Age assessment: practice guidance

Appendix 4: Trauma- informed Age Assessments

Background to trauma informed practice

Trauma –informed practice ^[16] is a framework for making sure the workforce is skilled and equipped to understand the incidence of trauma, recognise the potential effects of this trauma, minimise re-traumatisation and make sure the person who has experienced trauma is supported and helped to recover. What follows will use the trauma informed framework to explore how it can apply to the needs of unaccompanied asylum seeking children particularly in relation to the age assessment process. Undertaking age assessments is very difficult. Sometimes it can feel for the young person that they are being carried out for immigration purposes rather than for the needs of the young person. Moreover, as previously highlighted, there are no reliable ways of determining age. Age assessments have significant implications not only for a young person's care and their future safety, but also can have far–reaching implications for a young person's health and well-being. In such a difficult process where there is potential for the young person to feel that all aspects of their identity and experiences are being disbelieved, it is perhaps more important than ever for the process to be as trauma informed as possible.

Being trauma informed means knowing the incidence of trauma for unaccompanied asylum seeking children

We know that unaccompanied asylum seeking children have very high rates of traumatic experiences in their countries of origin ^[17] . They also have experienced very significant and multiple losses including the loss of caregivers and family members. Journeys to the UK are often fraught with danger and further trauma. Sometimes unaccompanied young people have also experienced trafficking for labour exploitation or sexual exploitation.

"As a group, unaccompanied asylum seeking children are unified by their separation not only from their family of origin, but from their community and country of origin and are seeking refuge from political, cultural, religious or other forms of persecution including armed conflict and war. Their experiences may include direct experience of beatings, rape or torture and they may have been witness to the beating, rape, torture and killing of others including family members. Some may have been 'child soldiers' or fleeing from attempts to enlist them as 'child soldiers' Their journeys to the U.K may include the payment and the involvement of human traffickers and those journeys may have been lengthy and fraught with danger and uncertainty. For some, the death of companions may have accompanied the journey and the possibility of death may never be far away ." ^[18]

When they arrive in the UK they often have to navigate what can be a harsh and sometimes re-traumatising asylum process. This process may make them feel that all aspects of their identity and history are being questioned and challenged in a hostile environment. Being age disputed or a negative experience of an age assessment process can have an impact on mental health and effects on young people's identity and self esteem that go beyond the serious implications for their asylum claim and their future safety. It is hard for them to feel they belong in Scotland because their future is uncertain. They are often preoccupied with not knowing whether family members are alive or dead. They fear being returned to situations of further trauma and danger.

The years of adolescence can be hard for all young people. But unaccompanied young people are likely to have faced multiple traumas including physical and sexual violence, sometimes exploitation through trafficking, and critically they are " unaccompanied". This means they are without anyone who is looking after them who can buffer the effects of trauma. They therefore have to face these multiple challenges without any safety or certainty about what the future holds, and who will be there to face it with them. Their situation is thus extremely precarious and the memories of the past, the stress of the present and the fear of the future often feel overwhelming to them. The combination of high rates of traumatic experiences at the same time as a loss of social support and a loss of other protective factors can be toxic to mental health.

Being trauma informed means knowing the effects of trauma on unaccompanied asylum seeking children

Incidence of mental health difficulties

It is not surprising therefore that studies have shown that unaccompanied asylum seeking children have a high rate of mental illness ^[19] and are at significantly higher risk of developing mental health difficulties than for example asylum seeking children who are accompanied. ^[20] Mental health difficulties can include PTSD, complex PTSD ( PTSD symptoms, along with other difficulties including emotional regulation difficulties, relationships difficulties and changes to their view of themselves and the world) anxiety, depression, sleep disturbance including nightmares, self harm, suicidal ideation, eating difficulties etc.

How Post migration factors can exacerbate mental health difficulties.

There is an increasing literature that shows how levels of support and inclusion in host countries, post migration, can affect the incidence of mental health difficulties for unaccompanied asylum seeking children. In the following quote from the review article "Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors" (Fazel M, Reed R., Panter-Brick C., Stein A., ^[21] ) it is clear that the circumstances in host countries can exacerbate or ameliorate the difficulties faced by unaccompanied asylum seeking children and affect their levels of well-being and mental health difficulties.

"Cumulative adversities usually worsen health outcomes, exerting more powerful effects than any factor alone. The most harmful pathways are those that involve exposure to violence—whether individually experienced, witnessed, or feared—and the loss of family support by death or violence, for both behavioural and emotional mental health outcomes. As emphasised by the WHO framework, risks cannot be simply added up, but the inter-related pathways that lead to the outcomes need to be assessed. Thus, although distal or premigration factors contribute to childhood adversities, repeated exposure to violence and lack of safety soon after migration or displacement are of pivotal importance ."

It is therefore very important that all procedures involving unaccompanied asylum seeking children are carried out in a safe and trauma- informed way, that they are not re-traumatising and they do not exacerbate or worsen mental health difficulties

Being trauma informed means understanding the effects of trauma on the age assessment process

The process may be re-traumatising:

• A process can be re-traumatising if aspects of the process, by their similarity to the original trauma, can evoke the same feelings in the young person. Thus for example being shut in a room and repeatedly questioned or challenged could be re-traumatising for a young person who has been tortured.

