Mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors

Unaccompanied refugee minors' early life narratives of physical abuse from caregivers and teachers in their home countries

The early life narratives of 34 unaccompanied refugee minors, especially their reports of interpersonal violence, were analyzed using Interpretative Phenomenological Analysis (IPA). The youth originated from eight countries, with Afghanistan, Eritrea, and Sri Lanka being the most frequent origins, and they arrived to Norway before the age of 15. Four of these youth were girls. The physical violence took place at home and/or at school and could be extremely harsh. Approximately half of the youth expressed some type of ambivalence toward the perpetrator. In analyzing how the youth understood the reasons for violence two categories of internal and three categories of external attributions were found. Several of the youth blamed their own behavior for the abuse, although such internal attributions were frequently combined with external attributions. Some different patterns of attributions emerged between home and school violence. Most of the youth placed the blame for school violence on their own behavior or that violence was part of normal school discipline. For violence at home there was a tendency to place more blame on the perpetrator (mostly fathers). Possible long-term consequences of the experiences and the different attributional styles as well as implications of the findings are discussed. Professionals should assess refugee children for interpersonal violence experiences as well as for other experiences in their home country.

Arab Adolescents: Health, Gender, and Social Context

This article reviews the evidence about adolescent health in the Arab world, against the background of social, economic, and political change in the region, and with a particular focus on gender. For the literature review, searches were conducted for relevant articles, and data were drawn from national population- and school-based surveys and from the Global Burden of Disease project. In some parts of the Arab world, adolescents experience a greater burden of ill health due to overweight/obesity, transport injuries, cardiovascular and metabolic conditions, and mental health disorders than those in other regions of the world. Poor diets, insufficient physical activity, tobacco use, road traffic injuries, and exposure to violence are major risk factors. Young men have higher risks of unsafe driving and tobacco use and young women have greater ill-health due to depression. Several features of the social context that affect adolescent health are discussed, including changing life trajectories and gender roles, the mismatch between education and job opportunities, and armed conflict and interpersonal violence. Policy makers need to address risk factors behind noncommunicable disease among adolescents in the Arab region, including tobacco use, unhealthy diets, sedentary lifestyles, unsafe driving, and exposure to violence. More broadly, adolescents need economic opportunity, safe communities, and a chance to have a voice in their future.

When community reintegration is not the best option: interethnic violence and the trauma of parental loss in South Sudan

The magnitude of violence and human loss in conflict settings often exceeds the caring capacity of traditional support systems for orphans. The aim of this study is to understand the developmental context for children experiencing armed conflict, parental loss, extreme poverty, violence and social exclusion in a setting affected by interethnic violence. This article challenges the received wisdom that community reintegration is always better than institutional provision. Using a case study employing interviews, focus groups, workshops and observations, we examined how children's experiences of armed violence and parental loss affected their mental well-being, and their relationships within their community. Emerging findings such as experienced violence and psychological distress were further investigated using a cross-sectional survey design to explore the generalisability or transferability of theories or conclusions drawn from qualitative data. Findings showed that parental loss had a major impact on children's lives in the context of armed violence. Four main outcomes of orphanhood emerged: (i) facing the situation and evading harm (feelings of rejection and stigmatisation); (ii) trauma exposure and mental health effects (associations of orphanhood with adverse mental health outcomes and the number and type of experienced trauma); (iii) dealing with psychological distress (seeking caring connections and decreased feelings of isolation); and (iv) education and acceptance (increasing knowledge, skills and attitude and being respected in their community). We discuss the role that contexts such as armed violence, parental loss and social exclusion play for children's mental well-being and their implications for psychosocial interventions and orphan care in humanitarian settings. Copyright © 2015 John Wiley & Sons, Ltd.

Perceived behavioral problems of school aged children in rural Nepal: a qualitative study

BACKGROUND

Studies on child behavioral problems from low and middle income countries are scarce, even more so in Nepal. This paper explores parents', family members' and teachers' perceptions of child behavioral problems, strategies used and recommendations to deal with this problem.

METHOD

In this study, 72 free list interviews and 30 Key Informant Interviews (KII) were conducted with community members of Chitwan district in Nepal.

RESULT

The result suggest that addictive behavior, not paying attention to studies, getting angry over small issues, fighting back, disobedience, and stealing were the most commonly identified behavioral related problems of children, with these problems seen as interrelated and interdependent. Results indicate that community members view the family, community and school environments as being the causes of child behavioral problems, with serious impacts upon children's personal growth, family harmony and social cohesion. The strategies reported by parents and teachers to manage child behavioral problems were talking, listening, consoling, advising and physical punishment (used as a last resort).

CONCLUSIONS

As perceived by children and other community dwellers, children in rural Nepalese communities have several behavioral related problems. The findings suggest that multi-level community-based interventions targeting peers, parents, teachers and community leaders could be a feasible approach to address the identified problems.

Familial separations, coping styles, and PTSD symptomatology in resettled refugee youth

Youth from refugee backgrounds have been found to experience high rates of posttraumatic stress disorder (PTSD), even after years of resettlement. The present study sought to investigate how familial separations and coping styles act as correlates of PTSD symptoms in resettled refugee youth (N = 50). Participants (Mage = 16.63; range: 12-21) completed self-report questionnaires assessing PTSD symptoms and their use of coping styles, and engaged in a semi-structured interview designed by the authors to investigate their resettlement and adaptational experiences in Australia. Youth who were separated from immediate family members demonstrated significantly more PTSD symptoms than their counterparts, and there was a relationship between avoidant coping and PTSD, although this diminished once the confound between scales was controlled for. This study found evidence for the integrity of the family unit as a correlate of PTSD in refugee youth, but no evidence of a relationship between coping style and family separations.

