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Validity of screening for psychiatric disorders in unaccompanied minor asylum seekers: Use of computer-based assessment
Abstract
Self-report screening is an important element of transcultural research. Problems concerning illiteracy, cultural sensitivity, and possible misunderstandings have been handled differently in different settings. The aim of this study was to evaluate the validity of two well-known instruments: the Hopkins Symptoms Check List (HSCL-25), and the Harvard Trauma Questionnaire (HTQ, Part IV), with a sample of 160 unaccompanied asylum-seeking adolescents from Afghanistan and Somalia. Assessments were performed 4 months after arrival in Norway, and the screening instruments were presented to the informants on computers with touch-screen function, using the program MultiCASI. Sound-files in the native languages of the informants appeared simultaneously with the written items and could be repeated by touch. We found that the screening procedures were well received and understood by the informants regardless of reading and writing abilities. Agreement between diagnoses (CIDI) and screening results were similar to other studies. Computer-based assessment in this setting was practical, cost effective, and can be recommended.
... Three studies were cultural adaptations of programs [31,32,37], several were described as feasibility or pilot studies [20, 22, 28, 36, 38, 42, 44-47, 50, 51, 60, 62], one was described as a usability study [59] and two appeared to be formative evaluations [55,56]. Some of the feasibility/pilot studies were randomized controlled trials, but the majority of randomized controlled trials were concerned with effectiveness as well as acceptability [22,25,28,30,34,35,39,41,43,48,49,52,53,60]. ...
... The majority of the papers described a mental health intervention. However, ten papers described nine unique diagnostic assessment studies or screening tools [22,23,[27][28][29][30][31][32] and two described the development, adaptation and/or usertesting of a screening tool and/or interventions [33,34]. ...
... While several interventions focused specifically on refugees or asylum seekers (See Table 1) [27,31,32,39,43,[56][57][58][59][61][62][63], a larger proportion of the papers focused on initiatives involving immigrants [20, 22-24, 28, 36, 38, 40, 41, 47-51, 54, 55, 60, 64, 65]. One study looked at East Asian international students in the USA [36]. ...
Immigrant and refugee populations face multiple barriers to accessing mental health services. This scoping review applies the (Levesque et al. in Int J Equity Health 12:18, 2013) Patient-Centred Access to Healthcare model in exploring the potential of increased access through virtual mental healthcare services VMHS for these populations by examining the affordability, availability/accommodation, and appropriateness and acceptability of virtual mental health interventions and assessments. A search in CINAHL, MEDLINE, PSYCINFO, EMBASE, SOCINDEX and SCOPUS following (Arksey and O'Malley in Int J Soc Res Methodol 8:19-32, 2005) guidelines found 44 papers and 41 unique interventions/assessment tools. Accessibility depended on individual (e.g., literacy), program (e.g., computer required) and contextual/social factors (e.g., housing characteristics, internet bandwidth). Participation often required financial and technical support, raising important questions about the generalizability and sustainability of VMHS' accessibility for immigrant and refugee populations. Given limitations in current research (i.e., frequent exclusion of patients with severe mental health issues; limited examination of cultural dimensions; de facto exclusion of those without access to technology), further research appears warranted.
... Thirty-three validation tests were conducted, with some studies evaluating multiple tools or different versions of the same tool. Nine studies looked at the Harvard Trauma Questionnaire (HTQ) (Sondergaard et al., 2003;de Fouchier et al., 2012;Jakobsen et al., 2011;Jakobsen et al., 2017;Lhewa et al., 2007;Mollica et al., 1992;Renner et al., 2006;Smith Fawzi et al., 1997;Blackmore et al., 2022), making it the most frequently researched tool. This is followed by the Impact of Event Scale (IES) (Sondergaard et al., 2003;Renner et al., 2006;Morina et al., 2017;Sack et al., 1998), which was validated in four different studies, and the Refugee Health Screener (RHS) (Bjarta et al., 2018;Hollifield et al., 2016;Kaltenbach et al., 2017), validated in three studies. ...
... Most studies used a diagnostic interview as the reference standard (n = 21) (Sondergaard et al., 2003;Nehring et al., 2021;de Fouchier et al., 2012;Jakobsen et al., 2011;Jakobsen et al., 2017;Lhewa et al., 2007;Mollica et al., 1992;Smith Fawzi et al., 1997;Blackmore et al., 2022;Morina et al., 2017;Sack et al., 1998;Kaltenbach et al., 2017;Ibrahim et al., 2018;Turner et al., 2003;Ahmad et al., 2000;Brink et al., 2016;Dao et al., 2012;Eytan et al., 2007;Hocking et al., 2018), but the diagnostic instrument varied. For example, some studies used the Composite International Diagnostic Interview (CIDI) or the Structured Clinical Interview (SCID), while some did not report details of the diagnostic interview. ...
... Four different modes of delivery were employed to administer the screening tools. Most instruments were self-report questionnaires that were either self-administered (n = 12) (Sondergaard et al., 2003;de Fouchier et al., 2012;Jakobsen et al., 2011;Jakobsen et al., 2017;Mollica et al., 1992;Smith Fawzi et al., 1997;Morina et al., 2017;Bjarta et al., 2018;Kaltenbach et al., 2017;Heeke et al., 2020;Brink et al., 2016), with staff assistance (n = 10) (Nehring et al., 2021;Lhewa et al., 2007;Renner et al., 2006;Blackmore et al., 2022;Sack et al., 1998;Mewes et al., 2016;Turner et al., 2003), or through an interview (n = 5) (Hollifield et al., 2016;Wulfes et al., 2019;Ibrahim et al., 2018;Barbieri et al., 2019). Eight of the tools were designed to be administered as interviews (Sondergaard et al., 2003;Renner et al., 2006;Ahmad et al., 2000;Dao et al., 2012;Eytan et al., 2007;Hocking et al., 2018;Lillee Hall et al., 2014). ...
Background
Refugees and asylum seekers often experience traumatic events resulting in a high prevalence of post-traumatic stress disorder (PTSD). Undiagnosed PTSD can have detrimental effects on resettlement outcomes. Immigration medical exams provide an opportunity to screen for mental health conditions in refugee and asylum seeker populations and provide links to timely mental health care.
Objective
To assess the diagnostic accuracy of screening tools for PTSD in refugee and asylum seeker populations.
Methods
We systematically searched Medline, Embase, PsycINFO, CENTRAL and CINAHL up to 29 September 2022. We included cohort-selection or cross-sectional study designs that assessed PTSD screening tools in refugee or asylum seeker populations of all ages. All reference standards were eligible for inclusion, with a clinical interview considered the gold standard. We selected studies and extracted diagnostic test accuracy data in duplicate. Risk of bias and applicability concerns were addressed using QUADAS-2. We meta-analyzed findings using a bivariate random-effects model. We partnered with a patient representative and a clinical psychiatrist to inform review development and conduct.
Results
Our review includes 28 studies (4,373 participants) capturing 16 different screening tools. Nine of the 16 tools were developed specifically for refugee populations. Most studies assessed PTSD in adult populations, but three included studies focused on detecting PTSD in children. Nine studies looked at the Harvard Trauma Questionnaire (HTQ) with diagnostic cut-off points ranging from 1.17 to 2.5. Meta-analyses revealed a summary point sensitivity of 86.6% (95%CI 0.791; 0.917) and specificity of 78.9% (95%CI 0.639; 0.888) for these studies. After evaluation, we found it appropriate to pool other screening tools (Posttraumatic Stress Disorder Checklist, the Impact of Event Scale, and the Posttraumatic Diagnostic Scale) with the HTQ. The area under the curve for this model was 79.4%, with a pooled sensitivity of 86.2% (95%CI 0.759; 0.925) and a specificity of 72.2% (95%CI 0.616; 0.808).
Conclusions
Our review identified several screening tools that perform well among refugees and asylum seekers, but no single tool was identified as being superior. The Refugee Health Screener holds promise as a practical instrument for use in immigration medical examinations because it supports the identification of PTSD, depression, and anxiety across diverse populations. Future research should consider tool characteristics beyond sensitivity and specificity to facilitate implementation in immigration medical exams.
Registration
Open Science Framework: 10.17605/OSF.IO/PHNJV
... (Mollica et al., 1992) was developed for adults. Although the HTQ has not been adapted for younger populations, the questionnaire is often used for assessing PTSD in adolescents (Jakobsen et al., 2017). The instrument consists of 16 items divided into three subscales, based on the DSM-IV criteria for PTSD. ...
... Thus, there is low quality of evidence for sufficient internal consistency of the instrument. Yet, there is moderate evidence for sufficient criterion validity, with very good sensitivity and average specificity (Jakobsen et al., 2017) 3.3.7. RATS The results on the structural validity are indeterminate, since only an EFA was performed. ...
... The internal consistency of the DHSCL was very good (Ertl et al., 2011). The internal consistency of the HSCL-25 total scale was excellent (Jakobsen et al., 2017). However, since no factor analysis was performed and the internal consistency of the anxiety and depression subscales was not reported, the quality of evidence is considered low. ...
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.
