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Dähne F, Jervelund SS, Primdahl NL, Siemsen N, Derluyn I, Verelst A, Spaas C, de Haene L, Skovdal M. Understanding how classroom drama workshops can facilitate social capital for newly arrived migrant and refugee adolescents: Insights from Denmark. Transcult Psychiatry 2024; 61:260-272. [PMID: 38304985 DOI: 10.1177/13634615231225099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Art-based interventions, such as classroom drama workshops (CDWs), increasingly form part of a collection of mental health-promoting activities introduced in school settings. While research points to the potential benefits of CDWs for the mental well-being of refugee and migrant adolescents, the mechanisms to such improvement are less understood. In this article we respond to the need for qualitative evidence of how CDW interventions affect refugee and migrant adolescents' experience. The study draws on eight focus group discussions (FGDs) with 41 adolescents, four semi-structured interviews with teachers and a school coordinator, and written documents from two drama therapists. Our thematic analysis revealed that the CDWs were found to foster trust and improve social relations in the classroom-key facets of bonding social capital. Several processes were described as being linked to these changes. Participants spoke about how the CDWs were facilitated in an emancipatory and safe manner, creating social spaces where the adolescents could have fun together, share, and bear witness to each other's stories, as well as experiencing a sense of agency. In some cases, however, activities in the CDWs crossed the learners' psychological boundaries, which led to withdrawal and a loss of trust. We conclude that whilst CDWs have the potential to facilitate bonding social capital amongst refugee and migrant adolescents and their teachers, this potential hinges on how the CDWs are facilitated.
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Affiliation(s)
- Finja Dähne
- Department of Public Health, Danish Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Denmark
| | - Signe Smith Jervelund
- Department of Public Health, Danish Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Denmark
| | - Nina Langer Primdahl
- Department of Public Health, Danish Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Denmark
| | - Nicoline Siemsen
- Department of Public Health, Danish Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Denmark
| | - Ilse Derluyn
- Department of Social Work and Social Pedagogy, Centre for the Social Study of Migration and Refugees, Ghent University, Belgium
| | - An Verelst
- Department of Social Work and Social Pedagogy, Centre for the Social Study of Migration and Refugees, Ghent University, Belgium
| | - Caroline Spaas
- Parenting and Special Education Research Unit, Faculty of Psychology and Educational Sciences, University of Leuven, Belgium
| | - Lucia de Haene
- Parenting and Special Education Research Unit, Faculty of Psychology and Educational Sciences, University of Leuven, Belgium
| | - Morten Skovdal
- Department of Public Health, Danish Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Denmark
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Alzaghoul AF, McKinlay AR, Archer M. Post-traumatic stress disorder interventions for children and adolescents affected by war in low- and middle-income countries in the Middle East: systematic review. BJPsych Open 2022; 8:e153. [PMID: 35938530 PMCID: PMC9380009 DOI: 10.1192/bjo.2022.552] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Millions of children and adolescents are exposed to wars, affecting their psychological well-being. This review focuses on psychosocial interventions in low and middle-income countries (LMICs) in the Middle East, where mental health services are limited. AIMS Our primary aim was to evaluate the effectiveness of trial-assessed psychosocial interventions in reducing post-traumatic stress disorder (PTSD) symptoms in children and adolescents aged ≤18 years who were exposed to war in LMICs in the Middle East. Changes in other psychological conditions and symptoms were evaluated where reported. METHOD PubMed, Cochrane Library and Ovid were searched without year restriction, in December 2021. Previous review reference lists were also checked. Only studies published in English were included. Each study was evaluated for risk of bias and results are presented as a narrative synthesis. RESULTS Three group-based interventions were identified and evaluated across six studies: 'Teaching Recovery Techniques', 'Writing for Recovery' and 'Advancing Adolescents'. Two studies took place in post-war settings, and four in a context of ongoing conflict. Positive experiences and improved social skills were indicated following most interventions, but Teaching Recovery Techniques was the only programme associated with a statistically significant reduction in PTSD score. Differences in follow-up interval limited comparability of outcomes. CONCLUSIONS This review highlights a paucity of evidence for effective treatment options for children and adolescents affected by war from LMICs in the Middle East. Promising indications of reductions in PTSD symptoms, specifically from Teaching Recovery Techniques, require further rigorous evaluation and long-term follow-up.
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Affiliation(s)
- Aseel F Alzaghoul
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Alison R McKinlay
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, UK
| | - Marc Archer
- Centre for Mental Health and Wellbeing, Department of Psychology, Faculty of Behavioural Sciences, HELP University, Malaysia
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Tran VM, Fozouni L, Denkinger JK, Rometsch C, Junne F, Vinck P, Pham P. Factors influencing utilization and perception of health care: a qualitative study among traumatized Yazidi refugees in Germany. BMC Psychiatry 2021; 21:346. [PMID: 34247590 PMCID: PMC8274022 DOI: 10.1186/s12888-021-03335-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 06/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ensuring adequate utilization of healthcare services for displaced populations is critical, yet there are well-documented treatment gaps. Yazidi women captured by the Islamic State (IS) were subjected to extreme trauma and violence. This study aims to understand perceptions of healthcare providers and utilization of these services among women who experienced extreme trauma. METHODS This is a qualitative study with voluntary participation offered to approximately 400 women resettled through the Special Quota Program. An empirical approach was used to collect data and a grounded theory approach was used for content analysis. Participants ranked their interactions with providers on a Likert scale. Posttraumatic stress disorder (PTSD) symptoms were assessed using the impact of event scale-revised questionnaire. RESULTS A total of 116 Yazidi women participated in this study. The women experienced an average of 6.8 months of captivity by IS and 93% met criteria for probable PTSD. Eighty-three percent of the women interacted with a physician; 80% found this interaction helpful. Sixty-nine percent interacted with psychologists; 61% found this interaction helpful. Six themes emerged: "reminders of trauma" and "hopelessness" in relation to the traumatic experience; "immediate relief" and "healing through pharmaceutical treatment" in relation to provider interventions, and "support" and "cultural differences" in relation to interactions with providers. CONCLUSIONS There exist major barriers to care for Yazidi women who experienced extreme trauma, particularly in regards to psychiatric care. Perceptions of healthcare providers and perceived effectiveness of therapy are critical factors that must be taken into consideration to improve healthcare utilization and outcomes.
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Affiliation(s)
- Virginia M. Tran
- grid.413529.80000 0004 0430 7173Department of Emergency Medicine, Highland Hospital-Alameda Health System, 1441 E 31st St, Oakland, CA 94602 USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston MA, 25 Shattuck St, Boston, MA 02115 USA
| | - Laila Fozouni
- grid.266102.10000 0001 2297 6811School of Medicine, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143 USA ,grid.38142.3c000000041936754XHarvard Humanitarian Initiative, Harvard University, 14 Story Street, Cambridge, MA 02138 USA
| | - Jana K. Denkinger
- grid.10392.390000 0001 2190 1447Medical University Hospital Tübingen, University of Tübingen, Osianderstraße 5, 72076 Tübingen, Germany
| | - Caroline Rometsch
- grid.10392.390000 0001 2190 1447Medical University Hospital Tübingen, University of Tübingen, Osianderstraße 5, 72076 Tübingen, Germany
| | - Florian Junne
- grid.10392.390000 0001 2190 1447Medical University Hospital Tübingen, University of Tübingen, Osianderstraße 5, 72076 Tübingen, Germany ,grid.5807.a0000 0001 1018 4307Department of Psychosomatic Medicine and Psychotherapy, University Hospital, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Patrick Vinck
- grid.38142.3c000000041936754XHarvard Medical School, Boston MA, 25 Shattuck St, Boston, MA 02115 USA ,grid.38142.3c000000041936754XHarvard Humanitarian Initiative, Harvard University, 14 Story Street, Cambridge, MA 02138 USA ,grid.38142.3c000000041936754XHarvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 USA ,grid.62560.370000 0004 0378 8294Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 USA
| | - Phuong Pham
- Harvard Medical School, Boston MA, 25 Shattuck St, Boston, MA, 02115, USA. .,Harvard Humanitarian Initiative, Harvard University, 14 Story Street, Cambridge, MA, 02138, USA. .,Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA. .,Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
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Associations between family-level adversity and society-level trauma with emotional and behavioural problems amongst children of West Papuan refugees. Eur Child Adolesc Psychiatry 2021; 30:909-920. [PMID: 32500279 DOI: 10.1007/s00787-020-01569-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
Few studies have examined associations between family-level parental factors, society-level violence, and the emotional and behavioral status of children of refugee populations. Our study used cross-sectional epidemiological data to test a theoretical model of these key associations amongst a community sample of children (n = 162) of West Papuan refugees living in remote town in Papua New Guinea (PNG), a setting of endemic violence and poverty. Culturally adapted instruments were used to assess three types of intra-familial factors (adverse parenting, physical and/or sexual abuse and emotional abuse) and three types of society-level violence and stressors (exposure to systematic violence, peer violence, living difficulties). Emotional and behavioural problems were assessed using the Youth Self-Report Checklist. Path analysis was used to test theoretical associations. Key findings include direct associations between both family-level physical and/or sexual abuse (β = .43; p < .001) and adverse parenting (β = .40; p < .001) with emotional and behavioural problems amongst children. In the broader social domain, peer violence (β = .29; p < .001) had a direct association with children's emotional and behavioural problems. Several indirect paths demonstrated a chain of relationships involving family- and society-level factors and emotional and behavioural problems in children. Only longitudinal data can provide further support for veridical causal pathways linking family and social factors with adverse emotional and behavioural outcomes in offspring of refugees, thereby supporting mechanisms leading to a transgenerational transmission of adverse mental health outcomes in refugee populations. Such data would give further support for a multisectoral approach to dealing with at risk families in refugee populations, in which attention should focus on supporting parents, and promoting the protection of children from abuse in the family and in the wider society.
