ObjectiveChildren and young adults comprise a significant proportion of the world´s refugee population and are disproportionately negatively affected by the social determinants of health. This heterogeneous group faces high rates of poor mental health, yet research investigating within-group inequalities in mental health remains limited. We performed a latent profile analysis to explore classes of mental health based on posttraumatic stress symptoms (PTSS), general functioning, and well-being. This study aimed to improve the understanding of mental health differences, thereby providing better guidance for assessment and tailored interventions.MethodThis study involved 131 children and 127 young adults with refugee backgrounds (mean age 18.21 years, 44.6% female, 23.6% unaccompanied) recruited nationwide in Sweden (2019-2022). To examine classes and their predictors, latent profile analysis was conducted, followed by multinomial logistic regression analysis.ResultsLatent profile analysis identified four distinct classes: Good Mental Health (58.1%; low PTSS, good functioning and well-being), Severe Mental Distress (13.6%; high PTSS, low functioning and well-being), Moderate Mental Strain (12.4%; low PTSS, moderate functioning, low well-being), and Resilient (15.9%, high PTSS, good functioning, moderate well-being). Social determinants of health, such as being unaccompanied, asylum status, exposure to multiple types of violence, sexual victimization, and child maltreatment, distinguished the classes.ConclusionChildren and young adults with refugee backgrounds can be categorized into classes based on clinically relevant mental health indicators. Focusing solely on those at the highest risk for poor mental health may overlook many who are mentally healthy and those who need more targeted support. Future research should aim to replicate findings and evaluate additional predictive factors at the family and societal levels.

Background: Currently, approximately 100 million people are displaced worldwide, including children and young adults. Previous studies showed exposure to violence and posttraumatic stress disorder (PTSD) are common in this sub-population. However, we still lack comprehensive data on well-being, mental health, and the ability to function. Methods: This study included 291 adolescent (aged 12-17 years) and young adult (18-25 years) refugees recruited nationwide in Sweden between 2019 and 2022. Sociodemographic, mental health and well-beingrelated data (well-being, post-traumatic stress symptoms, psychiatric diagnoses, and functional ability) were collected using semi-structured interviews with structured components. Associations between accompanied status and well-being/depression/suicidal thoughts, generalized anxiety disorder/panic disorder/PTSD symptoms, and functional ability were analyzed using linear and logistic regression, adjusted for age, gender, parental education, asylum status, and region of origin. Findings: Most study participants (mean age 17.9 years) originated from the Middle East and North Africa (70.6 %) or Sub-Saharan Africa (27.0 %). 16.1 % of adolescents and 32.3 % of young adults were unaccompanied. Nearly the entire study sample had experienced violence (92.8 %). However, the sample had a low prevalence of psychiatric diagnoses. For example, only 5.9 % fulfilled the criteria for clinical depression. Self-reported wellbeing (WHO-5, 71.09 (23.91)) and observer-rated functional ability (GAS/GAF, 81.76 (14.15)) were high. There were no significant differences in diagnosis prevalence by gender. However, significant differences existed between accompanied versus unaccompanied groups. Being an unaccompanied refugee individual was associated with a higher risk of suicidal thoughts, adjusted odds ratio, aOR 5.66 (95 % CI 2.15-14.88), higher rates of posttraumatic stress disorder symptoms /3 = 0.72 (0.39-1.05), lower mental well-being /3 = -10.86 95 % CI (- 18.23- -3.48) and lower functional ability /3 = -9.38 (- 13.84- -4.92). There were no differences in outcomes by gender except for worse well-being in males (/3 = 6.83 (1.01-12.66)). Interpretation: In this sample, we found lower prevalence rates for all psychiatric diagnoses compared to earlier published studies. Being an unaccompanied refugee individual was a risk factor for all adverse outcomes. Future studies need to confirm the relatively low rates of psychiatric diagnoses. Regardless, the results highlight the heterogeneous needs among newly arrived refugees.