Facilitating support groups for siblings of children with neurodevelopmental disorders using audio-conferencing: a longitudinal feasibility study

BACKGROUND

Siblings of children with chronic illness and disabilities are at increased risk of negative psychological effects. Support groups enable them to access psycho-education and social support. Barriers to this can include the distance they have to travel to meet face-to-face. Audio-conferencing, whereby three or more people can connect by telephone in different locations, is an efficient means of groups meeting and warrants exploration in this healthcare context. This study explored the feasibility of audio-conferencing as a method of facilitating sibling support groups.

METHODS

A longitudinal design was adopted. Participants were six siblings (aged eight to thirteen years) and parents of children with complex neurodevelopmental disorders attending the Centre for Interventional Paediatric Psychopharmacology (CIPP). Four of the eight one-hour weekly sessions were held face-to-face and the other four using audio-conferencing. Pre- and post-intervention questionnaires and interviews were completed and three to six month follow-up interviews were carried out. The sessions were audio-recorded, transcribed and thematic analysis was undertaken.

RESULTS

Audio-conferencing as a form of telemedicine was acceptable to all six participants and was effective in facilitating sibling support groups. Audio-conferencing can overcome geographical barriers to children being able to receive group therapeutic healthcare interventions such as social support and psycho-education. Psychopathology ratings increased post-intervention in some participants. Siblings reported that communication between siblings and their family members increased and siblings' social network widened.

CONCLUSIONS

Audio-conferencing is an acceptable, feasible and effective method of facilitating sibling support groups. Siblings' clear accounts of neuropsychiatric symptoms render them reliable informants. Systematic assessment of siblings' needs and strengthened links between Child and Adolescent Mental Health Services, school counsellors and young carers groups are warranted.

History of Persecution and Health Outcomes Among U.S. Refugees

Our goal was to describe the forms of persecution reported by adult refugees in the U.S. and the relationships between persecution and health status among this population. Data were derived from the 2003 New Immigrant Survey, a representative sample of new U.S. lawful permanent residents. Major depression, impairment in daily activities due to pain, poor self-reported health, and declining health were described for refugees who had and had not reported persecution prior to arrival in the U.S. Health status was also examined for refugees who reported different forms of persecution. Half of refugees (46.7 %) in this sample reported that they or an immediate family member had been persecuted. One in three persecuted refugees (31.8 %) reported both incarceration and physical punishment. Major depression, pain-related impairment, poor health, and declining health were twice as common among persecuted refugees than among non persecuted refugees. Notably, despite these adverse experiences, the majority of persecuted refugees did not report poor health outcomes.

Youth mental health after civil war: the importance of daily stressors

BACKGROUND

Recent evidence suggests that post-conflict stressors in addition to war trauma play an important role in the development of psychopathology.

AIMS

To investigate whether daily stressors mediate the association between war exposure and symptoms of post-traumatic stress and depression among war-affected youth.

METHOD

Standardised assessments were conducted with 363 Sierra Leonean youth (26.7% female, mean age 20.9, s.d. = 3.38) 6 years post-war.

RESULTS

The extent of war exposures was significantly associated with post-traumatic stress symptoms (P<0.05) and a significant proportion was explained by indirect pathways through daily stressors (0.089, 95% CI 0.04-0.138, P<0.001). In contrast, there was little evidence for an association from war exposure to depression scores (P = 0.127); rather any association was explained via indirect pathways through daily stressors (0.103, 95% CI 0.048-0.158, P<0.001).

CONCLUSIONS

Among war-affected youth, the association between war exposure and psychological distress was largely mediated by daily stressors, which have potential for modification with evidence-based intervention.

Parents make the difference: a randomized-controlled trial of a parenting intervention in Liberia

BACKGROUND

The objective of this study was to evaluate the impact of a brief parenting intervention, 'Parents Make the Difference'(PMD), on parenting behaviors, quality of parent-child interactions, children's cognitive, emotional, and behavioral wellbeing, and malaria prevention behaviors in rural, post-conflict Liberia.

METHODS

A sample of 270 caregivers of children ages 3-7 were randomized into an immediate treatment group that received a 10-session parent training intervention or a wait-list control condition (1:1 allocation). Interviewers administered baseline and 1-month post-intervention surveys and conducted child-caregiver observations. Intent-to-treat estimates of the average treatment effects were calculated using ordinary least squares regression. This study was pre-registered at ClinicalTrials.gov (NCT01829815).

RESULTS

The program led to a 55.5% reduction in caregiver-reported use of harsh punishment practices (p < 0.001). The program also increased the use of positive behavior management strategies and improved caregiver-child interactions. The average caregiver in the treatment group reported a 4.4% increase in positive interactions (p < 0.05), while the average child of a caregiver assigned to the treatment group reported a 17.5% increase (p < 0.01). The program did not have a measurable impact on child wellbeing, cognitive skills, or household adoption of malaria prevention behaviors.

CONCLUSIONS

PMD is a promising approach for preventing child abuse and promoting positive parent-child relationships in low-resource settings.