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Miller KE, Jordans MJD, Tol WA, Galappatti A. A call for greater conceptual clarity in the field of mental health and psychosocial support in humanitarian settings. Epidemiol Psychiatr Sci 2021; 30:e5. [PMID: 33413736 PMCID: PMC8057504 DOI: 10.1017/s2045796020001110] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/18/2020] [Accepted: 11/26/2020] [Indexed: 01/29/2023] Open
Abstract
AIMS When the Interagency Standing Committee (IASC) adopted the composite term mental health and psychosocial support (MHPSS) and published its guidelines for MHPSS in emergency settings in 2007, it aimed to build consensus and strengthen coordination among relevant humanitarian actors. The term MHPSS offered an inclusive tent by welcoming the different terminologies, explanatory models and intervention methods of diverse actors across several humanitarian sectors (e.g., health, protection, education, nutrition). Since its introduction, the term has become well-established within the global humanitarian system. However, it has also been critiqued for papering over substantive differences in the intervention priorities and conceptual frameworks that inform the wide range of interventions described as MHPSS. Our aims are to clarify those conceptual frameworks, to argue for their essential complementarity and to illustrate the perils of failing to adequately consider the causal models and theories of change that underlie our interventions. METHODS We describe the historical backdrop against which the term MHPSS and the IASC guidelines were developed, as well as their impact on improving relations and coordination among different aid sectors. We consider the conceptual fuzziness in the field of MHPSS and the lack of clear articulation of the different conceptual frameworks that guide interventions. We describe the explanatory models and intervention approaches of two primary frameworks within MHPSS, which we label clinical and social-environmental. Using the examples of intimate partner violence and compromised parenting in humanitarian settings, we illustrate the complementarity of these two frameworks, as well as the challenges that can arise when either framework is inappropriately applied. RESULTS Clinical interventions prioritise the role of intrapersonal variables, biological and/or psychological, as mediators of change in the treatment of distress. Social-environmental interventions emphasise the role of social determinants of distress and target factors in the social and material environments in order to lower distress and increase resilience in the face of adversity. Both approaches play a critical role in humanitarian settings; however, the rationale for adopting one or the other approach is commonly insufficiently articulated and should be based on a thorough assessment of causal processes at multiple levels of the social ecology. CONCLUSIONS Greater attention to the 'why' of our intervention choices and more explicit articulation of the causal models and theories of change that underlie those decisions (i.e., the 'how'), may strengthen intervention effects and minimise the risk of applying the inappropriate framework and actions to a particular problem.
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Affiliation(s)
| | - M. J. D. Jordans
- War Child Holland, Amsterdam, The Netherlands
- Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - W. A. Tol
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Children's learning and development in conflict- and crisis-affected countries: Building a science for action. Dev Psychopathol 2021; 33:506-521. [PMID: 33402231 DOI: 10.1017/s0954579420001789] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This paper critically reviews the opportunities and challenges in designing and conducting actionable research on the learning and development of children in conflict- and crisis-affected countries. We approached our review through two perspectives championed by Edward Zigler: (a) child development and social policy and (b) developmental psychopathology in context. The aim of the work was to answer the following questions: What works to enhance children's learning and development in such contexts? By what mechanisms? For whom? Under what conditions? How do experiences and conditions of crisis affect the basic processes of children's typical development? The review is based on a research-practice partnership started in the Democratic Republic of the Congo in 2010 and expanded to research in Niger and Lebanon in 2016. The focus of the research is on the impact of Healing Classrooms (a set of classroom practices) and Healing Classrooms Plus (an additional set of targeted social and emotional learning activities), developed by the International Rescue Committee, on children's academic outcomes and social and emotional learning. We sought to extract lessons from this decade of research for building a global developmental science for action. Special attention is paid to the importance of research-practice partnerships, conceptual frameworks, measurement and methodology. We conclude by highlighting several essential features of a global developmental science for action.
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Giordano F, Ungar M. Principle-driven program design versus manualized programming in humanitarian settings. CHILD ABUSE & NEGLECT 2021; 111:104862. [PMID: 33278731 DOI: 10.1016/j.chiabu.2020.104862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/21/2020] [Accepted: 11/24/2020] [Indexed: 06/12/2023]
Affiliation(s)
- F Giordano
- Department of Psychology - Resilience Research Unit, Università Cattolica del Sacro Cuore, Largo Gemelli 1, 20121, Milan, Italy.
| | - M Ungar
- Canada Research Chair in Child, Family and Community Resilience, Resilience Research Centre, Dalhousie University, PO Box 15000, Halifax, NS, B3H4R2, Canada.
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Hodes M, Vostanis P. Practitioner Review: Mental health problems of refugee children and adolescents and their management. J Child Psychol Psychiatry 2019; 60:716-731. [PMID: 30548855 DOI: 10.1111/jcpp.13002] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Since 2010, the numbers of refugees have increased and around half are under 18 years of age. It is known that experience of organised violence, displacement and resettlement increases the risk for psychiatric disorders and psychosocial impairment. This review integrates recent research into the risk and protective factors for psychopathology with service and treatment issues. METHODS We draw on and critically evaluate key systematic reviews in the selected areas, innovative robust studies and relevant government reports. RESULTS Many refugee children show resilience and function well, even in the face of substantial adversities. The most robust findings for psychopathology are that PTSD, and posttraumatic and depressive symptoms are found at higher prevalence in those who have been exposed to war experiences. Their severity may decrease over time with resettlement, but PTSD in the most exposed may show higher continuity. More severe psychiatric disorders including psychosis may also occur. Service delivery needs to take into account socioeconomic and cultural influences but, given the high level of unmet need even in high-income countries, stepped care delivery is required. The evaluation of psychological interventions, often delivered in group settings, suggests that they can be effective for many distressed children; however, for the more impaired, a greater range of disorder-specific therapies will be required. CONCLUSIONS Child and adolescent mental health clinicians and service providers need to be aware of the specific needs of this population and systems for service delivery. There are significant knowledge gaps in understanding risk and vulnerability, service delivery and treatment effectiveness.
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Affiliation(s)
- Matthew Hodes
- Centre for Psychiatry, Imperial College London, London, UK
| | - Panos Vostanis
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
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Kadir A, Shenoda S, Goldhagen J, Pitterman S, Suchdev PS, Chan KJ, Howard CR, McGann P, St Clair NE, Yun K, Arnold LD. The Effects of Armed Conflict on Children. Pediatrics 2018; 142:peds.2018-2586. [PMID: 30397168 DOI: 10.1542/peds.2018-2586] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
More than 1 in 10 children worldwide are affected by armed conflict. The effects are both direct and indirect and are associated with immediate and long-term harm. The direct effects of conflict include death, physical and psychological trauma, and displacement. Indirect effects are related to a large number of factors, including inadequate and unsafe living conditions, environmental hazards, caregiver mental health, separation from family, displacement-related health risks, and the destruction of health, public health, education, and economic infrastructure. Children and health workers are targeted by combatants during attacks, and children are recruited or forced to take part in combat in a variety of ways. Armed conflict is both a toxic stress and a significant social determinant of child health. In this Technical Report, we review the available knowledge on the effects of armed conflict on children and support the recommendations in the accompanying Policy Statement on children and armed conflict.
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Affiliation(s)
- Ayesha Kadir
- Centre for Social Paediatrics, Herlev Hospital, Herlev, Denmark
| | - Sherry Shenoda
- Division of Community and Societal Pediatrics, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida; and
| | - Jeffrey Goldhagen
- Division of Community and Societal Pediatrics, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida; and
| | - Shelly Pitterman
- United Nations High Commissioner for Refugees Regional Representative for the United States and the Caribbean, Washington, District of Columbia
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Eruyar S, Huemer J, Vostanis P. Review: How should child mental health services respond to the refugee crisis? Child Adolesc Ment Health 2018; 23:303-312. [PMID: 32677147 DOI: 10.1111/camh.12252] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Child mental health services and related agencies are faced with an increasing challenge in responding to the influx of refugee children around the world. There is strong evidence on the prevalence and complexity of these children's mental health problems and broader needs. AIMS To review the research literature on risk and protective factors, and associated mental health interventions for refugee children. METHODS Peer-reviewed studies were included for the period 2004-2017; if they included refugee, asylum-seeking or internally displaced children under 18 years; and adopted a quantitative design. Vulnerability and protective factors for refugee children were considered in this context, followed by the respective types of interventions at pre-, peri- and postmigration stage, and across high- and low-/middle-income countries. Eighty-two peer-reviewed studies fulfilled the selection criteria. RESULTS The existing body of literature is largely based on identifying risk factors among children with mental health problems and predominantly designing trauma-focused interventions to reduce their symptomatic distress. Recent research and services have gradually shifted to a broader and dynamic resilience-building approach based on ecological theory, that is at child, family, school, community and societal level. There is increasing evidence for the implementation and effectiveness of multimodal interventions targeting all these levels, despite the methodological constraints in their evaluation. CONCLUSIONS In high-income countries, child mental health services need to collaborate with all agencies in contact with refugee children, establish joint care pathways, and integrate trauma-focused interventions with family and community approaches. In low- and middle-income countries, where specialist resources are sparse, resilience-building should aim at maximising and upskilling existing capacity. A six-dimensional psychosocial model that applies to other children who experience complex trauma is proposed.