Research on complex posttraumatic stress disorder (CPTSD) among individuals with refugee backgrounds is limited, and its validity within this group remains underexplored. This study aimed to assess the prevalence and discriminant validity of posttraumatic stress disorder (PTSD) and CPTSD, as well as the risk factors for CPTSD, in a community sample of adolescents with refugee backgrounds residing in Sweden. This study involved 296 adolescents. Probable diagnoses were evaluated according to DSM-5 and ICD-11 criteria. Latent class analysis was employed to examine the discriminant validity of PTSD and CPTSD, while logistic regression analysis was used to explore risk factors for CPTSD. The findings indicated that 24.1% had a probable diagnosis of PTSD according to the DSM-5. For ICD-11, the equivalent proportions were 7.1% for PTSD and 10.8% for CPTSD. Latent class analysis identified three distinct classes: Low symptoms (46.9%), PTSD (29.6%), and CPTSD (23.6%). Compared to the PTSD class, membership in the CPTSD class was predicted by exposure to more types of violence and child maltreatment. It was also associated with higher posttraumatic stress symptoms, worse general functioning, poorer mental well-being, increased suicidal thoughts, more treatment-seeking behavior, and greater comorbidity. This study found a high prevalence of PTSD and CPTSD among adolescents with refugee backgrounds living in Sweden. Distinct classes aligned with the ICD-11 formulation of PTSD and CPTSD were identified, with exposure to violence and child maltreatment emerging as key risk factors for CPTSD. Results underscore the importance of identifying and addressing posttraumatic stress in adolescents with refugee backgrounds. Future research should aim to further validate the CPTSD diagnosis in larger samples of adolescents with refugee backgrounds.

Objectives: Research on complex posttraumatic stress disorder (CPTSD) among individuals with refugee backgrounds is limited, particularly in adolescents, and its validity in this group remains underexplored. The aim of this study was to assess the prevalence and discriminant validity of posttraumatic stress disorder (PTSD) and CPTSD, as well as the risk factors for CPTSD, in a community sample of adolescents with refugee backgrounds residing in Sweden.

Methods: The study included 296 adolescents with refugee backgrounds recruited nationwide in Sweden. Participants were aged 12-25 years, 45.3% were female, and 23.7% had unaccompanied status. Probable diagnoses were evaluated according to DSM-5 and ICD-11 criteria using questionnaires. Latent class analysis was employed to examine the discriminant validity of PTSD and CPTSD, while logistic regression analysis was used to explore risk factors for CPTSD.

Results: The findings indicated that 24.1% had a probable diagnosis of PTSD according to the DSM-5. For ICD-11, the equivalent proportions were 7.1% for PTSD and 10.8% for CPTSD. The probable diagnostic rates for DSM-5 PTSD were significantly higher than ICD-11 PTSD and CPTSD. Latent class analysis identified three distinct classes: Low symptoms (46.9%), PTSD (29.6%), and CPTSD (23.6%). Compared to the PTSD class, membership in the CPTSD class was predicted by exposure to more types of violence and child maltreatment. It was also associated with higher posttraumatic stress symptoms, worse general functioning, poorer mental well-being, increased suicidal ideation, more treatment-seeking behavior and greater comorbidity.

Conclusions: This study found a high prevalence of PTSD and CPTSD among adolescents with refugee backgrounds living in Sweden. Distinct classes aligned with the ICD-11 formulation of PTSD and CPTSD were identified, with exposure to more types of violence and child maltreatment emerging as key risk factors for CPTSD. Key messages • Adolescents with refugee backgrounds living in Sweden may be highly affected by PTSD and CPTSD. • The ICD-11 distinction between PTSD and CPTSD is likely valid for adolescents with refugee backgrounds. Exposure to more types of violence and child maltreatment may be risk factors for CPTSD.

The Nordic welfare model is often used as an example for the promotion of health and wellbeing, even in vulnerable groups of children, such as refugees. Nonetheless, there are no published reviews on resilience and/or risk and protective factors for physical and mental health among refugee children living in Nordic countries. In this systematic review, we identified 5181 studies on the topic, screened titles, and abstracts, viewed 632, and finally included 26 studies. These studies described 18 samples with a total of 34,080 individuals ranging in ages 0–18 years. Overall, the studies were of good quality. Nearly all studies assessed adversity. Six studies reported physical health outcomes and all studies mental health outcomes, most often post-traumatic stress disorder and anxiety. None explicitly studied resilience. While we found that age and sex are the most frequently studied  risk- and protective factors, findings are inconclusive, since the direction of the associations was different in the different studies. This systematic review indicates that there is still a need for well-designed and -powered studies using clear definitions of key study concepts to examine health outcomes and resilience among refugee children in Nordic countries.

