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doi:10.1111/jpc.12873
VIEWPOINT
Perspective: ‘The forgotten children: National inquiry into children in immigration detention (2014)’ Georgia Paxton,1,2 Shidan Tosif,1,3 Hamish Graham,1,3 Andrea Smith,1 Colette Reveley,1 Jane Standish,1,2,4 Kate McCloskey,2,4 Grant Ferguson,1,5 David Isaacs,6,7 Hasantha Gunasekera,6,7 Ben Marais,6,7 Philip Britton,6,7 Ameneh Khatami,6 Karen Zwi,8,9 Shanti Raman,7,9,10 Elizabeth Elliott,6,7 David Levitt,11 Joshua Francis,12 Paul Bauert,12 Peter Morris,12 Annie Whybourne,12,13,14 Sarah Cherian,15,16 Raewyn Mutch,15,16 David Forbes,15,16 David Rutherford15,17 and Suzanne Packer18,19 1
Royal Children’s Hospital, 2Murdoch Childrens Research Institute, 3University of Melbourne, 5Monash Health, Melbourne, 4Barwon Health, Geelong, Victoria, Children’s Hospital at Westmead, 7University of Sydney, 8Sydney Children’s Hospitals Network, 9University of New South Wales, 10South Western Sydney Local Health District, Sydney, New South Wales, 11Lady Cilento Children’s Hospital, Brisbane, 14James Cook University, Townsville, Queensland, 12Royal Darwin Hospital, Darwin, Northern Territory, 13Flinders University, Adelaide, South Australia, 15Princess Margaret Hospital for Children, 16University of Western Australia, 17University of Notre Dame, Perth, Western Australia, 18Canberra Hospital and 19Australian National University, Canberra, Australian Capital Territory, Australia 6
The Australian Human Rights Commission (AHRC) report ‘The Forgotten Children: National Inquiry into Children in Immigration Detention (2014)’ was released in February 2015 after being tabled by the Australian Government following submission in November 2014.1 We write this commentary as paediatricians and child health providers who see children in detention to provide an outline of the Inquiry’s findings and a perspective based on our cumulative clinical experience. The AHRC Inquiry into children in detention1 was conducted over eight months between February and October 2014, with 13 visits to 11 immigration detention centres from March to July 2014 and five public hearings with 41 witnesses. The Commission conducted 486 interviews with 638 children and 491 parents (1129 people) in detention centres and 104 children and parents in the community who had previous detention experience. The Inquiry received 239 submissions from a range of organisations and individuals, and assistance from the DepartCorrespondence: Dr Georgia Paxton, Royal Children’s Hospital, Flemington, Melbourne, Vic. 3052, Australia. Fax: 93454751; email: [email protected] Conflict of interest: Dr Gunasekera and Professor Isaacs have provided specialist paediatric services in Nauru in 2014, all proceeds were donated to the Children’s Hospital at Westmead refugee clinic. Dr Ferguson has provided medical services on Christmas Island in 2013. Dr Levitt has provided advice to International Health and Medical Services on paediatric services in Nauru in 2014. Dr Paxton has provided advice to the Department of Immigration and Border Protection through the Physical and Mental Health Sub-committee of the Nauru Joint Advisory Committee since 2013 and the Independent Health Advisors Panel since 2014. Associate Professor Zwi was the Royal Australasian College of Physicians Paediatrics and Child Health Division representative on the Detention Health and Immigration Health Advisory Groups (DeHAG/IHAG) to the Australian Government between 2010-2013. Dr Raman has provided independent specialist consultation and advice to Maurice Blackburn Lawyers in relation to asylum seeking families on Christmas Island in 2014. Associate Professor Zwi, Professor Elliot and Drs Paxton, Tosif and Packer assisted the AHRC with site visits to immigration detention facilities in Christmas Island, Adelaide, Melbourne and Darwin in 2014. Accepted for publication 23 February 2015.
ment of Immigration and Border Protection (DIBP) and the detention health services provider, International Health and Medical Services (IHMS). Five paediatricians and four child and adolescent psychiatrists assisted the Commission with separate site visits to detention centres. The key findings of the AHRC Inquiry1 are that mandatory and prolonged immigration detention of children is (i) harmful to children, (ii) contrary to Australia’s international obligations, and (iii) in violation of international law. The findings are presented by age, and considered against the relevant article(s) in the Convention on the Rights of the Child.2 The report includes chapters on unaccompanied children, mothers and babies in detention, and children on Nauru. The Inquiry found prolonged detention has profoundly negative effects on children’s mental health and development. Overall, 85% of parents and children indicated their mental health was negatively affected while in detention, 60% of parents were concerned about their child’s development, 30% of children were described as ‘always sad’ and 25% as ‘always worried’. Children in immigration detention were more likely to score highly on the ‘Health of Nations Outcome Scale for Children and Adolescents’ (HoNOSCA) mental health rating scale than children in the Australian community (34% compared with 2%). Unaccompanied children are identified as a particularly vulnerable group, with nearly half reporting depression and hopelessness ‘all of the time’. Children on Nauru were found to be suffering extreme levels of physical, emotional and psychological distress.1 Children in detention are exposed to adults with mental illness; 30% of adults in detention centres had moderate to severe mental health problems, and 38% met criteria for PostTraumatic Stress Disorder. Over 60% of parents reported they felt depressed ‘most or all of the time’, and 39% of parents with infants reported they felt hopeless ‘most or all of the time’. Between January 2013 and March 2014, there were 128 babies born to mothers in Australian detention centres; the Commission found unacceptable risks of harm to these infants and significant negative effects on mother–child attachment.