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Affiliation(s)
- Seyda Eruyar
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
| | - Julia Huemer
- Department of Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Panos Vostanis
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
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Mental health and psychosocial problems among conflict-affected children in Kachin State, Myanmar: a qualitative study. Confl Health 2018; 12:39. [PMID: 30250500 PMCID: PMC6145186 DOI: 10.1186/s13031-018-0175-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/21/2018] [Indexed: 01/08/2023] Open
Abstract
Background In Kachin State, Myanmar, collapse of a ceasefire in 2011 has resulted in widespread exposure to conflict and ongoing internal displacement. Such exposures are known risk factors for mental health and psychosocial (MHPS) problems, yet mental health services for children and youth are typically scarce in such circumstances. Following evaluation of a mental health treatment for adult trauma survivors on the Thailand-Myanmar border, our study team received requests to support the development of a similar intervention for displaced children in Kachin State. To inform this work, we conducted a brief qualitative needs assessment to explore priority MHPS problems among this population. Methods Data were collected in internally displaced persons camps in Kachin State during July and August, 2016. Free list interviews with a convenience sample of 28 adolescents and 12 adults produced a list of problems affecting children and adolescents in this area. Four problems were further explored in key informant interviews with a convenience sample of 26 adolescents and 4 adults. Data analysis was conducted by the local interview team. Results Priority problems included: behavior problems, substance use, effects of war, and feeling sad/depressed/hopeless. Descriptions emphasized the interconnectedness between the problems. Overall, most problems were related to specific events that suggest that the symptoms themselves are responses to unusual situations; however, the problems were also linked to current psychosocial stressors such as poverty, poor nutrition, and discrimination. Effects of war were described primarily as a constellation of social and economic problems rather than a list of mental health symptoms, although descriptions of these problems did include post-traumatic stress symptoms. Conclusions Findings fit well within explanatory models of distress that include both direct trauma exposure and exacerbation of daily stressors. Results of this study have been used to inform intervention adaptation and evaluation, but also contribute to the literature on the needs of young people in situations of protracted conflict.
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Richter LM, Lye SJ, Proulx K. Nurturing Care for Young Children under Conditions of Fragility and Conflict. New Dir Child Adolesc Dev 2018. [PMID: 29537179 DOI: 10.1002/cad.20232] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Forced displacement worldwide is at its highest in decades and millions of young children are living in conflict zones, in transitional or enduring refugee contexts, and in demographically diverse marginalized and informal settlements. There is a huge unmet need for delivering early childhood development interventions to ensure the safety and continued development of young children in these vulnerable contexts. In this paper, we discuss nurturing care as an important entry point for multisectoral collaborations to support families and reach young children. Nurturing care is a basic right of every child and encompasses health, nutrition, security and safety, responsive caregiving, and early learning. We review key elements of the biological and psychological development of children important to nurturing care and illustrate their application in case studies of war and displacement in Angola and Kenya. Building on long-term benefits of early interventions, scaled up support is essential to improve the health, development, and well-being of young children in contexts of conflict, violence, and insecurity. Not only do early childhood development interventions support the development of young children, but they also provide a potential pathway to violence reduction and a way to achieve more peaceful families, communities, and societies.
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Wessells MG. Supporting resilience in war-affected children: How differential impact theory is useful in humanitarian practice. CHILD ABUSE & NEGLECT 2018; 78:13-18. [PMID: 29254697 DOI: 10.1016/j.chiabu.2017.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 12/09/2017] [Indexed: 06/07/2023]
Abstract
This paper examines the utility of the Differential Impact Theory for child protection practitioners who work in humanitarian settings, with a focus on war-affected children. A primary advantage of DIT is that it focuses efforts to strengthen children's resilience on improving children's social ecologies at different levels. This ecological focus is more likely to address the sources of children's suffering and resilience and also helps to avoid the problems associated with an individualized focus. It also shows how DIT provides a differentiated view of war-affected children and stimulates multiple interventions at different ecological levels, avoiding the common error of taking a one size fits all approach to intervention. In keeping with DIT, it suggests that child protection practice would benefit from addressing macro-level risks such as poverty and discrimination that are drivers of various harms to children and from more systematic linkages between macro- and micro-levels. It concludes that DIT serves as a critical lens for viewing current work on child protection in humanitarian settings and also for illuminating ways to develop more comprehensive supports for children's resilience.
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Whitsett D, Sherman MF. Do resettlement variables predict psychiatric treatment outcomes in a sample of asylum-seeking survivors of torture? Int J Soc Psychiatry 2017; 63:674-685. [PMID: 28838279 DOI: 10.1177/0020764017727022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Mental health clinicians who work with asylum seekers provide services to patients who face stressful everyday living conditions. However, little is known about how these problems potentially impact psychiatric treatment within these populations. The purpose of this study was thus to examine whether resettlement factors predict outcomes of a mental health intervention for a sample of asylum-seeking survivors of torture. METHODS The study included data from a US outpatient clinic that specialized in treating asylum-seeking survivors of torture. Patients (primarily from Iraq, Afghanistan and African Countries) were evaluated on demographic factors at intake and psychiatric symptoms throughout the course of treatment. RESULTS Patients experienced significant reductions in depression, anxiety and trauma symptoms, although symptoms still remained near or above clinical thresholds. Stable, uncrowded housing conditions significantly predicted lower depression, anxiety and trauma symptoms at follow-up. CONCLUSION These findings support the hypotheses that individuals seeking asylum within the United States who have survived torture can benefit from psychiatric treatment and emphasize the importance of stable living conditions in improving treatment effectiveness. This suggests the need for further research on social predictors of treatment outcomes, as well as the need for clinicians and policymakers to target improved housing as a potentially important tool to reduce psychiatric problems related to torture and forced migration.
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Affiliation(s)
- David Whitsett
- Department of Psychology, Loyola University Maryland, Baltimore, MD, USA
| | - Martin F Sherman
- Department of Psychology, Loyola University Maryland, Baltimore, MD, USA
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15
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How Legacies of Genocide Are Transmitted in the Family Environment: A Qualitative Study of Two Generations in Rwanda. SOCIETIES 2017. [DOI: 10.3390/soc7030024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Harnisch H, Montgomery E. “What kept me going”: A qualitative study of avoidant responses to war-related adversity and perpetration of violence by former forcibly recruited children and youth in the Acholi region of northern Uganda. Soc Sci Med 2017; 188:100-108. [DOI: 10.1016/j.socscimed.2017.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 11/26/2022]
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Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry 2017; 16:130-139. [PMID: 28498581 PMCID: PMC5428192 DOI: 10.1002/wps.20438] [Citation(s) in RCA: 263] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
There has been an unprecedented upsurge in the number of refugees worldwide, the majority being located in low-income countries with limited resources in mental health care. This paper considers contemporary issues in the refugee mental health field, including developments in research, conceptual models, social and psychological interventions, and policy. Prevalence data yielded by cross-sectional epidemiological studies do not allow a clear distinction to be made between situational forms of distress and frank mental disorder, a shortcoming that may be addressed by longitudinal studies. An evolving ecological model of research focuses on the dynamic inter-relationship of past traumatic experiences, ongoing daily stressors and the background disruptions of core psychosocial systems, the scope extending beyond the individual to the conjugal couple and the family. Although brief, structured psychotherapies administered by lay counsellors have been shown to be effective in the short term for a range of traumatic stress responses, questions remain whether these interventions can be sustained in low-resource settings and whether they meet the needs of complex cases. In the ideal circumstance, a comprehensive array of programs should be provided, including social and psychotherapeutic interventions, generic mental health services, rehabilitation, and special programs for vulnerable groups. Sustainability of services, ensuring best practice, evidence-based approaches, and promoting equity of access must remain the goals of future developments, a daunting challenge given that most refugees reside in settings where skills and resources in mental health care are in shortest supply.