... Eleven studies were identified that investigated mental health screening approaches specific to refugee children and adolescents [52,[57][58][59]61,62,67,82,89,97,100]. Children and adolescents between the ages of 6 months to 18 years old were included and all identified screening programs were completed post-arrival to the resettlement country. ...
... Children and adolescent screening programs focused on a wider range of conditions which consider critical developmental stages. The psychological factors screened for included: emotional problems, conduct problems, hyperactivity, peer problems and prosocial behavior, stressful life events, PTSD [82,100], anxiety, depression [58,59,67,97], and somatization disorder [58]. Health risk behaviours, health-related quality of life, and physical and psychosocial well-being, including physical functioning, body pain, emotional problems, self-esteem, and family cohesion were also screened for [57,62]. ...
... Only two publications reported on the digital administration of mental health screening with adolescents. Of note, Jakobsen et al. utilized a computer-based system (laptops and touch-screen function) to administer their screening questionnaires to unaccompanied adolescents with limited school backgrounds [67]. Similarly, Sukale et al. administered a computer-based tool named 'Providing Online Resource and Trauma Assessment' (PORTA), which combines disorder-specific questionnaires on the topics of trauma (CATS), depression and anxiety (RHS + PHQ-9), behavioural problems (SDQ), and self-harm and suicidality (SITBI) [97]. ...
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.
... Studies were published from 2009 to 2019 and conducted in eight countries, predominately from the United States (n = 6). [23][24][25][26][27][28] Other countries include Canada (n = 3), [29][30][31] Sweden (n = 2), 32,33 and one study conducted in each of the following countries: Australia, 34 Norway, 35 South Africa, 36 Switzerland, 37 and The Netherlands. 38 Ten studies (equal numbers between studies on immigrants and refugees) used randomized controlled designs and six were quasi-experimental studies, with four being conducted among immigrants. ...
... Four studies were conducted among Chinese immigrants, 24,26,28,29 and the rest of studies targeted Indian immigrants, 23 Korean immigrants, 25 Kurdish immigrants, 33 Greek and Italian immigrants, 34 Turkish immigrants, 38 Cambodian refugees, 27 and Afghan refugees. 30 Of 16 studies, 12 of them were conducted among middle-aged and elderly participants [24][25][26][27][28][29][30][31]33,34,37,38 ; 3 were among young and adolescent refugees 32,35 and immigrants (international students) 23 ; and 1 was among refugees from diverse age backgrounds. 36 Study characteristics are summarized in Table 1. ...
... Of 16 studies, five applied digital health in screening, assessment, and diagnosis stages by using short messaging services console program 36 and computer-assisted selfassessment software. 30,31,35,37 Eight studies focused on intervention stage by using videoconferencing technologies, [24][25][26]28 a game application, 32 and web-/internetbased intervention. 23,33,34 Three studies utilized digital health widely from screening to intervention stage, for example, Everything under Control (an internet-based, guided, self-help intervention program 38 ). ...
Objective:
To explore and summarize (1) the existing digital health applications in mental health care (MHC) for immigrants and refugees and its outcomes; (2) how the ethical standards of digital health applications in MHC are implemented and reported; and (3) the challenges for scaling up digital health applications in MHC for immigrants and refugees.
Methods:
This review adopted a rapid review methodology. Available literature was searched in three online databases January 1, 2005, to February 28, 2019. Studies were included if they (1) applied digital health technologies, (2) focused on immigrants, refugees, or asylum seekers without age and country limitation, (3) reported nonclinical and/or clinical outcomes, and (4) were published in English or Indonesian. Narrative synthesis was developed based on the data extraction and quality assessment.
Results:
A total of 16 studies were reviewed that applied software, website, and videoconferencing technologies. These applications were applied in various stages of MHC (screening, assessment, diagnosis, and intervention). Participants reported satisfaction and positive attitudes toward applications of digital health in MHC, and positive improvement on their anxiety, depression, and post-traumatic stress disorder symptoms. However, the ethical standards of these digital health applications were poorly implemented and reported. Stigma toward mental disorders and lack of technology literacy were the main challenges in scaling up digital health applications for immigrants and refugees.
Conclusion:
Digital health applications in MHC are promising innovations that can improve the wellbeing of immigrants and refugees. As these technologies expand, ethical standards of practice and reporting need to be improved in delivering scalable digital MHC for immigrants and refugees.
... Heir, T. (2017). A controlled early group intervention study for unaccompanied minors: Can Expressive Arts alleviate symptoms of trauma and enhance life satisfaction? ...
... Each item was scored with 1 (not bothered) to 4 (extremely bothered). Scores ≥2 was considered probably clinically significant (Jakobsen et al., 2016). ...
... These 16 items are measured on a four point Likert scale, ranging from "not at all" (1) to "extremely" (4). Scores ≥2 was considered probably clinically significant (Jakobsen, Meyer DeMott & Heir, 2016). ...
Objective: This is the first controlled study of an expressive arts group intervention with unaccompanied minor asylum seeking children. The aim of the study was to examine whether such an intervention may alleviate symptoms of trauma and enhance life satisfaction.
Methods: 145 unaccompanied minor refugee boys with their stated age between 15 and 18 were allocated into a 10 session 5 weeks manualized expressive arts intervention (EXIT) or a life as usual (LAU) control group.
The participants were assessed on onset and 4 times over a period of 25 months with a battery of instruments measuring post-traumatic stress symptoms (PTSS), general psychological distress (HSCL-25A), current life satisfaction (CLS) and expected life satisfaction (ELS). The instruments were presented in the participants’ native languages, using touch-screen laptops and the computer program Multilingual Computer Assisted Interview (MultiCASI).
Results: There were significant time by group interactions in favor of the EXIT group for PTSS and CLS. At the end of the follow up the EXIT group had higher life satisfaction and hope for the future than the LAU group.
Conclusions: A manualized EXIT group intervention can have a beneficial effect on helping minor refugee boys to cope with symptoms of trauma, strengthen their life satisfaction and develop hope for the future. Our findings support previous studies showing that the arts may help people in reconstructing meaning and connection with others by focusing on resources and creativity.
Key words: Expressive Arts, Group intervention, Unaccompanied asylum-seeking boys, Trauma symptoms, Life satisfaction, Hope
... Heir, T. (2017). A controlled early group intervention study for unaccompanied minors: Can Expressive Arts alleviate symptoms of trauma and enhance life satisfaction? ...
... Each item was scored with 1 (not bothered) to 4 (extremely bothered). Scores ≥2 was considered probably clinically significant (Jakobsen et al., 2016). ...
... These 16 items are measured on a four point Likert scale, ranging from "not at all" (1) to "extremely" (4). Scores ≥2 was considered probably clinically significant (Jakobsen, Meyer DeMott & Heir, 2016). ...
This is the first controlled study of an expressive arts group intervention with unaccompanied minor asylum seeking children. The aim of the study was to examine whether such an intervention may alleviate symptoms of trauma and enhance life satisfaction and hope. One hundred forty five unaccompanied minor refugee boys with their stated age between 15 and 18 were allocated into a 10 session 5 weeks manualized expressive arts intervention (EXIT) or a life as usual (LAU) control group. The participants were assessed at onset and 4 times over a period of 25 months with a battery of instruments measuring post-traumatic stress symptoms (PTSS), general psychological distress (HSCL-25A), current life satisfaction (CLS) and expected life satisfaction (ELS). The instruments were presented in the participants’ native languages, using touch-screen laptops and the computer program Multilingual Computer Assisted Interview (MultiCASI). There were significant time by group interactions in favor of the EXIT group for PTSS and CLS. At the end of the follow up the EXIT group had higher life satisfaction and hope for the future than the LAU group. A manualized EXIT group intervention can have a beneficial effect on helping minor refugee boys to cope with symptoms of trauma, strengthen their life satisfaction and develop hope for the future. Our findings support previous studies showing that the arts may help people in reconstructing meaning and connection with others by focusing on resources and creativity.
... Previous uses of the HTQ included child and adolescent populations as young as 10 years of age. [10][11][12][13] The HTQ contains five parts: I, trauma events; II, two short open-format essay questions (which were translated by the second author, a native Syrian, and thematically coded by the first author); III, neurological trauma and starvation; IV, trauma symptoms; and V, torture history. A "DSM-IV PTSD score" was calculated from the average score of the first 16 items of Part IV of the HTQ (scoring according to Appendix D of HTQ), which were reported by participants on a 4-point scale (1 "not at all," 2 "a little," 3 "quite a bit," 4 "extremely") and which were derived from symptomatology of PTSD in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV). ...
... 34 Based on self-reported trauma symptoms, we estimate rates of 85% probable PTSD among minors. This prevalence rate is much higher than other studies that used the HTQ to determine PTSD rates in populations of minors from other conflict regions, 10,11 and higher than the 12%-45% reported for Syrian refugee and IDP minors. 35,36 Comparing locations and year of data collection, we suggest that our higher prevalence rate reflects the fact that minors were still in an active war zone at the time of data collection and had been exposed to military conflict for up to seven years at that time. ...