Journal of Paediatrics and Child Health 51 (2015) 365–368 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
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The Inquiry found that detention centres on the mainland and Christmas Island are not safe places for children. Between January 2013 and March 2014, DIBP/IHMS figures recorded: 233 assaults involving children; 128 incidents of self-harm in children aged 12–17 years; 171 incidents of threatened selfharm in children; 105 children monitored after being assessed as being at ‘high-imminent’ or ‘moderate’ risk of suicide or selfharm; 27 incidents of voluntary starvation/hunger strikes in children; and 33 reported sexual assaults, the majority involving children. While the numbers provide an overview, the descriptions of the detention environment and the impact of detention on family functioning, and the direct quotes from children and parents present a grim and harrowing narrative. The report has received support from a range of organisations including the United Nations High Commission for Refugees (UNHCR), the United Nations International Children’s Emergency Fund (UNICEF), Amnesty Australia, the Refugee Council of Australia, the Royal Australasian College of Physicians (RACP), the Royal Australian College of General Practitioners (RACGP) and the Royal Australian and New Zealand College of Psychiatrists (RANZCP).3–7 In contrast, the Australian Government has expressed concerns about the timing and nature of the report, with allegations the report is ‘partisan’ and ‘politicised’. The Government has emphasised the fact there were nearly 2000 children in detention in July 2013 under the previous government,8 and the numbers of children in Australian detention have decreased since this time, to 929 children in February 20149 and 211 children in January 2015.10 While releasing children from detention is positive progress, this focus ignores the duration of detention. The average length of detention increased from 72 days in July 2013 to 413 days by September 2014,11 and is currently 442 days.10 Appendix 8 of the report provides the DIBP response to the draft, noting among other concerns ‘Over-reliance on the Commission’s own experts’.1 As paediatricians, we have extensive experience working with refugee and asylum seeking children. We see children who are currently in locked detention in our clinics and hospital wards, and also children who have previously been in detention and require medical care. We work in Victoria, Western Australia, the Northern Territory, Queensland, the Australian Capital Territory and New South Wales. Collectively, we have more than 100 clinical years’ experience in refugee health. Several members of the group have been to Nauru or Christmas Island, while others assisted the Commission with the site visits, and/or contributed to AHRC Inquiry submissions. We did not contribute to compiling the final report. It is difficult to convey the complexity, strangeness and secrecy of the detention environment over the last 18 months, and the damage we have seen in children, adults and families who have experienced prolonged detention. We acknowledge the referral bias in our patient group – only children with medical issues are referred to external specialist services. However, almost all the detained children and parents we see appear to have pervasive and severe mental health problems, alongside their medical issues. When we have seen siblings opportunistically, we have found similar and significant mental and physical problems, highlighting the case for paediatric experts to review all detained children and adolescents. We 366
spend entire clinics assessing mental health, attachment, safety concerns and risk – for children and for their parents. We see and hear of parents who have spent months in their rooms incapacitated with depression, unable to care for their children, who are then cared for by the other parent or another relative. We see parents with profound psychomotor retardation from depression, and most consultations are spent with either parents or children, and sometimes interpreters, in tears. Many children have secondary enuresis commencing in detention, whereas this is an uncommon problem in refugee children arriving under the offshore program. Behavioural issues, poor appetite, sleep problems, developmental problems, irritability, anxiety, sadness and nightmares are so common they are considered typical and are expected by parents. Many children have missed months of school, consistent with the Commission’s finding that more than 100 school-age children on Christmas Island had no schooling between July 2013 and July 2014. We have seen mental health continue to decline over time, often precipitously, particularly in the last 6 months of 2014 as the duration of detention lengthened, long after the AHRC completed their site visits. The DIBP raised concerns about ‘reliance on anonymous and de-identified quotations as credible supporting evidence’.1 However, these quotations are some of the only direct descriptions of children’s detention experience available. The sources are known and documented, and a large number of children were interviewed. Over the period of the Inquiry site