We left one war and came to another: resource loss, acculturative stress, and caregiver-child relationships in Somali refugee families

Refugee families often encounter a number of acculturative and resettlement stressors as they make lives for themselves in host countries. These difficulties may be compounded by past trauma and violence exposure, posing increased risk for mental health problems. Greater knowledge is needed about protective processes contributing to positive development and adjustment in refugee families despite risk (e.g., resilience). The aims of this research were to identify and examine strengths and resources utilized by Somali refugee children and families in the Boston area to overcome resettlement and acculturative stressors. We used maximum variation sampling to conduct a total of 9 focus groups: 5 focus groups (total participants N = 30) among Somali refugee adolescents and youth, capturing gender and a range of ages (15 to 25 years), as well as 4 focus groups of Somali refugee mothers and fathers in groups (total participants N = 32) stratified by gender. Drawing from conservation of resources theory (COR), we identified 5 forms of resources comprising individual, family, and collective/community strengths: religious faith, healthy family communication, support networks, and peer support. "Community talk" was identified as a community dynamic having both negative and positive implications for family functioning. Protective resources among Somali refugee children and families can help to offset acculturative and resettlement stressors. Many of these locally occurring protective resources have the potential to be leveraged by family and community-based interventions. These findings are being used to design preventative interventions that build on local strengths among Somali refugees in the Boston area.

Stressful life experiences and mental health problems among unaccompanied asylum-seeking children

Unaccompanied asylum-seeking children aged 10-16 years (N = 93, M = 13.8, SD = 1.4, 81% boys) were assessed 6 months after arrival in Norway (SD = 5 months). Participants originated from 14 countries (63% Asia; 36% Africa). Severe life events (SLE) and psychological symptoms were measured by self-report. Participants reported a mean of 5.5 SLE (SD = 2.4), the most prevalent being death of a close person (68%), witnessing violence (63%), and war (62%). Some 54% scored above clinical cutoff on posttraumatic stress symptoms, 30% on anxiety symptoms, 20% on depressive symptoms, and 7% on externalizing symptoms. Number of SLE was associated with posttraumatic stress disorder symptoms (r =.50, p < .001), depression (r =.27, p = .020), and anxiety symptoms(r =. 34, p = .003), but not externalizing symptoms (r =.02, p = .874). None of the symptom variables were associated with age or gender. Results indicate that many unaccompanied asylum-seeking children have experienced not only war-related traumas but several other severe life adversities as well. It may thus be helpful to conduct early assessments on this group of children to assess their need for treatment or other psychosocial interventions.

Caretaker mental health and family environment factors are associated with adolescent psychiatric problems in a Vietnamese sample

Little is known about risk factors for adolescent mental health in Vietnam. The present study investigated the relationship between caretaker mental health and adolescent mental health in a cross-sectional Vietnamese sample. Primary caretakers completed measures of their own mental distress and general health status using the Self-Reporting Questionnaire-20 (SRQ-20) as well as reports of adolescent mental health using the parent version of the Strengths and Difficulties Questionnaire (SDQ). Multivariate regression models were used to examine the relationships between the caretaker and adolescent health variables. The demographic factors of age, sex, ethnicity, religious affiliation, and household wealth status demonstrated significant relationships with SDQ subscale scores. Caretaker mental health was positively associated with adolescent mental health, and this association remained significant even after accounting for other relevant demographic variables and caretaker general health status. Understanding correlates of adolescent mental health difficulties may help identify youth and families at risk for developing psychiatric problems and inform mental health interventions in Vietnam.

Mental, neurological, and substance use problems among refugees in primary health care: analysis of the Health Information System in 90 refugee camps

BACKGROUND

Population-based epidemiological research has established that refugees in low- and middle-income countries (LMIC) are at increased risk for a range of mental, neurological and substance use (MNS) problems. Improved knowledge of rates for MNS problems that are treated in refugee camp primary care settings is needed to identify service gaps and inform resource allocation. This study estimates contact coverage of MNS services in refugee camps by presenting rates of visits to camp primary care centers for treatment of MNS problems utilizing surveillance data from the Health Information System (HIS) of the United Nations High Commissioner for Refugees.

METHODS

Data were collected between January 2009 and March 2013 from 90 refugee camps across 15 LMIC. Visits to primary care settings were recorded for seven MNS categories: epilepsy/seizure; alcohol/substance use; mental retardation/intellectual disability; psychotic disorder; emotional disorder; medically unexplained somatic complaint; and other psychological complaint. The proportion of MNS visits attributable to each of the seven categories is presented by country, sex and age group. The data were combined with camp population data to generate rates of MNS visits per 1,000 persons per month, an estimate of contact coverage.

RESULTS

Rates of visits for MNS problems ranged widely across countries, from 0.24 per 1,000 persons per month in Zambia to 23.69 in Liberia. Rates of visits for epilepsy were higher than any of the other MNS categories in nine of fifteen countries. The largest proportion of MNS visits overall was attributable to epilepsy/seizure (46.91% male/35.13% female) and psychotic disorders (25.88% male/19.98% female). Among children under five, epilepsy/seizure (82.74% male/82.29% female) also accounted for the largest proportion of MNS visits.