Objective: The Syrian civil war produced at least 6.8 million internally displaced persons but estimates
of the prevalence of war-related traumatic experiences among the civilian population in hard-to-reach
areas of Syria are sparse. This study aimed to determine prevalence of these experiences, stratify the data
by gender and age, and estimate probable post-traumatic stress disorder (PTSD) prevalence rates from
self-reported symptoms.
Methods: This is an observational cohort study using the Harvard Trauma Questionnaire, Syrian version,
with data collected in Northern Syria from a sample of 142 Syrian civilians ages 12-70, recruited by chain
referral.
Results: In total, 109 adults (age (SD) = 33.1 (10.2); range: 18-70; 36 females) and 33 minors (age (SD) = 14.6
(1.7); range: 12-17; 3 females) participated in the study. War-related experiences included forced displacement,
air strikes, head injury, and starvation. We estimate that 70% of adults and 85% of minors reported
trauma symptom severity consistent with probable PTSD. Overall, 31% of the population experienced
beatings to the head and 18% associated loss of consciousness. Adult males reported beatings to the head
more frequently than females. Minors reported head injuries from explosions and other sources resulting
in subsequent loss of consciousness more frequently than adults.
Conclusion: War-related experiences are common but vary in symptoms and causes by sex and age. This
information may help international relief organizations planning mental health and neurological treatment
approaches in a post-war Syria and be useful to mental health care professionals in host countries to
appreciate the stratified trauma histories of Syrian refugees.
... PTSD was assessed using the Harvard Trauma Questionnaire (HTQ), which has been widely used with traumatized civilians, war veterans, torture victims, and refugees, including adolescents. [21][22][23] The first 16 items are consistent with the PTSD criteria in DSM-IV. These comprise 3 subdomains: reexperiencing traumatic events, avoidance and numbing, and increased arousal. ...
... 24 For depression, measured by the PHQ-9, mild and moderate depression were merged, and moderately severe and severe depression were merged. This created 3 categories: none (0-4), mild/ moderate depression (5)(6)(7)(8)(9)(10)(11)(12)(13)(14), and moderately severe/severe depression (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27). 27 Binary and multinomial logistic regression models were used to examine the associations between regions and PTSD, anxiety, and depression. ...
Objective
Very limited evidence is available on the psychological impact of war on adolescents in Ukraine. This study compared war experiences and posttraumatic stress disorder (PTSD), anxiety and depression in adolescents living in war-torn and peaceful region of Ukraine, more than two years after Russia first invaded in 2014.
Method
The cross-sectional study included 2766 students aged 11-17 years living in war-torn Donetsk region and in Kirovograd in central Ukraine. Self-reported PTSD, depression and anxiety levels were assessed by Harvard Trauma Questionnaire, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7. The data was collected from September 2016 to January 2017. Binary and multinomial logistic regression models were used to examine the association between PTSD, anxiety, depression, and regions.
Results
War trauma and daily stress were higher in adolescents in Donetsk region, for example, 881 (60.2%) of adolescents had witnessed armed attacks, 204 (13.9%) were victims of violence and 409 (27.9%) were forced to leave their homes. They also had significantly increased risks for PTSD, (Odds Ratio, OR 4.11; 95% CI 2.37-7.13), severe anxiety (OR 3.11; 95% CI 1.83-5.29), and moderately severe/severe depression (OR 2.65; 95% CI 1.79-3.92).
Conclusion
Traumatic events and daily stress were strongly associated with psychological distress in adolescents living in war-torn region in Ukraine. These findings can help us to understand, measure and address the long-term impact that the escalating war in Ukraine will have on adolescents’ mental health and social functioning.
... Scores≥2 was considered probably clinically significant. 17 Post-Traumatic Symptom Score (PTSS) The Harvard Trauma Questionnaire 18 (HTQ) is a comprehensive instrument that was developed to assess potentially traumatic experiences and post-traumatic symptoms in various cultural contexts. Its psychometric properties were first established in a highly traumatised, clinical population, but it has also been evaluated with a larger community sample and with asylum-seeking adolescents. ...
... Scores≥2 was considered probably clinically significant. 17 Computer-based assessment The chosen psychometric measurements were combined into a single questionnaire using the program Multi-CASI. 21 The questionnaires were filled in by the participants themselves, in their native languages, Dari, Pashto, Farsi or Somali, using laptops with touch-screen function. ...
Objectives
To examine the mental health of unaccompanied refugee minors prospectively during the asylum-seeking process, with a focus on specific stages in the asylum process, such as age assessment, placement in a supportive or non-supportive facility and final decision on the asylum applications.
Design
This was a2½ year follow-up study of unaccompanied minors (UM) seeking asylum in Norway. Data were collected within three weeks (n=138) and at 4 months (n=101), 15 months (n=84) and 26 months (n=69) after arrival.
Setting
Initially in an observation and orientation centre for unaccompanied asylum-seeking adolescents, and subsequently wherever the UM were located in other refugee facilities in Norway.
Participants
Male UM from Afghanistan, Somalia, Algeria and Iran.
Main outcome measures
Mental health symptoms assessed by Hopkins Symptom Checklist-25 and Harvard Trauma Questionnaire.
Results
At the group level, the young asylum seekers reported high levels of psychological distress on arrival and symptom levels that stayed relatively unchanged over time. According to age-assessment procedures, 56% of the population were not recognised as minors. Subsequent placement in a low-support facility was associated with higher levels of psychological distress in the follow-up period. Those who were placed in a reception centre for adults had higher levels of psychological distress symptoms both after 15 months and 26 months compared with the remaining participants who were placed in reception centres for youth. Refusal of asylum was highly associated with higher levels of psychological distress.
Conclusion
Mental health trajectory of young asylum seekers appears to be negatively affected by low support and refusal of asylum.
... We used the Hopkins Symptom Checklist-25 (HSCL-25) to assess symptoms of depression and anxiety (Bean et al., 2007) and a culturally adapted version of the PTSD Checklist-Civilian Version (PCL-C) to assess symptoms of PTSD (Weathers et al., 1993). These established measures are commonly used to assess mental health symptoms among Somali and other refugee populations (e.g., Gerritsen et al., 2006;Jakobsen et al., 2017;Robertson et al., 2006;Wind et al., 2017;Yeomans et al., 2010). Summing the 15 items assessing depression symptoms created a theoretical range of 0 to 60 and a Cronbach's alpha of 0.919. ...
This study examined the relationship between trauma exposure, psychosocial factors including difficulties with socialization, and substance use on the symptoms of common mental disorders (CMDs) among a sample of 250 urban Somali refugee youth in Kenya. We conducted four linear regression analyses followed by four moderated mediation analyses. The results showed that trauma exposure, aggression, and trouble socializing predicted CMD symptoms. Moderated mediation analyses showed a significant moderated mediating effect of trouble socializing on the indirect effect of trauma on CMD symptoms through substance use. A final regression model showed that Somali refugee youth who experienced violence, had low social functioning, and had low social support were more likely to have trouble socializing. This study highlights the potential impact of trouble socializing on the complex relationships between refugee trauma exposure, substance use, and mental health, suggesting the need for intervention programs to address socialization difficulties among urban refugee youth.
... Oferecer acesso à literatura atualizada e baseada em evidências e práticas é uma estratégia para auxiliar a instrumentalização de enfermeiros nas suas práticas com as famílias (5) . Pesquisas desenvolvidas em diferentes países contribuíram para o conhecimento sobre as situações de vida complexas de migrantes e refugiados (6) . Entretanto, as informações sobre as experiências deles disponíveis nos sistemas de saúde dos países de acolhimento mostraram que a necessidade de melhorar a qualidade dos cuidados de saúde é urgente (7) . ...
Objective
To report the experience of the International Family Nursing Association (IFNA) Practice Committee on developing a Toolkit of resources to care for refugee/migrating families as a response to the global migration and refugee crisis.
Method
Qualitative and descriptive study, experience report, which describes the development of a toolkit of resources for caring for refugee/migrating families.
Results
The development of this Toolkit of resources to care for refugee/migrating families is supported by current literature related to family-centered evaluation and intervention, culturally sensitive practice based on family strengths; statements of positioning on immigrant and refugee families; and nursing and health organizations that addressed the health of the refugee family.
Conclusions
The dissemination of the resources available in the Toolkit can support nursing practices, drive qualified approaches to assessments and interventions, capable of promoting family resilience as they adapt, providing well-being, and leading to the healing of traumas and adversities experienced by families in the process of migration or refuge.
DESCRIPTORS
Family Nursin; Emigration and Immigratio; Refugees
... Providing access to updated, evidence-based and practicebased literature is a strategy to support the instrumentalization of nurses in their practices with families (5) . Research developed in different countries has contributed to the knowledge about the complex situations of life of migrating individuals and refugees (6) , however, information on their experiences in health systems in their host countries shows that the need to improve the quality of health care is urgent (7) . Using a theoretical model of care in the approach to migrating/ refugee families is recommended (8,9) . ...
Objective
To report the experience of the International Family Nursing Association (IFNA) Practice Committee on developing a Toolkit of resources to care for refugee/migrating families as a response to the global migration and refugee crisis.