visits, the number of children in detention on the mainland and Christmas Island ranged from 895 in March 2014 to 712 in July 2014,12 so interviews with 638 children represent a high proportion of the total population. The consistency of experience across settings and across the visits is striking. Further, these quotations reflect our clinical experience working with this group. These are the stories and remarks we hear in our day-to-day work across Australia. External commentaries have also raised concerns about ‘emotionalism’ and a lack of impartial evidence and research.13 We are aware there are few direct studies/systematic reviews14–20 and limited recent/comparative data19,20 on detained children in Australia; however, available studies and other large-scale reports, including those of the Commonwealth Ombudsman,21 Joint Select Committee on Australia’s Immigration Detention Network,22 and the previous AHRC Inquiry,23 have consistently found detention is harmful for children. The relative lack of published academic literature on detained children reflects a lack of access to this group of children, and a paucity of systematic, longitudinal monitoring. The AHRC Inquiry is not only the largest Australian survey of detained children, the report includes the only current data on mental health screening and self-harm in this group, using information supplied by IHMS and the DIBP. A large proportion of children have high scores on the HoNOSCA. The number of self-harm incidents appears to have increased compared with earlier figures over 2010–2012 documented in the 2013 Commonwealth Ombudsman report,21 although the Ombudsman found the DIBP only started regularly analysing self-harm data in 2012, and noted self-harm data collected by the DIBP were poor quality and inconsistent. There are no other mental health screening data available. The IHMS dataset from July to
Journal of Paediatrics and Child Health 51 (2015) 365–368 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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September 2013 includes 2830 children but does not provide information by age and does not include child mental health screening data.24 While the Inquiry also quoted IHMS statistics indicating 36 (of 889) children had a diagnosed mental health disorder, this figure appears extremely low based on our clinical experience and given the high numbers of self-harm incidents reported. This raises significant questions about the adequacy of mental health screening in detained children. There are systemic issues in accessing information for children in detention. Referrals and/or the health discharge assessment (HDA, completed on release from detention) provide limited information. Health screening test results from IHMS or updates from DIBP case managers are difficult, often impossible, to obtain. DIBP/IHMS staff change frequently, undermining collaboration and trust, which take time to establish. We have not seen evidence of standardised mental health or developmental screening for children, and while it is possible this has been completed, this information is not included on referral letters or the HDA. Providing clinical care for this group is challenging, time consuming and sometimes overwhelming, requiring considerable resilience on the part of the clinician. Families who have experienced prolonged detention over the last 18 months are some of the most damaged children and parents we have seen in our professional careers. We draw attention to two quotes within the body of the report:1 I’ve spoken to IHMS about my children’s symptoms (anxiety, stress, crying) and was told this was normal for detention. (p. 116) We didn’t have normal people around to show us what’s normal. (p. 140) In our experience, trauma, mental illness, disrupted family functioning, developmental problems, loss of hope and profound uncertainty have been normalised within the detention environment. The AHRC report provides an account of this hidden situation, and in the absence of current research, internal or external monitoring, this account is essential. Prolonged detention causes harm to children, to parents, to families, to adults and to society. We commend the AHRC for their work on the Inquiry, and urge bipartisan support to end mandatory immigration detention, expedite the release of people seeking asylum from detention and implement the Inquiry’s recommendations. Addendum: The ‘Review into recent allegations relating to conditions and circumstances at the Regional Processing Centre In Nauru’ by the former Integrity Commissioner Philip Moss was released publicly on 20 March 2015 (available at: http://www.immi.gov.au/about/dept-info/ _files/review-conditions-circumstances-nauru.pdf). This review, ‘The Moss Inquiry’, raises wide-ranging protection concerns for detained children on Nauru, including allegations of sexual and physical assaults, sexual harassment and sexualised behaviour in children. The review was submitted to the Government in early February 2015, suggesting that this information was available around the time the AHRC report was released. The Moss Inquiry findings strongly support the AHRC Inquiry findings that detention centres are not safe places for children.
