Explainer: what is resignation syndrome and why is it affecting refugee children?

Reports from Nauru are raising concerns about an outbreak of a severe trauma-related mental disorder known as traumatic withdrawal syndrome, or resignation syndrome.

Recent legal action resulted in urgent medical evacuation of a child in an unconscious state following a progressive social withdrawal and failure to speak, eat or drink. The child was unresponsive, dehydrated and at risk of death from the physical complications of this extreme state.

Medical experts noted there are no adequate medical or mental health facilities on Nauru to treat this condition. This outbreak raises serious questions about the impact of our offshore facilities for vulnerable populations and the capacity of the current system to respond adequately.

Read more: FactCheck Q&A: Has the number of asylum seeker children in detention declined?

What is resignation syndrome?

Resignation syndrome is a rare psychiatric condition that presents as a progressive social withdrawal and reluctance to engage in usual activities such as school and play. Children may become isolated and appear depressed and irritable. They frequently resist others’ attempts to support or encourage them to engage.

As the condition progresses, the child may stop talking and isolate themselves in bed, and may stop eating and drinking. The most serious stage of the disorder is when the child enters a state of profound withdrawal and is unconscious or in a comatose state.

This appears to be a state of “hibernation” in response to an intolerable reality. They are unresponsive, even to pain. They appear floppy, without normal reflexes, and require total care, including feeding and intravenous fluids as they risk kidney failure and death from complications of immobility, malnutrition and dehydration.

This is a life-threatening condition needing high level medical care.

Various names have been used to describe this condition since it was originally described in children showing a retreat from external reality. Terms previously used for this condition include depressive devitalisation and pervasive arousal-withdrawal syndrome. Both point out the withdrawal and lack of response.

Many children with the condition were experiencing trauma, including environmental stress and psychiatric disorders in parents and carers. Common features are the ongoing nature of the trauma and the child’s feelings of hopelessness and helplessness in the face of inescapable stress.

In these situations, children appear to give up or resign themselves to an overwhelming situation and cope with this by a profound disengagement or withdrawal.

Read more: Report calls for royal commission into children in immigration detention: experts respond

Trauma in immigration detention

There are many factors contributing to trauma for child asylum seekers and refugees. Some are traumatised by experiences in their countries of origin and the process of fleeing. Experiences in detention and processing centres also directly contribute to feelings of lack of safety, anxiety and confusion.

Children are exposed to distress and despair in others around them and in their own parents. Some experience separation from important attachment figures. These traumas contribute to high rates of distress and mental health problems. As periods of time spent in these environments increase, mental health deteriorates.

In Nauru currently, some children may have been there for five years with little or no hope of finding a place of safe resettlement. Their mental health problems are compounded by a lack of support and mental health services and limited access to family support. Depression in parents further isolates vulnerable children.

Traumatic withdrawal has been seen in groups of asylum seeker and refugee children in European settings where families lack protection and resettlement options. The largest studied group in Sweden found seriously physically ill, withdrawn children requiring hospitalisation and high level care.

In Australia, similar cases have been seen in children exposed to the distress of immigration centres. Questions are now being asked about the possible development of an increase in cases on Nauru and how best to respond to this.

Read more: Are doctors ethically obliged to keep at-risk children out of detention?

Treatment

Treatment of severe withdrawal is urgent, and can only be undertaken in a hospital setting with specialist paediatric teams and capacity for nutritional support, intravenous rehydration and monitoring of kidney and other bodily functions. Children may remain in a comatose state for weeks and gradually emerge. They require mental health specialists to create feelings of safety and security.

Parents require treatment for their own mental health issues and support in providing care for their child. Families who are overwhelmed by stress may require longer-term counselling and trauma treatment.

The rate of recovery varies, but some children need support for 12 months. A crucial issue is to support the family in finding a safe haven and resolution of resettlement issues. For the current Nauru families, the lack of options and a loss of hope for the future is a major risk for mental breakdown and traumatic withdrawal.

The intensive and specialist treatment needed cannot be provided in Nauru.

Medical and mental health professionals and refugee rights groups are all calling for urgent care for these children. There’s serious concern about the use of Nauru as a processing centre and the adequacy of health services.

With government wanting to maintain policies to deter asylum seekers and prevent entry to Australia, they’re seemingly accepting harm done to those in limbo. In the middle of this debate are children who know nothing of politics, but know they are abandoned without a future. The moral imperative is to rethink current policy, and to act urgently to protect children and save lives.

Louise Newman is affiliated with the human rights group Doctors for Justice and is a past advisor to the Department of Immigration on the mental health of asylum seekers and refugees.