Psychological and psychosocial interventions for refugee children resettled in high-income countries

Infants born to first-time mothers with a refugee background faced an increased risk of regulatory problems

AIM

This study investigated the association between mothers' migration background and infant regulatory problems and analysed the mediating role of maternal mental health. We also explored whether the child's sex, parity and length of residence moderated the effect of a maternal migrant background.

METHODS

Child health surveillance data from the Danish home visiting programme were used. Community health nurses followed infants from birth to 12 months of age. The source population comprised 103 813 infants born between 1 January 2008 and 31 December 2018. The final sample comprised 62 964 infants, including 3.4% with a refugee background. A maternal migrant background was the primary exposure. The results are presented as risk ratios (RR) and 95% confidence intervals (CI).

RESULTS

A maternal refugee background increased the risk of regulatory problems in offspring (RR 1.34, 95% CI: 1.18-1.51). The effect was partially mediated by maternal postpartum mental health concerns. The association between maternal refugee background and infant regulatory problems was more pronounced in first-time mothers (RR 1.80, 95% CI: 1.51-2.15).

CONCLUSION

The risk of infant regulatory problems was higher in the first-born children of refugee mothers. First-time refugee parents may need tailored support to identify mental health needs and infants with regulatory problems.

Promoting positive development among refugee adolescents

Of the estimated 35.3 million refugees around the world (UNHCR, Figures at a Glance, 2022), approximately 50% are children under the age of 18. Refugee adolescents represent a unique group as they navigate developmental tasks in an unstable and often threatening environment or in resettlement contexts in which they often face marginalization. In addition to physiological, social, and psychological changes that mark adolescence, refugee youth often face traumatic experiences, acculturative stress, discrimination, and a lack of basic resources. In this consensus statement, we examine research on refugee adolescents' developmental tasks, acculturative tasks, and psychological adjustment using Suárez-Orozco and colleague's integrative risk and resilience model for immigrant-origin children and youth proposed by Suárez-Orozco et al. Finally, we discuss recommendations-moving from proximal to more distal contexts.

Effectiveness of psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in low- and middle-income countries: A systematic review and meta-analysis

Refugees and asylum seekers are more prone to posttraumatic stress disorder (PTSD) than the general population. This systematic review aims to determine which psychosocial interventions effectively treat PTSD among refugees and asylum seekers in low- and middle-income countries (LMIC). Relevant papers were retrieved from the bibliographic databases. PTSD symptoms post-intervention was the primary outcome. Ten studies were selected with 1981 participants. In meta-analyses of Randomised control trials (RCTs), psychosocial interventions for PTSD (SMD -0.60, 95% CI -0.96 to -0.23; I2 = 91%; 95% CI 75-100; nine studies, 1789 participants) were shown to be clinically effective. Also, in case of depression (SMD -0.59, 95% CI -0.95 to -0.22; I2 = 84%; 95% CI 50-90; seven studies, 1248 participants). Eye Movement Desensitization and Reprocessing (EMDR) had the greatest effect size among psychosocial therapies for this demographic. However, the number of studies is small, and their methodological rigour is limited, thus future study should concentrate on performing more rigorous trials.

Scalable interventions for refugees

Refugees experience a greater rate of common mental disorders relative to most other populations, and there remains a need to address these needs. However, most refugees are hosted in low-and-middle-income countries, where there is a lack of resources and mental health providers who can deliver mainstream mental health services. This situation has led to the emergence of scalable mental health interventions that can deliver evidence-based programs to refugees in need. Many countries hosting refugees have implemented programs that train local lay providers in interventions that can be delivered at scale. This review provides a narrative overview of these scalable interventions and critiques the evidence for their efficacy. It is noted that there are limitations to currently available scalable interventions, and there is a need for greater attention to determining the longer-term benefits of interventions, addressing the mental health needs of refugees who do not respond to these interventions, assisting refugees with more severe psychological disorders, and understanding the specific mechanisms that underpin observed benefits of these interventions.

Effectiveness of a brief group behavioural intervention on psychological distress in young adolescent Syrian refugees: A randomised controlled trial

BACKGROUND

Millions of young adolescents in low- and middle-income countries (LMICs) affected by humanitarian crises experience elevated rates of poor mental health. There is a need for scalable programs that can improve the mental health of young adolescents. This study evaluated the effectiveness of a nonspecialist delivered group-based intervention (Early Adolescent Skills for Emotions (EASE)) to improve young adolescents' mental health.