The forgotten children
References 1 Australian Human Rights Commission. The Forgotten Children: National Inquiry into Children in Immigration Detention. Sydney: Australian Human Rights Commission, 2014. Available from: http://www.humanrights.gov.au/publications/forgotten -children-national-inquiry-children-immigration -detention-2014 [accessed 21 February 2015]. 2 United Nations General Assembly. Convention on the Rights of the Child. Geneva: United Nations Treaty Series, 1989; 1577: 3. Available from: http://treaties.un.org/Pages/ViewDetails.aspx?mtdsg _no=IV-11&chapter=4&lang=en [accessed 7 December 2013]. 3 UNHCR Statement: The Forgotten Children: National Inquiry into Children in Immigration Detention 2014. Canberra: United Nations High Commissioner for Refugees. Regional Office. Australia, New Zealand, Papua New Guinea and the Pacific, 2015. Available from: http://www.unhcr.org.au/unhcr/index.php?option=com _content&view=article&id=571:unhcr-statement-the-forgotten -children-national-inquiry-into-children-in-immigration-detention -2014&catid=37:submissions&Itemid=61 [accessed 21 February 2015]. 4 Damning Evidence of Serious Child Harm in Detention. A joint Statement by Amnesty International Australia, Caritas Australia, Children’s Rights International, Human Rights Law Centre, Human Rights Council of Australia, Plan International Australia, Refugee Council of Australia, Save the Children, UNICEF Australia and World Vision Australia. Sydney: UNICEF, 2015. Available from: http://www.unicef.org.au/Media/Media-Releases/2--2015-February/ Damning-evidence-of-serious-child-harm-in-detentio.aspx [accessed 21 February 2015]. 5 Minister must Release Children from Detention. Sydney: Royal Australasian College of Physicians, 2015. Available from: http://www.racp.edu.au/index.cfm?objectid=D7FAA694-E371-4AB9 -BE41B937879A52E1 [accessed 21 February 2015]. 6 GPs Call for End of Mandatory Detention for Asylum Seekers. Melbourne: Royal Australian College of General Practitioners, 2015. Available from: http://www.racgp.org.au/yourracgp/news/media -releases/mandatory-detention/ [accessed 21 February 2015]. 7 Human Rights Report Proves Detention Harms Children. Melbourne: Royal Australian and New Zealand College of Psychiatrists, 2015. Available from: http://www.ranzcp.org/News-policy/News/ Human-rights-report-proves-detention-harms-childre .aspx [accessed 21 February 2015]. 8 Department of Immigration and Citizenship. Immigration Detention Statistics Summary 31 July 2013. Canberra: Australian Government, Department of Immigration and Citizenship, 2013. Available from: http://www.immi.gov.au/managing-australias-borders/detention/ _pdf/immigration-detention-statistics-july2013.pdf [accessed 21 February 2015]. 9 Department of Immigration and Border Protection. Immigration Detention and Community Statistics Summary 28 February 2014. Canberra: Australian Government, 2014. Available from: http://www.immi.gov.au/managing-australias-borders/detention/ _pdf/immigration-detention-statistics-feb2014.pdf [accessed 21 February 2015]. 10 Department of Immigration and Border Protection. Immigration Detention and Community Statistics Summary 31 January 2015. Canberra: Australian Government Department of Immigration and Border Protection, 2015. Available from: http://www.immi .gov.au/About/Documents/detention/immigration-detention -statistics-jan2015.pdf [accessed 21 February 2015]. 11 Department of Immigration and Border Protection. Immigration Detention and Community Statistics Summary 30 September 2014. Canberra: Australian Government, 2014. Available from:
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http://www.immi.gov.au/About/Documents/immigration -detention-statistics-for-30-september-2014.pdf [accessed 21 February 2015]. Department of Immigration and Border Protection. Immigration Detention and Community Statistics Summary 31 July 2014. Canberra: Australian Government, 2014. Available from: http://www.immi.gov.au/managing-australias -borders/detention/_pdf/immigration-detention-statistics -july2014.pdf [accessed 21 February 2015]. Oriel J Children in detention report uses emotion in place of objective fact. The Australian, 19 February 2015. Available from: http://www.theaustralian.com.au/opinion/children-in-detention -report-uses-emotion-in-place-of-objective-fact/story-e6frg6zo -1227224538997 [accessed 21 February 2015]. Sultan A, O’Sullivan K. Psychological disturbances in asylum seekers held in long term detention: a participant-observer account. Med. J. Aust. 2001; 175: 593–6. Steel Z, Momartin S, Bateman C et al. Psychiatric status of asylum seeker families held for a protracted period in a remote detention centre in Australia. Aust. NZ. J. Public Health. 2004; 28: 527–36. Mares S, Jureidini J. Psychiatric assessment of children and families in immigration detention – clinical, administrative and ethical issues. Aust. NZ. J. Public Health. 2004; 28: 520–6. Robjant K, Hassan R, Katona C. Mental health implications of detaining asylum seekers: systematic review. Br. J. Psychiatry 2009; 194: 306–12. Green JP, Eagar K. The health of people in Australian immigration detention centres. Med. J. Aust. 2010; 192: 65–70.
