Unbegleitete minderjährige Flüchtlinge

Psychotherapeutic and Psychosocial Interventions with Unaccompanied Minors: A Scoping Review

Unaccompanied minors (UAMs) are considered a particularly vulnerable population, facing severe threats regarding their physical and mental health. As their number has increased in recent years worldwide, research on mental health interventions has become necessary. The implementation of psychotherapeutic interventions has been documented, but psychosocial interventions seem to not have been consistently studied. In this review, we summarize the psychotherapeutic and psychosocial interventions with UAMs that have been studied up to now. Following the PRISMA guidelines for scoping reviews, we searched four databases and included studies and practice papers; there were no restrictions on publication date, geographical region, language, or method. We identified 46 studies on psychotherapeutic interventions and 16 studies on psychosocial interventions that met the inclusion criteria. Psychotherapeutic interventions were mainly based on cognitive behavioural, psychodynamic, narrative, art and transcultural approaches and aimed at improving UAMs' trauma, mental health and wellbeing, as well as professionals' skills and therapeutic protocols. Several studies showed promising results, with the cognitive behavioural approaches being the most researched. However, more research is needed in order to draw conclusions in terms of effectiveness. Psychosocial interventions followed various approaches and aimed at UAMs' empowerment, wellbeing, support and integration, as well as at improving caregivers' skills. Nonetheless, they seem not only very heterogeneous but also understudied, and we believe that a focus on them would be very useful. Methodological limitations and their implications for future research are discussed.

START adolescents: study protocol of a randomised controlled trial to investigate the efficacy of a low-threshold group treatment programme in traumatised adolescent refugees

Introduction

No evaluated therapeutic approaches, that can efficiently be established in routine mental healthcare, are currently available for traumatised adolescent refugees in Germany. This study evaluates the efficacy of the Stress-Traumasymptoms-Arousal-Regulation-Treatment (START) programme to reduce trauma-related symptoms and psychological distress in traumatised adolescent refugees based in Germany.

Methods and analysis

This randomised, waiting-list-controlled, multicentre trial with a 12-week follow-up will include 174 refugee minors with partial or full post-traumatic stress disorder who are fluent in either Arabic, Dari, English, German or Somali. Eligible refugee minors will be randomised to the START or waiting-list control groups. The manualised 8-week START programme is based on techniques of dialectical behaviour therapy (DBT), fosters adaptive coping with emotional distress and traumatic symptoms and comprises eight therapy modules and a booster session. Study assessments are planned at baseline, post-treatment (ie, after programme participation or waiting time), booster session at week 12 or 12-week waiting time, and at the 12-week follow-up. Primary and coprimary outcomes are changes in psychological distress and traumatic symptoms at post-treatment and will be analysed as response variables in linear mixed regression models. Secondary outcomes are changes in further trauma-related and other psychopathological symptoms, emotion regulation and intermediate effects of the programme at follow-up. We will also assess effects of the programme with ecological momentary assessments and on neuroendocrine stress parameters using hair cortisol.

Ethics and dissemination

This study has been approved by the lead ethics committee of Rhineland-Palatinate and the ethics committees of participating sites. The study results will be disseminated through peer-reviewed publications and scientific conferences.

Trial registration number

DRKS00020771.

An overview of systematic reviews on mental health promotion, prevention, and treatment of common mental disorders for refugees, asylum seekers, and internally displaced persons

BACKGROUND

Migrants who have been forced to leave their home, such as refugees, asylum seekers, and internally displaced persons (IDP), are likely to experience stressors which may lead to mental health problems. The efficacy of interventions for mental health promotion, prevention, and treatment may differ in this population.

OBJECTIVES

With this overview of systematic reviews, we will map the characteristics and methodological quality of existing systematic reviews and registered systematic review protocols on the promotion of mental health and prevention and treatment of common mental disorders among refugees, asylum seekers, and IDPs. The findings from this overview will be used to prioritise and inform future Cochrane reviews on the mental health of involuntary migrants.

