Screening for PTSD symptoms in unaccompanied refugee minors: a test of the CRIES-8 questionnaire in routine care

Practical recommendations for addressing the psychological needs of unaccompanied asylum-seeking children in England: A literature and service review

BACKGROUND

Globally, there is an increasing trend of forcibly displaced people, of which over 40% are children. Unaccompanied asylum-seeking children (UASC) are at risk of experiencing psychological distress and developing mental health difficulties. However, in the UK, the approach from statutory mental health services is inconsistent across different geographical areas.

AIM

This report outlines recommendations for statutory mental health services in the UK in relation to working with UASC.

METHOD

A rapid evaluation method was adopted including interviewing fifteen key informants as well as reviewing existing clinical guidelines. Key informants included clinicians, service managers, social workers and commissioners from Local Authorities, National Health Services, and third sector partners. Recommendations were synthesised using narrative synthesis.

RESULTS AND CONCLUSION

Existing service provision and barriers to the implementation of interventions were summarised and compared against existing guidelines. The report presents recommendations on assessments, screening tools, and psychological interventions for developing a pathway for UASC within statutory services.

The Cantril Ladder as a Measure of Well-Being and Life Satisfaction Among Refugee Youth Experiencing Symptoms of Post-Traumatic Stress

Given the number of refugee youth whom require mental health support, there is a need to provide community-based interventions that can be easily scaled-up at a low cost. Yet, safety procedures associated with community-based intervention require careful consideration. The Cantril Ladder is a visual scale used to assess life satisfaction. It could be a useful tool to track the well-being of participants throughout an intervention. However, concerns have been raised about the validity of single-item life satisfaction measures and it is recommended they are tested when used in specific populations. This is particularly relevant to the refugee youth population who experience ongoing stress due to concern for family, friends, housing, and schooling and whose perceptions of life satisfaction may differ to the cohorts the Cantril Ladder has previously been tested with. The purpose of this study was to explore the validity of the Cantril Ladder as a measure of well-being and life satisfaction in refugee youth experiencing post-traumatic stress symptoms by exploring the relationship between how the youth scored on the Cantril Ladder with their scores on measures of depression and self-efficacy. Hierarchical multiple linear regression was applied to self-reported survey data in order to test how refugee youth experiencing post-traumatic stress symptoms (n = 51) score on the Cantril Ladder compared with Patient Health Questionnaire-9 (PHQ-9) and General Self Efficacy Scale (GSE) scores. The mean Cantril Ladder score in the present sample was 5.33 (SD = 2.77). The PHQ-9 and GSE total scores together explained 19.1% of the variability in the Cantril Ladder score. The Cantril Ladder showed moderate concurrent validity with validated measures of depression and self-efficacy. These findings have important implications for intervention programs designed to support refugee youth experiencing post-traumatic stress, as the Cantril Ladder offers a promising way to track well-being throughout the program as part of a wider safety protocol procedure. Additional research is required to not only confirm these findings, but also to test the face validity of the Cantril Ladder for a more complete validation of life satisfaction.

Psychometric properties of the Children's Revised Impact of Event Scale (CRIES-8) among refugee adolescents from Afghanistan, Syria, and Somalia

Background: High levels of post-traumatic stress are well documented among refugees. Yet, refugee adolescents display high heterogeneity in their type of trauma and symptom levels.Objective: Following the recurrent plea for validated trauma screening tools, this study investigated the psychometric properties of the Children's Revised Impact of Event Scale (CRIES-8) among refugee adolescents from Afghanistan (n = 148), Syria (n = 234), and Somalia (n = 175) living in Europe.Method: The model fit for the confirmatory factor structures was tested, as well as measurement invariance between the three groups. The robustness of results was evaluated by testing measurement invariance between recently arrived and settled adolescents, and between different response labelling options. Reliability (α, ω, and ordinal α), criterion validity, and prevalence estimates were calculated.Results: The intrusion subscale showed a better stable model fit than the avoidance subscale, but the two-factor structure was mainly supported. Configural measurement invariance was achieved between Afghan and Somali adolescents, and strong measurement invariance between Syrian and Somali adolescents. The results were robust considering the time living in the host country and response labelling styles. Reliability was low among Afghan and Syrian adolescents (.717-.856), whereas it was higher among Somali adolescents (.831-.887). The total score had medium-sized correlations with emotional problems (.303-.418) and low correlations with hyperactivity (.077-.155). There were statistically significant differences in symptom prevalence: Afghan adolescents had higher prevalence (55.5%) than Syrian (42.8%) and Somali (37%) adolescents, and unaccompanied refugee minors had higher symptom prevalence (63.5%) than accompanied adolescents (40.7%).Conclusions: This study mostly supports the use of the CRIES-8 among adolescents from Afghanistan, Syria, and Somalia, and even comparative analyses of group means. Variation in reliability estimates, however, makes diagnostic predictions difficult, as the risk of misclassification is high.