Method
Qualitative and descriptive study, experience report, which describes the development of a toolkit of resources for caring for refugee/migrating families.
Results
The development of this Toolkit of resources to care for refugee/migrating families is supported by current literature related to family-centered evaluation and intervention, culturally sensitive practice based on family strengths; statements of positioning on immigrant and refugee families; and nursing and health organizations that addressed the health of the refugee family.
Conclusions
The dissemination of the resources available in the Toolkit can support nursing practices, drive qualified approaches to assessments and interventions, capable of promoting family resilience as they adapt, providing well-being, and leading to the healing of traumas and adversities experienced by families in the process of migration or refuge.
DESCRIPTORS
Family Nursin; Emigration and Immigratio; Refugees
... To aid participants in responding to items in this format, we also provided them with a visual scale of glasses filled with various amounts of water (adopted from Terheggen et al., 2001). We used the Hopkins Symptom Checklist-25, which has previously been used in Somali and refugee populations (Gerritsen et al., 2006;Jakobsen et al., 2017;Wind et al., 2017), to assess depression and anxiety symptoms. We summed the 15 items measuring depression symptoms to create a continuous depression symptoms variable (range = 0-60, a = .919) ...
Refugee youth experience tremendous trauma before and during forced migration, which has negative mental health impacts. It is important to identify and mitigate conditions that can increase the risk of refugee youth mental health issues and to search for potential protective factors; however, little research has considered these factors among Somali refugee youth. To fill this gap in research, this study examined the impact of child traumas and preventive factors on mental health outcomes among Somali refugee youth in urban Kenya. We used snowball sampling to recruit 250 Somali refugee youth, aged 15 to 35 years, living in Eastleigh, Kenya. We used a series of multiple linear regression models to examine the associations of child trauma (child abuse, witnessing domestic violence, corporal school punishment, female genital mutilation/cutting), symptom normalization, and parental death with symptoms of common mental disorders first in a mixed-gender sample and then with a female-only sample. Results indicated that child trauma significantly predicted mental health symptoms in all bivariate analyses with both samples and in all regression analyses with the mixed-gender sample. However, in regression analyses with the female-only sample, child trauma only significantly predicted anxiety and somatic symptoms. In addition, increased symptom normalization predicted mental health symptoms, and parental death predicted anxiety and somatic symptoms. These findings increase understanding of the impact of child trauma exposures in this understudied population and provide directions for future research, particularly regarding the impact of parental loss, and intervention to decrease mental health risk in Somali refugee youth.
... We used the PTSD Checklist-Civilian Version (PCL-C) and the Hopkins Symptom Checklist-25 (HSCL-25) to assess mental health symptoms at baseline and at posttest, both of which are commonly used to measure mental health symptoms in Somali and refugee populations (e.g., Jakobsen et al., 2017;Robertson et al., 2006;Wind et al., 2017;Yeomans et al., 2010). These items instructed participants to rank how much they agreed with a statement using a 5-point Likert-type scale ranging from not at all (= 1) to almost always (= 5). ...
Somali refugee youth present with a heightened risk for common mental disorders (CMDs), and yet few studies have discussed factors influencing mental health outcomes after psychosocial interventions. This study aimed to identify key factors that contribute to the improvement of CMD symptoms among Somali youth displaced in urban Kenya. Logistic regression analyses revealed that trauma exposure and emotional coping predict overall symptom improvement, pointing to a differential intervention effect on those with differing levels of religious belief and attitudes toward violence. This study provides insights into how psychosocial factors likely contribute to positive intervention outcomes in Somali refugee youth.
... Mental health symptoms. Symptoms of PTSD, depression, and anxiety were assessed using established measures previously used with Somali and refugee populations (Jakobsen et al., 2017;Wind et al., 2017;Yeomans et al., 2010). We used the 17-item PTSD Check List-Civilian Version (PCL-C) to assess symptoms of PTSD and the 25-item Hopkins Symptom Checklist-25 (HSCL-25) to assess symptoms of depression and anxiety. ...
Background
Refugee youth often face numerous adversities before and during forced migration. Although experiences vary across settings and subpopulations, common mental disorders are prevalent among refugee youth who are displaced in low- and middle-income countries. It is important to examine how risk factors are intricately linked and contribute to common mental health issues to inform clinical practice and social policy.
Aims
This study aims to test the pathways from risk factors previously identified as determinants of Somali refugee youth mental health (i.e. trauma exposure, substance use, social functioning, aggression) to symptoms of PTSD, depression, anxiety, and somatic pains.
Method
We collected survey data in 2013, using snowball sampling to recruit Somali refugee youth (15–35 years old) living in Eastleigh, Kenya. We ran three structural equation models to assess paths from trauma exposure to mental health symptoms, through psychosocial factors including substance use, aggression, and functional impairment. We first conducted this analysis with a mixed-gender sample ( N = 305) and then assessed gender differences by running one model for male participants ( n = 124) and another for female participants ( n = 181).
Results
In the mixed-gender sample, trauma exposure directly predicted substance use and both directly and indirectly predicted aggression, functional impairment, and mental health symptoms. Substance use directly predicted aggression and functional impairment, and substance use both directly and indirectly predicted mental health symptoms. The split-gender models revealed gender differences, with only functional impairment directly predicting mental health symptoms in the male sample and with many significant direct and indirect pathways in the female sample.
Conclusions
This study shows the role of trauma exposure, substance use, aggression, and social functioning in determining mental health outcomes among refugee youth and how CMD symptoms are differently manifested across genders in this population.
... An average score on the HSCL-25 ≥ 2.0 is commonly used as a conservative cut-off for identifying a high level of depressive and anxiety symptoms. 45 Detailed trend and prevalence data on the HSCL-25 in the SHoT study have been published elsewhere. 46 The Cronbach's alpha for the HSCL-25 in the current study was 0.94. ...
Background
Young adults with heart disease constitute a growing group with the risk of cognitive and physical impairment. The knowledge of their academic performance and mental and physical health is, however, scant. This study aimed to compare young adults with CHDs or arrhythmia with their peers.
Methods
Information on physical health (Somatic Symptom Scale-8), mental health problems (Hopkins Symptoms Checklist-25), quality of life (Satisfaction With Life Scale), physical activity, and academic performance was collected online in a national cross-sectional survey in Norway among students in higher education (the SHoT2018 study).
Results
Among 50,054 students, 172 (0.34%) reported CHD and 132 (0.26%) arrhythmias. Students reporting arrhythmias scored significantly higher than the control group on somatic symptoms (OR = 2.3 (95% CI: 1.62–3.27)), anxiety (OR = 1.60 (1.08–2.37)), depression (OR = 1.49 (1.05–2.11)), self-harm, and suicide attempt (OR = 2.72 (1.56–4.75)), and lower quality of life (OR 1.64 (1.16–2.32)) and more loneliness (OR = 1.99 (1.28–3.10)) compared to participants without heart disease. Participants with CHD reported an increased somatic symptom burden (OR = 1.58 (1.16–2.16)). Despite a tendency to a higher score, this group did not differ significantly from the control group on anxiety or depression, quality of life, or loneliness. However, the risk of self-harm thoughts and suicidality was significantly increased (OR for suicide attempt 2.22 (1.3–3.77)). There was no difference between the groups on academic performance.
Conclusions
Although Norwegian students with heart disease reported more somatic symptoms, their academic progress was not reduced compared to students without heart disease. Students with CHD or arrhythmias showed an increased risk of self-harm thoughts and suicidality.
... Based on feedback from community advisors, the item assessing suicidal ideation was removed, because suicide is culturally and religiously proscribed and asking this item may have resulted in drop-out or social 1 3 desirability bias. The HSCL has both demonstrated measurement invariance across refugee populations and been validated specifically within Somali refugee populations [39][40][41]. Responses to each question about symptoms ranged from 1 (not at all) to 4 (extremely). The HSCL anxiety subscale had a Cronbach's alpha of 0.87 at Wave 1 and 0.86 at Wave 2. The HSCL depression subscale had a Cronbach's alpha of 0.90 at Wave 1 and 0.91 at Wave 2. The depression and anxiety subscales were coded separately as standardized scores, with a mean of 0 and standard deviation of 1. ...
Background
A large body of research highlights the lasting impact of pre-resettlement violence on the mental health of refugees after resettlement. However, there is limited research on violence exposure after resettlement and its association with mental health. We examine the association of pre- and post-resettlement violence with post-resettlement mental health symptoms in a survey of Somali refugees in the US and Canada.
