It is a cold morning. A bit of sunshine, but apart from that, there is this cold and very sharp Viennese wind that drives me crazy, getting into my body, reaching every bone, no matter how many sweaters I wear.

I am tired, again, and my lips are cracking because it has been cold and busy and sleepless few weeks. A restless, dried lips, dried eyes feeling. I get into the Badner Bahn, the old- fashioned tramline that leaves right in front of the Viennese opera.

There are little tables in the tram. Why would anyone sit there and enjoy something to eat? am happy, though, that I am the only passenger of this incredibly outdated transportation vehicle.

The tram is slowly leaving the first district. It does not take long until the landscape and houses change. Very dispersed houses, mostly with blinds half way down. Fields of snow, of white and white and grey and grey. No doubt, I have left Vienna and have arrived in Lower Austria. Houses get more and more worn down, unused industrial buildings intermingle with farm houses.

Ok, I look at the watch, why can’t this tram go any faster, and why do we have to stop in every tiny little village. Anyway, it is too late again. And while the tram slowly makes its way through the snowy, sleepy Lower Austria, I think of the many things I still have to do before Christmas. And I remember my mother saying, like every year, “This time, Christmas will be much calmer… I really want a different Christmas this year, without any stress.” And I think, no, it won’t be a different Christmas for me this time. I still have to buy all the presents for everybody and I really want to choose something that is a big surprise and a great joy for everyone… Yet, it is already Friday and Christmas is on Sunday. I have the feeling that it could well be that I again would cause the major Christmas argument in the family with all the preceding tension of this holiday. And Christmas should definitely not be about this.

Finally, I arrive at Traiskirchen. This is where the biggest refugee camp of Austria is situated. My mobile is out of battery and I don’t know where to head next. I leave the tram with my huge bag – as usual, I packed too many things, but also there are actually a lot of things to carry; heart rate measure devices, video camera, a set of questionnaires, which are all part of my first research study I am carrying out, assessing trauma and resilience in African unaccompanied refugee adolescents living in Austria.

I ask people and they quickly lead me to an assembly of houses that remind me of a military complex. I will meet Moussa here. He comes from Somalia and is another unaccompanied refugee adolescent from Africa that I plan to interview for my study. I ask him to talk about his most stressful life event. And talk about anything that comes to his mind. And take a video of him. And record his narrative. And, and, and… I mean, why would he care about this multimodal study design after a journey of weeks away from the war zone of his country into the Lower Austrian province?

He is already at the meeting point. He wears a too short cotton jean without any socks, and he is shivering, his body bent, his pullover also much too tiny for his tall and slim body.

“Hello, are you Moussa?”

“Yes,” he answers, “Moussa, that is me.”

“I am Dr. Julia Huemer.”

Moussa waits outside because the door to the room which I tried to make a reservation for is closed.

“Moussa, I am sorry for the inconvenience.”

I try to reach people whom I had contacted to book the room. Nobody answers. It is extremely cold and I can’t believe that I am locked out 3 days before Christmas, standing there in the middle of snow and cold wind with a potentially traumatized refugee minor from Somalia. Maybe, this Christmas will be much more authentic than I had imagined.

I decide to not cancel the assessment and ask Moussa if he has ever been at some other place in Traiskirchen than the refugee camp structure or the little café at the railway station. He leads me to a house owned by some church institution. We walk there, about a kilometer, to some place in the middle of nowhere. I can’t believe this is happening. Snow, 3 days before Christmas, no place to be. I knock at the door and to my huge surprise a person opens. After formally and politely introducing myself, we are granted access to a big, cold room, which is used as a community center for church initiatives. As appealing as the Badner Bahn.

The assessment starts and Moussa skips through the questions of the self-report questionnaires quickly. Sometimes he pauses to ask for the meaning of certain terms and how this would relate to him. Every time he asks me I wonder if anything captured by these questionnaires is really capable of describing his current mental health state, taking into account his upbringing and cultural perceptions.

It is rather dark in the room and I feel that there is somehow finally a little bit of peace getting into this day.

Moussa seems calm, takes things very seriously and tries to do his best. I think of the initial considerations when we designed this study. Would all of these adolescents have some antisocial traits? How else would it be explicable that these adolescents could have fled from countries so far away that I could not imagine, endure hardships like staying for days in the cargo compartment of a boat, without any sight of daylight, like making their way through so many institutional hurdles without money, without being accompanied by an adult, a parent, a relative.

I think that our ideas about this were terribly wrong. Again, in front of me, I am facing an adolescent, with this, for me, unexpected mixture of appearing more like a child than an adult along with the appearance of a very good-hearted adult person who would take care of everyone.

We start with the free association task of the stress inducing speech task. In the course of his narrative, Moussa talks about what he likes in life – doing sports, running, reading, hanging out with friends. He tells me how happy he is to be here and how much he thanks God that he has arrived in a country without war. His face speaks a slightly different language – while he offers me a big, big smile, his eyes are constantly at the edge of being filled with tears. His account about having to stay strong, believing in the best and how happy he is here contrasts with his facial expression, and also with the grotesque surrounding of this interview situation.

Moussa talks about the war, about the family members that have been killed but constantly interrupts himself by reassuring how fine he is now and how happy he is to be at Traiskirchen. At one point he interrupts himself again.