The effectiveness of web-based training for parents on post-traumatic stress disorder in children

Introduction

Post-traumatic stress disorder (PTSD) after an injury such as accidents is common in children and can affect their overall physical and mental functioning and quality of life. Early intervention can have significant health benefits for children. This study aimed to investigate the effectiveness of web-based training for parents on post-traumatic stress disorder in children.

Method

This was a quasi-experimental study with intervention and control group. 110 parents of children aged 10-18 years with PTSD after a traumatic event were selected through available sampling and assigned to intervention and control groups. Data was collected by a researcher-made demographic questionnaire and the Child Revised Impact of Events Scale (CRIES-8). Parents in the intervention group received a 4-week training course through a researcher-designed website, but the control group received routine care by the clinical team, which the main focus of care and training was on the physical aspects of the disease, and no intervention was done for PTSD. Two weeks after the intervention, the level of child stress was measured and compared in both groups. Data were analyzed using SPSS V.22.

Results

The difference between the mean score of total traumatic stress and its subscales before intervention was not statistically significant (p = 0.23). But after intervention, the mean score of total traumatic stress and its subscales decreased in the intervention group and increased in the control group and this difference was statistically significant (p < 0.001).

Conclusion

E-learning parent training has the potential to support children with PTSD. This available and cost-effective procedure can be recommended to help children with PTSD and possibly increase recovery in these patients.

A systematic review of studies on resilience and risk and protective factors for health among refugee children in Nordic countries

The Nordic welfare model is often used as an example for the promotion of health and wellbeing, even in vulnerable groups of children, such as refugees. Nonetheless, there are no published reviews on resilience and/or risk and protective factors for physical and mental health among refugee children living in Nordic countries. In this systematic review, we identified 5181 studies on the topic, screened titles, and abstracts, viewed 632, and finally included 26 studies. These studies described 18 samples with a total of 34,080 individuals ranging in ages 0-18 years. Overall, the studies were of good quality. Nearly all studies assessed adversity. Six studies reported physical health outcomes and all studies mental health outcomes, most often post-traumatic stress disorder and anxiety. None explicitly studied resilience. While we found that age and sex are the most frequently studied  risk- and protective factors, findings are inconclusive, since the direction of the associations was different in the different studies. This systematic review indicates that there is still a need for well-designed and -powered studies using clear definitions of key study concepts to examine health outcomes and resilience among refugee children in Nordic countries.

Post-Traumatic Stress Disorder in Unaccompanied Refugee Minors: Prevalence, Contributing and Protective Factors, and Effective Interventions: A Scoping Review

In 2021, there were close to 37 million children displaced worldwide. There were 13.7 million refugees and an additional 22.8 million internally displaced. In Europe, this included 23,255 unaccompanied minors seeking asylum, up 72% compared with 2020 (13,550). The objective was to review the current literature regarding PTSD in unaccompanied refugee minors (URM). The authors searched Ovid Medline, Embase, and Cochrane Library from 1 January 2008 through 15 January 2019. Thirty full texts were chosen that specifically studied unaccompanied refugee minors (URM). The results showed that URM had a prevalence of post-traumatic stress disorder (PTSD of 17-85% across the studies reviewed. There were numerous factors that contributed to PTSD, including cumulative stress and trauma, guilt, shame, and uncertainty about legal status. Protective factors included resilience, a trusted mentor, belonging to a social network, religion, having an adult mentor, and having a family (even if far away). Immigrant youth can thrive most easily in multiculturally affirming countries. Five interventions demonstrated effectiveness, comprising trauma-focused cognitive behavioral therapy (TF-CBT); "Mein Weg", a TF-CBT combined with a group-processing mixed therapy approach; teaching recovery techniques (TRT), narrative exposure therapy for children (KIDNET), and expressive arts intervention (EXIT). The significant mental health conditions include depression, anxiety, internalizing and externalizing behaviors, and frequently PTSD. It is fair to conclude that the high levels of mental health problems experienced in URM are due to exposure to traumatic experiences, separation from parents, and lack of social support.

Changes in life satisfaction among unaccompanied asylum-seeking and refugee minors who participated in teaching recovery techniques (TRT)

BACKGROUND

Unaccompanied asylum-seeking and refugee minors report low life satisfaction and high levels of mental health problems, nevertheless they often do not seek or receive help for their problems. Teaching Recovery Techniques (TRT) is a low-threshold, five sessions intervention developed to reduce distressing war- and disaster-related trauma reactions among children and youth. In this study, we investigate if TRT can contribute to increased life satisfaction among unaccompanied asylum-seeking and refugee minors.

METHODS

Asylum-seeking and resettled unaccompanied minors participated in TRT carried out in 15 locations throughout Norway, n = 147, mean age = 16.61 (SD = 1.80), 88% boys, and 67% from Afghanistan. Life satisfaction was measured by the Cantril Ladder before the intervention, and two- and eight weeks post-intervention. We also included indices of intervention compliance and contextual variables, such as asylum status. We applied a pre- and post-intervention design with linear mixed model analyses to investigate change in life satisfaction.

RESULTS

Life satisfaction significantly increased from pre- to post- intervention, but not for youth whose asylum application had been rejected or who were still awaiting a decision. Indices of intervention compliance were associated with an increase in life satisfaction.