Studies indicate that individuals with current or former experiences of being a refugee are more likely to have experienced adverse events, like violence, and face mental health challenges in their host countries. After arrival in host countries, people with refugee experiences often confront various post-migration adversities like discrimination. However, research in this area has been hampered by limitations and a lack of child perspective. This thesis aims to examine both pre-, peri- and post-migration factors that impact the health, well-being, and experiences of children and adults who have migrated to Sweden as refugees.

Article I is a systematic review of Nordic studies on resilience, risk and protective factors for health in refugee children. We found that adversity was consistently identified as a risk factor for poorer health, but otherwise, findings were inconsistent. No study explicitly examined resilience. Article II examined the relationship between refugee experiences in childhood and health in adulthood in a nationally representative sample. The study found no clear link between childhood refugee experiences and worse health in adulthood. Article III investigated differences in health and health-related behaviours between sexual and gender minority refugees, migrants, and Swedish/Western-born individuals and their heterosexual peers. We found higher rates of mental and general ill-health and worse health-related behaviours in sexualand gender-minority individuals regardless of whether they were refugees, migrants, or Swedish and Western-born. Surprisingly, our study revealed no indications of inferior health outcomes among refugee or migrant sexual and gender minorities in comparison to Swedish/Western-born individuals. Article IV investigated mental health and functioning of refugee children and young adults in Sweden. We found lower rates of mental ill-health than previously reported in other studies on refugee children and young adults. Unaccompanied refugee children had worse outcomes than those accompanied. Article V explored the experiences of refugee children and their agency in constructing their own lives during migration. We found that child refugees express a longing for a good life and demonstrate active agency despite facing diverse challenges.

Overall, the prevalence rates for mental ill-health were lower than in many previously published studies even though the prevalence rates are higher than in many studies published on the general population of children in Sweden. Further, the results suggest that these effects are transient. The studies highlight the need to focus on the heterogeneity of the population, for example, by addressing factors that pose a risk to health and rights in refugee children and adults. Moreover, the research emphasizes the importance of adopting a perspective that simultaneously acknowledges both the strengths and vulnerabilities of refugee children. Additionally, this perspective should recognize individual differences, rights, and goals.

Tidigare forskning har visat att personer med nuvarande eller tidigare erfarenheter av flykt löper större risk att erfara negativa händelser och att drabbas av psykisk ohälsa. Efter flykten kan även motgångarna fortsätta i det nya landet exempelvis i form av diskriminering. Forskningen inom detta område har dock begränsats av metodologiska brister och en avsaknad av barnperspektiv. Denna avhandling syftar till att belysa både pre- , peri- och postmigratoriska faktorer som påverkar hälsa, välbefinnande och upplevelser hos barn och vuxna som har flytt till Sverige.

Artikel I är en systematisk översikt av studier om resiliens och riskoch skyddsfaktorer för fysisk och psykisk hälsa hos barn på flykt i de nordiska länderna. Vi fann att olika typer av negativa livshändelser genomgående identifierades som en riskfaktor för försämrad hälsa, medan resultaten för andra faktorer var inkonsekventa. Ingen studie undersökte uttryckligen resiliens. I artikel II undersöktes sambandet mellan att ha flytt i barndomen och senare hälsoutfall som vuxen i ett nationellt representativt urval. Studien fann ingen tydlig koppling mellan erfarenhet av flykt i barndomen och negativa hälsoutfall i vuxen ålder när man kontrollerade för störvariabler. Artikel III undersökte hälsa och hälsorelaterade beteenden hos flyktingar och migranter i jämförelse med de som är födda i Sverige eller annat land i väst som identifierar sig som homosexuella, bisexuella, transpersoner, personer med queera uttryck och identiteter. Vi fann högre nivåer av ohälsa och hälsorelaterade beteenden för sexuella och könsminoriteter oavsett om man var flykting, migrant eller född i Sverige eller annat land i väst. Vi fann dock inga bevis för sämre hälsa hos flyktingar- eller migranter jämfört med de födda i Sverige eller annat land i väst. Artikel IV undersökte förekomst av psykisk ohälsa och funktionsförmåga hos barn på flykt och unga vuxna på flykt i Sverige. Vi fann lägre förekomst av psykisk ohälsa än vad som tidigare rapporterats i andra studier av barn och unga vuxna på flykt. Ensamkommande barn hade sämre hälsa än barn som anlänt i familj. Artikel V utforskade barns upplevelse och deras förmåga att forma sina egna liv under flykten. Vi fann att barn som befinner sig på flykt, trots att de står inför olika utmaningar, uttrycker en längtan efter ett gott liv och visar aktiv handlingskraft.