METHODS AND FINDINGS

In this single-blind, parallel, controlled trial, Syrian refugees aged 10 to 14 years in Jordan were identified through screening of psychological distress as defined by scores ≥15 on the Paediatric Symptom Scale. Participants were randomised to either EASE or enhanced usual care (EUC) involving referral to local psychosocial services (on a 1:1.6 ratio). Participants were aware of treatment allocation but assessors were blinded. Primary outcomes were scores on the Paediatric Symptom Checklist (PSC; internalising, externalising, and attentional difficulty scales) assessed at week 0, 9 weeks, and 3 months after treatment (primary outcome time point). It was hypothesised that EASE would result in greater reductions on internalising symptoms than EUC. Secondary outcomes were depression, posttraumatic stress, well-being, functioning, school belongingness, and caregivers' parenting and mental health. Between June 2019 and January 2020, 1,842 young adolescent refugees were screened for eligibility on the basis of psychological distress. There were 520 adolescents (28.2%) who screened positive, of whom 471 (90.6%) agreed to enter the trial. Overall, 185 were assigned to EASE and 286 to EUC, and 169 and 254 were retained at 3 months for EASE and EUC, respectively. Intent-to-treat analyses indicated that at 3 months, EASE resulted in greater reduction on the PSC-internalising scale than EUC (estimated mean difference 0.69, 95% CI 0.19 to 1.19; p = 0.007; effect size, 0.38) but there were no differences for PSC-externalising (estimated mean difference 0.24, 95% CI -0.43 to 0.91; p = 0.49; effect size, -0.10), PSC-attentional problem (estimated mean difference -0.01, 95% CI -0.51 to 0.54; p = 0.97; effect size, -0.01) scores, or on depression, posttraumatic stress, well-being, functioning, or school belongingness. Relative to EUC, caregivers in EASE had less psychological distress (estimated mean difference 1.95, 95% CI 0.71 to 3.19; p = 0.002) and inconsistent disciplinary parenting (mean difference 1.54, 95% CI 1.03 to 2.05; p < 0.001). Secondary analyses that (a) focused on adolescents with probable internalising disorders; (b) completed the 3-month assessment; and (c) controlled for trauma exposure did not alter the primary results. Mediation analysis indicated that for caregivers in the EASE condition, reduction in inconsistent disciplinary parenting was associated with reduced attentional (β = 0.11, SE 0.07; 95% CI 0.003, 0.274) and internalising (β = 0.11, SE 0.07; 95% CI 0.003, 0.274) problems in their children. No adverse events were attributable to the intervention. A limitation was that EUC was not matched to EASE in terms of facilitator attention or group involvement.

CONCLUSIONS

EASE led to reduced internalising problems in young refugee adolescents and was associated with reduced distress and less inconsistent disciplinary parenting in caregivers. This intervention has the potential as a scalable intervention to mitigate young adolescents' emotional difficulties in LMIC.

TRIAL REGISTRATION

Prospectively registered at Australian and New Zealand Clinical Trials Registry: ACTRN12619000341123.

Trauma-affected refugees and their non-exposed children: A review of risk and protective factors for trauma transmission

The rates of posttraumatic stress syndrome (PTSD) are high among refugee populations. At the same time, evidence is emerging of intergenerational transmission of psychopathology. The objective of this study was to examine the current knowledge on risk and protective factors for adverse mental health outcomes in the non-exposed offspring of trauma-affected refugees. A systematic search was undertaken from 1 January 1981 to 5 February 2021 (PubMed, Embase, PSYCInfo). Studies were included if they reported on families of trauma-exposed refugee parents and mental health outcomes in their non-exposed children. The search yielded 1415 results and twelve articles met inclusion criteria. The majority of studies emphasized the negative effects of parental mental health symptoms. There was substantial evidence of an association between parental PTSD and increased risk of psychological problems in offspring. Parenting style was identified as both a potential risk and protective factor. Risk/protective factors at the individual and family level were identified, but findings were inconclusive due to sample sizes and study designs. There is a need for evidence-based interventions aimed at improving child outcomes, especially by improving parental mental health and reinforcing parenting skills. Future research should aim to incorporate broader aspects of child development.

Refugee Children and Interventions for Depression: A Review of Current Interventions and Implications of the Ecological Context

As of 2018, over 25.4 million people worldwide meet the criteria to be considered refugees, the highest number on record. Over half of these individuals are under 18 years old, leaving approximately 12 million children to cope with the trauma and stress typically encountered by refugees. Increased rates of depression in this population are well-documented in the literature. This article reviews the ecological determinants of depression for displaced children and current empirical methods for alleviating depression across contexts. PubMed and PsycINFO databases were reviewed for articles that met the following criteria for inclusion: published between January 1, 2000, and April 16, 2020; peer-reviewed empirical article; in English; reviewed an intervention targeting depression; and included a sample of refugees 18 years of age or younger. Sixteen interventions met inclusion criteria and were assessed using an ecological framework. The programs were analyzed for several methodological and outcome factors including intervention type, retention rate, participant demographics, participant country of origin and host country, ecological framework, and effectiveness. Major findings suggest that interventions including caregivers, involving the child's community, addressing multiple contexts, and that are culturally informed may improve outcomes. This article presents research surrounding risk and protective factors for depression within each context to inform existing interventions and presents additional avenues for services to meet the needs of refugee youth across contexts.

Mental and somatic disorders and the subsequent risk of all-cause and cause-specific mortality in refugees, non-refugee migrants and the Swedish-born youth: a population-based cohort study in Sweden

OBJECTIVES

The aims were to investigate the associations between specific mental and somatic disorders and subsequent all-cause and cause-specific mortality (suicide, external and other causes) in young refugees and non-refugee migrants compared with Swedish-born individuals of similar age.

METHODS

In this register-based prospective cohort study, all 1 003 760 individuals (40 305 refugees, 31 687 non-refugee migrants as the exposure groups and the rest as the Swedish-born comparison group), 16-25 years old, residing in Sweden on 31 December 2004 were included. These individuals were followed regarding the outcome of all-cause and cause-specific mortality (suicide and external causes) between 2005 and 2016. The study population was also stratified according to any use of specialised healthcare for mental or somatic diagnoses before baseline (2000-2004). Cox regression models yielding crude and multivariate Hazard Ratios (HR and aHR, respectively) with 95% Confidence Intervals (CI) were used to investigate the afore-mentioned associations.