CONCLUSIONS

TRT is a potential useful intervention to enhance life satisfaction among unaccompanied asylum-seeking and refugee minors and can be a measure to support positive development among youth at risk for mental health problems. However, TRT initiatives should consider the participant's stage of asylum process, because harsh immigration policies may overburden the coping capacity. Without further adaptation, TRT seems most useful for youth granted residence. The manual has been revised to include asylum-related stressors.

TRIAL REGISTRATION

ClinicalTrials.gov (16/54,571, registered 30.01.2019).

Measuring the Optimal Time Interval Between Arrival and First Mental Health Evaluation's for Refugees in Québec: A Scoping Review

To map the state of the existing literature to identify the optimal time frame between the arrival of refugees in a host country and psychosocial assessments. We conducted scoping review using the method of Arksey and O'Malley (2005). A systematic search of 5 databases including PubMed, Psycinfo (OVID), PsycINFO BD APA, Scopus and Web of Sciences) and grey literature identified 2698 references. Thirteen studies published between 2010 and 2021 were considered eligible. A data extraction grid was designed and tested by the research team. It is not so ease to identify the most appropriate time interval to assess the mental health of newly settled refugees. All the studies selected agree on the need to carry out an initial assessment when refugees arrive in their host country. Several authors agree on the need to carry out screening at least twice during the resettlement period. However, what is less clear is the best time to perform the second screening. This scoping review mainly helped in highlighting the lack of probing data on the mental health indicators focused on during the assessment and on the optimal timeline for the assessment of refugees. Further research is needed to determine whether developmental and psychological screening is beneficial, the right time to perform the screening, and the most appropriate collection instruments and interventions.

Associations between social factors and school belonging among newcomer and non-newcomer youth in Sweden

Feeling a sense of belonging at school is associated with important positive outcomes for youth and requires youth to engage in positive social relationships. Yet there is a limited understanding of the social factors most associated with youths' school belonging and limited evidence about whether correlates of school belonging vary for marginalized groups like newcomers compared to majority groups. Sweden provides an important context for investigation of these issues because, over the past two decades, the country has experienced an influx of asylum seekers and educational reforms that have altered the composition and functioning of Swedish secondary schools. This study addresses these gaps by (1) investigating which of eight social factors are associated with school belonging among diverse Swedish youth, and (2) examining whether newcomer status moderates the relationship between social factors and school belonging. Hierarchical regression and moderation analyses were used to analyze data from 14 to 19 year-old (n = 233) newcomers and non-newcomers in Sweden. An exploratory factor analysis revealed that the school belonging measure contained two factors: positive perceptions and negative perceptions (reverse coded). For both, stronger school belonging was associated with lower perceived ethnic discrimination. Positive perceptions of school belonging were also associated with more prosocial behaviours and lower emotional problems. Negative perceptions of school belonging were associated with more peer problems. Notably, quantity and quality of peer relationships were not associated with school belonging. There was no consistent evidence of newcomer status moderating the relationship between social factors and school belonging. These results highlight factors associated with school belonging which are modifiable and amenable to intervention or impact by policy-ethnic discrimination, prosocial behaviour, and emotional and peer problems. The absence of moderation by newcomer status suggests that school belonging interventions or related policies are likely to affect newcomer and non-newcomer students similarly.

Mental Health Screening Approaches for Resettling Refugees and Asylum Seekers: A Scoping Review

Refugees and asylum seekers often face delayed mental health diagnoses, treatment, and care. COVID-19 has exacerbated these issues. Delays in diagnosis and care can reduce the impact of resettlement services and may lead to poor long-term outcomes. This scoping review aims to characterize studies that report on mental health screening for resettling refugees and asylum seekers pre-departure and post-arrival to a resettlement state. We systematically searched six bibliographic databases for articles published between 1995 and 2020 and conducted a grey literature search. We included publications that evaluated early mental health screening approaches for refugees of all ages. Our search identified 25,862 citations and 70 met the full eligibility criteria. We included 45 publications that described mental health screening programs, 25 screening tool validation studies, and we characterized 85 mental health screening tools. Two grey literature reports described pre-departure mental health screening. Among the included publications, three reported on two programs for women, 11 reported on programs for children and adolescents, and four reported on approaches for survivors of torture. Programs most frequently screened for overall mental health, PTSD, and depression. Important considerations that emerged from the literature include cultural and psychological safety to prevent re-traumatization and digital tools to offer more private and accessible self-assessments.

Feasibility of a randomised trial of Teaching Recovery Techniques (TRT) with refugee youth: results from a pilot of the Swedish UnaccomPanied yOuth Refugee Trial (SUPpORT)

Background

Although post-traumatic stress is prevalent among unaccompanied refugee minors (URM), there are few evidence-based psychological interventions for this group. Teaching Recovery Techniques (TRT) is a brief, manualised intervention for trauma-exposed youth, which has shown promising results in exploratory studies. The aim of the present study was to assess the feasibility of conducting a randomised controlled trial (RCT) evaluating the use of TRT among URM by investigating key uncertainties relating to recruitment, randomisation, intervention delivery and data collection.