Methods and findings
We collected survey data from 383 Somalis across five cities in the US and Canada (Boston, MA; Minneapolis, MN; Lewiston, NC; Portland, ME; Toronto, Canada). Wave 1 data were collected between May 2013 and January 2014, while Wave 2 was collected between June 2014 and August 2015. Data from both waves were used to examine whether the association of past violence exposures persists across time and with more recent violence exposures. The War Trauma Screening Scale assessed exposure to any pre- and post-resettlement violence at Wave 1, while the My Exposure to Violence scale assessed any past-year violence exposure at Wave 2. Mental health outcomes included symptoms of depression and anxiety (Hopkins Symptom Checklist) and post-traumatic stress symptoms (Harvard Trauma Questionnaire). Separate linear regression models at Waves 1 and 2 examined the relationship of past violence exposure to standardized scores of mental health symptoms. Participants were 22 years of age, on average. Fifty-six percent of our sample had been exposed to violence after resettlement by Wave 2. At Wave 1, the associations of pre- and post-resettlement violence with mental health were comparable in magnitude across depression [β = 0.39, 95% CI (0.21 0.57) vs. β = 0.36, 95% CI (0.10 0.62)], anxiety [β = 0.33, 95% CI (0.12 0.55) vs. β = 0.38, 95% CI (0.01 0.75)], and PTSD [β = 0.55, 95% CI (0.37 0.72) vs. β = 0.47, 95% CI (0.21 0.74)]. At Wave 2, pre-resettlement violence was associated with depressive symptoms only [β = 0.23, 95% CI (0.06 0.40)], while past-year exposure to violence had the largest association with all mental health outcomes [depression: β = 0.39, 95% CI (0.17 0.62); anxiety: β = 0.46, 95% CI (0.01 0.75); PTSD: β = 0.67, 95% CI 0.46 0.88)].
Conclusions
Our study is the first to examine refugees’ exposure to post-resettlement violence across time, finding that Somali refugees’ exposure is both persistent and prevalent after resettlement. Post-resettlement violence had a larger association with mental health than pre-resettlement exposure by Wave 2. Our study highlights the urgent need to understand the role of post-resettlement violence exposure for refugees in the US and Canada.
... This measure has previously been used to assess symptoms of anxiety and depression in Somali and refugee populations (e.g. Gerritsen et al., 2006;Jakobsen et al., 2017;Wind et al., 2017). Because item response models in previous analyses using these data (see McDonald et al., 2019) indicated significant overlap between response categories, we collapsed response categories 2 (rarely) and 3 (sometimes) of the 1 to 5 range to create a 1 to 4 range for each depression and anxiety symptom. ...
Background
Comorbid common mental disorders (CMDs) are pervasive in refugee populations. However, limited research has explored psychosocial factors for mental disorder comorbidity in Somali refugee samples.
Aims
This study aims to explore potential risk and protective factors for comorbid depression-anxiety and comorbid depression-PTSD by examining associations between trauma exposure, psychosocial factors, and mental health symptoms among a sample of Somali refugees displaced in urban Kenya.
Methods
We used snowball sampling to recruit Somali youth aged 15 to 35years( N = 250, n = 143 female, n = 88 male, n = 19 unknown gender). We measured 16 common types of trauma exposure and three psychosocial factors (endorsing violence, willingness to share problems, and symptom awareness) and used the HSCL-25 and PCL-C to capture individual and comorbid CMD symptoms, using guided cutoff points and/or algorithms. We then ran a series of logistic regression analyses to examine relationships between trauma exposure, psychosocial factors, and individual and comorbid CMD symptoms.
Results
Findings showed that increased trauma exposure predicted symptoms of individual and comorbid CMDs. Increased symptom awareness and endorsement of violence predicted comorbid depression-PTSD and comorbid anxiety-depression symptoms, respectively. Willingness to share problems buffered depressive symptoms but did not predict comorbidity.
Conclusions
These findings revealed the high CMD comorbidity prevalence with differential effects of trauma and psychosocial factors on individual or comorbid mental disorders. This study suggests a need for transdiagnostic approaches that cut across Western diagnostic boundaries and consider culturally responsive and relevant items for mental health measures.
... We assessed depression symptoms with 15 items, using the Hopkins Symptom Checklist-25 (HSCL-25). This measure has been used previously to assess mental health symptoms among Somali and refugee populations (e.g., Gerritsen et al. 2006;Jakobsen et al. 2017;Wind et al. 2017). These 15 items were summed, producing the depression symptoms variable, with a theoretical range from 0 to 60. Cronbach's alpha indicated that in the current sample, the estimate of internal consistency for the 17 depression symptom items was 0.899. ...
The purpose of this study was to explore exposure to trauma as well as demographic and psychosocial factors as predictors of mental health symptoms among Somali refugees in Kenya. Participants were recruited via snowball sampling to complete a survey and included 86 Somali refugee youth, aged 15 to 34 years, who were living in Eastleigh. We measured trauma using a total number of traumas experienced variable as well as four trauma types categories (pre-migration/migration trauma, post-migration trauma, family trauma, and individual trauma). We measured anxiety and depression symptoms using the Hopkins Symptom Checklist-25 (HSCL-25) and PTSD using the PTSD Check List-Civilian Version (PCL-C). We ran descriptive statistics followed by multiple linear regression models with trauma exposure, education, gender, and willingness to share problems as predictors of mental health symptoms. Out of 12 possible traumatic events, most participants (83.7%) reported experiencing at least one trauma, and participants reported experiencing an average of 3.76 total traumas. The regression models predicted between 11.5% and 35.5% of the variance of the mental health symptoms. Willingness to share problems was a significant predictor of decreased mental health symptoms in most models. These findings highlight the role of trauma exposure and psychosocial factors in predicting Somali refugee mental health and indicate that implementing programs to encourage problem sharing may help address Somali refugee mental health needs. Further research is needed to explore the differential impact of trauma exposure and various psychosocial factors on Somali refugee mental health.
... Reliability for the 16-item HTQ is often reported in the range of .87-.92 (Housen et al., 2018;Ichikawa et al., 2006;Jakobsen et al., 2017Jakobsen et al., , 2011Lhewa et al., 2007;Mollica et al., 1999;Rasmussen et al., 2007). The lower reliability of the HTQ subscales reported here can be attributed to at least three circumstances. ...
Background
The Harvard Trauma Questionnaire (HTQ) is the predominant questionnaire for assessing PTSD in trauma-affected refugees. Although the scale is increasingly used for measuring treatment outcomes, it has never been specifically validated for such use. The current study does so by testing the HTQ with the Rasch model.
Methods
The analysis is based on 641 Arabic and Persian speaking refugees, diagnosed with PTSD and undergoing psychiatric treatment in Denmark. The responses were tested against the assumptions of the Rasch model, including unidimensionality, local independence and the absence of differential item function across subgroups.
Results
Results reveal two subscales that, when accounting for local dependence and differential item functioning, meet criteria for the Rasch model in the included samples: An arousal/intrusion subscale and an avoidance/numbing subscale.
Limitations
The included sample was highly chronic and suffered from major depressive disorder. Results may not be fully representative of less chronic populations, e.g. recently arrived refugees.
Conclusions
We recommend the use of the arousal/intrusion subscale and the avoidance/numbing subscale as an optimized way of summarizing responses to the HTQ, which remains simple to administer while effectively summarizing all the information available in the scores.
... Screening that includes interviewing multiple key informants [96][97][98] was recommended. Panelists praised the use of vignettes, pictorial representation, and socially-and culturally-sensitive electronic screening tools and post-screening interventions previously shown to be effective in LMICs [99][100][101][102][103][104][105]. ...
Despite their burden and high prevalence, mental health disorders of children and adolescents remain neglected in many parts of the world. In developing countries, where half of the population is younger than 18 years old, one of every five children and adolescents is estimated to suffer from a mental health disorder. It is then essential to detect these conditions through screening in a timely and accurate manner. But such screening is fraught with considerable ethical, social, and cultural challenges. This study systematically identifies, for the first time, these challenges, along with potential solutions to address them. We report on the results of an international multi- and inter-disciplinary three-round Delphi survey completed by 135 mental health experts from 37 countries. We asked these experts to identify and rank the main ethical, social, and cultural challenges of screening for child and adolescent mental health problems in developing nations, and to propose solutions for each challenge. Thirty-nine significant challenges emerged around eight themes, along with 32 potential solutions organized into seven themes. There was a high degree of consensus among the experts, but a few interesting disagreements arose between members of the panel from high-income countries and those from low- and middle-income nations. The panelists overwhelmingly supported mental health screening for children and adolescents. They recommended ensuring local acceptance and support for screening prior to program initiation, along with careful and comprehensive protection of human rights; integrating screening procedures into primary care; designing and implementing culturally appropriate screening tools, programs, and follow-up; securing long-term funding; expanding capacity building; and task-shifting screening to local non-specialists. These recommendations can serve as a guide for policy and decision-making, resource allocation, and international cooperation. They also offer a novel approach to reduce the burden of these disorders by encouraging their timely and context-sensitive prevention and management.
... Syv av åtte kvantitative studier omhandlet enslige mindreårige asylsøkere (9)(10)(11)(12)(13)(14)(15). I flere studier så man på prevalens av psykiske lidelser og symptomer i denne gruppen (10-14), i all hovedsak posttraumatisk stress, depresjon og angst. ...
Background:
Many asylum seekers arrived in Norway during autumn 2015, and there has been a call for more knowledge regarding the health of this group. The aim of this exploratory literature review was to investigate the state of knowledge about asylum seekers' health and use of healthcare services in Norway.