CONCLUSIONS

Refugee health systems must be prepared to manage severe neuropsychiatric disorders in addition to mental conditions associated with stress. Relatively low rates of emotional and substance use visits in primary care, compared to high prevalence of such conditions in epidemiological studies suggest that many MNS problems remain unattended by refugee health services. Wide disparity in rates across countries warrants additional investigation into help seeking behaviors of refugees and the capacity of health systems to correctly identify and manage diverse MNS problems.

Development of mental health problems - a follow-up study of unaccompanied refugee minors

BACKGROUND

Studies have shown that unaccompanied refugee children have elevated symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, and externalizing problems. Few studies have examined change in this group's mental health symptoms after resettlement in a new country, particularly for those who arrive to a host country when being under the age of 15.

METHOD

The sample included 75 unaccompanied refugee children (mean age 16.5 years, SD =1.6; 83% boys) who settled in Norway. We examined change in the number of stressful life events, symptoms of PTSD (Child PTSD Symptom Scale; CPSS), and symptoms of anxiety, depression and externalizing problems (Hopkins Symptom Checklist; HSCL-37A) from 6 months after arrival (T1) to 1.9 years (SD =0.6) later (T2) using paired samples t-tests. Linear regression models were used to examine whether length of stay, level of education or change in the number of experienced stressful life events predicted symptom change.

RESULTS

There was a small and non-significant change in the mean scores of both symptom scales between T1 and T2, although there was considerable variation among the participants. The number of children who remained above the clinical cut-off value from T1 to T2 was as follows: 28 of 47 (59.6%) on the CPSS and eight of 16 (50.0%) on the HSCL-37A. There was a significant increase in the number of reported stressful life events from T1 to T2. An increase in reported stressful life events predicted an increase in PTSS (β =1.481, 95% CI .552 to 2.411). Length of stay, increase in stressful life events and level of education did not predict changes in the HSCL-37A.

CONCLUSIONS

There was no average change in the level of PTSS, depression, anxiety, or externalizing problems in this group of unaccompanied refugee children from shortly after arrival to nearly two years later. The large variation in change scores across informants indicates a need for monitoring the development of mental health problems and securing that the youth's primary psychosocial needs are met. The high rate of children above clinical cut-off on the symptoms scales and with suicidal ideation indicates that many may be in need of treatment.

Mental health interventions in schools in low-income and middle-income countries

Increasing enrolment rates could place schools in a crucial position to support mental health in low-income and middle-income countries. In this Review, we provide evidence for mental health interventions in schools in accordance with a public mental health approach spanning promotion, prevention, and treatment. We identified a systematic review for mental health promotion, and identified further prevention and treatment studies. Present evidence supports schools as places for promotion of positive aspects of mental health using a whole-school approach. Knowledge of effectiveness of prevention and treatment interventions is more widely available for conflict-affected children and adolescents. More evidence is needed to identify the many elements likely to be associated with effective prevention and treatment for children exposed to a range of adversity and types of mental disorders. Dissemination and implementation science is crucial to establish how proven effective interventions could be scaled up and implemented in schools.

Low level prenatal blood lead adversely affects early childhood mental development

The effect of prenatal lead exposure on child development has been a topic of public health concern for decades. To estimate prenatal lead exposure effects on early childhood development, maternal blood (n = 364) and umbilical cord blood (n = 224) samples were collected during pregnancy and at delivery. Mental development was assessed using the Harold Ireton Early Child Development Inventory from 174 children. Maternal whole blood lead levels in the first trimester were significantly higher in children with developmental scores <20% than in those with normal scores (mean ± standard deviation: 6.3 ± 1.9 vs 4.0 ± 2.4 µg/dL, respectively, P = .01). Maternal blood lead levels in the first trimester were also inversely associated with the development scores (r = -0.155, P = .041). Logistic regression analysis showed a significant relationship between increasing maternal blood lead levels in the first trimester with low development scores (odds ratio = 1.74, 95% confidence interval = 1.18-2.57, P = .005). The findings of the present study showed a relatively low level of prenatal lead exposure (mean < 6.5 µg/dL) associated with lower developmental scores in early childhood.

Refugee children and their families: supporting psychological well-being and positive adaptation following migration

The support of refugee children and their families is a worldwide concern. This article will highlight models of mental health care for refugee children and their families, focusing on collaborative care with primary care providers. Case vignettes are provided to illustrate how collaborative care can support refugee children׳s psychological well-being and positive adaptation following migration.

Psychosocial interventions for children exposed to traumatic events in low- and middle-income countries: study protocol of an individual patient data meta-analysis

BACKGROUND

The burden of mental health and psychosocial problems in children exposed to traumatic events in humanitarian settings in low- and middle-income countries is substantial. An increasing number of randomized studies has shown promising effects of psychosocial interventions, but this evidence has shown complexity with regard to setting, conflict-phase, gender, and age. These complex findings raise the need of a detailed evaluation of the specific factors which influence size and direction of intervention effects.Individual patient data meta-analysis is a specific type of meta-analysis that allows the collection of exact information at an individual patient level, and to examine whether intervention and socio-demographic characteristics, trauma-related variables, environmental conditions, and social support may act as moderators and mediators of intervention effect.The aim of the present study is to carry out an individual patient data meta-analysis using data from all available randomized controlled trials (either published or unpublished) comparing psychosocial intervention with waiting list or no intervention arms in children exposed to traumatic events living in low- and middle-income countries.