Methods

A 3-month long non-blinded internal randomised pilot trial with a parallel-group design assessed the feasibility of a planned nationwide multi-site RCT. URM with or without granted asylum were eligible if they were 14 to 20 years old, had arrived in Sweden within the last 5 years and had screened positive for symptoms of post-traumatic stress disorder (PTSD). Quantitative data were collected pre- and post-intervention, and 18 weeks after randomisation. On-site individual randomisation (1:1) followed directly after pre-intervention assessment. Participants allocated to the intervention were offered seven weekly group-based TRT sessions. Quantitative pilot outcomes were analysed using descriptive statistics. Qualitative information was gathered through on-site observations and follow-up dialogue with group facilitators. A process for Decision-making after Pilot and feasibility Trials (ADePT) was used to support systematic decision-making in moving forward with the trial.

Results

Fifteen URM (mean age 17.73 years) with PTSD symptoms were recruited at two sites. Three of the youths were successfully randomised to either TRT or waitlist control (TRT n = 2, waitlist n = 1). Fourteen participants were offered TRT for ethical reasons, despite not being randomised. Six (43%) attended ≥ 4 of the seven sessions. Seventy-three percent of the participants completed at least two assessments, with a response rate of 53% at both post-intervention and follow-up.

Conclusions

The findings demonstrated a need for amendments to the protocol, especially with regard to the procedures for recruitment and randomisation. Upon refinement of the study protocol and strategies, an adequately powered RCT was pursued, with data from this pilot study excluded.

Trial registration

ISRCTN47820795, prospectively registered on 20 December 2018

Psychopathology in Children and Adolescents in Lebanon Study (PALS): a national household survey

INTRODUCTION

Psychiatric disorders are among the leading causes of disability in children and adolescents globally. In Lebanon, a country that has endured a prolonged history of conflict and economic and political uncertainty, mental health surveys in children and adolescents have been limited to specific disorders or specific settings or cities. PALS (Psychopathology in Children and Adolescents in Lebanon Study) is the first study to screen a nationally representative sample of children and adolescents for psychiatric disorders and estimate the national prevalence of children and adolescents at risk of having a psychiatric disorder.

METHODS

A nationally representative household sample of 1517 children and adolescents (aged 5 years 0 months to 17 years 11 months) was recruited through a multi-stage stratified proportionate sampling technique between February 2018 and November 2018. Parents and adolescents completed a battery of self-reported scales including the Strengths and Feelings Questionnaire (SDQ), Mood and Feelings Questionnaire (MFQ), Screen for Child Anxiety and Emotional Related Disorders (SCARED), the Peer Relations Questionnaire (PRQ), General Health Questionnaire (GHQ), and Conflict Behavior Questionnaire (CBQ), Child Revised Impact of Events Scale (CRIES), and a demographic/clinical information questionnaire. Logistic regression models were used to examine the correlates of screening positive for psychiatric disorders.

RESULTS

About a third of children and adolescents (32.7%, n = 497) screened positive for at least one psychiatric disorder, of whom only 5% (n = 25) reported ever seeking professional mental health help. Academic performance, having a chronic physical illness, higher parental GHQ scores, and involvement in bullying were associated with a higher odds of screening positive for a psychiatric disorder. Higher family income was negatively associated with screening positive for a psychiatric disorder.

CONCLUSION

This first national study shows a high prevalence of psychiatric symptoms in Lebanese children and adolescents and an alarming treatment gap. School-based primary prevention programs or screening in primary care settings are key for early detection and management of psychiatric symptoms, and prevention of psychiatric disorders.

Mental health screening and assessment tools for forcibly displaced children: a systematic review

Background: An unprecedentedly large number of people worldwide are forcibly displaced, of which more than 40 percent are under 18 years of age. Forcibly displaced children and youth have often been exposed to stressful life events and are therefore at increased risk of developing mental health issues. Hence, early screening and assessment for mental health problems is of great importance, as is research addressing this topic. However, there is a lack of evidence regarding the reliability and validity of mental health assessment tools for this population. Objective: The aim of the present study was to synthesise the existing evidence on psychometric properties of patient reported outcome measures [PROMs] for assessing the mental health of asylum-seeking, refugee and internally displaced children and youth. Method: Systematic searches of the literature were conducted in four electronic databases: MEDLINE, PsycINFO, Embase and Web of Science. The methodological quality of the studies was examined using the COSMIN Risk of Bias checklist. Furthermore, the COSMIN criteria for good measurement properties were used to evaluate the quality of the outcome measures. Results: The search yielded 4842 articles, of which 27 met eligibility criteria. The reliability, internal consistency, structural validity, hypotheses testing and criterion validity of 28 PROMs were evaluated. Conclusion: Based on the results with regard to validity and reliability, as well as feasibility, we recommend the use of several instruments to measure emotional and behavioural problems, PTSD symptoms, anxiety and depression in forcibly displaced children and youth. However, despite a call for more research on the psychometric properties of mental health assessment tools for forcibly displaced children and youth, there is still a lack of studies conducted on this topic. More research is needed in order to establish cross-cultural validity of mental health assessment tools and to provide optimal cut-off scores for this population. HIGHLIGHTS Research on the psychometric properties of mental health screening and assessment tools for forcibly displaced children and youth is slowly increasing.However, based on the current evidence on the validity and reliability of screening and assessment tools for forcibly displaced children, we are not able to recommend a core set of instruments. Instead, we provide suggestions for best practice.More research of sufficient quality is important in order to establish crsoss-cultural validity and to provide optimal cut-off scores in mental health screening and assessment tools for different populations of forcibly displaced children and youth.