“… I like to sing, I like African music, when I am in my house and I would like to sing one song for you in my language…. I would like to sing one song in African language for the doctor (sings)… this, this song means that I come to Austria to have my freedom and to live like… to have happiness in my life… I don’t come to trouble no one or to disturb no one… this song means that.. so I sing this song for the doctor who is making this interview… this song is from my mother’s, mother’s language… mother tongue… my mother taught me this song the time I was six years old… sometimes so… when I sit I think about my mother… I always sing this song when I am sad or when I feel… am feeling lonely… I like to sing this song to think about my mother… when you are angry or sad, anytime you can sing this song… it’s a happiness song… that’s why I like to sing this song…. (quote of Moussa’s narrative)”.

It is an awkward moment for me, being touched by this ever so soft song, in this cold surrounding of this crazy day in the middle of nowhere. I remember the soothing feeling I had when I heard my parents singing while falling asleep as a child.

I feel unbelievably sad and happy at the same time.

Moussa finishes his song, then says, it is time for him to go now and, sorry, he won’t be able to finalize the whole assessment because people from Vienna are calling him to maybe do some business.

I ask him, what business. He does not want to answer, just saying, “Well, you know, I need some money, I need a job, I need a girlfriend. I really can’t live like this.”

I get back to the Badner Bahn. I am colder than before. I return to the first district and decide to not do any Christmas shopping this year…. but, instead, search for an embrace. I wonder how Moussa will evolve and I feel awkward to have intruded into his life and occupied his time with the purpose of studying something that is possibly only the reflection of a scientific construct.

I feel like I am the alien, not Moussa.

Excerpt from: Unaccompanied refugee children.

Huemer J, Karnik N, Steiner H.

Lancet. 2009 Feb 21;373(9664):612-4.

Unaccompanied refugee children have been separated from parents and relatives and are not being cared for by an adult who, by law or custom, is responsible for doing so (1). In the population under the responsibility of the UN High Commissioner for Refugees, nearly 44% are aged under 18 years and 10% are under 5 years (2). In the USA, 7000–9000 unaccompanied children have been referred to the Office of Refugee Resettlement from the Department of Homeland Security each year since 2005 (3), while in Europe 13840 arrivals of these young people are described for 2006 (4).These children are difficult to trace because they are often hidden within existing populations of children and refugees. The medical and legal issues facing unaccompanied refugee children are probably a wider problem than previously appreciated despite their relatively small numbers. (…)

Unaccompanied refugee children have different ethnic backgrounds, countries of origin, and motivations to leave their home countries. For research and treatment purposes, they should not be aggregated within existing populations. Instead we need to be attentive when working with refugee populations that some of these young people may be unaccompanied, and therefore require greater attention. The limited research on mental health issues in this population has focused on the assessment of symptoms of post-traumatic stress disorder and on trauma-related issues. Most studies show that unaccompanied refugee children suffer from psychiatric disorders to a greater degree than the average age-matched population and that female sex and age are important factors contributing to the pathogenesis of post-traumatic stress disorder (5, 6).

Despite differences among unaccompanied refugee children, they also have elements which make them a cohesive group: they lack social relationships and a familial system at a crucial developmental period, they have struggled through numerous challenges to arrive in a country of asylum, and they have had to overcome the obstacles of cultural differences. Sadly, in some countries, unaccompanied refugee children lack full access to health and education systems because of the interface between institutional frameworks.

An understanding of the needs of unaccompanied refugee children might benefit from a developmental approach which recognizes that maturity can often lead to healing while also understanding the need for medical interventions. Such an approach also incorporates a risk-resiliency model to understand the processes that lead to psychopathology. The personality characteristics that enable these young people to survive the stressors of migration are probably partly protective against the development of severe post-traumatic stress disorder. Generally, they are, though, vulnerable to antisocial life trajectories, such as prostitution in girls and drugs and violence in boys (7, 8). This means that their resilience comes with a price because these children obviously retain trigger points for dysfunction which are activated by sudden changes in the environment or stressors in their lives, and therefore resulting in psychiatric morbidity.

RELATED LITERATURE

1 UNICEF. Convention on the rights of the child. http://www.unicef.org/crc (accessed Sept 15, 2008).
2 UNHCR. 2007 Global trends: refugees, asylum-seekers, returnees, internally displaced and stateless persons. June, 2008. http://www. unhcr.org/statistics/STATISTICS/4852366f2.pdf (accessed Sept 15, 2008).
3 Olga Byrne. Unaccompanied children in the United States: a literature review. April, 2008. http://www.vera.org/publication_pdf/478_884.pdf (accessed Oct 21, 2008).
4 Save the Children. Separated children in Europe programme. http://www. separated-children-europe-programme.org/index.html (accessed Aug 17, 2008).
5 Sourander A. Behavior problems and traumatic events of unaccompanied 10 refugee minors. Child Abuse Negl 1998; 22: 719–27.
6 Derluyn I, Broekaert E. Different perspectives on emotional and behavioural problems in unaccompanied refugee minors. Ethn Health 2007; 12: 141–62.
7 Steiner H, Garcia IG, Matthews Z. Posttraumatic stress disorder in incarcerated juvenile delinquents. J Am Acad Child Adolesc Psychiatry 1997; 36: 357–65.
8 Cauffman E, Feldman SS, Waterman J, Steiner H. Posttraumatic stress disorder among female juvenile offenders.
J Am Acad Child Adolesc Psychiatry 1998; 37: 1209–16.