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19 Francis JR, Cherian S, Forbes D. Seeking asylum: health and human rights in Australia. Med. J. Aust. 2013; 199: 99–100. 20 Mace AO, Mulheron S, Jones C, Cherian S. Educational, developmental and psychological outcomes of resettled refugee children in Western Australia: a review of School of Special Educational Needs: medical and mental health input. J. Paediatr. Child Health 2014; 50: 985–92. 21 Commonwealth Ombudsman. Suicide and Self-harm in the Immigration Detention Network. Canberra: Commonwealth Ombudsman, 2013. Available from: http://www.ombudsman .gov.au/files/suicide_and_self-harm_in_the_immigration _detention_network.pdf [accessed 21 February 2015]. 22 Joint Select Committee on Australia’s Immigration Detention Network. Final Report. Canberra: Commonwealth of Australia, 2012. Available from: http://www.aph.gov.au/∼/media/wopapub/senate/committee/ immigration_detention_ctte/report/report_pdf.ashx [accessed 21 February 2015]. 23 Human Rights and Equal Opportunities Commission. A Last Resort? The report of the national inquiry into children in immigration detention. Sydney: Human Rights and Equal Opportunities Commission; 2004. Available from: http://www.humanrights.gov.au/ sites/default/files/content/human_rights/children_detention_report/ report/PDF/alr_complete.pdf [accessed 21 February 2015]. 24 Cox W, Young P, Czech R, Shen M, Eager R. Health Data Set: July–September 2013. Version 1.04. Sydney: International Health and Medical Services, 2013. Available from: http://www.immi.gov.au/ About/foi/Documents/FA131200935.pdf [accessed 21 February 2015].
Journal of Paediatrics and Child Health 51 (2015) 365–368 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
doi:10.1111/jpc.12873
VIEWPOINT
Perspective: ‘The forgotten children: National inquiry into children in immigration detention (2014)’ Georgia Paxton,1,2 Shidan Tosif,1,3 Hamish Graham,1,3 Andrea Smith,1 Colette Reveley,1 Jane Standish,1,2,4 Kate McCloskey,2,4 Grant Ferguson,1,5 David Isaacs,6,7 Hasantha Gunasekera,6,7 Ben Marais,6,7 Philip Britton,6,7 Ameneh Khatami,6 Karen Zwi,8,9 Shanti Raman,7,9,10 Elizabeth Elliott,6,7 David Levitt,11 Joshua Francis,12 Paul Bauert,12 Peter Morris,12 Annie Whybourne,12,13,14 Sarah Cherian,15,16 Raewyn Mutch,15,16 David Forbes,15,16 David Rutherford15,17 and Suzanne Packer18,19 1
Royal Children’s Hospital, 2Murdoch Childrens Research Institute, 3University of Melbourne, 5Monash Health, Melbourne, 4Barwon Health, Geelong, Victoria, Children’s Hospital at Westmead, 7University of Sydney, 8Sydney Children’s Hospitals Network, 9University of New South Wales, 10South Western Sydney Local Health District, Sydney, New South Wales, 11Lady Cilento Children’s Hospital, Brisbane, 14James Cook University, Townsville, Queensland, 12Royal Darwin Hospital, Darwin, Northern Territory, 13Flinders University, Adelaide, South Australia, 15Princess Margaret Hospital for Children, 16University of Western Australia, 17University of Notre Dame, Perth, Western Australia, 18Canberra Hospital and 19Australian National University, Canberra, Australian Capital Territory, Australia 6
The Australian Human Rights Commission (AHRC) report ‘The Forgotten Children: National Inquiry into Children in Immigration Detention (2014)’ was released in February 2015 after being tabled by the Australian Government following submission in November 2014.1 We write this commentary as paediatricians and child health providers who see children in detention to provide an outline of the Inquiry’s findings and a perspective based on our cumulative clinical experience. The AHRC Inquiry into children in detention1 was conducted over eight months between February and October 2014, with 13 visits to 11 immigration detention centres from March to July 2014 and five public hearings with 41 witnesses. The Commission conducted 486 interviews with 638 children and 491 parents (1129 people) in detention centres and 104 children and parents in the community who had previous detention experience. The Inquiry received 239 submissions from a range of organisations and individuals, and assistance from the DepartCorrespondence: Dr Georgia Paxton, Royal Children’s Hospital, Flemington, Melbourne, Vic. 3052, Australia. Fax: 93454751; email: [email protected] Conflict of interest: Dr Gunasekera and Professor Isaacs have provided specialist paediatric services in Nauru in 2014, all proceeds were donated to the Children’s Hospital at Westmead refugee clinic. Dr Ferguson has provided medical services on Christmas Island in 2013. Dr Levitt has provided advice to International Health and Medical Services on paediatric services in Nauru in 2014. Dr Paxton has provided advice to the Department of Immigration and Border Protection through the Physical and Mental Health Sub-committee of the Nauru Joint Advisory Committee since 2013 and the Independent Health Advisors Panel since 2014. Associate Professor Zwi was the Royal Australasian College of Physicians Paediatrics and Child Health Division representative on the Detention Health and Immigration Health Advisory Groups (DeHAG/IHAG) to the Australian Government between 2010-2013. Dr Raman has provided independent specialist consultation and advice to Maurice Blackburn Lawyers in relation to asylum seeking families on Christmas Island in 2014. Associate Professor Zwi, Professor Elliot and Drs Paxton, Tosif and Packer assisted the AHRC with site visits to immigration detention facilities in Christmas Island, Adelaide, Melbourne and Darwin in 2014. Accepted for publication 23 February 2015.
