1: Schematic representation of the process for asylum seekers without a valid entry visa for obtaining a Temporary Protection Visa*

* Information from Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) website (www.immi.gov.au/facts/index.htm).

†A Temporary Protection Visa entitles the holder to: temporary residence for 3 years; limited Welfare and resettlement assistance; access to Medicare benefits; no access to government English lessons; no family reunion; cannot leave and re-enter Australia (www.immi.gov.au/facts/64protection.htm).

2: Clinical record — a 6-year-old boy with recurrent refusal to eat or drink

A 6-year-old boy presented to the Emergency Department of the Children’s Hospital at Westmead in May 2001. He was accompanied by his mother, infant sister and a uniformed officer from the Villawood Detention Centre. His mother reported, via an interpreter, that he had refused to talk or eat for the last 4 days, but that she had managed to coerce him to take small amounts of liquid. This episode began after the boy observed a man cutting his wrists (in the boy’s words “killing himself”) at the detention centre.

The family was of Middle Eastern origin and belonged to a small religious group regarded as heretics in their country of origin. They had arrived in Australia by boat in March 2000, and then spent 11 months at Woomera Detention Centre and almost 3 months at Villawood Detention Centre. The younger child was born in detention. The family had been refused refugee status at all the initial stages of processing (Box 1), and were making a final-resort appeal to the Minister for Immigration and Multicultural and Indigenous Affairs for humanitarian consideration, a process seldom successful. The chronology of events is shown in Box 3.

For 6 months before presentation, the boy had withdrawn from play with other children, and had been drawing similar repetitive images (Box 4). He became startled when he heard two-way radios used by detention centre officers. His mother described a chronic history of bedwetting and nightmares, which began after he witnessed riots and people setting themselves alight at the Woomera Detention Centre. Before this, he had been healthy, with normal development, although he had refused to eat and talk for half a day after one incident at Woomera.

On examination, the boy was pale, listless and had clinical signs of mild dehydration. His height and weight were on the 75th and 50th percentiles, respectively. He was admitted to hospital for 6 days during which he gradually resumed talking and eating, although his bedwetting and nightmares persisted. Mental-state examination revealed a dull affect with slow, quiet speech and an anxious penetrating stare. He was unable to verbalise any wishes for the future, and said there was no point in making friends, because they all left while he remained in the “camp”. He described bad dreams about officers taking his father to gaol, and people cutting children with glass. The only drawing he produced in which the figures were not covered with bars was one of “the man who cut himself” (Box 5). He displayed extreme separation anxiety when his father departed after visits.

He was assessed by the child psychiatry team as having acute on chronic post-traumatic stress disorder, fulfilling the Diagnostic and statistical manual of mental disorders (DSM-IV) criteria6 in that: (i) he was exposed to traumatic events; (ii) his response involved intense fear and helplessness; (iii) he had persistent re-experiencing of his trauma (through nightmares and with various triggers); (iv) he had a numbing of general responsiveness (with social withdrawal and refusal to speak or eat); and (v) he had symptoms of increased arousal (resulting in disturbed sleep).

The differential diagnosis included depression, but this was considered less likely when many of his symptoms resolved within his short admission.

He was discharged back to the detention centre after 6 days in hospital, with follow-up arranged with the centre psychologist and hospital team. The discharge summary, copied to the Centre Manager of Villawood Detention Centre, stated that he was at high risk of recurrence unless a more normal environment could be provided, that he should remain together with his family, and that access to a school with stable peer relationships would be important.

In addition, it was asserted that the uncertainty about his family’s future was likely to be perpetuating his symptoms.

Six days later, the boy re-presented to the hospital with refusal to eat or drink and mild dehydration. His readmission necessitated a series of complex interagency negotiations in an attempt to provide a reasonable standard of care. The negotiations involved Australasian Correctional Management (the agency managing the detention centres), Villawood Detention Centre management and health services teams, and various case managers assigned by the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA), and covered coordinating parental visits and family counselling sessions, interpreters, visitors, culturally appropriate food, and possible discharge arrangements. Other difficulties included the lack of a structured daily program (as an asylum seeker, he was not eligible to attend the hospital [Department of Education] school), the social alienation of the child and family within the ward, the emotional distress experienced by the interpreters encountering the family situation, and dealing with the dilemma of whether the hospital should be acting as a place of safety for the child. Since protection from trauma was the most important part of treatment, discharge to the detention centre was likely to re-traumatise him.

During the 8-week hospital stay, the boy became increasingly frustrated and difficult to contain because of his limited access to recreational, educational and other stimulating activities. He resented that detention centre officers were in close proximity at all times. His separation anxiety was fuelled by unpredictable parental visits, and the alternating arrangement of one parent staying with him. Multiple case planning meetings involving Villawood and DIMIA representatives failed to produce a resolution to the dilemma of a discharge placement for the child. The municipal office of the Department of Community Services was unable to intervene. There was no alternative except to discharge him back to the detention centre.

The child now entered a phase of repeated presentations to the emergency department every few days over a period of 4 weeks, with a pattern of food refusal and dehydration. On each occasion, he required nasogastric rehydration and stayed for 1–2 days. His mother described how he would become pale, quiet and sweaty when he saw the fences that featured in his drawings. After six such presentations, he was readmitted for nutritional review as he had lost 3 kg. Two weeks later, his parents agreed to DIMIA’s offer of discharge to foster carers, and DIMIA arranged Department of Community Services approval of the nominated carer.

DIMIA declared the boy’s new home and school a “place of detention”, and engaged a private psychotherapist. He was reported to have frequent emotional outbursts, disrupted sleep and difficulty coping with separations from his family after weekend access. The foster carers were ill-prepared for dealing with his distress, and the placement was continuously under threat.

With no placement alternative, DIMIA granted permission for the boy to live with his mother and sister in the community. Seven months later, his father joined them when the Federal Court allowed re-application to the Refugee Review Tribunal and Temporary Protection Visas were granted. Of interest is that no new evidence was presented, compared with the family’s original application. These visas are valid for 3 years, and the future thereafter is uncertain for the family.

Although an eager learner at school, the boy currently has regular nightmares and is fearful that his family may be returned to the “camp”. At the time of publication, the family are being seen by therapists at a state-funded trauma counselling service.

3: Chronology of events related to the child

4: The child’s drawings were dominated by the fence

“They’re crying. They’re all scared. Scared of officers — all of them” (the child’s description of the people in the foreground).

“It’s a stick. They bash up children with that wood” (the child’s description of the person in the background).

5: The child’s drawing after seeing a detainee cut his wrists

“The man who cut himself”