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Affiliation(s)
- Derrick Silove
- School of Psychiatry, University of New South Wales, and Psychiatry Research and Teaching Unit, Academic Mental Health Centre, Southwestern Sydney Local Health District, Sydney, Australia
| | - Peter Ventevogel
- Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Susan Rees
- School of Psychiatry, University of New South Wales, and Psychiatry Research and Teaching Unit, Academic Mental Health Centre, Southwestern Sydney Local Health District, Sydney, Australia
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Addressing the Needs of Children and Youth in the Context of War and Terrorism: the Technological Frontier. Curr Psychiatry Rep 2017; 19:30. [PMID: 28447296 DOI: 10.1007/s11920-017-0786-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This paper reviews recent literature on the mental health needs of youth in the context of war and terrorism. A human rights lens is used to explore issues of accessibility and sustainability in service utilization during times of crisis. The authors present the evolution of services over the last several decades, progressing through individual, school-based, and community-wide interventions by exploring models that focus on symptom reduction and building resilience. This paper highlights the benefits and limitations of traditional intervention methods and proposes a new frontier of intervention development and research. The authors focus on the emerging field of e-mental health services and specifically highlight the utility of virtual reality games in treating trauma-exposed youth. The rapid and easily accessible nature of e-mental health models is presented as one potential solution to barriers in accessibility that can help promote the human rights of youth exposed to war and terrorism.
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Amone-P Olak K, Ovuga E. The influence of types of war experiences on conduct problems in war-affected youth in Northern Ugandan: Findings from the WAYS study. Psychiatry Res 2017; 251:14-19. [PMID: 28171768 PMCID: PMC5369637 DOI: 10.1016/j.psychres.2017.01.092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 11/09/2016] [Accepted: 01/21/2017] [Indexed: 11/25/2022]
Abstract
Exposure to war is associated with poor psychosocial outcomes. Yet the effects of different types of war events on various psychosocial outcomes such as conduct problems remain unknown. This study aims to assess whether various war events differ in predicting conduct problems. Using data from an on-going longitudinal research project, the WAYS study, the current article examined the relationship between specific war events and conduct problems in war-affected youth in Northern Uganda (N=539, baseline age=22.39; SD=2.03, range 18-25). Regression analyses were conducted to relate each type of war experience to conduct problems. War categories of "witnessing violence", "deaths", "threat to loved ones" and "sexual abuse" were associated with reporting conduct problems. Multivariable models yielded independent effects of ''witnessing violence'' (β=0.09, 95% CI: 0.01, 0.18) and ''Sexual abuse'' (β=0.09, 95% CI: 0.02, 0.19) on conduct problems while "duration in captivity" independently and negatively predicted conduct problems (β=-0.14, 95% CI: -0.23, -0.06). Types of war events vary in predicting conduct problems and should be considered when designing interventions to alleviate negative consequences of exposure to war. Moreover, longer duration in captivity appear to protect war-affected youth from conduct problems.
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Affiliation(s)
- Kennedy Amone-P Olak
- University of Botswana, Department of Psychology, Private Bag UB 00705, Gaborone, Botswana.
| | - Emilio Ovuga
- Gulu University, Department of Psychiatry and Mental Health, P.O. Box 166, Gulu, Uganda
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Coping and mental health outcomes among Sierra Leonean war-affected youth: Results from a longitudinal study. Dev Psychopathol 2016; 29:11-23. [DOI: 10.1017/s0954579416001073] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
AbstractThis study explored how coping with war-related traumatic events in Sierra Leone impacted mental health outcomes among 529 youth (aged 10–17 at baseline; 25% female) using longitudinal data from three time points (Time 1 in 2002, Time 2 in 2004, and Time 3 in 2008). We examined two types of coping items (approach and avoidance); used multiple regression models to test their relations with long-term mental health outcomes (internalizing behaviors, externalizing behaviors, adaptive/prosocial behaviors, and posttraumatic stress symptoms); and used mediation analyses to test whether coping explained the relation between previous war exposures (being raped, death of parent(s), or killing/injuring someone during the war) and those outcomes. We found that avoidance coping items were associated with lower internalizing and posttraumatic stress behaviors at Time 3, and provided some evidence of mediating the relation between death of parent(s) during the war and the two outcomes mentioned above. Approach coping was associated with higher Time 3 adaptive/prosocial behaviors, whereas avoidance coping was associated with lower Time 3 adaptive/prosocial behaviors. Avoidance coping may be a protective factor against mental illness, whereas approach coping may be a promotive factor for adaptive/prosocial behaviors in war-affected societies. This study has important implications for designing and implementing mental health interventions for youth in postconflict settings.
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Promoting children's learning and development in conflict-affected countries: Testing change process in the Democratic Republic of the Congo. Dev Psychopathol 2016; 29:53-67. [PMID: 27866501 DOI: 10.1017/s0954579416001139] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Improving children's learning and development in conflict-affected countries is critically important for breaking the intergenerational transmission of violence and poverty. Yet there is currently a stunning lack of rigorous evidence as to whether and how programs to improve learning and development in conflict-affected countries actually work to bolster children's academic learning and socioemotional development. This study tests a theory of change derived from the fields of developmental psychopathology and social ecology about how a school-based universal socioemotional learning program, the International Rescue Committee's Learning to Read in a Healing Classroom (LRHC), impacts children's learning and development. The study was implemented in three conflict-affected provinces of the Democratic Republic of the Congo and employed a cluster-randomized waitlist control design to estimate impact. Using multilevel structural equation modeling techniques, we found support for the central pathways in the LRHC theory of change. Specifically, we found that LRHC differentially impacted dimensions of the quality of the school and classroom environment at the end of the first year of the intervention, and that in turn these dimensions of quality were differentially associated with child academic and socioemotional outcomes. Future implications and directions are discussed.
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Syria. INTERVENTION-INTERNATIONAL JOURNAL OF MENTAL HEALTH PSYCHOSOCIAL WORK AND COUNSELLING IN AREAS OF ARMED CONFLICT 2016. [DOI: 10.1097/wtf.0000000000000118] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Betancourt TS, McBain RK, Newnham EA, Brennan RT. The intergenerational impact of war: longitudinal relationships between caregiver and child mental health in postconflict Sierra Leone. J Child Psychol Psychiatry 2015; 56:1101-7. [PMID: 25665018 DOI: 10.1111/jcpp.12389] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Trauma from witnessing events such as bombings and killings as well as direct victimization or participation in violence has been associated with psychosocial distress and poor mental health among war-exposed children and adolescents. This study examines the relationship between caregiver mental health and child internalizing (anxiety and depression) symptoms over a 4-year period in postconflict Sierra Leone. METHODS The sample included 118 adolescent Sierra Leonean youth (73% male; mean age = 16.5 years at Time 1) and their caregivers (40% male; mean age = 39.0 at Time 1). To measure depression and anxiety symptoms, the Hopkins Symptom Checklist-25 was used with adults and the Oxford Measure of Psychosocial Adjustment - previously validated for use with children and adolescents in the region - was used to assess youth. A multivariate hierarchical linear model (HLM) for studying change within dyads was implemented to study covariation in internalizing symptoms among caregivers and youth over time; these models also included covariates at the individual, family and community levels. The relationship of caregiver mental health to child's internalizing was tested in a latent variable extension of the HLM. RESULTS The latent variable extension estimated that a one standard deviation (SD) change in caregiver anxiety/depression was associated with a .43 SD change in youth internalizing (p < .01) over the 4-year period. Family acceptance was negatively related to youth internalizing (p < .001), while community stigma was positively associated (p < .001). CONCLUSIONS The findings highlight an important interplay between caregiver and child mental health within the postconflict setting and the need for psychosocial interventions to extend beyond the individual to account for family dynamics.
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Affiliation(s)
- Theresa S Betancourt
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA.,François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, Boston, MA, USA
| | - Ryan K McBain
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Elizabeth A Newnham
- François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, Boston, MA, USA.,School of Psychology, The University of Western Australia, Perth, WA, Australia
| | - Robert T Brennan
- François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, Boston, MA, USA
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Kohrt BA, Burkey M, Stuart EA, Koirala S. Alternative approaches for studying humanitarian interventions: propensity score methods to evaluate reintegration packages impact on depression, PTSD, and function impairment among child soldiers in Nepal. Glob Ment Health (Camb) 2015; 2:e16. [PMID: 28596864 PMCID: PMC5269618 DOI: 10.1017/gmh.2015.13] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 05/07/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Ethical, logistical, and funding approaches preclude conducting randomized control trials (RCTs) in some humanitarian crises. A lack of RCTs and other intervention research has contributed to a limited evidence-base for mental health and psychosocial support (MHPS) programs after disasters, war, and disease outbreaks. Propensity score methods (PSMs) are an alternative analysis technique with potential application for evaluating MHPS programs in humanitarian emergencies. METHODS PSMs were used to evaluate impacts of education reintegration packages (ERPs) and other (vocational or economic) reintegration packages (ORPs) v. no reintegration programs on mental health of child soldiers. Propensity scores were used to determine weighting of child soldiers in each of the three treatment arms. Multiple linear regression was used to estimate adjusted changes in symptom score severity on culturally validated measures of depression, post-traumatic stress disorder (PTSD), and functional impairment from baseline to 1-year follow-up. RESULTS Among 258 Nepali child soldiers participating in reintegration programs, 54.7% completed ERP and 22.9% completed ORP. There was a non-significant reduction in depression by 0.59 (95% CI -1.97 to 0.70) for ERP and by 0.60 (95% CI -2.16 to 0.96) for ORP compared with no treatment. There were non-significant increases in PTSD (1.15, 95% CI -1.55 to 3.86) and functional impairment (0.91, 95% CI -0.31 to 2.14) associated with ERP and similar findings for ORP (PTSD: 0.66, 95% CI -2.24 to 3.57; functional impairment (1.05, 95% CI -0.71 to 2.80). CONCLUSION In a humanitarian crisis in which a non-randomized intervention assignment protocol was employed, the statistical technique of PSMs addressed differences in covariate distribution between child soldiers who received different integration packages. Our analysis did not demonstrate significant changes in psychosocial outcomes for ERPs and ORPs. We suggest the use of PSMs in evaluating non-randomized interventions in humanitarian crises when non-randomized conditions are not utilized.