Schools' and teachers' roles and challenges in supporting the mental wellbeing of refugee youths: a qualitative study with Swedish teachers

PURPOSE

Resettled refugee youths are increasingly entering host-country school systems and are at risk of poor mental wellbeing. Schools and teachers are often expected to provide psychosocial support to youths with refugee backgrounds, but the teachers' views on this expectation are poorly understood. We investigated the question: What do Swedish teachers believe is the role of (1) schools and (2) teachers in supporting refugee youths' mental wellbeing?

METHOD

Four semi-structured focus groups were conducted with 30 Swedish educators from five schools. Interview transcripts were analysed and themes reflecting the key concepts were constructed using reflexive thematic analysis.

RESULTS

Seven themes were constructed. Three addressed the role of schools in supporting refugee youths' mental wellbeing: Promoting Belonging, Offering Refuge, and Instilling Civic Literacy. Four addressed the role of teachers: Building Relationships with Students, Maintaining a Non-therapeutic Relationship, Connecting to Professionals, and Instructing in the Classroom.

CONCLUSION

Teachers believe that both schools and teachers play an important role in supporting refugee youths' mental wellbeing and each contributes in unique ways. However, schools and teachers are not always successful in supporting refugee youth and teachers reported facing challenges such as unclear roles and a lack of resources.

Mental Health of Refugee and Non-refugee Migrant Young People in European Secondary Education: The Role of Family Separation, Daily Material Stress and Perceived Discrimination in Resettlement

While scholarly literature indicates that both refugee and non-refugee migrant young people display increased levels of psychosocial vulnerability, studies comparing the mental health of the two groups remain scarce. This study aims to further the existing evidence by examining refugee and non-refugee migrants' mental health, in relation to their migration history and resettlement conditions. The mental health of 883 refugee and 483 non-refugee migrants (mean age 15.41, range 11-24, 45.9% girls, average length of stay in the host country 3.75 years) in five European countries was studied in their relation to family separation, daily material stress and perceived discrimination in resettlement. All participants reported high levels of post-traumatic stress symptoms. Family separation predicted post-trauma and internalizing behavioral difficulties only in refugees. Daily material stress related to lower levels of overall well-being in all participants, and higher levels of internalizing and externalizing behavioral difficulties in refugees. Perceived discrimination was associated with increased levels of mental health problems for refugees and non-refugee migrants. The relationship between perceived discrimination and post-traumatic stress symptoms in non-refugee migrants, together with the high levels of post-traumatic stress symptoms in this subsample, raises important questions on the nature of trauma exposure in non-refugee migrants, as well as the ways in which experiences of discrimination may interact with other traumatic stressors in predicting mental health.

Readiness of Allied Professionals to Join the Mental Health Workforce: A Qualitative Evaluation of Trained Lay Trauma Counsellors' Experiences When Refugee Youth Disclose Suicidal Ideation

The recent refugee crisis presented a huge challenge for the Swedish mental health workforce. Hence, innovative mental health workforce solutions were needed. Unaccompanied refugee minors (URM) are a particularly vulnerable refugee group. Teaching Recovery Techniques (TRT) was introduced as a community-based intervention utilising trained lay counsellors in a stepped model of care for refugee youth experiencing trauma symptoms. Professionals (e.g., teachers, social workers) can deliver the Cognitive Behavioural Therapy-based intervention after a brief training. A point of debate in this workforce solution is the readiness of trained lay counsellors to deal with potentially demanding situations like disclosure of suicidal ideation. This study aimed to explore the TRT trained lay counsellors’ experiences of procedures upon URM’s disclosure of suicidal ideation. Individual semi-structured interviews with TRT trained lay counsellors were conducted, then analysed using systemic text condensation. The analysis revealed four themes: “Importance of safety structures”, “Collaboration is key”, “Let sleeping dogs lie” and “Going the extra mile”. Dealing with suicidal ideation is challenging and feelings of helplessness occur. Adding adequate supervision and specific training on suicidal ideation using role play is recommended. Collaboration between agencies and key stakeholders is essential when targeting refugee mental health in a stepped care model.

