Asylum seeking and refugee adolescents' mental health service use and help-seeking patterns: a mixed-methods study

The study addresses the mental health needs and help-seeking patterns of asylum-seeking and refugee (ASR) adolescents in Germany, a group exposed to pre-, peri-, and post-migration adversities (e.g., trauma, disrupted education, legal uncertainty, discrimination) and known to have elevated risks of depression, anxiety, and PTSD compared to non-refugee peers. Despite compulsory schooling and high enrollment, structural and systemic barriers in Germany constrain equitable access to mental healthcare for ASR minors, including restrictive entitlements in the first 18 months post-arrival, language barriers, interpreter coverage gaps, administrative hurdles, provider readiness, and discrimination. Prior research in Germany has focused mainly on unaccompanied refugee minors, leaving a gap regarding accompanied ASR adolescents’ mental health-related help-seeking. The purpose of this mixed-methods study is to describe ASR adolescents’ mental health status and psychotherapy utilization, identify predictors of different help-seeking patterns, and contextualize access challenges from mental health professionals’ perspectives, to inform strategies for more equitable care.

Existing evidence indicates high heterogeneity but elevated prevalence of mental disorders among refugee and asylum-seeking children and adolescents, with meta-analytic estimates around 14% for depression, 16% for anxiety, and 23% for PTSD, suggesting substantial need for specialized services. In Germany, ASR face additional barriers: during the first 18 months, entitlements are restricted to acute and essential care; interpreter services are often not covered once in statutory insurance; there is limited mental health system literacy, fear of legal consequences, voucher/EHC access complexities, and variable provider readiness to treat ASR. Studies among unaccompanied minors show high mental distress and unmet need, and overall persistent inequities in timely, appropriate mental health access for ASR. There is limited evidence on accompanied ASR adolescents’ help-seeking, and the connection between need and service use is complex, underscoring the value of mapping care pathways and predictors of help-seeking.

Design: Mixed-methods study combining cross-sectional quantitative survey data with qualitative semi-structured interviews to contextualize mental healthcare access. Setting and participants (quantitative): Baseline data from the YOURHEALTH longitudinal consortium collected Feb 2019–Nov 2020 in schools and refugee accommodations across three German federal states (North and South). Target group: ASR adolescents aged 11–18 from Syria, Afghanistan, and Iraq, who arrived after 2015 and spoke one of Arabic, Farsi, Sorani, Kurmancî, Pashto, or German. Subsample analyzed: N=216 who answered mental healthcare-related questions. Consent: information provided via multilingual videos; parental/guardian consent obtained for <16; participants received a 20€ voucher. Data collection procedures: Self-administered surveys (≈93% tablet, 7% paper), offered in native languages with written and audio options; simplified language; multilingual assistants present; 80.6% chose German version. To reduce burden, questionnaires (>400 items in the larger study) were split over two sessions when possible. Mental health first aid protocol and post-session support cards with regional services were provided. Measures: - Mental health indicators: (a) Self-report of emotional difficulties needing help (yes/no). (b) Internalizing and externalizing symptoms via HSCL-37A (anxiety 10 items, depression 15 items; externalizing: conduct 5, oppositional-defiant 2, substance use 5). Four-point Likert (1–4); subscale sums computed with limited imputation (≤2 missing internalizing items; ≤1 missing externalizing item), internal consistency α=0.90 (internalizing), α=0.65 (externalizing). Clinical cutoff referenced from prior literature at total score >69. - Help-seeking patterns: Constructed two binary variables from (1) ever talked to anyone about emotional difficulties (multiple sources); and (2) ever been to a psychotherapist (yes/no/no but intend to). Binaries captured: seeking help from mental health-related professionals (doctor, psychotherapist, social worker) yes/no; seeking help from people outside the mental healthcare system (parents, family, friends, teachers, religious leaders, lawyers, compatriots, refugee center staff) yes/no. - Satisfaction with psychotherapy (for those with experience): satisfaction (very/somewhat/not), interpreter presence and perceived quality/trust, current continuation, and reasons for discontinuation. - Perceived/experienced barriers to psychotherapy: 12-item (no psychotherapy experience) or 19-item (with experience) scale adapted from BMHSS-R, four-point Likert (1–4). Composite mean scores computed using available item analysis after MCAR check (Little’s MCAR p=0.25); internal consistency α=0.90 for both versions. - Social resources: knowing someone who can help find a psychotherapist (yes/no); having been told by someone to go to a psychotherapist (yes/no). Statistical analysis: Descriptive analyses; three regression models—(1) binary logistic regression among those reporting emotional difficulties to predict seeking help from mental health-related professionals from barriers, internalizing, externalizing; (2) binary logistic regression among those reporting emotional difficulties to predict seeking help from people outside the system from age, internalizing, externalizing; (3) multinomial logistic regression predicting psychotherapy status (no, intend, went) from barriers, reporting emotional difficulties, and social resources (knowing a helper; being told to go). Assumptions checked (Box–Tidwell for linearity in the logit; collinearity via Tolerance/VIF); listwise deletion applied; SPSS 26; α=0.05. Qualitative component: Semi-structured interviews (n=9) with mental health professionals in one region (six districts in a Northern German state): four child psychotherapists, four school psychologists, one social worker/pedagogue. Recruitment via mapping and snowballing. Interviews (German) conducted in-person (n=4) or online (n=5), 40–78 minutes, audio-recorded and transcribed. Analysis followed situational analysis with open/axial coding, constant comparison, and reflexive memos (AF, DP, YN) using MAXQDA 2020. Themes were used to contextualize quantitative findings.