RESULTS

A lower proportion of both refugees (12%) and non-refugee migrants (10%) had college/university education compared with the Swedish-born individuals (17%). The proportion of unemployed (>180 days) among refugees (2.3%) and non-refugees (2.9%) was higher than the Swedish born (1.4%). Refugees and non-refugee migrants had about a 20% lower risk of all-cause mortality and external causes of mortality compared with Swedish-born individuals. An even greater reduction in suicide risk (aHR 0.51, 95% CI 0.37 to 0.70, and 0.63, 95% CI 0.49 to 0.82 for non-refugees and refugees, respectively) was found. When restricted to those with a mental or somatic disorder, a lower risk of both general and specific mortality was also found among both refugees and non-refugee migrants compared with Swedish-born individuals. Refugees had, however, equal point estimates of all-cause mortality associated with substance misuse disorder and neoplasms as their Swedish-born peers with these disorders.

CONCLUSIONS

With few exceptions, young migrants with specific mental and somatic disorders have a mortality advantage compared with their Swedish-born peers with the same disorders. Further research on protective factors is warranted.

Community-based interventions for improving mental health in refugee children and adolescents in high-income countries

BACKGROUND

An unprecedented number of people around the world are experiencing forced displacement due to natural or man-made events. More than 50% of refugees worldwide are children or adolescents. In addition to the challenges of settling in a new country, many have witnessed or experienced traumatic events. Therefore, refugee children and adolescents are at risk of developing mental health problems such as post-traumatic stress disorder, and require appropriate and effective support within communities.

OBJECTIVES

To assess the effectiveness and acceptability of community-based interventions (RCTs only) in comparison with controls (no treatment, waiting list, alternative treatment) for preventing and treating mental health problems (major depression, anxiety, post-traumatic stress disorder, psychological distress) and improving mental health in refugee children and adolescents in high-income countries.

SEARCH METHODS

Databases searches included the Cochrane Common Mental Disorders Controlled Trials Register (all available years), CENTRAL/CDSR (2021, Issue 2), Ovid MEDLINE, Embase, six other databases, and two trials registries to 21 February 2021. We checked reference lists of included study reports.  SELECTION CRITERIA: Studies of any design were eligible as long as they included child or adolescent refugees and evaluated a community-based mental health intervention in a high-income country. At a second stage, we selected randomised controlled trials.

DATA COLLECTION AND ANALYSIS

For randomised controlled trials, we extracted data relating to the study and participant characteristics, and outcome data relating to the results of the trial. For studies using other evaluation methods, we extracted data relating to the study and participant characteristics. W derived evidence on the efficacy and availability of interventions from the randomised controlled trials only. Data were synthesised narratively.

MAIN RESULTS

We screened 5005 records and sought full-text manuscripts of 62 relevant records. Three randomised controlled trials were included in this review. Key concerns in the risk of bias assessments included a lack of clarity about the randomisation process, potential for bias is outcome measurement, and risk of bias in the selection of results. Primary outcomes There was no evidence of an effect of community-based interventions when compared with a waiting list for symptoms of post-traumatic stress (mean difference (MD) -1.46, 95% confidence interval (CI) -6.78 to 3.86: 1 study; low-certainty evidence), symptoms of depression (MD 0.26, 95% CI -2.15 to 2.67: 1 study; low-certainty evidence), and psychological distress (MD -10.5, 95% CI -47.94 to 26.94; 1 study; very low-certainty evidence).  There were no data on adverse events. Secondary outcomes Three trials reported on short-term changes in child behaviour, using different measures, and found no evidence of an effect of the intervention versus a waiting list (low to very low certainty). None of the trials reported on quality of life or well-being, participation and functioning, or participant satisfaction.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the efficacy and acceptability of community-based mental health interventions for refugee children and adolescents.

Differences in psychiatric care utilization between refugees, non-refugee migrants and Swedish-born youth

BACKGROUND

The study aimed to examine differences in, and characteristics of psychiatric care utilization in young refugees who came to Sweden as unaccompanied or accompanied minors, compared with that of their non-refugee immigrant and Swedish-born peers.

METHODS

This register-linkage cohort study included 746 688 individuals between 19 and 25 years of age in 2009, whereof 32 481 were refugees (2896 unaccompanied and 29 585 accompanied) and 32 151 non-refugee immigrants. Crude and multivariate Cox regression models yielding hazard ratios (HR) and 95% confidence intervals (CI) were conducted to investigate subsequent psychiatric care utilization for specific disorders, duration of residence and age at migration.

RESULTS

The adjusted HRs for psychiatric care utilization due to any mental disorder was significantly lower in both non-refugee and refugee immigrants when compared to Swedish-born [aHR: 0.78 (95% CI 0.76-0.81) and 0.75 (95% CI 0.72-0.77, respectively)]. Within the refugee group, unaccompanied had slightly lower adjusted risk estimates than accompanied. This pattern was similar for all specific mental disorders except for higher rates in schizophrenia, reaction to severe stress/adjustment disorders and post-traumatic stress disorder. Psychiatric health care utilization was also higher in immigrants with more than 10 years of residency in Sweden entering the country being younger than 6 years of age.

CONCLUSIONS

For most mental disorders, psychiatric health care utilization in young refugees and non-refugee immigrants was lower than in their Swedish-born peers; exceptions are schizophrenia and stress-related disorders. Arrival in Sweden before the age of 6 years was associated with higher rates of overall psychiatric care utilization.

