European Child & Adolescent Psychiatry

, Volume 22, Issue 4, pp 251–258 | Cite as

Pervasive refusal syndrome among inpatient asylum-seeking children and adolescents: a follow-up study

  • Carl-Magnus ForslundEmail author
  • Björn Axel Johansson
Brief Report



Pervasive refusal syndrome (PRS) is a rare but severe condition, characterised by social withdrawal and a pervasive active refusal in terms of eating, mobilisation, speech and personal hygiene. PRS has been proposed as a new diagnostic entity in child and adolescent psychiatry, although the diagnostic criteria are debated. In the past 10 years there has been an increase in PRS symptoms among asylum-seeking children and adolescents in Sweden. Here, we describe five cases of PRS among asylum-seeking children and adolescents.


Three females and 2 males, 7–17 years of age with the clinical picture of PRS, treated as inpatients at the Department of Child and Adolescent Psychiatry, Malmö, Sweden, 2002–2010, were analysed on the basis of their medical records. Subjects were diagnosed using previously suggested criteria for PRS. At follow-up, a semi-structured interview focusing on the inpatient stay and current status was performed. The subjects were assessed with Global Assessment of Functioning (GAF) and self-rating questionnaires regarding depression and post-traumatic stress disorder (PTSD).


The pattern of refusal varied among the five subjects. All subjects originated from former Soviet republics, indicating a possible cultural factor. Mean period of inpatient treatment was 5 months. All subjects received intense nursing and were treated with nasogastric tube feeding. Parents were involved and were given support and instructions. All subjects gradually improved after receiving permanent residency permits. Depression and PTSD were co-morbid states. At follow-up, 1–8 years after discharge, all subjects were recovered.


Although a severe condition, our five cases suggest a good prognosis for PRS among asylum-seeking children and adolescents.