ment of Immigration and Border Protection (DIBP) and the detention health services provider, International Health and Medical Services (IHMS). Five paediatricians and four child and adolescent psychiatrists assisted the Commission with separate site visits to detention centres. The key findings of the AHRC Inquiry1 are that mandatory and prolonged immigration detention of children is (i) harmful to children, (ii) contrary to Australia’s international obligations, and (iii) in violation of international law. The findings are presented by age, and considered against the relevant article(s) in the Convention on the Rights of the Child.2 The report includes chapters on unaccompanied children, mothers and babies in detention, and children on Nauru. The Inquiry found prolonged detention has profoundly negative effects on children’s mental health and development. Overall, 85% of parents and children indicated their mental health was negatively affected while in detention, 60% of parents were concerned about their child’s development, 30% of children were described as ‘always sad’ and 25% as ‘always worried’. Children in immigration detention were more likely to score highly on the ‘Health of Nations Outcome Scale for Children and Adolescents’ (HoNOSCA) mental health rating scale than children in the Australian community (34% compared with 2%). Unaccompanied children are identified as a particularly vulnerable group, with nearly half reporting depression and hopelessness ‘all of the time’. Children on Nauru were found to be suffering extreme levels of physical, emotional and psychological distress.1 Children in detention are exposed to adults with mental illness; 30% of adults in detention centres had moderate to severe mental health problems, and 38% met criteria for PostTraumatic Stress Disorder. Over 60% of parents reported they felt depressed ‘most or all of the time’, and 39% of parents with infants reported they felt hopeless ‘most or all of the time’. Between January 2013 and March 2014, there were 128 babies born to mothers in Australian detention centres; the Commission found unacceptable risks of harm to these infants and significant negative effects on mother–child attachment.
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The Inquiry found that detention centres on the mainland and Christmas Island are not safe places for children. Between January 2013 and March 2014, DIBP/IHMS figures recorded: 233 assaults involving children; 128 incidents of self-harm in children aged 12–17 years; 171 incidents of threatened selfharm in children; 105 children monitored after being assessed as being at ‘high-imminent’ or ‘moderate’ risk of suicide or selfharm; 27 incidents of voluntary starvation/hunger strikes in children; and 33 reported sexual assaults, the majority involving children. While the numbers provide an overview, the descriptions of the detention environment and the impact of detention on family functioning, and the direct quotes from children and parents present a grim and harrowing narrative. The report has received support from a range of organisations including the United Nations High Commission for Refugees (UNHCR), the United Nations International Children’s Emergency Fund (UNICEF), Amnesty Australia, the Refugee Council of Australia, the Royal Australasian College of Physicians (RACP), the Royal Australian College of General Practitioners (RACGP) and the Royal Australian and New Zealand College of Psychiatrists (RANZCP).3–7 In contrast, the Australian Government has expressed concerns about the timing and nature of the report, with allegations the report is ‘partisan’ and ‘politicised’. The Government has emphasised the fact there were nearly 2000 children in detention in July 2013 under the previous government,8 and the numbers of children in Australian detention have decreased since this time, to 929 children in February 20149 and 211 children in January 2015.10 While releasing children from detention is positive progress, this focus ignores the duration of detention. The average length of detention increased from 72 days in July 2013 to 413 days by September 2014,11 and is currently 442 days.10 Appendix 8 of the report provides the DIBP response to the draft, noting among other concerns ‘Over-reliance on the Commission’s own experts’.1 As paediatricians, we have extensive experience working with refugee and asylum seeking children. We see children who are currently in locked detention in our clinics and hospital wards, and also children who have previously been in detention and require medical care. We work in Victoria, Western Australia, the Northern Territory, Queensland, the Australian Capital Territory and New South Wales. Collectively, we have more than 100 clinical years’ experience in refugee health. Several members of the group have been to Nauru or Christmas Island, while others assisted the Commission with the site visits, and/or contributed to AHRC Inquiry submissions. We did not contribute to compiling the final report. It is difficult to convey the complexity, strangeness and secrecy of the detention environment over the last 18 months, and the damage we have seen in children, adults and families who have experienced prolonged detention. We acknowledge the referral bias in our patient group – only children with medical issues are referred to external specialist services. However, almost all the detained children and parents we see appear to have pervasive and severe mental health problems, alongside their medical issues. When we have seen siblings opportunistically, we have found similar and significant mental and physical problems, highlighting the case for paediatric experts to review all detained children and adolescents. We 366
