of war and a corresponding weakening of the social fabric. Low levels of literacy, frequent exposure to loss and trauma, and limited access to health facilities underscores the impact of psychosocial adversities in their upbringing. In that respect, our findings are similar to previous studies using estimates of “caseness” according to selfreport instruments [8-11]. In general, studies on refugee minors show higher prevalence of psychopathology than studies on youth from the main population. In a comparable study with adolescents from different racial and ethnic groups in the USA, they found a prevalence of PTSD from 7,4% (Latino) to 3,4% (Non-Latino Black) [30].

The burden of psychosocial problems and postmigrational events for adult asylumseekers and refugees in their new host countries, are well documented [31, 32]. Our finding that symptom levels of general psychological distress and posttraumatic stress were stable from arrival to the time of the diagnostic interviews, indicate that the psychiatric morbidity was present when the youth arrived, and therefore probably not an effect of the stressors connected to life as an asylum seeker per se. Psychiatric morbidity related to psychosocial problems later in the refugees lives may also be compounded by the presence of a considerable number of traumatic experiences from their former lives [9]. An illustration of this may be the experiences chosen as the “worst incident” related to the PTSD diagnoses with this research population. Life-threatening experiences dominated together with witnessing cruelty against others, and severe prison events. Many of these young men told us that their worst experience happened while they were imprisoned in transit countries, such as Lebanon, Greece and Italy.

Our study demonstrated a gap between self reported age and the official age estimates given by the immigration authorities, on the basis of x-rays and dental examinations performed after some months. This reflects a considerable uncertainty about the participant’s true chronological age. Birth registration services are often nonfunctioning in the countries the UASC come from, and the scientific basis for age assessment is controversial, since the tests have their greatest uncertainty in the ages with the greatest natural variation, e.g. ages 15 to 21[33]. The uncertainty with skeletal and dental age assessment is considered to be large, i.e. between two and five years [34]. This could have crucial consequences for a large part of the young asylum seekers, since they no longer are considered minors and in need of special protection according to UNHCR [35]. The increase from 5 to 99 in the numbers of asylum seekers over 18 years in our population, due to age testing later on, may impact our claim that we have conducted a prevalence study on unaccompanied refugee minors. In that respect, our study population should be considered to be more representative for UASC according to self report, since this was the only source of age determination available on arrival.

Strength of this study is the use of structured diagnostic interviews with trained health professionals, and unlimited use of time and interpreters. We also argue that the recruitment procedures gave a representative sample of UASC from the chosen countries.

The self-report instruments were filled in by the informants themselves, regardless of literacy, because of the MultiCASI method [22]. There was no need to exclude illiterate subjects, or treat them differently than the other informants. We believe that this improved the validity of the testing procedure.

The life situation of the informants, together with the distance, both physically and culturally to their countries of origin, gave us limited access to objective data concerning their backgrounds. The informants themselves were the only source of information, and the clinical assessments may have been influenced by inaccurate data. The health professionals performing the CIDI interviews were all experienced clinicians, who had worked extensively with refugees, using interpreters. We argue that this has improved the validity of the diagnostic procedures.

The study sample was recruited from young asylum seekers that arrived Norway in a period of two years. UASC areas of origin vary over time and thus, our results may not be representative for populations of UASC from other parts of the world.

Unique to this study is that these high numbers of unaccompanied minor asylum seekers with a psychiatric diagnosis were found a relatively short time after the UASC arrived, and thus in the early stages of their stay in the country where they apply for asylum. As far as we know, this has not been the focus of any previous study, and contrasts earlier findings that most refugees experience a period of wellbeing and hopefulness shortly after arrival in the host country [36, 37], with lower mental health problems, and clearly illustrates the overall vulnerable situation of UASC.

The manifest presence of severe symptoms presents a challenge for the host country as it may be difficult to meet the complex needs for support UASC have in this specific phase of their lives. Therefore, expanded and multi-disciplinary professional staff in the reception centres for UASC who recently arrived is needed in order to give appropriate physical and emotional support, and to create a safe living environment for all UASC [3, 38]. This involves ensuring basic needs, and sufficient time to support all UASC in developing a sense of stability, safety and trust [39].

Forced migration is part of a global process where populations from different corners of the world interact because of war and natural catastrophes. Increased trade, mass media, the internet, and improved communications are also factors related to the movement of people [40]. These developments affect public health in the host countries, and pose a challenge to the systems responsible for treatment and follow up of psychiatric health problems.

We believe that the prognosis may be better if traumatized children are threated in an early phase. This would also ease the integration process on all levels of society.

The authors confirm that this article content has no conflict of interest.