Trauma-focused treatments for refugee children: study protocol for a randomized controlled trial of the effectiveness of KIDNET versus EMDR therapy versus a waitlist control group (KIEM)

BACKGROUND

Prevalence of posttraumatic stress disorder (PTSD) in refugees is reportedly higher in comparison to the general population. Refugee children specifically are often coping with trauma and loss and are at risk for mental health difficulties. With staggering numbers of people seeking refuge around the world and 50% being 18 years or younger, research examining the effects of trauma-focused therapies for refugee children with PTSD is highly needed. Both Eye Movement Desensitization and Reprocessing (EMDR) therapy and the child version of Narrative Exposure Therapy (KIDNET) have been used for refugees, although these treatment methods have not been systematically compared. The aim of the current study is to investigate the effectiveness of EMDR and KIDNET, compared to a waitlist control group and with each other, offered to refugee children.

METHODS

A randomized controlled three-arm trial has been designed. The primary outcome is PTSD diagnosis and symptom severity assessed with the Clinician-Administered PTSD Scale for Children DSM5 (CAPS-CA-5) at baseline (T1), 1 month post-treatment, or after 8 weeks of waiting (T2) and 3 months follow-up (T3). Additionally, instruments to assess posttraumatic stress symptoms, behavioral and emotional problems, and quality of life perception in children aged 8-18 are conducted at T1, T2, and T3.

DISCUSSION

This is the first RCT that examines the effectiveness of EMDR and KIDNET in refugee children aged 8-18 years specifically, compared to a waitlist control group intended to reduce PTSD diagnosis and severity of posttraumatic stress symptoms and comorbid complaints in a growing and challenging population.

TRIAL REGISTRATION

Dutch Trial Register NL40769 . Retrospectively registered on June 16, 2021.

Health-related quality of life in refugee minors from Syria, Iraq and Afghanistan resettled in Sweden: a nation-wide, cross-sectional study

PURPOSE

To examine health-related quality of life (HRQoL) in refugee minors resettled in Sweden and compare results to a European reference population, while exploring associations between sociodemographic factors and HRQoL dimensions.

METHODS

A cross-sectional, nation-wide study was conducted with a stratified sample of refugee minors ages 12-15 and 16-18 from Afghanistan, Iraq and Syria, resettled in Sweden between 2014 and 2018. HRQoL was measured using KIDSCREEN-27. HRQoL dimension scores of the sample were compared to mean scores of European age and gender-matched reference population. Associations between sociodemographic factors and HRQoL dimensions were investigated with independent t tests and ANOVA. A multivariable regression analysis was performed to identify the sociodemographic factors associated with HRQoL.

RESULTS

The questionnaire was sent to 10,000 potential respondents. The response rate was 26%, yielding n = 2559 refugee minors (boys 55%, girls 45%) in the study sample. Compared to European references, minors in the present study had significantly lower scores of HRQoL within psychological wellbeing and peers and social support, whereas levels for autonomy and parent/guardian relations and school environment were higher. Several sociodemographic factors were significantly associated with all HRQoL dimensions, with those 16-18 years old, having average or poor family economy, and living with an unrelated adult or family reporting lower levels of HRQoL. Minors from Afghanistan had significantly lower scores of HRQoL for all dimensions compared to those from Iraq and Syria.

CONCLUSION

Refugee minors had significantly lower levels of HRQoL for psychological wellbeing and peers and social support compared to European references. Future research should further investigate this potential HRQoL gap further.

The feasibility of implementing autism intervention methods in formal education settings welcoming refugee and asylum-seeking children: A systematic review of the literature

Given the significant amount of time that refugee and asylum-seeking children (RASC) spend in schools, these institutions play an important role in their lives and represent an ideal environment in which to help them to adapt to their host society. The present study aimed to draw attention to the possibility of transferring intervention methods designed for children with ASD to formal education settings welcoming newly arrived RASC to support their adaptation to their new school environment. For this purpose, a systematic review was undertaken to assess the feasibility of implementing three specific ASD intervention methods (i.e., TEACCH, PECS, and PMI) in schools welcoming RASC. While the review did not reveal previous attempts to implement and evaluate ASD intervention methods with newcomer RASC, 21 records were uncovered providing preliminary evidence in support of this idea. Hypothesized strengths and limitations, as well as considerations about implementation, are discussed.

"Everything was stuck in my inside and I just wanted to get it out": Psychological distress, coping, and help-seeking for young adult Australian Hazaras from refugee backgrounds

Hazaras form an Afghan ethnic minority group in Australia who arrived as refugees and through humanitarian resettlement schemes over the past three decades. This qualitative study explored psychological distress in a community sample of young adult Hazaras with a refugee background. The aim was to contribute to a more detailed understanding of their mental health, coping, and help-seeking in Australia. Eighteen Hazaras, nine males and nine females aged 18-30 years (M  =  22.39, SD  =  3.35), in Perth, Melbourne, or Sydney, who had been living in Australia on average 7.17 years (range 1 to 16 years), participated in a semi-structured interview based on Kleinman's explanatory model framework. Participants described mental and physical health as interconnected and their explanatory models for psychological distress focused on their current difficult life experiences as refugees. Findings indicated noteworthy gender differences, with young women reporting less distress associated with adaptation than did young men. Some young people used positive coping strategies in the community, while others engaged with a variety of mental health services. Level of satisfaction with these services varied considerably, with satisfaction highest for services provided by multicultural centers. Generally, respondents were not focused on their past traumas, but more interested in planning for their futures in Australia. Key implications for culturally appropriate training and specialized interventions for use with young adult Hazaras from refugee backgrounds are discussed.