METHODS

We searched Ovid MEDLINE (1945 onwards), Ovid Embase (1974 onwards), Ovid PsycINFO, ProQuest PTSDpubs, Web of Science Core Collection, Cochrane Database of Systematic Reviews, NIHR Journals Library, CRD databases (archived), DoPHER, Epistemonikos, Health Evidence, 3ie International Initiative for Impact Evaluation, and PROSPERO, to identify systematic reviews of mental health interventions for involuntary migrants. We did not apply any restrictions on date, language, or publication status to the searches. We included systematic reviews or protocols for systematic reviews of interventions aimed at refugees, asylum seekers, and internally displaced persons. Interventions must have been aimed at mental health promotion (for example, classroom-based well-being interventions for children), prevention of mental health problems (for example, trauma-focussed Cognitive Behavioural Therapy to prevent post-traumatic stress disorder), or treatment of common mental disorders and symptoms (for example, narrative exposure therapy to treat symptoms of trauma). After screening abstracts and full-text manuscripts in duplicate, we extracted data on the characteristics of the reviews, the interventions examined in reviews, and the number of primary studies included in each review. Methodological quality of the included systematic reviews was assessed using AMSTAR 2.

MAIN RESULTS

The overview includes 23 systematic reviews and 15 registered systematic review protocols. Of the 23 published systematic reviews, meta-analyses were conducted in eight reviews. It was more common for the search strategy or inclusion criteria of the reviews to state that studies involving refugees were eligible for inclusion (23/23), than for asylum seekers (14/23) or IDPs (7/23) to be explicitly mentioned. In most reviews, study eligiblity was either not restricted by participant age (9/23), or restricted to adults (10/23). Reviews commonly reported on studies of diagnosis or symptoms of post-traumatic stress disorder or trauma (11/23) and were less likely to report on depression or anxiety (6/23). In 15 reviews the intervention of interest was focused on/ specific to psychological therapy. Across all 23 reviews, the interventions most commonly identified from primary studies were general Cognitive Behavioural Therapy, Narrative Exposure Therapy, and a range of different integrative and interpersonal therapies. Even though many reviews included studies of participants without a diagnosis of a mental health problem, they often assessed mental health treatments and did not usually distinguish between promotion, prevention, and treatment in the review aims. Together the 23 systematic reviews included 336 references, of which 175 were unique primary studies. Limitations to the methodological quality of reviews most commonly related to reporting of selection criteria (21/23), absence of a protocol (19/23), reporting of study design (20/23), search strategy (22/23), and funding sources of primary studies (19/23).

AUTHORS' CONCLUSIONS

Gaps exist in the evidence on mental health interventions for refugees, asylum seekers, and internally displaced persons. Most reviews do not specify that internally displaced persons are included in the selection criteria, even though they make up the majority of involuntary migrants worldwide. Reviews specific to mental health promotion and prevention of common mental disorders are missing, and there is more evidence available for adults or mixed populations than for children. The literature is focused on post-traumatic stress disorder and trauma-related symptoms, with less attention for depression and anxiety disorders. Better quality systematic reviews and better report of review design and methods would help those who may use these reviews to inform implementation of mental health interventions.

Gewalterfahrungen und psychische Gesundheit im Verlauf bei unbegleiteten minderjährigen Flüchtlingen in Deutschland

Zusammenfassung. Hintergrund: Über die seelische Gesundheit von minderjährigen Flüchtlingen, die ohne sorgeberechtigte Person nach Deutschland gereist sind, liegen bisher kaum Daten und keinerlei längsschnittliche Untersuchungen vor. Fragestellung: Ziel ist es daher, die psychische Gesundheit im Zusammenhang mit stressvollen Erfahrungen (insbesondere familiäre und organisierte Gewalterfahrungen) sowie deren Entwicklung nach etwa zwei Jahren bei unbegleiteten minderjährig Geflüchteten in Deutschland zu untersuchen. Methode: In einer Querschnittsstudie wurden belastende Erlebnisse sowie posttraumatische, depressive und psychosomatische Symptome bei 57 unbegleiteten und 22 begleiteten minderjährig eingereisten Flüchtlingen mittels strukturierter klinischer Interviews untersucht. Nach durchschnittlich 20 Monaten wurde eine Subgruppe der unbegleiteten Minderjährigen erneut untersucht. Ergebnisse: Ein Drittel der Teilnehmer erfüllte die Kriterien einer PTBS-Diagnose nach DSM-IV. Nach Einbezug einer Gruppe begleiteter minderjähriger Flüchtlinge zeigte sich, dass vor allem organisierte und familiäre Gewalterfahrungen sowie die Dauer der Flucht bedeutsame Prädiktoren hinsichtlich der PTBS-Symptomschwere waren. Für das psychische Wohlbefinden insgesamt waren die erfahrene Gewalt in der Herkunftsfamilie, bestehende Freundschaften und das Vorhandensein von Privatsphäre relevant. Ergebnisse einer Folgeuntersuchung mit einer Teilgruppe der UMF etwa 20 Monate später zeigten, dass die psychische Beeinträchtigung im Durchschnitt unverändert hoch geblieben war. Fazit: Die Möglichkeit einer frühzeitigen psychischen Untersuchung mit Erfassung kindlicher Gewalterlebnisse sowie ein verbesserter Zugang zu einer traumafokussierten Behandlung mit Sprachmittlern sind wichtig, um Leid zu reduzieren und Integration zu ermöglichen.