METHODS/DESIGN

All randomized trials comparing selective preventive psychosocial intervention versus waiting list or no treatment conditions in children (0-18 years) living in low- and middle-income countries will be included. Studies will be identified in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. There will be no restrictions on publication type, status, language, or date of publication. The primary outcome measures will be psychological symptoms (post-traumatic stress disorder, anxiety, depression). Secondary outcomes will be positive mental health outcomes (coping methods, social support, self-esteem), and function impairment.

DISCUSSION

We are expecting that some variables, like socio-demographic characteristics, trauma-related variables, environmental conditions, and social support will act as moderators/mediators of intervention effect. The investigation of the role of these factors on the intervention effects will help in the appropriate selection, development, implementation, and dissemination of evidence-based programs in low- and middle-income countries.

TRIAL REGISTRATION

This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42013006960).

Caregiver-child mental health: a prospective study in conflict and refugee settings

BACKGROUND

In humanitarian settings, family-level drivers of mental health are insufficiently documented; we examined the strength of caregiver-child associations with two-wave, family-level Afghan data.

METHODS

We recruited a gender-balanced sample of 681 caregiver-child dyads (n = 1,362 respondents) using stratified random-sampling in government schools in Kabul (364 dyads) and refugee schools in Peshawar (317 dyads). One year after baseline, we re-interviewed 64% of Kabul and 31% of Peshawar cohorts (n = 331 dyads, 662 respondents), retaining fewer Peshawar families due to refugee repatriation. In multivariable analyses adjusted for baseline, we assessed the extent to which caregiver mental health (Self-Report Questionnaire, SRQ-20) was associated with child symptom scores of post-traumatic stress (Child Revised Impact of Events Scale, CRIES), depression (Depression Self-Rating Scale, DSRS), psychiatric difficulties, impact, and prosocial strength (Strength and Difficulties Questionnaire, SDQ).

RESULTS

Caregiver mental health was prospectively associated with all eight measures of child mental health at follow-up, adjusted for baseline. For post-traumatic stress, caregiver mental health had a predictive impact comparable to the child experiencing one or two lifetime trauma events. For depression, caregiver mental health approached the predictive impact of female gender. Thus a one SD change in caregiver SRQ-20 was associated with a 1.04 point change on CRIES and a 0.65 point change in DSRS. For multi-informant SDQ data, caregiver-child associations were strongest for caregiver ratings. For child-rated outcomes, associations were moderated by maternal literacy, a marker of family-level dynamics. Both adults and children identified domestic violence and quality of home life as independent risk and protective factors.

CONCLUSIONS

In the context of violence and displacement, efforts to improve child mental health require a thoughtful consideration of the mental health cascade across generations and the cluster of adversities that impact family wellbeing. We identify culturally meaningful leverage points for building family-level resilience, relevant to the prevention and intervention agenda in global mental health.

The importance of establishing reliability and validity of assessment instruments for mental health problems: An example from Somali children and adolescents living in three refugee camps in Ethiopia

Assessing mental health problems cross-culturally for children exposed to war and violence presents a number of unique challenges. One of the most important issues is the lack of validated symptom measures to assess these problems. The present study sought to evaluate the psychometric properties of two measures to assess mental health problems: the Achenbach Youth Self-Report and the Child Posttraumatic Stress Disorder Symptom Scale. We conducted a validity study in three refugee camps in Eastern Ethiopia in the outskirts of Jijiga, the capital of the Somali region. A total of 147 child and caregiver pairs were assessed, and scores obtained were submitted to rigorous psychometric evaluation. Excellent internal consistency reliability was obtained for symptom measures for children and their caregivers. Validation of study instruments based on local case definitions was obtained for the caregivers but not consistently for the children. Sensitivity and specificity of study measures were generally low, indicating that these scales would not perform adequately as screening instruments. Combined test-retest and inter-rater reliability was low for all scales. This study illustrates the need for validation and testing of existing measures cross-culturally. Methodological implications for future cross-cultural research studies in low- and middle-income countries are discussed.

Mental disorders, disability and treatment gap in a protracted refugee setting

BACKGROUND

Studies have shown high levels of distress and mental disorder among people living in refugee camps, yet none has confirmed diagnosis through clinical reappraisal.

AIMS

To estimate the prevalence of mental disorders, related disability and treatment gap in adult refugees living in the Burj el-Barajneh camp.

METHOD

Randomly selected participants were screened by household representative (n = 748) and individual (n = 315) interviews; clinical reappraisal was performed on a subset (n = 194) of 326 selected participants. Weighted prevalence estimates and 95% confidence intervals were calculated.

RESULTS

The prevalence of current mental disorders was 19.4% (95% CI 12.6-26.2); depression was the most common diagnosis (8.3%, 95% CI 4.4-12.2) and multiple diagnoses were common (42%) among the 88 persons with mental disorder. Lifetime prevalence of psychosis was 3.3% (95% CI 1.0-5.5). Mental disorders were associated with moderate to severe dysfunction (odds ratio = 8.8, 95% CI 4.5-17.4). The treatment gap was 96% (95% CI 92-100).

CONCLUSIONS

A range of mental disorders and associated disability are common in this long-term refugee setting. Combined with an important treatment gap, findings support the current consensus-based policy to prioritise availability of mental health treatment in refugee camps, especially for the most severe and disabling conditions.