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Affiliation(s)
- B. A. Kohrt
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
- Duke Global Health Institute and Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - M. Burkey
- Division of Child and Adolescent Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - E. A. Stuart
- Departments of Mental Health, Biostatistics and Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - S. Koirala
- Transcultural Psychosocial Organization (TPO) Nepal, Kathmandu, Nepal
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Collinson L. The role of academic research and teaching in addressing health in situations of conflict and instability. Med Confl Surviv 2014; 30:175-81. [PMID: 25144953 DOI: 10.1080/13623699.2014.919555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The key roles of academic research and teaching in addressing health in situations of conflict and instability are to better inform and better equip actors with the knowledge and skills to address health problems. The four key contributions of research are: quantifying the health problem, examining the contextual circumstances, investigating the epidemiology of health problems and evaluation of health care and humanitarian interventions. The role of teaching can complement research by distributing its' findings in addition to teaching skill sets to apply this knowledge and conduct further research. Academic research and teaching both play imperative roles in enabling more successful approaches in addressing health in situations of conflict and instability.
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Tyrer RA, Fazel M. School and community-based interventions for refugee and asylum seeking children: a systematic review. PLoS One 2014; 9:e89359. [PMID: 24586715 PMCID: PMC3933416 DOI: 10.1371/journal.pone.0089359] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 01/21/2014] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Rebecca A. Tyrer
- Oxford University Department of Psychiatry, Warneford Hospital, Oxford, United Kingdom
| | - Mina Fazel
- Oxford University Department of Psychiatry, Warneford Hospital, Oxford, United Kingdom
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Vindevogel S, Schryver MD, Broekaert E, Derluyn I. War-related experiences of former child soldiers in northern Uganda: comparison with non-recruited youths. Paediatr Int Child Health 2013; 33:281-91. [PMID: 24196702 DOI: 10.1179/2046905513y.0000000084] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Armed conflict imposes huge hardship on young people living in war zones. This study assessed former child soldiers' experience and perception of stress in common war events during the armed conflict in northern Uganda and compares it with their non-recruited counterparts. AIM To investigate whether child soldiers experienced more severe exposure to war events, and explore how war might affect youths differently, depending on the co-occurrence of these events. METHODS The study was undertaken in four northern Ugandan districts in 22 secondary schools with a sample size of 981 youths, about half of whom had been child soldiers. The participants completed a questionnaire on socio-demographic characteristics and stressful war events which was analyzed using descriptive statistics, a probabilistic index and correlation network analysis. RESULTS Former child soldiers had significantly greater experience of war events than their non-recruited counterparts. The violence of war is more central in their experience and perception of stress, whereas the scarcity of resources and poor living conditions are most central for non-recruited participants. The extent to which a war event, such as separation from the family, is perceived as stressful depends on the experience and perception of other stressful war events, such as confrontation with war violence for former child soldiers and life in an Internally Displaced Persons' camp for non-recruited participants. CONCLUSION The network approach permitted demonstration of the many ways in which war-affected youths encounter and appraise stressful war events. War events might function as moderators or mediators of the effect that other war events exert on the lives and well-being of young people living in war zones. This demands comprehensive and individualized assessment.
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Meyer S, Murray LK, Puffer ES, Larsen J, Bolton P. The nature and impact of chronic stressors on refugee children in Ban Mai Nai Soi camp, Thailand. Glob Public Health 2013; 8:1027-47. [PMID: 23886374 DOI: 10.1080/17441692.2013.811531] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Sarah Meyer
- a Department of International Health, Johns Hopkins Bloomberg School of Public Health , Johns Hopkins University , Baltimore , MD , USA
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O'Callaghan P, McMullen J, Shannon C, Rafferty H, Black A. A randomized controlled trial of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese girls. J Am Acad Child Adolesc Psychiatry 2013; 52:359-69. [PMID: 23582867 DOI: 10.1016/j.jaac.2013.01.013] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 01/04/2013] [Accepted: 01/31/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To assess the efficacy of trauma-focused cognitive behavioral therapy (TF-CBT) delivered by nonclinical facilitators in reducing posttraumatic stress, depression, and anxiety and conduct problems and increasing prosocial behavior in a group of war-affected, sexually exploited girls in a single-blind, parallel-design, randomized,+ controlled trial. METHOD Fifty-two 12- to 17-year-old, war-affected girls exposed to rape and inappropriate sexual touch in the Democratic Republic of Congo were screened for trauma, depression and anxiety, conduct problems, and prosocial behavior. They were then randomized to a 15 session, group-based, culturally modified TF-CBT (n = 24) group or a wait-list control group (n = 28). Primary analysis, by intention-to-treat, involving all randomly assigned participants occurred at pre- and postintervention and at 3-month follow-up (intervention group only). RESULTS Compared to the wait list control, the TF-CBT group experienced significantly greater reductions in trauma symptoms (F(1,49) = 52.708, p<0·001, χ(p)2 = 0.518). In addition, the TF-CBT group showed a highly significant improvement in symptoms of depression and anxiety, conduct problems, and prosocial behavior. At 3-months follow-up the effect size (Cohen's d) for the TF-CBT group was 2.04 (trauma symptoms), 2.45 (depression and anxiety), 0.95 (conduct problems), and-1.57 (prosocial behavior). CONCLUSIONS A group-based, culturally modified, TF-CBT intervention delivered by nonclinically trained Congolese facilitators resulted in a large, statistically significant reduction in posttraumatic stress symptoms and psychosocial difficulties among war-affected girls exposed to rape or sexual violence. Clinical trial registration information-An RCT of TF-CBT with sexually-exploited, war-affected girls in the DRC; http://clinicaltrials.gov/; NCT01483261.
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Betancourt TS, Meyers-Ohki SE, Charrow AP, Tol WA. Interventions for children affected by war: an ecological perspective on psychosocial support and mental health care. Harv Rev Psychiatry 2013; 21:70-91. [PMID: 23656831 PMCID: PMC4098699 DOI: 10.1097/hrp.0b013e318283bf8f] [Citation(s) in RCA: 175] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Children and adolescents exposed to armed conflict are at high risk of developing mental health problems. To date, a range of psychosocial approaches and clinical/psychiatric interventions has been used to address mental health needs in these groups. AIMS To provide an overview of peer-reviewed psychosocial and mental health interventions designed to address mental health needs of conflict-affected children, and to highlight areas in which policy and research need strengthening. METHODS We used standard review methodology to identify interventions aimed at improving or treating mental health problems in conflict-affected youth. An ecological lens was used to organize studies according to the individual, family, peer/school, and community factors targeted by each intervention. Interventions were also evaluated for their orientation toward prevention, treatment, or maintenance, and for the strength of the scientific evidence of reported effects. RESULTS Of 2305 studies returned from online searches of the literature and 21 sources identified through bibliography mining, 58 qualified for full review, with 40 peer-reviewed studies included in the final narrative synthesis. Overall, the peer-reviewed literature focused largely on school-based interventions. Very few family and community-based interventions have been empirically evaluated. Only two studies assessed multilevel or stepped-care packages. CONCLUSIONS The evidence base on effective and efficacious interventions for conflict-affected youth requires strengthening. Postconflict development agendas must be retooled to target the vulnerabilities characterizing conflict-affected youth, and these approaches must be collaborative across bodies responsible for the care of youth and families.
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Affiliation(s)
- Theresa S Betancourt
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02115, USA. Theresa_
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Trani JF, Bakhshi P. Vulnerability and mental health in Afghanistan: looking beyond war exposure. Transcult Psychiatry 2013; 50:108-39. [PMID: 23427259 DOI: 10.1177/1363461512475025] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study examined the prevalence of mental distress among groups in Afghanistan considered to be at risk. Data were drawn from a representative cross-sectional disability survey carried out in Afghanistan including 5,130 households in 171 clusters throughout the 34 provinces of the country. The sample included 838 nondisabled control participants aged above 14, and 675 disabled participants. Results showed that various vulnerable groups (disabled people, the unemployed, the elderly, minority ethnic groups, as well as widowed, divorced or separated women) were at higher risk of experiencing mild to severe mental health problems. The adjusted odds ratio for war-related disability compared to nondisabled was 4.09 (95% confidence interval 2.09 to 7.99) for mild mental distress disorders, and 7.10 (3.45-14.5) and 14.14 (3.38-59.00) for moderate or severe mental distress disorders, respectively. Women with disabilities (whatever the cause of impairment) when compared with nondisabled men, as well as poorer segments of society compared to the richest, had a higher prevalence of mental health problems. Women with non-war-related disabilities compared with nondisabled men were respectively 3.35 (1.27-8.81) and 8.57 (3.03-24.1) times more likely to experience mild or moderate mental distress disorders. People who experience multiple vulnerabilities are more at risk of deteriorating mental health in conflict zones. The study shows that mental health, in times of war, is influenced by a combination of demographic and socioeconomic characteristics linked to social exclusion mechanisms that were in place before the conflict began and that are redefined in relation to the changing social, cultural, and economic contexts. Mental health policies and programmes must prioritise the most vulnerable segments of Afghan society.