Material and method:
We conducted two literature searches for the periods 2007-2017 and 2017-2019 in 12 databases using the keywords 'refugees' and related terms, with a filter for research undertaken in or about Norway and published in Norwegian or English. The title and summary were read first, after which relevant articles were read in full text. Publications concerning asylum seekers in Norway and related to health and/or use of health services were included.
Results:
A total of 28 publications met the criteria for inclusion: 22 peer-reviewed articles and six reports. The most common topics were mental health and infectious diseases. Other topics that the studies dealt with were nutrition, functional impairment and healthcare services.
Interpretation:
Little research has been undertaken on asylum seekers' health and use of healthcare services. Research on asylum seekers' health in Norway primarily concerns mental health and infectious diseases, and there is little research on other somatic disorders.
... Eight studies pertaining to child and adolescent populations met the inclusion criteria, 29-32,41-44 after a final exclusion of three papers which reported duplicate datasets. [45][46][47] One study was published in German and professionally translated for inclusion. 30 The eight eligible studies provided data on 779 child and adolescent refugees and asylum seekers. ...
Objective:
Over half of the world's refugee population are under the age of 18 years. This systematic review aims to summarise the current body of evidence for the prevalence of mental illness in child and adolescent refugee populations.
Method:
Eight electronic databases, grey literature, and Google Scholar were searched for articles from 1 January 2003 to 5 February 2018. Strict inclusion criteria regarding the diagnosis of mental illness were imposed. Study quality was assessed using a template according to study design, and study heterogeneity using I2 statistic. Random effects meta-analyses results were presented given heterogeneity among studies. The protocol for this systematic review was registered with PROSPERO (CRD42016046349).
Results:
Eight studies were eligible, involving 779 child and adolescent refugees and asylum seekers, with studies conducted in five countries. The overall prevalence of post-traumatic stress disorder (PTSD) was 22.71% (95% CI 12.79-32.64), depression 13.81% (95% CI 5.96-21.67), and anxiety disorders 15.77% (95% CI 8.04-23.50). Attention-deficit/hyperactivity disorder (ADHD) was 8.6% (1.08-16.12) and oppositional defiant disorder (ODD) was 1.69% (95% CI -0.78 - 4.16). Due to high heterogeneity, further subgroup analyses were conducted.
Conclusion:
Refugee and asylum seeker children have high rates of PTSD, depression, and anxiety. Without the serious commitment by health and resettlement services to provide early support to promote mental health, these findings suggest a high proportion of refugee children are at risk of educational disadvantage and poor social integration in host communities, potentially affecting their life course.
... De nombreuses études publiées de psychiatrie transculturelle [12,13] font état des différents troubles psychologiques ou psychiatriques de ces populations vulnérables (troubles anxieux ou dépressifs, syndrome de stress post-traumatiques pour les plus sévères) mais aussi de la capacité de résilience de cette population. ...
The medical care and the social care of newly arrived foreign migrant children can both be challenging. One of the recent migratory phenomena in Europe since the 1990s, which has grown over the past decade, is the arrival of "unaccompanied foreign minors" (UFM) who come without their parents in France. Ile-De-France area and the departments of Paris (75) and Seine-Saint-Denis (93) are the most concerned by these migratory flows. A specific national scheme was introduced in 2013 to shelter, assess and guide unaccompanied foreign minors. These are part of a specific legal process (temporary placement order by the public prosecutor) and social protection under the Social Childhood Assistance (ESA) whose mission is to put in place administrative, social and medical protection measures. The main pathologies encountered in these newly arrived children are infectious diseases (latent primary tuberculous infection, tuberculosis-disease, schistosomiasis, digestive parasitosis, hepatitis B). Many unaccompanied minors, from sub-Saharan Africa, experienced a traumatic journey through Libya (torture, physical abuse) and while crossing the Mediterranean (witnessing numerous drownings). Some of them have post-traumatic stress disorder upon arrival. A multi-disciplinary medical, psychological and social care, part of a coordinated care path, is necessary and represents a definite public health issue.
This chapter describes the elements that make up a comprehensive psychiatric‐mental health assessment of children and adolescents. This assessment can be used in primary care settings to help identify children and adolescents in need of mental health services. Key areas include history taking, physical examination process, risk, protective factors, teaching needs of the child or adolescent and family, and ways to communicate the assessment findings to the patient and family and, if appropriate, the school so that they are able to pursue appropriate treatment as needed. The chapter provides advanced practice registered nurses and other primary care practitioners (PCPs) in primary care and mental health settings with a way to systematically approach the assessment of the behavioral and mental health of their patients. It aims to assist PCPs with the knowledge and confidence to proceed with their evaluation of the child's history, behavior, complaints, school performance, social skills, family functioning, and available resources for care.
Outcome measurement in intercultural psychotherapy is complex and lags behind standards of outcome measurement in Western populations. This chapter presents recommendations, challenges, and pitfalls related to the choice of assessment tools measuring outcome in intercultural psychotherapy, whether for clinical evaluation or research. Item response theory (IRT) is presented as a promising method for testing measure’s and item’s intercultural validity and reliability. IRT-validated measures are presently mostly available for disability and quality of life. Finally, with a renewed focus on personal recovery in mental health, the chapter also introduces patient-generated outcome measures, focusing on empowerment, and documentation of patient perspectives, which are particularly important in intercultural treatment settings.
There are no valid and reliable cross-cultural instruments capable of measuring torture, trauma, and trauma-related symptoms associated with the DSM-III-R diagnosis of posttraumatic stress disorder (PTSD). Generating such standardized instruments for patients from non-Western cultures involves particular methodological challenges. This study describes the development and validation of three Indochinese versions of the Harvard Trauma Questionnaire (HTQ), a simple and reliable screening instrument that is well received by refugee patients and bicultural staff. It identifies for the first time trauma symptoms related to the Indochinese refugee experience that are associated with PTSD criteria. The HTQ's cultural sensitivity may make it useful for assessing other highly traumatized non-Western populations.
Unaccompanied asylum-seeking children (UASC) are known to be subjected to several potentially traumatic life events, risking more mental health problems than other populations of same age. In this study, we aimed to explore the prevalence of psychiatric morbidity at an early stage after arrival to the host country. We performed structured clinical interviews (CIDI) with 160 male UASC from different countries (Afghanistan, Somalia, Iran), after four months in Norway. Most of the participants had experienced life threatening events (82%), physical abuse (78%), or loss of a close relative (78%) in their former life. Altogether 41.9% of the participants fulfilled diagnostic criteria for a current psychiatric disorder. The most prevalent diagnosis was PTSD (30, 6%), followed by MDD (9, 4%), Agoraphobia (4, 4%) and GAD (3, 8%). Implications of this vulnerability call for more mental health resources in the early stages of the asylum process. Increased awareness of psychiatric morbidity in UASC may improve the prognosis, give more appropriate care, and ease the integration process on all levels of society.
The population of the Netherlands has become increasingly diverse in terms of ethnicity and religion, and anti-immigrant attitudes have become more apparent. At the same time, interest in issues linked to transcultural psychiatry has grown steadily. The purpose of this article is to describe the most important results in Dutch transcultural psychiatric research in the last decade and to discuss their relationship with relevant social and political developments in the Netherlands. All relevant PhD theses (N = 27) between 2000 and 2011 were selected. Screening of Dutch journals in the field of transcultural psychiatry and medical anthropology and a PubMed query yielded additional publications. Forensic and addiction psychiatry were excluded from this review. The results of the review indicate three main topics: (a) the prevalence of psychiatric disorders and their relation to migration issues as social defeat and ethnic density, showing considerable intra- and interethnic differences in predictors and prevalence rates, (b) the social position of refugees and asylum seekers, and its effect on mental health, showing especially high risk among asylum seekers, and (c) the patterns of health-seeking behaviour and use of mental health services, showing a differentiated picture among various migrant groups. Anthropological research brought additional knowledge on all the above topics. The overall conclusion is that transcultural psychiatric research in the Netherlands has made a giant leap since the turn of the century. The results are of international importance and invite redefinition of the relationship between migration and mental health, and reconsideration of its underlying mechanisms in multiethnic societies.
While clinician-administered symptom rating scales are the most commonly used outcome measures in pharmaceutical research,
error variance due to poor inter-rater reliability increases the risk of type II errors in multi-center clinical trials. Such
error variance could obscure true differences between active drug and placebo, or between two comparator compounds. Computer-administered
versions of symptom rating scales originally designed to be administered by trained clinicians offer a solution to this problem.
This paper reviews the empirical data on the reliability, validity and equivalence of computer-administered rating scales.
Computer-administered versions of clinician-administered scales are now available for the assessment of depression, anxiety,
obsessive-compulsive disorder, and social phobia. Validation studies support the reliability, validity and equivalence of
these scales. Patient reaction has been positive, with patients generally more honest with and often preferring the computer
for assessing sensitive areas such as suicide, alcohol or drug abuse, sexual behavior, or HIV related symptoms. Applications
using Interactive Voice Response (IVR) technology facilitate longitudinal monitoring of patients without requiring office
visits to collect data, increase the accessibility of information to the clinician, and the quality of patient care through
more informed decision making. When used in accordance with established ethical guidelines, computers offer a reliable, inexpensive,
accessible, and time-efficient means of assessing psychiatric symptoms.