School and community-based interventions for refugee and asylum seeking children: a systematic review

BACKGROUND

Research for effective psychological interventions for refugee and asylum-seeking children has intensified. The need for interventions in environments more easily accessed by children and families is especially relevant for newly arrived populations. This paper reviews the literature on school and community-based interventions aimed at reducing psychological disorders in refugee and asylum-seeking children.

METHODS AND FINDINGS

Comprehensive searches were conducted in seven databases and further information was obtained through searching reference lists, grey literature, and contacting experts in the field. Studies were included if they reported on the efficacy of a school or community-based mental health intervention for refugee or asylum-seeking children. Two independent reviewers made the final study selection, extracted data, and reached consensus on study quality. Results were summarized descriptively. The marked heterogeneity of studies excluded conducting a meta-analysis but study effect-sizes were calculated where possible. Twenty one studies met inclusion criteria for the review reporting on interventions for approximately 1800 refugee children. Fourteen studies were carried out in high-income countries in either a school (n = 11) or community (n = 3) setting and seven studies were carried out in refugee camps. Interventions were either primarily focused on the verbal processing of past experiences (n = 9), or on an array of creative art techniques (n = 7) and others used a combination of these interventions (n = 5). While both intervention types reported significant changes in symptomatology, effect sizes ranged from 0.31 to 0.93 and could mainly be calculated for interventions focusing on the verbal processing of past experiences.

CONCLUSIONS

Only a small number of studies fulfilled inclusion criteria and the majority of these were in the school setting. The findings suggest that interventions delivered within the school setting can be successful in helping children overcome difficulties associated with forced migration.

The hidden effects of child maltreatment in a war region: correlates of psychopathology in two generations living in Northern Uganda

Adverse life experiences are a major risk factor for psychopathology. Studies from industrialized countries have consistently shown the detrimental effects of child maltreatment on the mental health of the victims. Research in war-affected populations, however, has mostly been restricted to the psychological damage caused by the war. Both war trauma and child maltreatment have rarely been studied simultaneously. In a comparative study of 2 generations living in severely war-affected regions in Northern Uganda, we determined the relationship between both trauma types and posttraumatic stress disorder (PTSD), anxiety, depression, and suicide ideation. A total of 100 adolescents, 50 with and 50 without a history of abduction by the rebel army with both their parents (100 mothers and 100 fathers) living in camps in northern Uganda were interviewed. The study showed that both generations were severely affected by war and child maltreatment. Both trauma types were independently correlated with psychological disorders in the adolescent group. Only child maltreatment, however, not war violence, accounted for PTSD symptoms in the parent group (β = .253, p = .002). We conclude that, even in the context of severe war, the impact of child maltreatment on psychological disorders surpasses the damage of war trauma.

Resilience definitions, theory, and challenges: interdisciplinary perspectives

In this paper, inspired by the plenary panel at the 2013 meeting of the International Society for Traumatic Stress Studies, Dr. Steven Southwick (chair) and multidisciplinary panelists Drs. George Bonanno, Ann Masten, Catherine Panter-Brick, and Rachel Yehuda tackle some of the most pressing current questions in the field of resilience research including: (1) how do we define resilience, (2) what are the most important determinants of resilience, (3) how are new technologies informing the science of resilience, and (4) what are the most effective ways to enhance resilience? These multidisciplinary experts provide insight into these difficult questions, and although each of the panelists had a slightly different definition of resilience, most of the proposed definitions included a concept of healthy, adaptive, or integrated positive functioning over the passage of time in the aftermath of adversity. The panelists agreed that resilience is a complex construct and it may be defined differently in the context of individuals, families, organizations, societies, and cultures. With regard to the determinants of resilience, there was a consensus that the empirical study of this construct needs to be approached from a multiple level of analysis perspective that includes genetic, epigenetic, developmental, demographic, cultural, economic, and social variables. The empirical study of determinates of resilience will inform efforts made at fostering resilience, with the recognition that resilience may be enhanced on numerous levels (e.g., individual, family, community, culture).

Health needs of refugee children younger than 5 years arriving in New Zealand

BACKGROUND

New Zealand accepts 750 refugees annually who enter via the Mangere Refugee Resettlement Centre.

AIMS

To evaluate the health needs of refugee children less than 5 years of age.

METHODS

Retrospective audit on the outcomes of health screening and referrals in children less than 5 years of age at the Mangere Refugee Resettlement Centre between 2007 and 2011.

RESULTS

Of the 343 children, the most common infectious diseases were latent tuberculosis (15%) and parasitic infections (15%). In those older than 1 year old who had rubella and measles serology information, immunity was found in 50% and 59%, respectively. Hepatitis B immunity was found in 68%. Complete vaccination certificates were available for 66% on arrival to New Zealand. Vaccinations were administered to 73% while at the Mangere Refugee Resettlement Centre. Iron deficiency and vitamin D deficiency were the main noninfectious diseases found and were present in 33% and 12%, respectively. The total requiring referral for further medical assessment or support was 58% with 19% requiring referral to more than one service.

CONCLUSIONS

Screening identified health needs in otherwise asymptomatic newly arriving refugee children. A proportion of children required access to multiple specialized medical services and may benefit from a comprehensive pediatric service.