Same but different: meaning-making among refugee and non-refugee youths

Purpose

There is substantial research on the experiences, needs and well-being of unaccompanied refugee adolescents, but less is known about existential aspects of their lives. The purpose of the current study is to explore existential meaning-making among unaccompanied refugee children.

Design/methodology/approach

The informants in this study are young unaccompanied refugees (n = 30) living in Norway, and young Norwegians (n = 46). The authors undertook a secondary analysis of in-depth qualitative refugee interview data and a quantitative analysis of questionnaire data from Norwegian informants.

Findings

Both the refugee youths and the Norwegian youths expressed that social relationships and connections to others were most important for meaning. Moreover, both groups emphasized the importance of relatedness and generativity, i. e. commitment to worldly affairs beyond one’s immediate needs. The main differences between the two groups were related to the significance attached to religion and to loneliness.

Research limitations/implications

The comparison between the two groups is only possible to some degree. Secondary analyses have some limitations, as well as strengths.

Practical implications

The findings may be useful for supporting young refugees, as they provide insights into less-studied aspects of their lives.

Originality/value

The originality of this study lies in the focus on and broad interpretation of meaning, of secondary data analyses, and of comparisons between youths that are refugees versus non-refugees.

Syrian Refugee Youth Resettled in Norway: Mechanisms of Resilience Influencing Health-Related Quality of Life and Mental Distress

Background: The importance of resilience factors in the positive adaptation of refugee youth is widely recognised. However, their actual mechanism of impact remains under-researched. The aim of this study was therefore to explore protective and promotive resilience mechanisms to inform future interventions and policy. Promotive resilience is seen as a direct main effect and protective resilience as a moderating effect.

Methods: This was a cross-sectional study of Syrian youth recently resettled in Norway, aged 13–24 years. Regression and moderation analyses were used to explore different interactions, including moderated mediation using the PROCESS macro for SPSS.

Result: A direct main effect of promotive resilience was found for health-related quality of life (HRQoL) and general mental distress, but not for post-traumatic stress disorder (PTSD). No moderating effects of protective resilience were found. Post-migration stressors mediated the effects of potentially traumatic events (PTE) from war and flight, and this indirect effect was present at all levels of resilience.

Conclusion: Despite high risk exposure and mental distress, resilience was also high. Broad resilience interventions targeting multiple factors would likely benefit the group, but these should include both individual assets and building supportive environments. Additionally, reducing current stress and providing treatment for those in need could enable recovery and increase the efficacy of resilience factors already present.

Cultural diversity approaches in schools and adolescents' willingness to support refugee youth

BACKGROUND

Culturally diverse schools contribute to adolescents' intergroup relations. Complex and inclusive social identities are mechanisms that can explain the link between structural school cultural diversity (i.e., proportion of students of immigrant descent and the number of different ethnic groups) and positive intergroup relations. We expected that similar mechanisms might be at play linking cultural diversity approaches in schools with adolescents' intergroup relations.

AIM

We examined the link between two sub-dimensions of cultural diversity approaches (i.e., equal treatment; heritage and intercultural learning) and adolescents' prosocial intentions and behaviour towards refugee youth. Then, we explored the mediating role of identity inclusiveness (i.e., perceived similarity of the self with others).

SAMPLE AND METHODS

We sampled culturally diverse eighth grade adolescents from 54 classrooms in Berlin (N = 503, M_age  = 13.76 years, 50.6% female). Surveys measured perceived cultural diversity norms, adolescents' perceived identity inclusiveness with refugee youth, prosocial intentions to support refugee youth, and willingness to donate to a project for refugee youth.

RESULTS

Multilevel models revealed that adolescents' perception of heritage and intercultural learning predicted adolescents' prosocial intentions towards refugee youth, but not their willingness to donate. Equal treatment was not a significant predictor of adolescents' prosocial intentions towards refugee youth, or their willingness to donate. Identity inclusiveness did not mediate the relation between cultural diversity approaches and prosocial intentions. However, identity inclusiveness did positively relate adolescents' prosocial intentions and willingness to donate.

CONCLUSIONS

We conclude that culturally diverse schools that engage in heritage and intercultural learning might help to promote positive relations between local and refugee youth in schools and society. Fostering inclusive identities may enhance local adolescent's prosocial intention and behaviour.

Refugee Mental Health, Global Health Policy, and the Syrian Crisis

The most recent global refugee figures are staggering, with over 82.4 million people forcibly displaced and 26.4 million registered refugees. The ongoing conflict in Syria is a major contributor. After a decade of violence and destabilization, over 13.4 million Syrians have been displaced, including 6.7 million internally displaced persons and 6.7 million refugees registered in other countries. Beyond the immediate political and economic challenges, an essential component of any response to this humanitarian crisis must be health-related, including policies and interventions specific to mental health. This policy and practice review addresses refugee mental health in the context of the Syrian crisis, providing an update and overview of the current situation while exploring new initiatives in mental health research and global health policy that can help strengthen and expand services. Relevant global health policy frameworks are first briefly introduced, followed by a short summary of recent research on refugee mental health. We then provide an update on the current status of research, service provision, and health policy in the leading destinations for Syrians who have been forcibly displaced. This starts within Syria and then turns to Turkey, Lebanon, Jordan, and Germany. Finally, several general recommendations are discussed, including the pressing need for more data at each phase of migration, the expansion of integrated mental health services, and the explicit inclusion and prioritization of refugee mental health in national and global health policy.

