Children and forced displacement

Children represent 39% of FDP. ¹ Forcibly displaced children (FDC) living in refugee camps or shelters often have physical, emotional, educational, neuropsychiatric and developmental needs. FDC are at higher risk of undernutrition, infectious diseases, child labour, child marriage, persecution, recruitment to armed groups, kidnapping and physical and/or sexual violence. ³ Such experiences are associated with higher risks of severe psychological and physical sequelae and may lead to lifelong invalidation and handicap. ³ Also, among refugees and asylum seekers, there is a high prevalence of epilepsy. ^{Reference Hallab and Sen4} The main risk factors of paediatric epilepsy in LMICs are perinatal complications, infectious diseases of the central nervous system and traumatic brain injuries. Although post-traumatic epilepsy secondary to war-related injuries might be an additional factor, it is possible that conflict-associated psychological distress also contributes to the high incidence of seizures in this cohort. ^{Reference Hallab and Sen4}

Emotional burdens of forced displacement and seizure risk in children

A study exploring new seizure onset in FDC during the war in the Balkans found that the incidence of epilepsy was quadrupled in children originating from war-affected areas compared with those who did not have such an experience. ^{Reference Bosnjak, Vukovic-Bobic and Mejaski-Bosnjak5} Biological studies have explored surrogate markers of stress. Hair cortisol levels, for example, can be significantly higher in children with a first epileptic seizure than in those without epilepsy, indicative of a higher level of stress during the 3 months prior to seizure onset. ^{Reference Stavropoulos, Pervanidou, Gnardellis, Loli, Theodorou and Mantzou6} A large longitudinal study in Taiwan of 31 405 adult patients showed that people with post-traumatic stress disorder (PTSD) are at significantly higher risk of developing epilepsy than healthy controls (2.63 v. 0.33 per 1000 person-years, p < 0.001). ^{Reference Chen, Wei, Bai, Hsu, Huang and Su7}

Reports from the United Nations Relief and Works Agency for Palestine Refugees in the Near East show that the incidence of schooled children affected by epilepsy increases directly following armed conflicts. Also, the prevalence of epilepsy in newly schooled children is around five times higher than the total prevalence in schooled children. ^{Reference Hallab and Sen4} This might be because children with epilepsy are at higher risk of leaving school early and, consequently, remaining incompletely educated. In addition to the debilitating effect of recurrent seizures, the cognitive impairment associated with epilepsy, and the lack of adequate neuropsychological support, might explain, at least partly, the lower rates of education among children with epilepsy. ^{Reference Hallab and Sen4}

Psychological distress may be associated with both epileptic seizures and functional seizures (also known as psychogenic non-epileptic seizures or dissociative seizures). ^{Reference Binzer, Stone and Sharpe8} Functional seizures are events that may have clinical characteristics similar to seizures but that do not associate with abnormal neuronal activity. Although all of these factors contribute to an increased risk of seizures in FDP, epilepsy remains a highly stigmatised condition. In some cultures, seizures are interpreted as demonic possession, a curse, transmissible illness or some form of madness. Affected persons might be denied access to education, rejected from jobs, banned from marriage or experience multiple other forms of discrimination, segregation and isolation. Children, in particular, may experience impairment in their physical, emotional and societal well-being, leading to exclusion and isolation. ^{Reference Coates, Hudson, Schröder, Frow and Frayne9} Double stigma – the phenomenon when two highly stigmatised conditions such as epilepsy and psychiatric disorders (for example, depression, anxiety, PTSD) coexist – might further increase burdens and lead to a vicious circle of co-aggravation of both conditions. ^{Reference Mula and Kaufman10} All these factors can lead to underreporting, especially if there is a perception that declaring a diagnosis of epilepsy may prejudice asylum claims. ^{Reference Hallab and Sen4} Because seizures are treatable, refraining from disclosing the diagnosis may leave FDC without access to the medications necessary to control epileptic seizures and the psychological help that may benefit functional seizures. ^{Reference Hallab and Sen4}