Sample and needs: Among N=216 ASR adolescents (mean age 14.66, SD 1.84; 52.6% male), 30.1% (65/216) reported emotional difficulties needing help. On HSCL-37A, 12.3% scored above the clinical cutoff (>69). Mean internalizing score was 39.80 (SD 9.57) and mean externalizing was 15.18 (SD 2.97). Help-seeking and social resources: 53.2% knew someone who could help find a psychotherapist; 13.4% had been told to go to a psychotherapist. Overall, 6.9% had been to a psychotherapist and 4.3% intended to go. Among those reporting emotional difficulties (n=65), 15.4% had been to a psychotherapist and 10.8% intended to go. Psychotherapy experience: Of 15 who had attended psychotherapy, 11 were satisfied. An interpreter was present for 8; all rated interpretation quality as good, and 5 found the interpreter trustworthy. Three participants were still in therapy. Reported reasons for discontinuation included feeling better (n=6), not feeling comfortable with the therapist (n=7), lack of therapist continuity (n=2), discouragement by friends/family (n=2), alternative coping suggested by a religious leader (n=2), perceiving therapy as unhelpful (n=1), transport difficulties (n=1), and not receiving a call back (n=1). Regression analyses: - Seeking help from mental health-related professionals among those with emotional difficulties: Model significant, χ²(3, N=49)=9.23, p<0.05; Nagelkerke R²=0.25; 89.8% correctly classified. Higher perceived/experienced barriers predicted greater odds of seeking help (Expβ=3.56, 95% CI 1.06–12.01, p<0.05). Higher externalizing symptoms predicted greater odds (Expβ=1.38, 95% CI 1.03–1.86, p<0.05). Internalizing symptoms were not significant. - Seeking help from people outside the mental healthcare system among those with emotional difficulties: Model significant, χ²(3, N=46)=17.12, p=0.001; Nagelkerke R²=0.42; 76.1% correctly classified. Younger age predicted greater odds (Expβ=0.59, 95% CI 0.39–0.89, p<0.05; odds decrease with increasing age). Higher internalizing symptoms predicted greater odds (Expβ=1.16, 95% CI 1.03–1.30, p<0.01). Lower externalizing symptoms predicted greater odds (Expβ=0.56, 95% CI 0.37–0.86, p<0.05). - Seeking psychotherapy (multinomial): Model significant, χ²(8, N=113)=24.15, p=0.001; Nagelkerke R²=0.25; 87.1% correctly classified. Overall significant predictors were reporting emotional difficulties, χ²(2, N=134)=10.86, p<0.01, and being told by someone to go to a psychotherapist, χ²(2, N=134)=7.16, p<0.05. Reporting emotional difficulties increased likelihood of intending to go to psychotherapy vs. no (Expβ=6.87, 95% CI 1.28–36.80, p<0.05). Being told to go increased likelihood of actually having gone vs. no (Expβ=6.72, 95% CI 1.63–27.70, p<0.01). Knowing someone who could help and perceived/experienced barriers did not significantly predict psychotherapy status in this model. Qualitative insights: Providers reported systemic barriers including administrative hurdles (limited reimbursable sessions, canceled-session income loss), interpreter organization and funding uncertainties, legal status constraints (school/apprenticeship requirements for residence), insufficient service capacity and long waitlists (>6 months), coordination issues with school schedules, and variability in referral pathways and training needs. School psychologists emphasized schools’ stabilizing role and the need for low-threshold, non-clinical supports. Older adolescents may receive less support due to age-based service thresholds.

