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

Millions of children and adolescents are forcibly displaced globally due to conflict, persecution, and other factors. Forced migration presents significant challenges, including disruptions to education and social life, trauma exposure, and difficulties with immigration processes. Studies consistently show higher rates of mental health disorders among ASR children and adolescents compared to their non-migrant peers, including depression, anxiety, and PTSD. In Germany, a substantial portion of asylum seekers are minors, many of whom are enrolled in school. However, ASR children and adolescents face barriers to accessing healthcare, particularly mental healthcare, due to restrictive entitlement policies (only covering emergency care for the first 18 months post-arrival), language barriers, cultural competence issues among providers, discrimination, and unfamiliarity with the German healthcare system. While research exists on unaccompanied minors, limited studies focus on accompanied ASR adolescents and their help-seeking patterns in Germany. This study addresses this gap by investigating the mental health needs and service use of accompanied ASR adolescents, exploring the factors influencing their help-seeking behaviors, and gaining perspectives from mental health professionals.

Existing literature highlights the high prevalence of mental health issues among refugee children and adolescents, particularly unaccompanied minors. Studies in various European countries reveal consistent barriers to accessing adequate healthcare services for ASR and migrants in general, stemming from legal restrictions, language barriers, lack of cultural competence, discrimination, and financial constraints. The situation in Germany is further complicated by restrictive healthcare entitlement policies for asylum seekers during their first 18 months in the country. Even after gaining access to statutory health insurance, challenges remain, including interpreter service limitations and insufficient information about the mental healthcare system. Previous research in Germany points to inequitable access to mental health services, particularly for unaccompanied minors, but data on accompanied minors’ service utilization is lacking. This study aims to fill this gap and contribute to understanding the complexities of mental healthcare access and utilization among accompanied ASR adolescents.

This mixed-methods study employed a cross-sectional design using quantitative and qualitative data. Quantitative data came from a larger longitudinal study (YOURHEALTH consortium) involving ASR adolescents (aged 11-18) from Syria, Afghanistan, and Iraq who arrived in Germany after 2015. Data were collected between February 2019 and November 2020 in schools and refugee accommodations across three German states. Participants completed a self-assessment questionnaire on tablets (93%) or paper (7%), including measures on emotional difficulties, internalizing and externalizing symptoms (using the HSCL-37A), help-seeking patterns, satisfaction with psychotherapy, barriers to psychotherapy (adapted from the BMHSS-R), and social resources for psychotherapy. To ensure accessibility, questionnaires were available in multiple languages (Arabic, Farsi, Sorani, Kurmancî, Pashto, and German) with audio translations. Qualitative data were collected through semi-structured interviews with nine mental health professionals (child psychotherapists, social workers, school psychologists, and pedagogues) in one region. Interviews focused on factors enabling or hindering ASR adolescents’ access to mental healthcare. Quantitative data were analyzed using descriptive statistics and logistic/multinomial regression to identify predictors of help-seeking patterns. Qualitative data were analyzed using situational analysis, involving open and axial coding and constant comparative analysis.

Of the 216 participants, 65 (30.1%) reported emotional difficulties needing help. 12.3% scored above the clinical cutoff on the HSCL-37A for psychological distress. Mean scores for externalizing and internalizing symptoms were 15.18 (SD=2.97) and 39.80 (SD=9.57) respectively. Only 6.9% had used psychotherapy services, and 4.3% intended to. Among those reporting emotional difficulties, 15.4% had used, and 10.8% intended to use, psychotherapy. Those who used psychotherapy were generally satisfied. Reasons for discontinuation included feeling better, discomfort, inconsistent therapist, family discouragement, religious alternative coping suggestions, perceived ineffectiveness, transportation issues, and lack of therapist follow-up. Logistic regression showed that higher perceived/experienced barriers and higher externalizing symptoms predicted seeking help from mental health professionals. Younger age, higher internalizing symptoms, and lower externalizing symptoms predicted seeking help from informal sources. Multinomial regression indicated that reporting emotional difficulties and being advised to seek psychotherapy predicted actual or intended psychotherapy use. Qualitative data from mental health professionals highlighted administrative hurdles, uncertainties around interpreter services and payment, ambiguities regarding legal status and healthcare entitlements, insufficient service capacity, long waitlists, and coordination difficulties between various support systems.

The study reveals significant underutilization of mental health services among ASR adolescents despite considerable reported emotional distress. The findings highlight the crucial role of perceived access barriers, symptom type, and social resources in shaping help-seeking patterns. The finding that externalizing symptoms were more likely to lead to referral to professional mental health services, while internalizing symptoms were more likely to lead to help-seeking from informal sources, reflects the existing biases in both referral and research patterns. The significant role of social resources underscores the importance of empowering informal support systems and improving communication between informal support systems and mental health professionals. While our sample showed lower internalizing and externalizing symptom scores compared to some previous studies, this might reflect the fact that our sample comprised mainly accompanied minors and adolescents who had been in school for some time, potentially benefitting from family support and improved stability.

This study demonstrates the significant mental health needs of ASR adolescents in Germany and the considerable barriers they face in accessing appropriate services. Addressing these challenges requires multi-faceted interventions including increasing the accessibility of low-threshold mental health services, improving coordination between different support systems, providing training for those working with ASR adolescents to better identify and address mental health needs, and empowering informal support networks. Future research could explore longitudinal effects of migration experiences on mental health, the specific needs of different subgroups within the ASR population, and the effectiveness of culturally sensitive interventions to improve mental healthcare access and utilization.

The study's generalizability is limited by its convenience sampling method, relatively small sample size, and the presence of missing data which could have influenced the statistical results. The cross-sectional design prevents drawing causal conclusions. The reliance on self-reported data might lead to under-reporting of certain issues. The heterogeneity of the sample with respect to mental health issues and service experience might also impact interpretability. The high number of questionnaire items might have contributed to missing values and difficulties understanding the concept of psychotherapy could have influenced response rates. The lack of data on factors such as length of stay, legal status, and healthcare entitlements is also a limitation, but this gap was partially addressed through qualitative data from professionals.