The importance of health literacy has grown considerably among researchers, clinicians, patients, and policymakers. Better instruments and measurement strategies are needed. Our objective was to develop a new health literacy instrument using novel health information technology and modern psychometrics. We designed Health LiTT as a self-administered multimedia touchscreen test based on item response theory (IRT) principles. We enrolled a diverse group of 619 English-speaking, primary care patients in clinics for underserved patients. We tested three item types (prose, document, quantitative) that worked well together to reliably measure a single dimension of health literacy. The Health LiTT score meets psychometric standards (reliability of 0.90 or higher) for measurement of individual respondents in the low to middle range. Mean Health LiTT scores were associated with age, race/ethnicity, education, income, and prior computer use (p < .05). We created an IRT-calibrated item bank of 82 items. Standard setting needs to be performed to classify and map items onto the construct and to identify measurement gaps. We are incorporating Health LiTT into an existing online research management tool. This will enable administration of Health LiTT on the same touchscreen used for other patient-reported outcomes, as well as real-time scoring and reporting of health literacy scores.
Surveys of risk behaviors have been hobbled by their reliance on respondents to report accurately about engaging in behaviors
that are highly sensitive and may be illegal. An audio computer-assisted self-interviewing (audio-CASI) technology for measuring
those behaviors was tested with 1690 respondents in the 1995 National Survey of Adolescent Males. The respondents were randomly
assigned to answer questions using either audio-CASI or a more traditional self-administered questionnaire. Estimates of the
prevalence of male-male sex, injection drug use, and sexual contact with intravenous drug users were higher by factors of
3 or more when audio-CASI was used. Increased reporting was also found for several other risk behaviors.
The CIDI is a fully standardised diagnostic interview designed for assessing mental disorders based on the definitions and criteria of ICD-10 and DSM-III-R. Field trials with the CIDI have been conducted in 18 centres around the world, to test the feasibility and reliability of the CIDI in different cultures and settings, as well as to test the inter-rater agreement for the different types of questions used. Of 590 subjects interviewed across all sites and rated by an interviewer and observer, 575 were eligible for analysis. The CIDI was judged to be acceptable for most subjects and was appropriate for use in different kinds of settings. Many subjects fulfilled criteria for more than one diagnosis (lifetime and six-month). The most frequent lifetime disorders were generalised anxiety, major depression, tobacco use disorders, and agoraphobia. Percentage agreements for all diagnoses were above 90% and the kappa values were all highly significant. No significant numbers of diagnostic disconcordances were found with lifetime, six-month, and four-week time frames.
The original versions of the Harvard Trauma Questionnaire and Hopkins Symptoms Checklist-25 were written and subsequently validated in the Cambodian, Laotian, and Vietnamese languages. For use in a Dutch treatment center, with refugee patients mostly speaking other languages, additional translations were made. The objective of this study was examination of the psychometric properties of some of these new translations, i.e., the Arabic, Farsi, Serbo-Croatian, Russian, and English bilingual adaptations. It is concluded that the psychometric properties of both tests are adequate across those different cultures and are, in general, applicable to measure symptoms of depression, anxiety, and posttraumatic stress disorder.
Refugees experience multiple traumatic events and have significant associated health problems, but data about refugee trauma and health status are often conflicting and difficult to interpret.
To assess the characteristics of the literature on refugee trauma and health, to identify and evaluate instruments used to measure refugee trauma and health status, and to recommend improvements.
MEDLINE, PsychInfo, Health and PsychoSocial Instruments, CINAHL, and Cochrane Systematic Reviews (searched through OVID from the inception of each database to October 2001), and the New Mexico Refugee Project database.
Key terms and combination operators were applied to identify English-language publications evaluating measurement of refugee trauma and/or health status.
Information extracted for each article included author; year of publication; primary focus; type (empirical, review, or descriptive); and type/name and properties of instrument(s) included. Articles were excluded from further analyses if they were review or descriptive, were not primarily about refugee health status or trauma, or were only about infectious diseases. Instruments were then evaluated according to 5 criteria (purpose, construct definition, design, developmental process, reliability and validity) as described in the published literature.
Of 394 publications identified, 183 were included for further analyses of their characteristics; 91 (49.7%) included quantitative data but did not evaluate measurement properties of instruments used in refugee research, 78 (42.6%) reported on statistical relationships between measures (presuming validity), and 14 (7.7%) were only about statistical properties of instruments. In these 183 publications, 125 different instruments were used; of these, 12 were developed in refugee research. None of these instruments fully met all 5 evaluation criteria, 3 met 4 criteria, and 5 met only 1 of the criteria. Another 8 standard instruments were designed and developed in nonrefugee populations but adapted for use in refugee research; of these, 2 met all 5 criteria and 6 met 4 criteria.
The majority of articles about refugee trauma or health are either descriptive or include quantitative data from instruments that have limited or untested validity and reliability in refugees. Primary limitations to accurate measurement in refugee research are the lack of theoretical bases to instruments and inattention to using and reporting sound measurement principles.
In 1999 the UK received 4346 refugees from Kosovo.
To determine the prevalence of mental health problems in this group.
A sample of 842 adults was surveyed. All were asked to complete self-report questionnaires (translated into Kosovan Albanian). A subset of 120 participants were later interviewed in Albanian using the Clinician Administered PTSD (post-traumatic stress disorder) Scale and a depression interview.
The study yielded estimates of prevalence of PTSD and depression. Self-report measures appear to overestimate the prevalence of these disorders. Just under half of the group surveyed had a diagnosis of PTSD and less than one-fifth had a major depressive disorder.
These results may be taken as a sign of the resilience of many who survived this conflict but they also imply that there is still a substantial need for good health and social care in a significant proportion. Psychosocial interventions are likely to be an important part of the treatment programme.
The diagnostic process and treatment of victims of war and torture is associated with a number of difficulties. This article will provide an overview of three different approaches on how the new media may be integrated into the treatment of survivors of torture and war to face some of the challenges. Illiteracy is a common problem and makes it difficult to apply standardized psychological assessment procedures. Also, the majority of survivors of torture and war do not have access to any psychotherapeutic treatment due to geographical limitations or limitations concerning psychotherapeutic treatment capacity. Furthermore, chronic psychological disorders such as (complex) Posttraumatic Stress Disorder (PTSD) are often seen with comorbid chronic pain disorders, which present a therapeutic challenge. The Treatment Center for Torture Victims, Berlin, in cooperation with the University of Zurich, developed a number of approaches to address these challenges: 1) MultiCASI - to standardize the diagnostic process an audiovisual diagnostic tool was developed which allows illiterate individuals to answer standardized psychological questionnaires whithout the help of interpreters; 2) A virtual treatment center for posttraumatic stress disorder for traumatized patients in Iraq and other Arab speaking postconflict countries; 3) Utility of Biofeedback (BF) in chronic (somatoform) pain and in traumatized patients: to address the chronic pain syndrome presented by most survivors, a biofeedback supported cognitive-behavioral therapy approach was developed and successfully tested in a pilot study.
Mental health problems are prevalent in asylum seekers and refugees. Screening instruments may be effective tools for identifying
individuals with severe mental health problems, which will allow us to offer them further assessment and treatment. The aim
of this study was to evaluate the utility of screening instruments in asylum seekers. The Harvard Trauma Questionnaire (HTQ)
and the Hopkins Symptom Checklist (HSCL-25) were validated against the Composite International Diagnostic Interview (CIDI)
in a sample of 65 asylum seekers in Norway. In this sample, exposure to traumatic events was reported by 95 per cent of participants,
and the prevalence of any mental disorder was high (70 per cent). An apparently high agreement between the two screening instruments
and CIDI interviews concealed major differences between two subgroups (MENA and Somalia). Mental health problems were consistently
overestimated for the MENA group, and underestimated for the Somali group. The area of origin was significantly associated
with symptom reporting. The results of the screening instruments could not be interpreted in the same manner across the two
main groups in this study. Hence, our results did not unequivocally support the use of screening instruments to identify asylum
seekers in need of treatment.
• The Composite International Diagnostic Interview (CIDI), written at the request of the World Health Organization/US Alcohol, Drug Abuse, and Mental Health Administration Task Force on Psychiatric Assessment Instruments, combines questions from the Diagnostic Interview Schedule with questions designed to elicit Present State Examination items. It is fully structured to allow administration by lay interviewers and scoring of diagnoses by computer. A special Substance Abuse Module covers tobacco, alcohol, and other drug abuse in considerable detail, allowing the assessment of the quality and severity of dependence and its course. This article describes the design and development of the CIDI and the current field testing of a slightly reduced "core" version. The field test is being conducted in 19 centers around the world to assess the interviews' reliability and its acceptability to clinicians and the general populace in different cultures and to provide data on which to base revisions that may be found necessary. In addition, questions to assess International Classification of Diseases, ninth revision, and the revised DSM-III diagnoses are being written. If all goes well, the CIDI will allow investigators reliably to assess mental disorders according to the most widely accepted nomenclatures in many different populations and cultures.