Findings indicate substantial unmet mental health needs among ASR adolescents: nearly one-third reported emotional difficulties, yet only a minority accessed psychotherapy. Different symptom profiles mapped onto distinct help-seeking pathways: higher externalizing symptoms were associated with seeking professional help, likely due to visibility and institutional responses (e.g., school referrals), whereas higher internalizing and lower externalizing symptoms were associated with seeking informal support outside the healthcare system. Social resources were pivotal: self-recognition of difficulties predicted intention to seek therapy, and prompting by others strongly predicted actual attendance, highlighting the multistep nature of care pathways and the importance of intermediaries (family, teachers, social workers). Qualitative data contextualized quantitative results by detailing structural barriers (entitlements, interpreter policies, administrative and legal constraints, capacity shortfalls) that hinder timely, continuous care. Compared with national estimates of risk among general adolescents (e.g., KIGGS2 ~16.9%), ASR adolescents showed higher reported difficulties (~30.1%), aligning with international literature on refugee youth’s elevated burden. The results stress the need for ecological, system-level approaches that enhance mental health literacy, reduce stigma, support non-clinical settings (especially schools), and equip key adults around ASR adolescents to recognize problems and facilitate navigation to care.

The study contributes evidence that ASR adolescents in Germany exhibit notable mental health needs with underutilization of specialized services. Help-seeking patterns differ by symptom type, and social resources—including problem recognition and encouragement from others—are critical drivers of actual or intended psychotherapy use. Policy and practice should prioritize widespread, accessible, and low-threshold mental health initiatives within everyday settings (schools, refugee accommodations), provide navigation support through trained intermediaries, recognize and respond to internalizing symptoms, and strengthen the capacity and coordination of referral networks (youth services, pediatricians, schools). Ensuring stability and safety via secure legal status is fundamental to enabling effective mental healthcare. Future research should use longitudinal designs, include diverse regions and legal statuses, and evaluate interventions that bolster mental health literacy and system navigation among ASR adolescents and their support networks.

Generalizability is limited by a non-representative convenience sample from selected regions, relatively small sample size, and missing data contributing to wide confidence intervals. Recruitment depended on institutional gatekeepers, some of whom declined participation, potentially introducing selection bias. The self-report survey, despite language simplification and support, limits reliable assessment of contextual variables (e.g., precise legal status, entitlements), which were therefore not analyzed quantitatively. Conceptual unfamiliarity with psychotherapy may have affected responses. Cross-sectional design precludes causal inference in help-seeking and symptom relationships. The sample composition (predominantly from Syria and Iraq) may reflect comparatively less precarious legal statuses than other ASR groups, further limiting generalizability.