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Affiliation(s)
- Jean-François Trani
- Brown School of Social Work, Washington University in St. Louis, MO 63130, USA
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Betancourt TS, Borisova I, Williams TP, Meyers-Ohki SE, Rubin-Smith JE, Annan J, Kohrt BA. Psychosocial adjustment and mental health in former child soldiers--systematic review of the literature and recommendations for future research. J Child Psychol Psychiatry 2013; 54:17-36. [PMID: 23061830 PMCID: PMC4167714 DOI: 10.1111/j.1469-7610.2012.02620.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS AND SCOPE This article reviews the available quantitative research on psychosocial adjustment and mental health among children (age <18 years) associated with armed forces and armed groups (CAAFAG)--commonly referred to as child soldiers. METHODS PRISMA standards for systematic reviews were used to search PubMed, PsycInfo, JSTOR, and Sociological Abstracts in February 2012 for all articles on former child soldiers and CAAFAG. Twenty-one quantitative studies from 10 countries were analyzed for author, year of publication, journal, objectives, design, selection population, setting, instruments, prevalence estimates, and associations with war experiences. Opinion pieces, editorials, and qualitative studies were deemed beyond the scope of this study. Quality of evidence was rated according to the systematic assessment of quality in observational research (SAQOR). FINDINGS According to SAQOR criteria, among the available published studies, eight studies were of high quality, four were of moderate quality, and the remaining nine were of low quality. Common limitations were lack of validated mental health measures, unclear methodology including undefined sampling approaches, and failure to report missing data. Only five studies included a comparison group of youth not involved with armed forces/armed groups, and only five studies assessed mental health at more than one point in time. Across studies, a number of risk and protective factors were associated with postconflict psychosocial adjustment and social reintegration in CAAFAG. Abduction, age of conscription, exposure to violence, gender, and community stigma were associated with increased internalizing and externalizing mental health problems. Family acceptance, social support, and educational/economic opportunities were associated with improved psychosocial adjustment. CONCLUSIONS Research on the social reintegration and psychosocial adjustment of former child soldiers is nascent. A number of gaps in the available literature warrant future study. Recommendations to bolster the evidence base on psychosocial adjustment in former child soldiers and other war-affected youth include more studies comprising longitudinal study designs, and validated cross-cultural instruments for assessing mental health, as well as more integrated community-based approaches to study design and research monitoring.
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Affiliation(s)
- Theresa S Betancourt
- Department of Global Health and Population, François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, Boston, MA 02115, USA
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Moderators of treatment effectiveness for war-affected youth with depression in northern Uganda. J Adolesc Health 2012; 51:544-50. [PMID: 23174463 DOI: 10.1016/j.jadohealth.2012.02.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 02/09/2012] [Accepted: 02/09/2012] [Indexed: 01/05/2023]
Abstract
PURPOSE As we build the evidence base of interventions for depression among war-affected youth, it is critical to understand factors moderating treatment outcomes. The current study investigated how gender and history of abduction by Lord's Resistance Army rebels moderated treatment outcomes for war-affected youth. METHODS The study-a three-armed, randomized, controlled trial-was conducted with internally displaced war-affected adolescents in northern Uganda. Participants with significant depression symptoms (N = 304; 57% female; 14-17 years of age) were randomly assigned to an interpersonal psychotherapy group (IPT-G), a creative play/recreation group, or a wait-list control condition. Secondary analyses were conducted on data from this randomized controlled trial. RESULTS A history of abduction by Lord's Resistance Army rebels was reported by 42% of the sample. Gender and abduction history interacted to moderate the effectiveness of IPT-G for the treatment of depression. In the IPT-G intervention arm, treatment effectiveness was greatest among female subjects without an abduction history, with effect size = 1.06. IPT-G was effective for the treatment of depression for both male and female subjects with a history of abduction (effect size = .92 and .50, respectively). Male subjects with no abduction history in IPT-G showed no significant improvement compared with those in the control conditions. CONCLUSIONS Abduction history and gender are potentially important moderators of treatment effects, suggesting that these factors need to be considered when providing interventions for war-affected youth. IPT-G may be an effective intervention for female subjects without an abduction history, as well as for both male and female former child soldiers, but less so for male subjects without an abduction history.
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Marquer C, Barry C, Mouchenik Y, Hustache S, Djibo DM, Manzo ML, Falissard B, Révah-Lévy A, Grais RF, Moro MR. A rapid screening tool for psychological distress in children 3-6years old: results of a validation study. BMC Psychiatry 2012; 12:170. [PMID: 23072651 PMCID: PMC3503833 DOI: 10.1186/1471-244x-12-170] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 10/10/2012] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The mental health needs of young children in humanitarian contexts often remain unaddressed. The lack of a validated, rapid and simple tool for screening combined with few mental health professionals able to accurately diagnose and provide appropriate care mean that young children remain without care. Here, we present the results of the principle cross-cultural validation of the "Psychological Screening for Young Children aged 3 to 6" (PSYCAa3-6). The PSYCa 3-6 is a simple scale for children 3 to 6 years old administered by non-specialists, to screen young children in crises and thereby refer them to care if needed. METHODS This study was conducted in Maradi, Niger. The scale was translated into Hausa, using corroboration of independent translations. A cross-cultural validation was implemented using quantitative and qualitative methods. A random sample of 580 mothers or caregivers of children 3 to 6 years old were included. The tool was psychometrically examined and diagnostic properties were assessed comparing the PSYCa 3-6 against a clinical interview as the gold standard. RESULTS The PSYCa 3-6 Hausa version demonstrated good concurrent validity, as scores correlated with the gold standard and the Clinical Global Impression Severity Scale (CGI-S) [rho = 0.41, p-value = 0.00]. A reduction procedure was used to reduce the scale from 40 to 22 items. The test-retest reliability of the PSYCa 3-6 was found to be high (ICC 0.81, CI95% [0.68; 0.89]). In our sample, although not the purpose of this study, approximately 54 of 580 children required subsequent follow-up with a psychologist. CONCLUSIONS To our knowledge, this is the first validation of a screening scale for children 3 to 6 years old with a cross-cultural validation component, for use in humanitarian contexts. The Hausa version of the PSYCa 3-6 is a reliable and a valuable screening tool for psychological distress. Further studies to replicate our findings and additional validations of the PSYCa 3-6 in other populations may help improve the delivery of mental health care to children.
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Affiliation(s)
| | - Caroline Barry
- Inserm U669, Université Paris-Sud et Université Paris Descartes, Paris, France
| | - Yoram Mouchenik
- Université Toulouse le Mirail, Toulouse, France
- Hospital Sainte-Anne, Paris, France
- Médecins Sans Frontières, Paris, France
| | | | - Douma M Djibo
- National program of mental health, Ministry of Health, Niamey, Niger
| | | | - Bruno Falissard
- Inserm U669, Université Paris-Sud et Université Paris Descartes, Paris, France
| | - Anne Révah-Lévy
- Inserm U669, Université Paris-Sud et Université Paris Descartes, Paris, France
| | | | - Marie-Rose Moro
- Inserm U669, Université Paris-Sud et Université Paris Descartes, Paris, France
- Médecins Sans Frontières, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
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Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet 2012; 379:266-82. [PMID: 21835459 DOI: 10.1016/s0140-6736(11)60051-2] [Citation(s) in RCA: 558] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We undertook a systematic search and review of individual, family, community, and societal risk and protective factors for mental health in children and adolescents who are forcibly displaced to high-income countries. Exposure to violence has been shown to be a key risk factor, whereas stable settlement and social support in the host country have a positive effect on the child's psychological functioning. Further research is needed to identify the relevant processes, contexts, and interplay between the many predictor variables hitherto identified as affecting mental health vulnerability and resilience. Research designs are needed that enable longitudinal investigation of individual, community, and societal contexts, rather than designs restricted to investigation of the associations between adverse exposures and psychological symptoms. We emphasise the need to develop comprehensive policies to ensure a rapid resolution of asylum claims and the effective integration of internally displaced and refugee children.
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Reed RV, Fazel M, Jones L, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors. Lancet 2012; 379:250-65. [PMID: 21835460 DOI: 10.1016/s0140-6736(11)60050-0] [Citation(s) in RCA: 235] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Children and adolescents who are forcibly displaced represent almost half the world's internally displaced and refugee populations. We undertook a two-part systematic search and review of the evidence-base for individual, family, community, and societal risk and protective factors for the mental health outcomes of children and adolescents. Here we review data for displacement to low-income and middle-income settings. We draw together the main findings from reports to identify important issues and establish recommendations for future work. We draw attention to exposure to violence as a well established risk factor for poor mental health. We note the paucity of research into predictor variables other than those in the individual domain and the neglect of other variables for the assessment of causal associations, including potential mediators and moderators identifiable in longitudinal work. We conclude with research and policy recommendations to guide the development and assessment of effective interventions.