The Refugee and Immigrant Core Stressors Toolkit (RICST): Understanding the Multifaceted Needs of Refugee and Immigrant Youth and Families Through a Four Core Stressors Framework

Research indicates that refugee and immigrant youth commonly face four core stressors during resettlement in a new country and culture: trauma, acculturative stress, resettlement stress, and isolation. This Four Core Stressors framework can be used to educate providers about these populations’ unique needs and support assessment of relevant socioecological factors influencing health. To facilitate education, training, and dissemination of this framework and complement existing provider resources, we developed the Refugee & Immigrant Core Stressors Toolkit (RICST), a free, web-based toolkit that provides an overview of the Four Core Stressors framework, assessment questions across the four domains, scaffolding to identify needs and points of triage, and recommended interventions. Public hosting of the RICST via REDCap began in March 2018. In addition to the toolkit, users are prompted to provide location of service delivery, intended purpose of use, and interface feedback. Between March 2018 and October 2020, the RICST was used over 2300 times across 6 continents. Most providers used the toolkit to learn more about the needs of refugee and immigrant youth in general, and several noted that it is a valuable educational tool for staff unfamiliar with these populations. Open-ended qualitative feedback indicated high usability. Amidst historically high levels of forced displacement, tools to support provider effectiveness in working with these populations are increasingly needed. The RICST shows promise as an educational, assessment, and treatment-planning tool for providers working with refugee and immigrant families globally. Future directions include location-specific resource mapping and culture-specific intervention strategies.

Towards closing the treatment gap: a team-led model of brief psycho-educational intervention

Purpose

Many pupils who experience distress and emotional difficulties are left untreated because of the shortage of mental health professionals at schools. This study aims to explore a brief psycho-educational intervention based on school psychologist–teacher cooperation aimed at closing this treatment gap.

Design/methodology/approach

With a randomized controlled methodology, 79 preschools to 12th grade teachers were asked to lead a brief psycho-educational intervention with one of their pupils. A second pupil was assigned to a waiting list (control group). Each teacher and one of her/his colleagues filled a Pupil Adjustment questionnaire, being developed for this study, before and after the intervention.

Findings

The findings show that the intervention significantly improved the adjustment of the participating pupils, compared to the control group. That improvement related to all the dimensions of adjustment (i.e. social, protection and learning).

Originality/value

Teacher–school psychologist cooperation, as described here, is hardly practiced. It emerges as an effective model to assist many pupils who are currently left with no treatment. The discussion traces the next stages for outreaching that would apply to pupils in many countries and cultures.

The Effects of a Reading-Based Intervention on Emotion Processing in Children Who Have Suffered Early Adversity and War Related Trauma

Early adversity and trauma can have profound effects on children's affective development and mental health outcomes. Interventions that improve mental health and socioemotional development are essential to mitigate these effects. We conducted a pilot study examining whether a reading-based program (We Love Reading) improves emotion recognition and mental health through socialization in Syrian refugee (n = 49) and Jordanian non-refugee children (n = 45) aged 7-12 years old (M = 8.9, 57% girls) living in Jordan. To measure emotion recognition, children classified the expression in faces morphed between two emotions (happy-sad and fear-anger), while mental health was assessed using survey measures of optimism, depression, anxiety, distress, and insecurity. Prior to the intervention, both groups of children were significantly biased to interpret ambiguous facial expressions as sad, while there was no clear bias on the fear-anger spectrum. Following the intervention, we found changes in Syrian refugee children's bias in emotion recognition away from sad facial expressions, although this returned to pre-intervention levels 2 months after the end of the program. This shift in the bias away from sad facial expressions was not associated with changes in self-reported mental health symptoms. These results suggest a potential positive role of the reading intervention on affective development, but further research is required to determine the longer-term impacts of the program.

The Use of Sleep Medication in Youth Residential Care

Objectives: To investigate the use of sleep medication and concomitant psychotropic medication in children and adolescents placed under residential care (RC). Methods: Participants were youth 0-20 years of age placed in RC institutions at least once during 2016. Data on filled prescriptions were taken from the Norwegian Prescription Database to compare the use of sleep medication in RC with the general child population (GenPop) and how it covaried with gender, age, reasons for RC placement, and concomitant use of other psychotropic medications (antidepressants, anxiolytics, antipsychotics, and psychostimulants). Results: A total of 2171 youths were identified in RC at mean age 14 years (82% ≥ 13 years). Seventeen percent (371/2171) used sleep medications (melatonin 11%, alimemazine 7%, and benzodiazepines/z-hypnotics 2%) significantly more than the 2.3% who used in GenPop. The girl/boy ratio for medication use in RC was 1.8 (95% confidence interval [CI] = 1.5-2.2), not significantly different from the corresponding ratio in GenPop (1.4; 95% CI = 1.3-1.5). The use of sleep medication increased with age. When comparing reasons for placement in RC, medication use was particularly low among unaccompanied minor asylum seekers (2%). About half of the youths used concomitant psychotropic medication, with clear gender differences; girls used about twice as much antidepressants, anxiolytics, and antipsychotics, whereas boys used 1.3 times more psychostimulants. Conclusion: Youths in RC used more sleep medication and concomitant psychotropic medication than the GenPop, most likely reflecting the increased psychosocial strain and mental disorders reported in this population. Further studies of prevalence, assessment, and treatment of sleep problems in RC populations are warranted.

Common mental disorders among young refugees in Sweden: The role of education and duration of residency

BACKGROUND

Studies investigating risks of common mental disorders (CMDs) in refugee youth are sparse. The current study examined health care use due to CMDs in unaccompanied and accompanied refugee youth and Swedish-born, and the role of education and residency duration.