Jugendliche Flüchtlinge

Zusammenfassung. Die psychischen Belastungen von jugendlichen Flüchtlingen sind vielfältig und äußern sich in Stressreaktionen, die sich vor allem in einer Posttraumatischen Belastungsstörung, Ängsten und Depression zeigen. Die Prävalenzen sind bei unbegleiteten minderjährigen Flüchtlingen besonders hoch ausgeprägt. Neben fluchtspezifischen Stressoren kommt akkulturationsbezogenem Stress eine wichtige Rolle zu. Ein ungünstiger Akkulturationsstil besitzt einen hohen Vorhersagewert für die Entwicklung einer Posttraumatischen Belastungsstörung und einer Depression. In den letzten Jahren konnten Belege gesammelt werden, die im Rahmen der Behandlung vor allem verhaltenstherapeutische Ansätze als wirksam ausweisen. Gesellschaftliche Anstrengungen (z. B. im Rahmen der Jugendhilfe) und therapeutische Bemühungen sind Teile einer perspektivenreichen Integration jugendlicher Flüchtlinge.

Begleitete minderjährige Geflüchtete

Zusammenfassung. Aufgrund erhöhter psychopathologischer Vulnerabilität bei minderjährigen Geflüchteten (MG), sind wirksame psychotherapeutische Interventionen versorgungsrelevant. Die Mehrzahl MG flieht im Familienverbund. Die Familie wirkt dabei einerseits als stabilisierende Ressource, anderseits als Stressor, so dass der Einbezug der Eltern in die Therapie von Bedeutung ist. Dieses Reviews gibt einen Überblick über den aktuellen Forschungsstand zur Wirksamkeit psychotherapeutischer Maßnahmen mit Familieneinbezug bei begleiteten minderjährigen Geflüchteten (BMG). Insgesamt konnten fünf Studien identifiziert werden. Für die Kinder wurden in vier der fünf, für die Mütter in zwei der fünf Studien signifikante Effekte berichtet. Insgesamt ist die Befundlage gering und die Qualität der Primärstudien oft unzureichend. Replikationen der Ergebnisse unter Berücksichtigung der methodischen Qualität sowie die Implementierung weiterer Maßnahmen sind notwendig.

Resilienztraining für unbegleitete minderjährige Flüchtlinge

Zusammenfassung. Die hohen Flüchtlingszahlen und die fortlaufende Ankunft schwer traumatisierter unbegleiteter minderjähriger Flüchtlinge (UMF) verschärfen die Suche nach wirksamen und niederschwelligen Präventions- und Interventionsprogrammen. Die vorliegende Pilotstudie evaluiert die Effektivität eines nicht-indizierten, sechs Sitzungen umfassenden Resilienztrainings für UMF. Teilnehmende (N = 55) wurden in einem randomisiert-kontrollierten Wartelistendesign vor (T1) und nach (T2) dem Gruppenprogramm untersucht. Abhängige Variablen waren das allgemeine Wohlbefinden sowie Symptome von Traumafolgestörungen. Weiter wurden aus mehreren Perspektiven (Teilnehmer, Dolmetscher, Gruppenleitende, Betreuende) qualitative Daten erfasst. Während Traumafolgestörungssymptome unverändert blieben, berichtete die Interventionsgruppe nach dem Programm einen Anstieg im Wohlbefinden, nicht jedoch die Kontrollgruppe. Die qualitativen Daten wiesen perspektivenübergreifend auf positive Veränderungen in mehreren Funktionsbereichen hin. Ein kurzes Resilienztraining hat somit das Potential Verbesserungen zu bewirken. Für eine Minderung von Traumafolgestörungssymptomen sind jedoch wohl längere bzw. traumaspezifischere Interventionen erforderlich.