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Affiliation(s)
- Ruth V Reed
- Oxford Health NHS Foundation Trust, Oxford, UK
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Tol WA, Barbui C, Galappatti A, Silove D, Betancourt TS, Souza R, Golaz A, van Ommeren M. Mental health and psychosocial support in humanitarian settings: linking practice and research. Lancet 2011; 378:1581-91. [PMID: 22008428 PMCID: PMC3985411 DOI: 10.1016/s0140-6736(11)61094-5] [Citation(s) in RCA: 278] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This review links practice, funding, and evidence for interventions for mental health and psychosocial wellbeing in humanitarian settings. We studied practice by reviewing reports of mental health and psychosocial support activities (2007-10); funding by analysis of the financial tracking service and the creditor reporting system (2007-09); and interventions by systematic review and meta-analysis. In 160 reports, the five most commonly reported activities were basic counselling for individuals (39%); facilitation of community support of vulnerable individuals (23%); provision of child-friendly spaces (21%); support of community-initiated social support (21%); and basic counselling for groups and families (20%). Most interventions took place and were funded outside national mental health and protection systems. 32 controlled studies of interventions were identified, 13 of which were randomised controlled trials (RCTs) that met the criteria for meta-analysis. Two studies showed promising effects for strengthening community and family supports. Psychosocial wellbeing was not included as an outcome in the meta-analysis, because its definition varied across studies. In adults with symptoms of post-traumatic stress disorder (PTSD), meta-analysis of seven RCTs showed beneficial effects for several interventions (psychotherapy and psychosocial supports) compared with usual care or waiting list (standardised mean difference [SMD] -0·38, 95% CI -0·55 to -0·20). In children, meta-analysis of four RCTs failed to show an effect for symptoms of PTSD (-0·36, -0·83 to 0·10), but showed a beneficial effect of interventions (group psychotherapy, school-based support, and other psychosocial support) for internalising symptoms (six RCTs; SMD -0·24, -0·40 to -0·09). Overall, research and evidence focuses on interventions that are infrequently implemented, whereas the most commonly used interventions have had little rigorous scrutiny.
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Affiliation(s)
- Wietse A Tol
- Global Health Initiative, MacMillan Center, Yale University, New Haven, CT 06520-8206, USA.
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Kohrt BA, Jordans MJD, Tol WA, Luitel NP, Maharjan SM, Upadhaya N. Validation of cross-cultural child mental health and psychosocial research instruments: adapting the Depression Self-Rating Scale and Child PTSD Symptom Scale in Nepal. BMC Psychiatry 2011; 11:127. [PMID: 21816045 PMCID: PMC3162495 DOI: 10.1186/1471-244x-11-127] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Accepted: 08/04/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The lack of culturally adapted and validated instruments for child mental health and psychosocial support in low and middle-income countries is a barrier to assessing prevalence of mental health problems, evaluating interventions, and determining program cost-effectiveness. Alternative procedures are needed to validate instruments in these settings. METHODS Six criteria are proposed to evaluate cross-cultural validity of child mental health instruments: (i) purpose of instrument, (ii) construct measured, (iii) contents of construct, (iv) local idioms employed, (v) structure of response sets, and (vi) comparison with other measurable phenomena. These criteria are applied to transcultural translation and alternative validation for the Depression Self-Rating Scale (DSRS) and Child PTSD Symptom Scale (CPSS) in Nepal, which recently suffered a decade of war including conscription of child soldiers and widespread displacement of youth. Transcultural translation was conducted with Nepali mental health professionals and six focus groups with children (n=64) aged 11-15 years old. Because of the lack of child mental health professionals in Nepal, a psychosocial counselor performed an alternative validation procedure using psychosocial functioning as a criterion for intervention. The validation sample was 162 children (11-14 years old). The Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) and Global Assessment of Psychosocial Disability (GAPD) were used to derive indication for treatment as the external criterion. RESULTS The instruments displayed moderate to good psychometric properties: DSRS (area under the curve (AUC)=0.82, sensitivity=0.71, specificity=0.81, cutoff score ≥ 14); CPSS (AUC=0.77, sensitivity=0.68, specificity=0.73, cutoff score ≥ 20). The DSRS items with significant discriminant validity were "having energy to complete daily activities" (DSRS.7), "feeling that life is not worth living" (DSRS.10), and "feeling lonely" (DSRS.15). The CPSS items with significant discriminant validity were nightmares (CPSS.2), flashbacks (CPSS.3), traumatic amnesia (CPSS.8), feelings of a foreshortened future (CPSS.12), and easily irritated at small matters (CPSS.14). CONCLUSIONS Transcultural translation and alternative validation feasibly can be performed in low clinical resource settings through task-shifting the validation process to trained mental health paraprofessionals using structured interviews. This process is helpful to evaluate cost-effectiveness of psychosocial interventions.
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Affiliation(s)
- Brandon A Kohrt
- Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
| | - Mark JD Jordans
- Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
- HealthNetTPO, Amsterdam, The Netherlands
| | - Wietse A Tol
- Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
- HealthNetTPO, Amsterdam, The Netherlands
- Global Health Initiative, Yale University, New Haven, USA
| | - Nagendra P Luitel
- Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
| | - Sujen M Maharjan
- Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
- Central Department of Psychology, Tribhuvan University, Kirtipur, Nepal
| | - Nawaraj Upadhaya
- Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
- Dept of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
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Mental health interventions for children in adversity: pilot-testing a research strategy for treatment selection in low-income settings. Soc Sci Med 2011; 73:456-66. [PMID: 21742426 DOI: 10.1016/j.socscimed.2011.06.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 05/31/2011] [Accepted: 06/01/2011] [Indexed: 11/22/2022]
Abstract
This study aimed to develop a research strategy to make informed decisions for intervention selection, especially for low- and middle-income countries, as a response to the urgent need to scale-up mental health care for children globally. With this study we address the critical lack of translation of research findings into policy and practice. The research strategy was piloted for development of a family-based intervention in violence-affected areas in Burundi. The research comprised four phases; (a) a qualitative phase to assess needs and determine tentative intervention objectives; (b) a global expert panel to identify and prioritize intervention modalities for low-resource settings; (c) systematic literature review and distillation of practice elements from evidence-based treatments; and (d) stakeholder meetings to explore social-cultural feasibility and acceptability of the developed intervention. The study was conducted between January and November 2010. The research strategy resulted in the development of a stepped family-based care intervention, which combines community mobilization, parent-management training and cognitive behavior therapy elements. This pilot-tested research strategy, encompassing global and local knowledge on needs, feasibility and effectiveness, has the potential to be useful for developing mental health and psychosocial interventions in other settings.
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Betancourt TS, Meyers-Ohki SE, Stevenson A, Ingabire C, Kanyanganzi F, Munyana M, Mushashi C, Teta S, Fayida I, Cyamatare FR, Stulac S, Beardslee WR. Using Mixed-Methods Research to Adapt and Evaluate a Family Strengthening Intervention in Rwanda. AFRICAN JOURNAL OF TRAUMATIC STRESS 2011; 2:32-45. [PMID: 25309851 PMCID: PMC4189126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Research in several international settings indicates that children and adolescents affected by HIV and other compounded adversities are at increased risk for a range of mental health problems including depression, anxiety, and social withdrawal. More intervention research is needed to develop valid measurement and intervention tools to address child mental health in such settings. OBJECTIVE This article presents a collaborative mixed-methods approach to designing and evaluating a mental health intervention to assist families facing multiple adversities in Rwanda. METHODS Qualitative methods were used to gain knowledge of culturally-relevant mental health problems in children and adolescents, individual, family and community resources, and contextual dynamics among HIV-affected families. This data was used to guide the selection and adaptation of mental health measures to assess intervention outcomes. Measures were subjected to a quantitative validation exercise. Qualitative data and community advisory board input also informed the selection and adaptation of a family-based preventive intervention to reduce the risk for mental health problems among children in families affected by HIV.. Community-based participatory methods were used to ensure that the intervention targeted relevant problems manifest in Rwandan children and families and built on local strengths. RESULTS Qualitative data on culturally-appropriate practices for building resilience in vulnerable families has enriched the development of a Family-Strengthening Intervention (FSI). Input from community partners has also contributed to creating a feasible and culturally-relevant intervention. Mental health measures demonstrate strong performance in this population. CONCLUSION The mixed-methods model discussed represents a refined, multi-phase protocol for incorporating qualitative data and community input in the development and evaluation of feasible, culturally-sound quantitative assessments and intervention models. The mixed-methods approach may be applied to research in other parts of sub-Saharan Africa and beyond.