METHODS

This longitudinal cohort study included 746,517 individuals (whereof 36,347 refugees) between 19 and 25 years, residing in Sweden in 2009. Refugees were classified as unaccompanied/accompanied. Risk estimates of CMDs, measured as health care use and antidepressant treatment, between 2010-2016 were calculated as adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Highest attained education in 2009, and residency duration were examined as potential modifiers.

RESULTS

Compared to Swedish-born youth, refugees had a lower risk of treated major depressive and anxiety disorders (aHR): 0.67 (95% CI 0.63-0.72) and 0.67 (95% CI 0.63-0.71) respectively), but a higher risk for posttraumatic stress disorders (PTSD). Compared to Swedish-born, unaccompanied had a nearly 6-fold elevated risk for PTSD (aHR: 5.82, 95% CI 4.60-7.34) and accompanied refugees had a 3-fold risk of PTSD (aHR: 3.08, 95% CI 2.54-3.74). Rates of PTSD decreased with years spent in Sweden. The risk of CMDs decreased with increasing education.

LIMITATIONS

The study lacked information on pre-migration factors. There may further be a potential misclassification of untreated CMDs.

CONCLUSION

Refugees had a lower risk of treated depressive and anxiety disorders but a higher risk for PTSD. In refugees, the rates of anxiety disorders increased slightly over time whereas the rates of PTSD decreased. Last, low education was an important predictor for CMDs.

Everyday life experiences and mental health among conflict-affected forced migrants: A meta-analysis

BACKGROUND

There are a growing number of forced migrants worldwide. Early detection of poor adjustment and interventions to facilitate positive adaptation within these communities is a critical global public health priority. A growing literature points to challenges within the post-migration context as key determents of poor mental health.

AIMS

The current meta-analysis evaluated the association between daily stressors and poor mental health among these populations.

METHOD

A systematic search in PsycINFO, PubMed, and Web of Science identified relevant studies from inception until the end of 2018. Effect sizes (correlation coefficients) were pooled using Fisher's Z transformation and reported with 95% confidence intervals. Moderator and mediator analyses were conducted. The protocol is available in PROSPERO [CRD42018081207].

RESULTS

Analysis of 59 eligible studies (n = 17,763) revealed that daily stressors were associated with higher psychiatric symptoms (Zr=0.126-0.199, 95% CI=0.084-0.168, 0.151-0.247, p<0.001) and general distress (Zr=0.542, 95% CI=0.332-0.752, p<0.001). Stronger effect sizes were observed for mixed daily stressors relative to subjective, interpersonal, and material daily stressors, and for general distress relative to posttraumatic stress symptoms and general well-being. Effect sizes were also stronger for children and adolescents relative to adults. Daily stressors fully mediated the associations of prior trauma with post-migration anxiety, depressive, and post-traumatic stress disorder symptoms.

CONCLUSIONS

This meta-analysis provides a synthesis of existing research on the role of unfavorable everyday life experiences and their associations with poor mental health among conflict-affected forced migrants. Routine assessment and intervention to reduce daily stressors can prevent and reduce psychiatric morbidity in these populations.

Pre-Post Study to Assess EMDR-Based Group Therapy for Traumatized Refugee Preschoolers

Cross-culturally effective, low-threshold therapies for refugees that can be carried out quickly are urgently required. Worldwide, therapies are lacking, particularly for preschool refugee children, which support coping and prevent chronification of posttraumatic stress. This pilot study examined eye movement desensitization and reprocessing (EMDR)-based group treatment for preschool refugee children in German daycare centers. Ten refugee preschool children aged 4–6 years (n = 5 female) with posttraumatic stress disorder (PTSD) symptoms took part in an EMDR-based group treatment (with 2–4 children per group). PTSD symptoms were rated by parents and preschool teachers using items from the Child Behavior Checklist (CBCL 1½–5), pre- and posttreatment, and at 3-month follow-up. After treatment children tended to display less fear of animals or situations than before treatment. According to preschool teachers' perspective, the total number of PTSD symptoms dropped significantly at posttreatment (d = .93) and at follow-up (d = .81). Before the intervention, preschool teachers rated the children as being more defiant than their parents did (p = .020). After the intervention, the PTSD symptoms of boys were significantly higher than those of girls (p = .036) according to preschool teachers. The results indicate that timely psychotherapeutic interventions can be conducted with refugee children displaying PTSD symptoms in daycare centers. The efficacy of this intervention needs to be studied in a larger sample under controlled randomized conditions.

Promoting well-being in refugee children: An exploratory controlled trial of a positive psychology intervention delivered in Greek refugee camps

Rigorously evaluated interventions that target protective factors and positive resources rather than ameliorating negative outcomes in child refugees are rare. To address this, we developed and evaluated a short, group-based resilience-building intervention called Strengths for the Journey (SFJ), which was designed for war-affected children. We conducted a quasi-randomized pilot study of the SFJ intervention with 72 7- to 14-year-old forcibly displaced children (Mage = 10.76, 64.8% female) in three refugee camps in Lesvos, Greece. Intervention effectiveness was assessed by measuring pre-post changes in well-being, self-esteem, optimism, and depressive symptoms from before (T1) to immediately after the intervention/wait-list task (T2). Four focus group interviews were conducted with 31 of the participants to discuss their views on the effects of the intervention and the continued use of the skills that were learned. Using repeated-measures ANOVAs, we found improvements in well-being, F (1, 46) = 42.99, ηp2 = .48, self-esteem, F (1, 56) = 29.11, ηp2 = .40, optimism, F (1, 53) = 27.16, ηp2 = .34, and depressive symptoms, F (1, 31) = 62.14, ηp2 = .67, in the intervention group compared with the wait-listed group (p < .05). Focus group participants highlighted the importance of SFJ in developing a sense of togetherness and building their strengths. Child refugees in low-resource settings may benefit from brief, first-line interventions that target protective factors such as well-being, hope, self-esteem, and belonging.