Evaluation of a school-based intervention to promote mental health of refugee youth in Sweden (The RefugeesWellSchool Trial): study protocol for a cluster randomized controlled trial

BACKGROUND

Sweden is home to a large and growing population of refugee youths who may be at risk of mental health problems such as post-traumatic stress disorder (PTSD). Thus, there is a need for interventions that address mental health problems in these populations. Schools have been identified as an ideal setting for delivering such interventions as they offer a non-stigmatizing space and are often central to young refugees' social networks. The RefugeesWellSchool trial in Sweden will investigate an intervention comprising two programmes: Teaching Recovery Techniques (TRT) and In-service Teacher Training (INSETT), delivered in a school setting, among refugee youth. TRT is a group-based programme for children and adolescents, informed by Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). INSETT is a multi-module course for teachers providing information on trauma and the refugee experience to build teachers' cultural competence and capacity for supporting refugee youths in schools.

METHODS

This trial employs a cluster randomized-control design with two arms: (1) the intervention arm in which the TRT and INSETT programmes are offered (n = 350), (2) the wait-list control arm (n = 350) in which services are provided as usual until the TRT and INSETT programmes are offered approximately six months later. Data will be collected prior to the intervention, immediately following the intervention, and at three months post-intervention. Outcomes for the trial arms will be compared using linear mixed models or ANCOVA repeated measures as well as the Reliable Change Index (RCI).

DISCUSSION

This study will provide knowledge about the effectiveness of an intervention comprising two programmes: a group-based programme for youth reporting symptoms of PTSD and a training course for teachers, in order to build their competence and ability to support refugee youths in schools.

TRIAL REGISTRATION

ISRCTN, ISRCTN48178969 , Retrospectively registered 20/12/2019.

International consensus on a standard set of outcome measures for child and youth anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder

A major barrier to improving care effectiveness for mental health is a lack of consensus on outcomes measurement. The International Consortium for Health Outcomes Measurement (ICHOM) has already developed a consensus-based standard set of outcomes for anxiety and depression in adults (including the Patient Health Questionnaire-9, the Generalised Anxiety Disorder 7-item Scale, and the WHO Disability Schedule). This Position Paper reports on recommendations specifically for anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder in children and young people aged between 6 and 24 years. An international ICHOM working group of 27 clinical, research, and lived experience experts formed a consensus through teleconferences, an exercise using an adapted Delphi technique (a method for reaching group consensus), and iterative anonymous voting, supported by sequential research inputs. A systematic scoping review identified 70 possible outcomes and 107 relevant measurement instruments. Measures were appraised for their feasibility in routine practice (ie, brevity, free availability, validation in children and young people, and language translation) and psychometric performance (ie, validity, reliability, and sensitivity to change). The final standard set recommends tracking symptoms, suicidal thoughts and behaviour, and functioning as a minimum through seven primarily patient-reported outcome measures: the Revised Children's Anxiety and Depression Scale, the Obsessive Compulsive Inventory for Children, the Children's Revised Impact of Events Scale, the Columbia Suicide Severity Rating Scale, the KIDSCREEN-10, the Children's Global Assessment Scale, and the Child Anxiety Life Interference Scale. The set's recommendations were validated through a feedback survey involving 487 participants across 45 countries. The set should be used alongside the anxiety and depression standard set for adults with clinicians selecting age-appropriate measures.

Prevalence of common mental disorders among Syrian refugee children and adolescents in Sultanbeyli district, Istanbul: results of a population-based survey

AIMS

Research demonstrates elevated levels of common mental disorders among Syrian refugees, but the majority of studies have, to date, focused on adult populations. This study aims to estimate the prevalence of depression, anxiety and post-traumatic stress disorder (PTSD) among Syrian children and adolescents living in Sultanbeyli district of Istanbul, Turkey.

METHODS

A population-based survey among Syrian children and adolescents aged 8-17 years living in Sultanbeyli district was conducted in 2019, as part of an all-age survey of disability. 80 clusters of 50 participants (all-ages) were selected from the local municipality's refugee registration database using probability proportionate to size sampling. Children aged 8-17 years were assessed for symptoms of common mental disorders using the Child Revised Impact of Event Scale (CRIES-8) and abbreviated versions of the Center for Epidemiologic Studies Depression Scale for Children (CES-DC) and the Screen for Child Anxiety Related Disorders (SCARED).

RESULTS

Of the 852 participants, 23.7% (95% CI 19.9-27.2) screened positive for symptomatic depression, PTSD and anxiety. The prevalence estimates for depression, PTSD and anxiety were 12.5% (95% CI 9.8-15.6), 11.5% (95% CI 9.1-14.4) and 9.2% (95% CI 6.8-12.1), respectively. Depression and PTSD were significantly more common in older adolescents, whilst anxiety and PTSD were significantly more common in girls. Depression was more common in children from poorer households and those who had received no education. Children coming from larger households were less likely to show symptoms of PTSD.

CONCLUSIONS

Syrian refugee children and adolescents are vulnerable to common mental disorders, and culturally appropriate prevention and intervention support are needed for this population.

Children at risk: A nation-wide, cross-sectional study examining post-traumatic stress symptoms in refugee minors from Syria, Iraq and Afghanistan resettled in Sweden between 2014 and 2018

Background

The objective of the present study was to assess nation-wide, representative prevalence estimates for symptom-defined posttraumatic stress disorder (PTSD) within populations of refugee minors from Afghanistan, Syria and Iraq resettled in Sweden.