The relative impacts of uncertainty and mothers' communication on hopelessness among Palestinian refugee youth

The life of adolescent refugees has been described as uncertainty laden. Yet no quantitative data exist to elucidate that experience of uncertainty, investigate its implications in that population, or explore potential moderators. This study applies the Entropy Model of Uncertainty (Hirsh, Mar, & Peterson, 2012) and the stress-buffering hypothesis (for review, see Hegelson, 2003) to examine the experience of uncertainty among adolescent Palestinians living in refugee camps in Lebanon. It then tests the role of mothers' uncertainty-related communication for adolescent hopelessness. One hundred and sixty-two adolescents across 2 refugee camps in Lebanon participated in the study. Results support the existence of elevated levels of uncertainty about both personal and macrosecurity, show an association between uncertainty regarding personal security and levels of hopelessness, and suggest that uncertainty's negative impact may overwhelm the role of mothers' supportive communication as a buffer against hopelessness. Interestingly, the data also suggest surprisingly little hopelessness in this population.

Broadening the scope of epidemiology in conflict-affected settings: opportunities for mental health prevention and promotion

This editorial proposes a shift in emphasis in the field of mental health epidemiology in conflict-affected settings. After a brief summary of the nature of contemporary armed conflicts, we consider the current and potential roles that epidemiology can play with regard to: (1) establishing the burden of mental disorders; (2) identifying risk and protective factors; and (3) intervention research. We advocate for improved methodological rigor; more attention to mixed methods approaches and multi-level longitudinal research; inclusion of the determinants of mental health beyond conflict-related violence; and consideration of a wider array of mental health outcomes. We particularly highlight the importance of expanding interest to epidemiological research that advances prevention and promotion interventions (e.g., in the early childhood period), in order to fill the gap between epidemiology and mental health practice in conflict-affected settings.

The nature and impact of chronic stressors on refugee children in Ban Mai Nai Soi camp, Thailand

Refugee camps are replete with risk factors for mental health problems among children, including poverty, disruption of family structure, family violence and food insecurity. This study, focused on refugee children from Burma, in Ban Mai Nai Soi camp in Thailand, sought to identify the particular risks children are exposed to in this context, and the impacts on their mental health and psychosocial well-being. This study employed two qualitative methods--free list interviews and key informant interviews--to identify the main problems impacting children in Ban Mai Nai Soi camp and to explore the causes of these problems and their impact on children's well-being. Respondents in free list interviews identified a number of problems that impact children in this context, including fighting between adults, alcohol use by adults and children, and child abuse and neglect. Across the issues, the causes included economic and social conditions associated with living in the camp and changes in family structures. Children are chronically exposed to stressors during their growth and development in the camp environment. Policies and interventions in areas of protracted displacement in camp-based settings should work to address these stressors and their impacts at community, household and individual levels.

Childhood psychological problems in school settings in rural Southern Africa

Background

Many children can be exposed to multiple adversities in low and middle-income countries (LMICs) placing them at potential risk of psychological problems. However, there is a paucity of research using large representative cohorts examining the psychological adjustment of children in school settings in these countries. Children’s psychological adjustment has been shown to affect educational progress which is critical for their future. This study, based in a rural, socio-economically disadvantaged area of South Africa, aimed to examine the prevalence of children’s psychological problems as well as possible risk and protective factors.

Methods

Rates of psychological problems in 10–12 year olds were examined using teacher- and child-report questionnaires. Data on children from 10 rural primary schools, selected by stratified random sampling, were linked to individual and household data from the Agincourt health and socio-demographic surveillance system collected from households over 15 years.

Results

A total of 1,025 children were assessed. Teachers identified high levels of behavioural and emotional problems (41%). Children reported lower, but substantial rates of anxiety/depression (14%), and significant post-traumatic stress symptoms (24%); almost a quarter felt unsafe in school. Risk factors included being a second-generation former refugee and being from a large household. Protective factors highlight the importance of maternal factors, such as being more educated and in a stable partnership.

Conclusion

The high levels of psychological problems identified by teachers are a serious public health concern, as they are likely to impact negatively on children’s education, particularly given the large class sizes and limited resources in rural LMIC settings. Despite the high levels of risk, a proportion of children were managing well and research to understand resilience could inform interventions.

Annual Research Review: Resilience and mental health in children and adolescents living in areas of armed conflict--a systematic review of findings in low- and middle-income countries

BACKGROUND

Researchers focused on mental health of conflict-affected children are increasingly interested in the concept of resilience. Knowledge on resilience may assist in developing interventions aimed at improving positive outcomes or reducing negative outcomes, termed promotive or protective interventions.

METHODS

We performed a systematic review of peer-reviewed qualitative and quantitative studies focused on resilience and mental health in children and adolescents affected by armed conflict in low- and middle-income countries.

RESULTS

Altogether 53 studies were identified: 15 qualitative and mixed methods studies and 38 quantitative, mostly cross-sectional studies focused on school-aged children and adolescents. Qualitative studies identified variation across socio-cultural settings of relevant resilience outcomes, and report contextually unique processes contributing to such outcomes. Quantitative studies focused on promotive and protective factors at different socio-ecological levels (individual, family-, peer-, school-, and community-levels). Generally, promotive and protective factors showed gender-, symptom-, and phase of conflict-specific effects on mental health outcomes.

CONCLUSIONS

Although limited by its predominantly cross-sectional nature and focus on protective outcomes, this body of knowledge supports a perspective of resilience as a complex dynamic process driven by time- and context-dependent variables, rather than the balance between risk- and protective factors with known impacts on mental health. Given the complexity of findings in this population, we conclude that resilience-focused interventions will need to be highly tailored to specific contexts, rather than the application of a universal model that may be expected to have similar effects on mental health across contexts.