A Brief Introduction to the Multidimensional Intercultural Training Acculturation Model (MITA) for Middle Eastern Adolescent Refugees

The large number of adolescent refugees around the world constitutes a great challenge for societies. However, current models of acculturation have been developed for migrants, but not specifically for adolescent refugees. Crucial factors to describe adolescent refugee acculturation, such as intentions to return to their homeland, especially with respect to adolescent refugees with temporary residency and experiences of potentially traumatic events, are missing. Hence, the Multidimensional Intercultural Training Acculturation (MITA) model is introduced. The model proposes that two major concerns for adolescent refugees, which are socio-cultural adjustment and mental health, are predicted by intercultural and social–emotional competence, intentions to return to their homeland, and experiences of traumatic events. Moreover, the effects of three modes of acculturation are also proposed in the model. It is expected that these variables mediate the effects of intercultural competence, social–emotional competence, intentions to return to the homeland, and experiences of traumatic events on socio-cultural adjustment as well as mental health. Finally, it is also expected that in-group social support and out-group social support moderate the direct connection between the experiences of traumatic events and mental health.

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

Large numbers of refugee children are arriving in high-income countries. The evidence to date suggests that they have mental health needs that are higher than for the general population and that these are exacerbated by the numbers of traumatic events they have experienced and the post-migration stressors they continue to be exposed to. The importance of a thorough and thoughtful assessment is discussed. Treatments of note are described for post-traumatic stress disorder, family functioning, general mental health problems and school environments. Future opportunities to operationalise outcome measures, develop multimodal interventions and utilise implementation science methodology are considered.

Promoting Mental Health in Unaccompanied Refugee Minors: Recommendations for Primary Support Programs

During the last years, the number of refugees around the world increased to about 22.5 million. The mental health of refugees, especially of unaccompanied minors (70% between the ages of 16 and 18 years) who have been exposed to traumatic events (e.g., war), is generally impaired with symptoms of post-traumatic stress disorder, depression, and anxiety. Several studies revealed (1) a huge variation among the prevalence rates of these mental problems, and (2) that post-migration stressors (e.g., language barriers, cultural differences) might be at least as detrimental to mental health as the traumatic events in pre- and peri-flight. As psychotherapy is a limited resource that should be reserved for severe cases and as language trainings are often publicly offered for refugees, we recommend focusing on intercultural competence, emotion regulation, and goal setting and goal striving in primary support programs: Intercultural competence fosters adaptation by giving knowledge about cultural differences in values and norms. Emotion regulation regarding empathy, positive reappraisal, and cultural differences in emotion expression fosters both adaptation and mental health. Finally, supporting unaccompanied refugee minors in their goal setting and goal striving is necessary, as they carry many unrealistic wishes and unattainable goals, which can be threatening to their mental health. Building on these three psychological processes, we provide recommendations for primary support programs for unaccompanied refugee minors that are aged 16 to 18 years.

Flüchtlingskinder

Zusammenfassung. Die Anzahl und die kulturelle Verschiedenheit der unbegleiteten Kinder und Jugendlichen, die in den letzten Monaten nach Deutschland gekommen sind, stellen eine große Herausforderung dar. Soziale Integration bildet die generelle Anforderung, wobei die Vielzahl der Erwartungen, unterschiedliche Wertesysteme und psychische Belastungen Barrieren einer erfolgreichen Integration bilden. Psychologische und therapeutische Maßnahmen sowie Angebote der Jugendhilfe können viele Probleme abfangen und als umfassendes Betreuungsangebot wertvolle Dienste leisten.