Methods

A nation-wide, cross-sectional, questionnaire study with a stratified sample of refugee minors, aged 16–18 years, from Afghanistan, Iraq and Syria, resettled in Sweden between 2014 and 2018 (N = 5071) was conducted. The response rate was 22.3%, leaving n = 1129 refugee minors (boys 53.1% / girls 46.9%) in the final sample. Symptom-defined prevalences of PTSD were measured using CRIES-8 with ≥17 as cut-off. Data were analyzed using frequency distributions, and strata-specific PTSD prevalences with 95% confidence intervals (95% CIs), were estimated. The association between migratory status on arrival (unaccompanied vs. accompanied) and PTSD was estimated using crude and adjusted odds ratios (OR) utilizing logistic regression analyses with 95% CIs.

Results

Overall, the weighted PTSD prevalence was 42% (95% CI 38.9–45.1), with minors from Afghanistan presenting the highest prevalence (56.9, 95% CI 51.5–62.2), compared to minors from Iraq (36.8, 95% CI 28.9–45.4) and Syria (33.4, 95% CI 29.4–37.6). Unaccompanied minors from Afghanistan had higher odds of PTSD compared to accompanied minors from Afghanistan (OR = 1.92, 95% CI 1.08–3.40). Gender differences were non-significant.

Conclusions

High prevalences of symptom-defined PTSD among refugee minors in general and in unaccompanied minors from Afghanistan in particular, were revealed. Findings calls for continued efforts to support this especially vulnerable group.

Evaluation of the teaching recovery techniques community-based intervention for accompanied refugee children experiencing post-traumatic stress symptoms (Accompanied refugeeS In Sweden Trial; ASsIST): study protocol for a cluster randomised controlled trial

BACKGROUND

Refugee children have often experienced traumas and are at significant risk of developing mental health problems, such as symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, which can continue for years after resettlement. The Accompanied refugeeS In Sweden Trial (ASsIST) aims to evaluate a community-based intervention, called 'Teaching Recovery Techniques' (TRT), for accompanied refugee minors experiencing PTSD symptoms.

METHODS/DESIGN

A cluster randomised controlled trial will be conducted in which participants will be randomly allocated to one of the two possible arms: the intervention arm (n=113) will be offered the TRT programme and the waitlist-control arm (n=113) will receive services as usual, followed by the TRT programme around 20 weeks later. Outcome data will be collected at three points: pre-intervention (T1), post-intervention (T2; c.8 weeks after randomisation) and follow-up (T3; c.20 weeks after randomisation).

ETHICS AND DISSEMINATION

Ethical approval was granted by the Regional Ethical Review Board in Uppsala (Ref. 2018/382) (24^th February 2019). Results will be published in scientific journals.

TRIAL REGISTRATION DETAILS

ISRCTN17754931. Prospectively registered on 4^th June 2019.

Evaluation of the Teaching Recovery Techniques community-based intervention for unaccompanied refugee youth experiencing post-traumatic stress symptoms (Swedish UnaccomPanied yOuth Refugee Trial; SUPpORT): study protocol for a randomised controlled trial

Background

In 2015, 162,877 persons sought asylum in Sweden, 35,369 of whom were unaccompanied refugee minors (URMs). Refugee children, especially URMs, have often experienced traumas and are at significant risk of developing mental health problems, such as symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, which can continue years after resettlement. The Swedish UnaccomPanied yOuth Refugee Trial (SUPpORT) aims to evaluate a community-based intervention, called Teaching Recovery Techniques (TRT), for refugee youth experiencing PTSD symptoms.

Methods/design

A randomised controlled trial will be conducted in which participants will be randomly allocated to one of two possible arms: the intervention arm (n = 109) will be offered the TRT programme, and the waitlist-control arm (n = 109) will receive services as usual, followed by the TRT programme around 20 weeks later. Outcome data will be collected at three points: pre-intervention (T1), post-intervention (T2; about 8 weeks after randomisation) and follow-up (T3; about 20 weeks after randomisation).

Discussion

This study will provide knowledge about the effect and efficiency of a group intervention for URMs reporting symptoms of PTSD in Sweden.

Trial registration

ISRCTN, ISRCTN47820795. Prospectively registered on 20 December 2018.

Implementing Narrative Exposure Therapy for unaccompanied asylum-seeking minors with post-traumatic stress disorder: A pilot feasibility report

There are high rates of post-traumatic stress disorder (PTSD) in unaccompanied asylum-seeking minors (UAM) and there is a requirement for feasible, acceptable and evidence-based treatments. Narrative Exposure Therapy (NET) is a short-term treatment for PTSD following multiple traumatic events. This article aims to examine the applicability of NET for UAM in routine clinical practice and to provide preliminary feasibility, acceptability and effectiveness data. The participants were four UAM receiving NET within a dedicated child and adolescent mental health service for refugee children. Semi-structured interviews were conducted to understand the acceptability of this approach and standardised measures of PTSD were used to provide preliminary data regarding the effectiveness of NET for these clients. The clients attended NET consistently with few missed appointments. At post-treatment, two clients' symptom scores were below the clinical cut-off for PTSD and all three clients who completed NET met reliable improvement criteria. The clients reported improvements in functional outcomes and mentioned that they would encourage other young people with similar difficulties to engage in NET. This study was limited by the small sample size and naturalistic time limitations in clinicians' contracts. This article highlights that it is possible to implement NET within routine clinical practice and observed improvements in PTSD symptoms and functional outcomes for UAM.