spend entire clinics assessing mental health, attachment, safety concerns and risk – for children and for their parents. We see and hear of parents who have spent months in their rooms incapacitated with depression, unable to care for their children, who are then cared for by the other parent or another relative. We see parents with profound psychomotor retardation from depression, and most consultations are spent with either parents or children, and sometimes interpreters, in tears. Many children have secondary enuresis commencing in detention, whereas this is an uncommon problem in refugee children arriving under the offshore program. Behavioural issues, poor appetite, sleep problems, developmental problems, irritability, anxiety, sadness and nightmares are so common they are considered typical and are expected by parents. Many children have missed months of school, consistent with the Commission’s finding that more than 100 school-age children on Christmas Island had no schooling between July 2013 and July 2014. We have seen mental health continue to decline over time, often precipitously, particularly in the last 6 months of 2014 as the duration of detention lengthened, long after the AHRC completed their site visits. The DIBP raised concerns about ‘reliance on anonymous and de-identified quotations as credible supporting evidence’.1 However, these quotations are some of the only direct descriptions of children’s detention experience available. The sources are known and documented, and a large number of children were interviewed. Over the period of the Inquiry site visits, the number of children in detention on the mainland and Christmas Island ranged from 895 in March 2014 to 712 in July 2014,12 so interviews with 638 children represent a high proportion of the total population. The consistency of experience across settings and across the visits is striking. Further, these quotations reflect our clinical experience working with this group. These are the stories and remarks we hear in our day-to-day work across Australia. External commentaries have also raised concerns about ‘emotionalism’ and a lack of impartial evidence and research.13 We are aware there are few direct studies/systematic reviews14–20 and limited recent/comparative data19,20 on detained children in Australia; however, available studies and other large-scale reports, including those of the Commonwealth Ombudsman,21 Joint Select Committee on Australia’s Immigration Detention Network,22 and the previous AHRC Inquiry,23 have consistently found detention is harmful for children. The relative lack of published academic literature on detained children reflects a lack of access to this group of children, and a paucity of systematic, longitudinal monitoring. The AHRC Inquiry is not only the largest Australian survey of detained children, the report includes the only current data on mental health screening and self-harm in this group, using information supplied by IHMS and the DIBP. A large proportion of children have high scores on the HoNOSCA. The number of self-harm incidents appears to have increased compared with earlier figures over 2010–2012 documented in the 2013 Commonwealth Ombudsman report,21 although the Ombudsman found the DIBP only started regularly analysing self-harm data in 2012, and noted self-harm data collected by the DIBP were poor quality and inconsistent. There are no other mental health screening data available. The IHMS dataset from July to
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September 2013 includes 2830 children but does not provide information by age and does not include child mental health screening data.24 While the Inquiry also quoted IHMS statistics indicating 36 (of 889) children had a diagnosed mental health disorder, this figure appears extremely low based on our clinical experience and given the high numbers of self-harm incidents reported. This raises significant questions about the adequacy of mental health screening in detained children. There are systemic issues in accessing information for children in detention. Referrals and/or the health discharge assessment (HDA, completed on release from detention) provide limited information. Health screening test results from IHMS or updates from DIBP case managers are difficult, often impossible, to obtain. DIBP/IHMS staff change frequently, undermining collaboration and trust, which take time to establish. We have not seen evidence of standardised mental health or developmental screening for children, and while it is possible this has been completed, this information is not included on referral letters or the HDA. Providing clinical care for this group is challenging, time consuming and sometimes overwhelming, requiring considerable resilience on the part of the clinician. Families who have experienced prolonged detention over the last 18 months are some of the most damaged children and parents we have seen in our professional careers. We draw attention to two quotes within the body of the report:1 I’ve spoken to IHMS about my children’s symptoms (anxiety, stress, crying) and was told this was normal for detention. (p. 116) We didn’t have normal people around to show us what’s normal. (p. 140) In our experience, trauma, mental illness, disrupted family functioning, developmental problems, loss of hope and profound uncertainty have been normalised within the detention environment. The AHRC report provides an account of this hidden situation, and in the absence of current research, internal or external monitoring, this account is essential. Prolonged detention causes harm to children, to parents, to families, to adults and to society. We commend the AHRC for their work on the Inquiry, and urge bipartisan support to end mandatory immigration detention, expedite the release of people seeking asylum from detention and implement the Inquiry’s recommendations. Addendum: The ‘Review into recent allegations relating to conditions and circumstances at the Regional Processing Centre In Nauru’ by the former Integrity Commissioner Philip Moss was released publicly on 20 March 2015 (available at: http://www.immi.gov.au/about/dept-info/ _files/review-conditions-circumstances-nauru.pdf). This review, ‘The Moss Inquiry’, raises wide-ranging protection concerns for detained children on Nauru, including allegations of sexual and physical assaults, sexual harassment and sexualised behaviour in children. The review was submitted to the Government in early February 2015, suggesting that this information was available around the time the AHRC report was released. The Moss Inquiry findings strongly support the AHRC Inquiry findings that detention centres are not safe places for children.