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Affiliation(s)
- Theresa S Betancourt
- Harvard School of Public Health, François-Xavier Bagnoud Center for Health and Human Rights
| | - Sarah E Meyers-Ohki
- Harvard School of Public Health, François-Xavier Bagnoud Center for Health and Human Rights
| | - Anne Stevenson
- Harvard School of Public Health, François-Xavier Bagnoud Center for Health and Human Rights
| | | | | | | | | | - Sharon Teta
- Partners In Health, Rwanda/ Inshuti Mu Buzima
| | | | | | - Sara Stulac
- Partners In Health, Rwanda/ Inshuti Mu Buzima
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Miller KE, Rasmussen A. Mental health and armed conflict: The importance of distinguishing between war exposure and other sources of adversity: A response to Neuner. Soc Sci Med 2010. [DOI: 10.1016/j.socscimed.2010.07.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Harel-Fisch Y, Radwan Q, Walsh SD, Laufer A, Amitai G, Fogel-Grinvald H, Abdeen Z. Psychosocial outcomes related to subjective threat from armed conflict events (STACE): Findings from the Israeli-Palestinian cross-cultural HBSC study. CHILD ABUSE & NEGLECT 2010; 34:623-638. [PMID: 20663554 DOI: 10.1016/j.chiabu.2009.12.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 11/26/2009] [Accepted: 12/01/2009] [Indexed: 05/29/2023]
Abstract
OBJECTIVE This study investigates the relationship between exposure to armed conflict and terror events, and an array of mental and behavioral outcomes within a large cross-cultural scientifically representative sample of 24,935 Palestinian (7,430 West Bank and 7,217 Gaza) and Israeli (5,255 Jewish and 6,033 Arab) 11-, 13-, and 15-year-old school children. The children of the Middle East have been subjected to exposure from armed conflict and terrorism repeatedly with no adequate research or interventions aimed at shielding them from the hazards of such exposure to their mental and social well-being. METHOD This paper studies the relationship between a newly developed scale (STACE) measuring levels of subjective perceptions of threat/fear due to exposure to armed conflict events and its predicting association with six psychosocial and behavioral outcomes covering (1) poor mental health, (2) positive well-being, and (3) risk behaviors. It also examines the role of parental support in "buffering" the effects of exposure to armed conflict events within the four target populations. RESULTS Results showed that STACE has significant and strong effects on all six dependent variables representing (1) mental post trauma, (2) diminished well-being, and (3) elevated risk behaviors. STACE strongly affects all four populations with the greatest impact among the Jewish Israeli population and the least impact shown for the Arab Israeli youth. Parental support ("significant adult") has both a direct main effect on the outcomes of all six variables as well as a significant "buffering" effect on the impact of STACE on certain outcome variables (posttraumatic symptoms, life satisfaction, positive life perceptions, and tobacco use). CONCLUSIONS AND PRACTICE IMPLICATIONS Regardless of the type of armed conflict events, the perception of threat and fear that a child experiences has a universal significant negative impact on mental, social, and behavioral well-being. The importance of the existence of a supporting significant adult in exposed children's lives is also emphasized. The findings show major implications for the development of community-based interventions focusing on enhancing parental, and other adult support in the lives of children living in armed conflict regions of the world.
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Affiliation(s)
- Yossi Harel-Fisch
- The International Research Program on Adolescent Well-Being and Health, School of Education, Bar Ilan University, Ramat Gan, Israel
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Combining qualitative and quantitative research methods to support psychosocial and mental health programmes in complex emergencies. INTERVENTION-INTERNATIONAL JOURNAL OF MENTAL HEALTH PSYCHOSOCIAL WORK AND COUNSELLING IN AREAS OF ARMED CONFLICT 2009. [DOI: 10.1097/wtf.0b013e32833462f9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Miller KE, Rasmussen A. War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks. Soc Sci Med 2009; 70:7-16. [PMID: 19854552 DOI: 10.1016/j.socscimed.2009.09.029] [Citation(s) in RCA: 586] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Indexed: 11/17/2022]
Abstract
This paper seeks to bridge the divisive split between advocates of trauma-focused and psychosocial approaches to understanding and addressing mental health needs in conflict and post-conflict settings by emphasizing the role that daily stressors play in mediating direct war exposure and mental health outcomes. The authors argue that trauma-focused advocates tend to overemphasize the impact of direct war exposure on mental health, and fail to consider the contribution of stressful social and material conditions (daily stressors). Drawing on the findings of recent studies that have examined the relationship of both war exposure and daily stressors to mental health status, a model is proposed in which daily stressors partially mediate the relationship of war exposure to mental health. Based on that model, and on the growing body of research that supports it, an integrative, sequenced approach to intervention is proposed in which daily stressors are first addressed, and specialized interventions are then provided for individuals whose distress does not abate with the repair of the social ecology.
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Affiliation(s)
- Kenneth E Miller
- Harvard School of Public Health, Research Program on Children and Global Adversity, François-Xavier Bagnoud Center for Health and Human Rights, 651 Huntington Avenue, Boston, MA 02115, USA.
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Abstract
BACKGROUND Studies in Afghanistan have shown substantial mental health problems in adults. We did a survey of young people (11-16 years old) in the country to assess mental health, traumatic experiences, and social functioning. METHODS In 2006, we interviewed 1011 children, 1011 caregivers, and 358 teachers, who were randomly sampled in 25 government-operated schools within three purposively chosen areas (Kabul, Bamyan, and Mazar-e-Sharif municipalities). We assessed probable psychiatric disorder and social functioning in students with the Strength and Difficulties Questionnaire multi-informant (child, parent, teacher) ratings. We also used the Depression Self-Rating Scale and an Impact of Events Scale. We assessed caregiver mental health with both international and culturally-specific screening instruments (Self-Reported Questionnaire and Afghan Symptom Checklist). We implemented a checklist of traumatic events to examine the exposure to, and nature of, traumatic experiences. We analysed risk factors for mental health and reports of traumatic experiences. FINDINGS Trauma exposure and caregiver mental health were predictive across all child outcomes. Probable psychiatric ratings were associated with female gender (odds ratio [OR] 2.47, 95% CI 1.65-3.68), five or more traumatic events (2.58, 1.36-4.90), caregiver mental health (1.11, 1.08-1.14), and residence areas (0.29, 0.17-0.51 for Bamyan and 0.37, 0.23-0.57 for Mazar-e-Sharif vs Kabul). The same variables predicted symptoms of depression. Two thirds of children reported traumatic experiences. Symptoms of post-traumatic stress were associated with five or more traumatic events (3.07, 1.78-5.30), caregiver mental health (1.06, 1.02-1.09), and child age (1.19, 1.04-1.36). Children's most distressing traumatic experiences included accidents, medical treatment, domestic and community violence, and war-related events. INTERPRETATION Young Afghans experience violence that is persistent and not confined to acts of war. Our study emphasises the value of school-based initiatives to address child mental health, and the importance of understanding trauma in the context of everyday forms of suffering, violence, and adversity. FUNDING Wellcome Trust.
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Bannink-Mbazzi F, Lorschiedter A. Psychosocial support to vulnerable youth in vocational schools in northern Uganda. INTERVENTION-INTERNATIONAL JOURNAL OF MENTAL HEALTH PSYCHOSOCIAL WORK AND COUNSELLING IN AREAS OF ARMED CONFLICT 2009. [DOI: 10.1097/wtf.0b013e32832ff4b8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Supporting the mental health and psychosocial well-being of former child soldiers. J Am Acad Child Adolesc Psychiatry 2009; 48:587-590. [PMID: 19454914 DOI: 10.1097/chi.0b013e3181a1f77b] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Developing inter-agency guidelines on mental health and psychosocial support in emergency settings. INTERVENTION 2008. [DOI: 10.1097/wtf.0b013e328321e142] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Betancourt TS, Simmons S, Borisova I, Brewer SE, Iweala U, Soudière MDL. High Hopes, Grim Reality: Reintegration and the Education of Former Child Soldiers in Sierra Leone. COMPARATIVE EDUCATION REVIEW 2008; 52:565-587. [PMID: 19337570 PMCID: PMC2662600 DOI: 10.1086/591298] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Betancourt TS, Khan KT. The mental health of children affected by armed conflict: protective processes and pathways to resilience. Int Rev Psychiatry 2008; 20:317-28. [PMID: 18569183 PMCID: PMC2613765 DOI: 10.1080/09540260802090363] [Citation(s) in RCA: 293] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This paper examines the concept of resilience in the context of children affected by armed conflict. Resilience has been frequently viewed as a unique quality of certain 'invulnerable' children. In contrast, this paper argues that a number of protective processes contribute to resilient mental health outcomes in children when considered through the lens of the child's social ecology. While available research has made important contributions to understanding risk factors for negative mental health consequences of war-related violence and loss, the focus on trauma alone has resulted in inadequate attention to factors associated with resilient mental health outcomes. This paper presents key studies in the literature that address the interplay between risk and protective processes in the mental health of war-affected children from an ecological, developmental perspective. It suggests that further research on war-affected children should pay particular attention to coping and meaning making at the individual level; the role of attachment relationships, caregiver health, resources and connection in the family, and social support available in peer and extended social networks. Cultural and community influences such as attitudes towards mental health and healing as well as the meaning given to the experience of war itself are also important aspects of the larger social ecology.
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