Sammantaget var prevalensen av psykisk ohälsa lägre än vad som observerats i många tidigare publicerade studier, även om den fortfarande var högre än många studier om barn födda i Sverige. Vidare tyder resultaten på att dessa effekter kanske inte är permanenta. Studierna belyser behovet av att uppmärksamma gruppens heterogenitet avseende psykisk ohälsa, exempelvis genom att hantera faktorer som utgör risker för ohälsa och rättigheter hos både barn och vuxna på flykt. Slutligen betonar forskningen vikten av ett nyanserat perspektiv som erkänner både sårbarhet och motståndskraft, och som också respekterar dessa barns rättigheter, kompetenser, mål och styrkor.

Children with refugee backgrounds are often exposed to violence and other adverse experiences with well-known detrimental consequences on mental health. However, the current group of approximately 40 million child refugees is heterogeneous, stressing the importance of first-person perspectives in understanding children's unique experiences and needs related to the migration process. Identifying contextual factors promoting health and resilience is also essential. For instance, the roles children play as active agents in constructing their own lives and adapting to different environments are poorly described in contemporary research on child refugees and their mental health. To address these knowledge gaps, we conducted qualitative interviews with a reflexive thematic analysis with eighteen children with refugee backgrounds in Sweden. This resulted in two main themes: Longing for a good life that cannot be taken for granted and Challenged agency and changing rights. The narratives indicate that children, although exposed to different challenges in different migration phases and based on gender and asylum status, have experiences of ordinary childhood with a desire for a good life with prospects. The results also show that children execute active and adaptable agency that is impacted by various factors. Reaching the full age appears to be a confusing and ambivalent transition due to changes in rights. The results pinpoint several possibilities to address factors that pose a risk to health and restrictions of rights among child refugees.

The population of internationally forcibly displaced people, which includes refugees and asylum seekers, is large and heterogeneous. To determine the varying reasons for and experiences during the migration journey, including exposure to violence and health- and integration-related needs, there is an urgent need to involve children with refugee backgrounds in research and development activities. This chapter describes a model for the child participatory approach developed at Barnafrid, a national competence centre on violence against children at Linköping University in Sweden. The model has been tested in the Long Journey to Shelter study, which investigated exposure to violence and its consequences on mental health and functional ability among forcibly displaced children and young adults. As part of this project, we conducted workshops with children (n = 36, aged 13–18 years) to design a questionnaire on exposure to community violence in the country of resettlement. Experiences recounted during the child participatory workshops indicated no problems involving newly arrived children with refugee backgrounds and Swedish-born adolescents in research activities. However, attention should be paid to proper preparatory work and the need for adjustments. We discuss the results in light of other studies on refugee child participation, the United Nations Convention on the Rights of a Child and diversity considerations.

Studies on experiences of migration in childhood and subsequent health in adulthood report conflicting results. While there is limited research on the long-term health outcomes of refugee children as they transition into adulthood, it is often observed that refugee children experience adverse health conditions upon their arrival in the host country. We examined whether adults with a childhood refugee experience were more likely to have poorer mental health, general health, and risk-behaviours compared to non-refugee migrants and Swedish-born peers We included a nationally representative sample of 18-64-year-olds who answered the Swedish National Public Health survey in 2018 or 2020. Using official register data, we categorized individuals as: 1) refugees in childhood (<age 18 years); 2) migrants in childhood; or 3) Swedish-born. Associations between childhood status (refugee, migrant, or Swedish-born) and all outcomes in adulthood were analyzed using logistic regression. The final model was adjusted for age, sexual- and gender-minority (SGM) identity, and stratified by sex. We also analysed the above and all outcomes stratified by age (18–25, 26–64), adjusted for sex and SGM-identity. We found that a childhood refugee experience was not associated with worse self-rated general or mental health, or more risk behaviours in adulthood, compared to non-refugee migrants or Swedish-born individuals. Additionally, adults with a childhood refugee experience had lower odds of at-risk alcohol use and substance use than Swedish-born peers. In general, a childhood refugee experience was not associated with worse self-rated health or risk behaviours in adulthood when considering age and sexual- and gender-minority status.