Prevalence of mental disorders in young refugees and asylum seekers in European Countries: a systematic review

The European Union member states received about 385,000 asylum applications from children and adolescents below 18 years in 2015, and 398,000 in 2016. The latest political crises and war have led to an upsurge in refugee movements into European countries, giving rise to a re-evaluation of the epidemiology of psychiatric disorders and mental health problems among young refugees and asylum seekers. We systematically searched five electronic databases and reference lists of pertinent review articles. We then screened the results of forward citation tracking of key articles for relevant studies in the field for the period from January 1990 to October 2017. We dually reviewed citations and assessed risk of bias. We reported the results narratively, as meta-analyses were impeded due to high heterogeneity. We included 47 studies covered in 53 articles. Overall, the point prevalence of the investigated psychiatric disorders and mental health problems varied widely among studies (presenting interquartile ranges): for posttraumatic stress disorder between 19.0 and 52.7%, for depression between 10.3 and 32.8%, for anxiety disorders between 8.7 and 31.6%, and for emotional and behavioural problems between 19.8 and 35.0%. The highly heterogeneous evidence base could be improved by international, methodologically comparable studies with sufficiently large sample sizes drawn randomly among specific refugee populations. The prevalence estimates suggest, nevertheless, that specialized mental health care services for the most vulnerable refugee and asylum-seeking populations are needed. REGISTRATION: The systematic review protocol was registered in PROSPERO on October 19th, 2017 with the number: CRD42017080039 and is available from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=80039.

Morbidity profile and sociodemographic characteristics of unaccompanied refugee minors seen by paediatric practices between October 2014 and February 2016 in Bavaria, Germany

Background

This study aimed to investigate the morbidity profile and the sociodemographic characteristics of unaccompanied refugee minors (URM) arriving in the region of Bavaria, Germany, between October 2014 and February 2016.

Methods

The retrospective cross sectional study included 154 unaccompanied refugee minors between 10 and 18 years of age. The data was derived from medical data records of their routine first medical examination in two paediatric practices and one collective housing for refugees in the region of Bavaria, Germany.

Results

Only 12.3% of all participants had no clinical finding at arrival. Main health findings were skin diseases (31.8%) and mental disorders (25%). In this cohort the hepatitis A immunity was 92.8%, but only 34.5% showed a constellation of immunity against hepatitis B. Suspect cases for tuberculosis were found in 5.8% of the URM. There were no HIV positive individuals in the cohort. Notably, 2 females were found to have undergone genital mutilations.

Conclusions

The majority of arriving URM appear to have immediate health care needs, whereas the pathologies involved are mostly common entities that are generally known to the primary health care system in Germany. Outbreaks due to hepatitis A virus are unlikely since herd immunity can be assumed, while this population would benefit from hepatitis B vaccination due to low immunity and high risk of infection in crowded housing conditions. One key finding is the absence of common algorithms and guidelines in health care provision to URM.

Teaching Recovery Techniques: evaluation of a group intervention for unaccompanied refugee minors with symptoms of PTSD in Sweden

In 2015, a total of 35,369 unaccompanied refugee minors (URMs) sought asylum in Sweden. In a previous study of 208 URMs, we found that 76% screened positive for PTSD. This study aimed to (1) evaluate the indicated prevention program Teaching Recovery Techniques (TRT) in a community setting and describe the program's effects on symptoms of PTSD and depression in URMs; and (2) examine participants' experiences of the program. The study included 10 groups. Methods for evaluation included the Children's Revised Impact of Event Scale (CRIES-8) and the Montgomery-Åsberg Depression Rating Scale Self-report (MADRS-S) at baseline and at post-intervention. Qualitative interviews were conducted with 22 participating URMs to elicit their experiences. Pre- and post-measures were available for 46 participants. At baseline, 83% of the participants reported moderate or severe depression and 48% suicidal ideation or plans. Although more than half (62%) of the participants reported negative life events during the study period, both PTSD (CRIES-8) and depression (MADRS-S) symptoms decreased significantly after the intervention (p = 0.017, 95% CI - 5.55; - 0.58; and p < 0.001, 95% CI - 8.94; - 2.88, respectively). The qualitative content analysis resulted in six overall categories: social support, normalisation, valuable tools, comprehensibility, manageability, and meaningfulness when the youth described their experiences of the program, well reflecting TRT's program theory. Overall, results indicate that TRT, delivered in a community setting, is a promising indicated preventive intervention for URMs with PTSD symptoms. This successful evaluation should be followed up with a controlled study.