Pervasive refusal syndrome Asylum-seeking Adolescents Follow-up Prognosis 



We wish to express our gratitude towards the subjects and their families for their participation in the study. We also wish to thank Leslie Walke for linguistic help. Grants from Kronoberg County Council, FoU Kronoberg, Växjö, Sweden, reference number 24/2011, were received.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Lask B, Britten C, Kroll L, Magagna J, Tranter M (1991) Children with pervasive refusal. Arch Dis Child 66(7):866–969PubMedCrossRefGoogle Scholar
  2. 2.
    Jaspers T, Hanssen GM, van der Valk JA, Hanekom JH, van Well GT, Schieveld JN (2009) Pervasive refusal syndrome as part of the refusal–withdrawal–regression spectrum: critical review of the literature illustrated by a case report. Eur Child Adolesc Psychiatry 18(11):645–651PubMedCrossRefGoogle Scholar
  3. 3.
    Thompson SL, Nunn KP (1997) The pervasive refusal syndrome: the RAHC experience. Clin Child Psychol Psychiatry 2:145–165CrossRefGoogle Scholar
  4. 4.
    American Psychiatric Association. DSM-5 Development. Psych. Org Accessed 15 May 2012
  5. 5.
    Lask B (2004) Pervasive refusal syndrome. Adv Psychiatr Treat 10:153–159CrossRefGoogle Scholar
  6. 6.
    Nunn KP, Sl Thompson (1996) Pervasive refusal syndrome: learned helplessness and hopelessness. Clin Child Psychol Psychiatry 1:121–132CrossRefGoogle Scholar
  7. 7.
    Bodegård G (2005) Life threatening loss of function in refugee children: another expression of pervasive refusal syndrome? Clin Child Psychol Psychiatry 10:337–350CrossRefGoogle Scholar
  8. 8.
    Wright B, Beverley D (2011). Pervasive refusal syndrome. Clin Child Psychol Psychiatry. doi: 10.1177/1359104511403680 (6 July, Epub ahead of print) 6 July
  9. 9.
    Guirguis S, Reid C, Rao S, Grahame V, Kaplan C (2011) Follow-up study of four cases of pervasive refusal syndrome. Eur Child Adolesc Psychiatry 20(5):271–274PubMedCrossRefGoogle Scholar
  10. 10.
    Christensen AM, Thelle T (2011). Afvisningssyndrom hos en 12-årig dreng (Refusal syndrome in a 12-year-old boy). Ugeskr Laeger 18;173(16–17):1214–1215Google Scholar
  11. 11.
    Bodegård G (2004) Asylsökande flyktingbarn utvecklar livshotande funktionsbortfall (Asylum-seeking children develop a life-threatening lack of function). Läkartidningen 101:1696–1699PubMedGoogle Scholar
  12. 12.
    Bodegård G (2005) Pervasive loss of function in asylum-seeking children in Sweden. Acta Paediatr 94(12):1706–1707PubMedCrossRefGoogle Scholar
  13. 13.
    Aronsson B, Wiberg C, Sandstedt P, Hjern A (2009) Asylum-seeking children with severe loss of activities of daily living: clinical signs and course during rehabilitation. Acta Paediatr 98(12):1977–1981PubMedCrossRefGoogle Scholar
  14. 14.
    Von Folsach LL, Montgomery E (2006) Pervasive refusal syndrome among asylum-seeking children. Clin Child Psychol Psychiatry 11(3):457–473CrossRefGoogle Scholar
  15. 15.
    Heptinstall E, Sethna V, Taylor E (2004) PTSD and depression in refugee children: associations with pre-migration trauma and post-migration stress. Eur Child Adolesc Psychiatry 13(6):373–380PubMedCrossRefGoogle Scholar
  16. 16.
    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders—DSM-IV-TR. American Psychiatric Association, Washington, DCGoogle Scholar
  17. 17.
    Bondolfi G, Jermann F, Rouget BW, Gex-Fabry M, McQuillan A, Dupont-Willemin A, Aubry JM, Nguyen C (2011) Self- and clinician-rated Montgomery–Asberg Depression Rating Scale: evaluation in clinical practice. J Affect Disord 121(3):268–272CrossRefGoogle Scholar
  18. 18.
    McDonald SD, Calhoun PS (2010) The diagnostic accuracy of the PTSD checklist: a critical review. Clin Psychol Rev 30(8):976–987PubMedCrossRefGoogle Scholar
  19. 19.
    Personal contact with Hans Nidsjö, statistical administrator. Swedish Migration Board, Planning and Control, Norrköping, Sweden. ( Scholar
  20. 20.
    Jans T, Ball J, Preiss M, Haberhausen M, Warnke A, Renner TJ (2011) Pervasive refusal syndrome. Three German cases provide further illustration. Z Kinder Jugendpsychiatr Psychother 39(5):351–358 (quiz 359)PubMedCrossRefGoogle Scholar
  21. 21.
    Joelsson L, Dahlin K (2005). Asylprocess grogrund för apati hos vissa barn (Asylum-seeking process a breeding ground for apathy among certain children. A negative decision concerning the residence permit is often a triggering factor). Läkartidningen 102(48):3646–3650Google Scholar
  22. 22.
    Ahmadi N (2006). Asylsökande barn med uppgivenhetssymtom—trauma, kultur, asylprocess (Asylum-seeking children with symptoms of resignation—trauma, culture, asylum process). Statens offentliga utredningar SOU 2006:49. Edita, StockholmGoogle Scholar
  23. 23.
    Robjant K, Hassan R, Katona C (2009) Mental health implications of detaining asylum seekers: systematic review. Br J Psychiatry 194(4):306–312PubMedCrossRefGoogle Scholar
  24. 24.
    Swedish Migration Board (2009). Migrationsverket statistik 2009-02-18, Tabell 1 2008 (Swedish Migration Board, Statistics 2009-02-18, Table 1)Google Scholar
  25. 25.
    Ascher H, Gustavsson T (2008). Clearing conference about children with refusal symptoms. Läkartidningen 9–15;105(1–2):31–33Google Scholar
  26. 26.
    Markowitsch HJ (2003) Psychogenic amnesia. Neuroimage 20(Suppl 1):S132–S138PubMedCrossRefGoogle Scholar
  27. 27.
    Söndergaard HP, Kushnir MM, Aronsson B, Sandstedt P, Bergquist J (2012) Patterns of endogenous steroids in apathetic refugee children are compatible with long-term stress. BMC Res Notes 19(5):186CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Open Care Unit, Department of Child and Adolescent Psychiatry, Psychiatry SkåneSkåne University HospitalMalmöSweden
  2. 2.Clinical Health Promotion Centre, Department of Health SciencesLund UniversityLundSweden
  3. 3.Emergency Unit, Department of Child and Adolescent Psychiatry, Psychiatry SkåneSkåne University HospitalMalmöSweden

Personalised recommendations