• Having to recall traumatic memories can trigger reliving and/or flashbacks whereby the young person believes that the trauma is happening again and experiences the same thoughts, feelings and/or behaviours as they did during the traumatic event .It may for example make the young person recall the same feelings of fear or terror. It may elicit similar responses in the young person as happened at the time of the trauma when they were trying to survive what was happening, for example, the young person may dissociate (cut off in some way from what is happening).

Trauma related difficulties may interfere with the young person's ability to answer questions:

• If a young person's trust has been repeatedly abused they may find it hard to trust the worker and this can interfere with their ability to feel safe and comfortable and to go along with the process
• Fear, shame, guilt may interfere with their ability to recall aspects of what has happened to them for example if they experienced sexual violence.
• Depression and PTSD can interfere with memory. It may make it difficult to remember specific events. It may make it difficult to give a consistent or coherent autobiographical account. ^[22]
• Those who have been violent or abusive to young people may have told them not to give information to others or have threatened them or family members with violence if they disclose and this can contribute to the fear and difficulty of giving information. The feared consequences of giving information may terrify the young person into silence or denial.

Trauma-related difficulties mean that workers have to be very careful about how they understand and interpret a young person's responses:

• Avoidance of painful memories, dissociation and numbing, may mean that young people don't show the emotion the worker expects.
• Other mental health difficulties eg. irritability associated with depression or the effects of flashbacks may be erroneously viewed as a young person's unwillingness to cooperate.
• There may be cultural and gender differences in the meaning made of trauma and in how the young person responds

Being trauma informed means operating according to the principles of trauma informed practice

The following are agreed principles of trauma informed practice and should apply to the process of conducting age assessments. Trauma experiences undermine safety, take away an individual's control, demean and dis-empower. Principles of trauma informed practice do the opposite.

Safety:

• Before an age assessment is carried out a young person needs to be physically safe eg. safe from traffickers but also to feel safe e.g. that they have emotional support from others and that they have ways that they can soothe and comfort themselves if they become distressed
• A young person should not re-traumatised by having to repeat giving distressing information that they have already given in a different context
• A safe interview may mean practical things like helping the young person to be able to take breaks or stop interviews if they become distressed and by attending to the physical layout of a room or building, the gender of the worker etc.
• This may mean making sure that all interactions with a young person are the opposite of traumatic and are conducted in a context of care where there is a commitment to making sure the young person is getting all the help they need.
• Ensuring young people are getting the mental health input they need if there are signs that the traumatic past is interfering with their current sense of safety or where there are other signs of distress or of dissociation.
• Taking advice from mental health professionals if relevant about whether and how to conduct an age assessment process where there are concerns about mental health

Trustworthiness:

• This could mean that there should be a transparency and accountability about how the process is conducted, how the process is explained to young people and what information any judgment is based upon.
• Other people in the young person's life should not be asked to contribute without the young person's awareness and consent, unless consent is not required per exceptions in the law.
• It could mean making sure the young person understands what is happening and there isn't anything unpredictable about the process.
• It may mean keeping to all agreements and earning respect by the way the worker relates to the young person
• It means a commitment to acting according to the "best interests" principle at all times and to the principle that whatever the age these young people are estimated to be, they are likely to be traumatised, they are vulnerable and they are alone and may be in need of care and protection.
• It may mean being transparent about what is possible and what is not possible in the age assessment process for example it is not possible to determine age as there is no scientifically accurate or reliable way to do this, it is only possible to make a judgment about age.

Empowerment:

• This means involving the young people in all aspects of the process and listening well to what the young person is communicating. It means involving them in responding to the preliminary decision, helping to explain to them how the decision was reached it and allowing them the opportunity to respond in ways that may affect the final outcome. The young person can then offer further information or explanation before a final decision is made.
• It may mean making sure they have a way of appealing any decisions they are not happy with
• It means acting in ways that respect children's rights
• It means operating in ways that give young people the benefit of any doubt
• It means a commitment to their ongoing safety and a life free of trauma so they can recover from what they have been through and flourish

Choice:

• This may mean giving genuine choices about how the process is conducted, for example gender of worker or interpreter.
• It may mean giving genuine choices about where and with whom the process is conducted so it is as safe and comfortable as possible.
• Collaboration:
• This could involve a commitment to conducting the process in a spirit of joint inquiry, not as an adversarial process where the credibility of young people is being questioned
• It could mean making sure there are no interpretations of the young person's behaviour made that cannot be shared and talked through with the young person so that they always have a chance to explain or to get another worker to help them explain

Help to recover

The goal of all trauma informed practice is to help the person recover from the effects of their trauma experiences. The age assessment process fits within other tasks that social work has to do in order to ensure the needs of this vulnerable group are met. This can include helping the young person to heal or recover from the potential effects of trauma and helping those who have physical or mental health difficulties as a result of their trauma to get the help they need. It is important therefore to consider:

• How unaccompanied asylum seeking children are screened to pick up physical and mental health difficulties when they arrive and ensuring that they get timely, accessible and appropriate help, using an understanding of any difficulties to inform the age assessment process. ^[23]
• Making sure that any concerns picked up during age assessment process and any needs identified are acted upon
• Making sure there is multiagency collaboration over the process and conclusions of the age assessment process to make sure they are as trauma informed as possible
• Having knowledge of evidence-based psychological therapies and the access pathways to make sure young people who have mental health difficulties linked to their trauma experiences can access timely and appropriate help