The forgotten children
References 1 Australian Human Rights Commission. The Forgotten Children: National Inquiry into Children in Immigration Detention. Sydney: Australian Human Rights Commission, 2014. Available from: http://www.humanrights.gov.au/publications/forgotten -children-national-inquiry-children-immigration -detention-2014 [accessed 21 February 2015]. 2 United Nations General Assembly. Convention on the Rights of the Child. Geneva: United Nations Treaty Series, 1989; 1577: 3. Available from: http://treaties.un.org/Pages/ViewDetails.aspx?mtdsg _no=IV-11&chapter=4&lang=en [accessed 7 December 2013]. 3 UNHCR Statement: The Forgotten Children: National Inquiry into Children in Immigration Detention 2014. Canberra: United Nations High Commissioner for Refugees. Regional Office. Australia, New Zealand, Papua New Guinea and the Pacific, 2015. Available from: http://www.unhcr.org.au/unhcr/index.php?option=com _content&view=article&id=571:unhcr-statement-the-forgotten -children-national-inquiry-into-children-in-immigration-detention -2014&catid=37:submissions&Itemid=61 [accessed 21 February 2015]. 4 Damning Evidence of Serious Child Harm in Detention. A joint Statement by Amnesty International Australia, Caritas Australia, Children’s Rights International, Human Rights Law Centre, Human Rights Council of Australia, Plan International Australia, Refugee Council of Australia, Save the Children, UNICEF Australia and World Vision Australia. Sydney: UNICEF, 2015. Available from: http://www.unicef.org.au/Media/Media-Releases/2--2015-February/ Damning-evidence-of-serious-child-harm-in-detentio.aspx [accessed 21 February 2015]. 5 Minister must Release Children from Detention. Sydney: Royal Australasian College of Physicians, 2015. Available from: http://www.racp.edu.au/index.cfm?objectid=D7FAA694-E371-4AB9 -BE41B937879A52E1 [accessed 21 February 2015]. 6 GPs Call for End of Mandatory Detention for Asylum Seekers. Melbourne: Royal Australian College of General Practitioners, 2015. Available from: http://www.racgp.org.au/yourracgp/news/media -releases/mandatory-detention/ [accessed 21 February 2015]. 7 Human Rights Report Proves Detention Harms Children. Melbourne: Royal Australian and New Zealand College of Psychiatrists, 2015. Available from: http://www.ranzcp.org/News-policy/News/ Human-rights-report-proves-detention-harms-childre .aspx [accessed 21 February 2015]. 8 Department of Immigration and Citizenship. Immigration Detention Statistics Summary 31 July 2013. Canberra: Australian Government, Department of Immigration and Citizenship, 2013. Available from: http://www.immi.gov.au/managing-australias-borders/detention/ _pdf/immigration-detention-statistics-july2013.pdf [accessed 21 February 2015]. 9 Department of Immigration and Border Protection. Immigration Detention and Community Statistics Summary 28 February 2014. Canberra: Australian Government, 2014. Available from: http://www.immi.gov.au/managing-australias-borders/detention/ _pdf/immigration-detention-statistics-feb2014.pdf [accessed 21 February 2015]. 10 Department of Immigration and Border Protection. Immigration Detention and Community Statistics Summary 31 January 2015. Canberra: Australian Government Department of Immigration and Border Protection, 2015. Available from: http://www.immi .gov.au/About/Documents/detention/immigration-detention -statistics-jan2015.pdf [accessed 21 February 2015]. 11 Department of Immigration and Border Protection. Immigration Detention and Community Statistics Summary 30 September 2014. Canberra: Australian Government, 2014. Available from:
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http://www.immi.gov.au/About/Documents/immigration -detention-statistics-for-30-september-2014.pdf [accessed 21 February 2015]. Department of Immigration and Border Protection. Immigration Detention and Community Statistics Summary 31 July 2014. Canberra: Australian Government, 2014. Available from: http://www.immi.gov.au/managing-australias -borders/detention/_pdf/immigration-detention-statistics -july2014.pdf [accessed 21 February 2015]. Oriel J Children in detention report uses emotion in place of objective fact. The Australian, 19 February 2015. Available from: http://www.theaustralian.com.au/opinion/children-in-detention -report-uses-emotion-in-place-of-objective-fact/story-e6frg6zo -1227224538997 [accessed 21 February 2015]. Sultan A, O’Sullivan K. Psychological disturbances in asylum seekers held in long term detention: a participant-observer account. Med. J. Aust. 2001; 175: 593–6. Steel Z, Momartin S, Bateman C et al. Psychiatric status of asylum seeker families held for a protracted period in a remote detention centre in Australia. Aust. NZ. J. Public Health. 2004; 28: 527–36. Mares S, Jureidini J. Psychiatric assessment of children and families in immigration detention – clinical, administrative and ethical issues. Aust. NZ. J. Public Health. 2004; 28: 520–6. Robjant K, Hassan R, Katona C. Mental health implications of detaining asylum seekers: systematic review. Br. J. Psychiatry 2009; 194: 306–12. Green JP, Eagar K. The health of people in Australian immigration detention centres. Med. J. Aust. 2010; 192: 65–70.
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