Mental Health of Refugee Children and Youth: Epidemiology, Interventions, and Future Directions

The number of refugee youth worldwide receives international attention and is a top priority in both academic and political agendas. This article adopts a critical eye in summarizing current epidemiological knowledge of refugee youth mental health as well as interventions aimed to prevent or reduce mental health problems among children and adolescents in both high- and low-to-middle-income countries. We highlight current challenges and limitations of extant literature and present potential opportunities and recommendations in refugee child psychiatric epidemiology and mental health services research for moving forward. In light of the mounting xenophobic sentiments we are presently witnessing across societies, we argue that, as a first step, all epidemiological and intervention research should advocate for social justice to guarantee the safety of and respect for the basic human rights of all refugee populations during their journey and resettlement. A constructive dialogue between scholars and policy makers is warranted.

Evaluation of students' mental and social health promotion educational programs: A systematic review

INTRODUCTION

Various programs are implemented internationally to promote the mental and social health of the students in schools. This study systematically reviewed and categorized all resources, indicators, and criteria for evaluating mental and social programs of schools.

MATERIALS AND METHODS

This systematic review was conducted by collecting data from the PubMed, Google Scholar, Scopus, ProQuest, and Web of Science databases using the keywords of "evaluation, mental health program, social health program, behavioral and emotional program." In the initial review, 4295 studies were found, which reduced to 75 after removing the repetitions and evaluating the studies' quality. The articles were selected using the PRISMA chart.

RESULTS

The findings resulted in three main categories of structure, process, and outcome; 16 subcategories; and 166 codes. The category of structure included the subcategories of human resources, physical space, facilities, training, needed committees and teams, financing, and implementing mental and social programs. The subcategories of process category were functional indicators, guidelines and protocols, communication, documentation, planning/coordination, time management, and monitoring. The subcategories of behavioral-therapeutic, satisfaction, and educational outcomes were associated with the outcome category.

CONCLUSION

Application of the structure, process, and outcome indicators, derived from the findings of this study, will greatly improve evaluation of the international mental health programs in schools.

Health Care Needs in School-Age Refugee Children

Most European countries have systematic health assessments of refugees with a main focus on infectious diseases. The aim of this study was to describe the broader health care needs identified in newly settled refugee children in a school health setting. The study population consisted of all 609 recently settled Non-European refugee and asylum-seeking children in the age range 6-15 years who were enrolled in the schools of Malmö, Sweden during the autumn semester of 2015, of which 265 had arrived in Sweden unaccompanied. The data were collected in a structured routine intake interview by an experienced school nurse. Almost half of the children had obvious untreated caries. For the unaccompanied children, prominent mental health needs were present in almost one in three. Previously unidentified vision and/or hearing problems were identified in one in ten and around 5% had a daily medication, and 4.5% of the unaccompanied children and 1.2% of the accompanied children were judged to be in need of immediate care and were referred accordingly. Newly settled refugee children in northern Europe have considerable health care needs apart from communicable diseases. School health services have a unique platform to identify and initiate this care.

Efficacy and acceptability of psychosocial interventions in asylum seekers and refugees: systematic review and meta-analysis

AimsIn the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.

METHODS

We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.

RESULTS

We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = -0.71; 95% confidence interval [CI] -1.01 to -0.41; I2 = 83%; 95% CI 78-88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = -1.02; 95% CI -1.52 to -0.51; I2 = 89%; 95% CI 82-93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = -1.05; 95% CI -1.55 to -0.56; I2 = 87%; 95% CI 79-92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.

CONCLUSIONS

Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.

Clinical Tools Working at Home with Immigrants and Refugees

At a time of evolving demographics and turbulent policy changes, pediatric providers have a critical role in the care of all children, regardless of where the child or parent was born. Pediatric providers can facilitate access to high-quality care and critical community-based resources for immigrant children and families. In this article, we delineate the primary domains for clinical care and offer clinical tools to achieve the provision of accessible, comprehensive, high-quality care within a family-centered medical home.

A literature review of the psychological status of asylum-seeking children: implications for nursing practice

Europe is in the midst of a large-scale migration crisis, which has implications for healthcare provision for asylum-seeking children and families. The authors set out to identify the psychological status of asylum-seeking children and highlight their needs. A search of three electronic databases was carried out, resulting in 15 studies. Data show that asylum-seeking children appear to experience many mental health difficulties, including post-traumatic stress disorder, depression, self-harm, sleep disturbance and behavioural difficulties. The daily living situation includes a range of psychological stressors, such as lack of space and control; fear of deportation; feelings of inadequacy and hopelessness; poor parental mental health; lack of recreational facilities; communication issues; and financial worries. Since many asylum-seeking children have experienced past trauma, hospitalisation and healthcare encounters may trigger traumatic memories and cause further distress. Awareness of the psychological impact of the situation on children and families may help nurses to provide empathetic, sensitive and culturally competent care.