Current challenges

Conflicts currently embroiling several countries and regions, including Ukraine, ^{Reference Kumar, James, Hargreaves, Bozorgmehr, Mosca and Hosseinalipour11} Afghanistan, ^{Reference Sen, Hallab, Cross, Sander and Newton12} the Middle East ^{Reference Ashour, Jlambo and Abuzerr13,Reference Nadel, Lightstone, Moshal, Taylor and Sorene14} and Africa, ^{Reference Hassan, Abuassa and Ibrahim15} have resulted in some of the largest migrations seen in modern history. Many of those fleeing conflict are children who may be especially vulnerable to psychological trauma and seizures, whether epileptic or psychogenic in origin. The Committee on Ethics and Task Force on Migration and Mental Health of the European Psychiatry Association has recently highlighted the ethical dilemma and concerns related to the mental health of migrants, refugees and asylum seekers. ^{Reference Schouler-Ocak, Bäärnhielm, Tarricone, Adorjan, Samochowiec and Chumakov16} Depression, anxiety, psychosis, PTSD, addiction and behavioural disorders at younger ages are highly prevalent among FDP. Limited healthcare access, delayed treatments, stigma, lack of ‘cultural competence’, racism and other forms of discrimination are major risk factors for increasing the incidence of mental health disorders and worsening their outcome. Political, social and legal stressors in post-migration stages can impair the integration process and lead to a chronification of the mental and physical health issues of displaced persons. ^{Reference Schouler-Ocak, Bäärnhielm, Tarricone, Adorjan, Samochowiec and Chumakov16}

During armed conflicts, access to healthcare structures may be interrupted owing to logistics, security issues and the destruction of healthcare facilities, whether intentional or accidental. During the ongoing war in Ukraine, for example, paediatric healthcare structures seem to have been specifically targeted, as have field hospitals. ^{Reference Sennersten, Frogh, Påhlsson, Wladis, Alvinius and Bäckström17} Disruptions in electricity and shortages in food and medication supply further compromise the delivery of healthcare, as does the lack of healthcare workers. Migration, injuries, mortality, war-related mental health issues and interruption of studies in medical schools all dramatically reduce skilled healthcare worker availability. ^{Reference Sennersten, Frogh, Påhlsson, Wladis, Alvinius and Bäckström17}

Poor infrastructure in receiving countries and a lack of understanding of epilepsy, or its specific connotations, in displaced societies can further impair access to treatments. In evacuation centres, overcrowding, limited hygiene and emotional tensions leading to increased cases of physical-, sexual- and gender-based violence present further traumatic conditions to children, particularly given their intrinsic vulnerability and limited capacity for self-defence. ^{Reference Sennersten, Frogh, Påhlsson, Wladis, Alvinius and Bäckström17}

Potential solutions

Ensuring equitable access to healthcare structures and adequate treatment for all FDC with seizures needs to be prioritised. A milestone was achieved following the inclusion of levetiracetam in the World Health Organization Essential Medicines List. ^{Reference Sen, Chowdhary, Hallab, Romoli, Cross and Cappello18} Much still needs to be done. The development of more portable electroencephalogram systems has shown promising results in terms of deployment feasibility and the ability to detect pathology. ^{Reference Sen, Newton and Ngwende19} The use of telemedicine to ensure continuous collaboration between healthcare providers onsite and experienced doctors abroad allows valuable academic and emotional support while enabling the empowerment of local resources. Organising regular training sessions dedicated to persons in charge of FDC might reduce the emotional burdens associated with both trauma-related psychiatric disorders and seizures, as well as improving the quality of healthcare. ^{Reference Sen, Newton and Ngwende19} Similarly, deploying culturally adapted age-specific offline-compatible digital mental health interventions might help reduce stress-related disorders in children, provide a stigma-free understanding of their mental and physical health and ensure a higher adherence to treatment. ^{Reference Iriqat, Rocha-Jimenez and Romero de la Cruz20}

Differentiating functional seizures from epileptic seizures can be difficult. Better appreciation that psychological comorbidity can contribute to both epileptic and functional seizures may, however, offer opportunities to help reduce seizure burden. Underpinning all such endeavours with openness, and enabling FDC with epilepsy or functional seizures to declare a pre-existing diagnosis without fear of prejudice, are also essential.

A key intervention to improving mental health and seizure-related risks in FDC might be raising awareness among accompanying forcibly displaced adults. Host communities need to be educated about mental health, trauma-related health issues, the biological nature of seizures and the effectiveness of available treatments. People with epilepsy, their families and local care teams need to know how to avoid provoking factors for seizures: for example, ensuring regular sleep, having a balanced diet, being enabled to take medication regularly, avoiding alcohol excess and not taking recreational substances.

Policies and regulations acknowledging the particular needs of FDC with seizures and securing their rights in healthcare, education, safety and protection are essential. Responsibility lies with all relevant stakeholders so that such changes are delivered, adhered to and sustained.

More research is clearly needed to evaluate more thoroughly the risks of seizures in FDC. Research should be culturally contextualised. For example, receiving healthcare systems will need to better understand the causes of epilepsy in refugees, as well as how epilepsy may be perceived in those who have been displaced. It will be crucial to mitigate potential provoking factors for seizures, including the assurance of good access to anti-seizure medications. Promoting appropriate medical management of acute events, screening for tropical infections and substantially improving preventive perinatal healthcare will also help reduce seizures and their impact on FDC. Such interventions can all be delivered at low cost and, with a world in such turmoil, demand prompt attention.