Annual Research Review: Resilience and child well-being--public policy implications

BACKGROUND

There has been an 8-fold increase in use of the term resilience within scientific and scholar literature over the last twenty years. The arena of public policy has also seen increasing use made of the concept, both with respect to child well-being and development and wider issues.

METHOD

A focal sample of literature comprising 108 papers addressing public policy implications of work on child resilience was identified by a structured bibliographic search.

RESULTS

This literature suggests that current work: is characterized by a breadth of sectoral engagement across the fields of education, social work, and health; demonstrates diversity with regard to the systemic levels--individual (biological and psychological), communal (including systems of faith and cultural identity), institutional and societal--with which it engages; but is based more upon conceptual rather than empirical analysis. Major themes of policy recommendation target strengthened family dynamics, increased capacity for counseling and mental health services, supportive school environments, development of community programs, promotion of socioeconomic improvement and adoption of a more comprehensive conception of resilience. Evaluations of resiliency-informed policy initiatives are limited in number, with greatest rigor in design associated with more discrete programmatic interventions.

CONCLUSION

A number of strategies to strengthen research-policy linkages are identified. These include greater commitment to operationalize indicators of resilience at all levels of analysis; more coherent engagement with the policy making process through explicit knowledge translation initiatives; and developing complex adaptive systems models amenable to exploring policy scenarios.

Refugee children: mental health and effective interventions

The mental health consequences of war and other forms of organized violence for children represent a serious global public health issue. Much of the research on the mental health of war-affected civilians has focused on refugees who have sought asylum in high-income countries and face the dual stress of a traumatic past and resettlement. This review will focus on the mental health of refugee children who have fled war as well as interventions to both prevent and treat adverse mental health outcomes. While war can have devastating mental health consequences, children raised in the midst of armed conflict also display resilience. Effective interventions for refugee children will be discussed both in terms of prevention and treatment of psychopathology, with a focus on recent developments in the field.

Short and longer-term psychological consequences of Operation Cast Lead: documentation from a mental health program in the Gaza Strip

BACKGROUND

There is growing recognition of the psychological impact of adversity associated with armed conflict on exposed civilian populations. Yet there is a paucity of evidence on the value of mental health programs in these contexts, and of the chronology of psychological sequelae, especially in prolonged conflicts with repeated cycles of extreme violence. Here, we describe changes in the psychological profile of new patients in a mental health program after the military offensive Cast Lead, in the context of the prolonged armed conflict involving the Gaza Strip.

METHODS

This study analyses routinely collected program data from a Médecins Sans Frontières mental health program in the Gaza Strip spanning 2007-2011. Data consist of socio-demographic as well as clinical baseline and follow-up data on new patients entering the program. Comparisons were made through Chi square and Fisher's exact tests, univariate and multivariate logistic and linear regression.

RESULTS

PTSD, depression and other anxiety disorders were the most frequent psychopathologies, with 21% having multiple diagnoses. With a median of nine sessions, clinical improvement was recorded for 83% (1122/1357), and more common for those with separation anxiety, acute and posttraumatic disorders as principal diagnosis (855/1005), compared to depression (141/183, p<0.01). Noted changes proximal to Operation Cast Lead were: a doubling in patient case load with a broader socio-economic background, shorter interval from an identified traumatic event to seeking care, and a rise in diagnoses of acute and posttraumatic stress disorders. Sustained changes included: high case load, more distal triggering events, and increase in diagnoses of other anxiety disorders (especially for children 15 years and younger) and depression (especially for patients 16 years and older).

CONCLUSION

Evolving changes in patient volume, diagnoses and recall period to triggering events suggest a lengthy and durable effect of an intensified exposure to violence in a context of prolonged conflict. Our findings suggest that mental health related humanitarian relief in protracted conflicts might need to prepare for an increase in patients with changing profiles over an extended period following an acute flare-up in violence.

Children and young people who are refugees, internally displaced persons or survivors or perpetrators of war, mass violence and terrorism

PURPOSE OF REVIEW

This article draws upon articles published since 2009 to identify research evidence about the psychosocial aspects of children and young people's responses to their exposure to war, collective violence and terrorism.

RECENT FINDINGS

Recent research describes children's distress and the disorders they may develop consequent on their direct and indirect exposure to war. This article covers general responses as well as those that affect refugees, displaced children, and child soldiers. Dose of exposure is the main predictor of their degree of distress. Often, loss of parental support predicts distress or disorder. Research on children who are refugees and internally displaced persons has found that they cope better with the distressing events surrounding their flight if their parents accompany them. Studies of child soldiers show that they suffer from guilt as well as experiencing many violent distressing events. Research has identified the factors that contribute to their resilience, which include their acceptance by the communities to which they return. There are personal and social sources of resilience, including emotion regulation, parenting, and social support, for children who are exposed to war.

SUMMARY

Much of the recent research confirms earlier findings, which demonstrate that their exposure to war and collective violence leads to distress for many children and/or mental disorders for a smaller but substantial minority of them. The literature shows interest in identifying and measuring protective factors. The emphasis in the articles we reviewed on social as well as personal factors that confer psychosocial resilience reflects the broad interest in the two canons of literature on children's development and disasters. The findings point powerfully to people's needs for holistic and community-level interventions.