Despite increasing numbers of unaccompanied refugee minors (UM) in Europe and heightened concerns for this group, research on their mental health has seldom included the factor “time since arrival.” As a result, our knowledge of the mental health statuses of UM at specific points in time and over periods in their resettlement trajectories in European host countries is limited. This study therefore examined the mental health of UM shortly after their arrival in Norway (n = 204) and Belgium (n = 103) through the use of self‐report questionnaires (HSCL‐37A, SLE, RATS, HTQ). High prevalence scores of anxiety, depression and posttraumatic stress disorder (PTSD) symptoms were found. In addition, particular associations were found with the number of traumatic events the UM reported. The results indicate that all UM have high support needs on arrival in the host country. Longitudinal studies following up patterns of continuity and change in their mental health during their trajectories in the host country are necessary.
This study evaluated the reliability and criterion validity of the Byumba Social Functioning Questionnaire (BSFQ), an instrument to measure social functioning in Rwanda. The instrument was locally composed in concordance with a well-described method for culture-specific and sex-specific function assessment. Respondents in a Northern Province of Rwanda (N = 393) were assessed with the BSFQ and a 19-item scale (SF-19) drawn from the Medical Outcomes Study 36-Item Short-Form (SF-36). The BSFQ's internal consistency was just acceptable for women but poor for men, while the SF-19 had good to excellent internal consisteny. BSFQ total scores showed a strong floor effect, while the SF-19 showed more variation in total score distribution. The BSFQ did not perform as well as we expected, and appears not to be suitable for measuring social functioning in the study context. This outcome seems to reflect the conceptualization of social functioning used in constructing the BSFQ. Implications for the development of culture-specific measures of functional status are discussed.
Abstract Preparing instruments ,for transcultural research is a difficult task. Researchers typically do not,publish their attempts to create equival- ent translation. The quality of the translation depends ,mostly on the translators’ ability to be consistent in identifying and correcting incompre- hensible, unacceptable, incomplete and irrelevant translated items. This paper presents a translation monitoring ,form to enhance ,the methodical preparation of instruments for transcultural use. Use of the form requires the systematic use of strategies advocated by previous translation and adap- tation researchers. A detailed example of use of the translation monitoring form with Nepali-speaking Bhutanese refugees illustrates the usefulness of the form as well as the difficulties of creating equivalent translation. Key words Bhutan • Nepali language • refugees • test adaptation • trans-
Previous research on political violence has shown an inverse relationship between overall exposure and psychological well-being. The aim of this study was to examine this relationship in more detail by exploring the impact of specific types of war-related events upon psychological well-being, as well as the role of social and political context in moderating these outcomes. The psychological well-being of 337 Bosnian adolescents living in two towns on opposite sides of the war was assessed using the Hopkins Symptom Checklist-25 (HSCL-25) and the Harvard Trauma Questionnaire (HTQ). Based on the combined symptom scores, and in-depth interviews regarding life history, war experiences, and subjective experience of psychological well-being a gender-matched sub-sample of 40 adolescents was selected and completed a 45-item trauma event scale. Results from the quantitative and qualitative analyses showed that the relationship between exposure, displacement and well-being varied significantly depending on the community in which the adolescents lived. Specific meanings given to different types of war events were important in moderating their effect. Living in a neglected, isolated and depressed community, worry about school performance, missing friends and family breakdown could have as significant an effect on well-being as exposure to war-related events. The findings demonstrate the need to take social context and meaning of events into account when examining the impact of war exposure on psychological well-being.
Unaccompanied asylum-seeking children (UASC) are considered at high risk for mental health problems, yet few studies focus on single ethnic populations. This study presents results from the largest Afghan UASC mental health survey in the UK. Specifically, the study aims to estimate the prevalence of emotional and behavioural problems and to investigate the associations of these problems with demographic variables, cumulative traumatic events, and care and migration variables. A census sample of 222 Afghan UASC was interviewed using validated self-report screening measures. Emotional and behavioural problems were screened using the Hopkins Symptoms Checklist 37A (HSCL-37A). Pre-migration stressful life events were screened using the Stressful Life Events Questionnaire. Administrative data on care and asylum were provided by the local authority social services and the UK Border Agency. Approximately one-third (31.4 %) scored above cut-offs for emotional and behavioural problems, 34.6 % for anxiety and 23.4 % for depression. Ordinary least squares regression indicated a significant dose-response relationship between total pre-migration traumatic events and distress as well as between increased time in the country and greater behavioural problems. Compound traumatic events in the pre-migration stages of forced migration have a deleterious association with UASC well-being. Increased time in country suggests a possible peer effect for these children. Consistent with other studies on refugee children, it should be stressed that the majority of UASC scored below suggested cut-offs, thus displaying a marked resilience despite the experience of adverse events.
This study concerned the mental health of Afghan unaccompanied asylum-seeking children in the United Kingdom (UK). Afghans are the largest group of children seeking asylum in the UK, yet evidence concerning their mental health is limited. This study presents an estimate of probable posttraumatic stress disorder (PTSD) within this group and describes its associations with the cumulative effect of premigration traumatic events, immigration/asylum status, and social care living arrangements. Male adolescents (N = 222) aged 13-18 years completed validated self-report screening measures for traumatic experiences and likely PTSD. One-third (34.3%) scored above a selected cutoff, suggesting that they are likely to have PTSD. A higher incidence of premigration traumatic events was associated with greater PTSD symptomatology. Children living in semi-independent care arrangements were more likely to report increased PTSD symptoms when compared to their peers in foster care. A substantial majority in this study did not score above the cutoff, raising the possibility of notable levels of resilience. Future research should consider approaching mental health issues from a resilience perspective to further the understanding of protective mechanisms for this at-risk population.
This article presents multicultural ways to advance knowledge of children's problems, to fashion conceptual and practical mental health tools, and to use these tools to help children. Diagnostically based scales and statistically derived syndromes are scored from parallel forms completed by population samples of parents, caregivers, teachers, and youths in many societies. The scores are incorporated into multicultural norms for evaluating individual children, as rated by different respondents in relation to relevant norms, such as norms for host societies where immigrant children reside and norms for their families' home societies. Syndrome structures have been supported in 44 societies. Certain age, gender, and SES effects are consistent across many societies. As reported in over 7000 publications from 85 societies and cultural groups, evidence-based assessment provides a common data language for clinicians, trainees, and researchers around the world.
There are no valid and reliable cross-cultural instruments capable of measuring torture, trauma, and trauma-related symptoms associated with the DSM-III-R diagnosis of posttraumatic stress disorder (PTSD). Generating such standardized instruments for patients from non-Western cultures involves particular methodological challenges. This study describes the development and validation of three Indochinese versions of the Harvard Trauma Questionnaire (HTQ), a simple and reliable screening instrument that is well received by refugee patients and bicultural staff. It identifies for the first time trauma symptoms related to the Indochinese refugee experience that are associated with PTSD criteria. The HTQ's cultural sensitivity may make it useful for assessing other highly traumatized non-Western populations.
The growth of cross-cultural psychiatry is now occurring at a time when psychiatry in general is emphasizing diagnostic clarity and the use of quantifiable and reliable methods of collecting clinical and research data. It is now imperative that cross-cultural psychiatry also examine its methods for developing instruments for use in cross-cultural research. This paper outlines a method for developing instruments designed in one culture for use in a second, and particular attention is given to cross-cultural validity or equivalence. Five types of equivalence are enumerated and defined: content, semantic, technical, criterion, and conceptual equivalence. These concepts are illustrated by examples from the authors' experience in research on internal migrants in Peru.
Research into the mental health of refugees has burgeoned in recent times, but there is a dearth of studies focusing specifically on the factors associated with psychiatric distress in asylum-seekers who have not been accorded residency status.
Forty consecutive asylum-seekers attending a community resource centre in Sydney, Australia, were interviewed using structured instruments and questionnaires.
Anxiety scores were associated with female gender, poverty, and conflict with immigration officials, while loneliness and boredom were linked with both anxiety and depression. Thirty subjects (79%) had experienced a traumatic event such as witnessing killings, being assaulted, or suffering torture and captivity, and 14 subjects (37%) met full criteria for PTSD. A diagnosis of PTSD was associated with greater exposure to pre-migration trauma, delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, racial discrimination, and loneliness and boredom.
Although based on correlational data derived from'a convenient' sample, our findings raise the possibility that current procedures for dealing with asylum-seekers may contribute to high levels of stress and psychiatric symptoms in those who have been previously traumatised.
The definition of case is a core issue in psychiatric epidemiology. Psychiatric symptom screening scales have been extensively used in population studies for many decades. Structured diagnostic interviews have become available during recent years to give exact diagnoses through carefully undertaken procedures. The aim of this article was to assess how well the Hopkins Symptom Checklist-25 (HSCL-25) predicted cases by the Composite International Diagnostic Interview (CIDI), and find the optimal cut-offs on the HSCL-25 for each diagnosis and gender. Characteristics of concordant and discordant cases were explored. In a Norwegian two-stage survey mental health problems were measured by the HSCL-25 and the CIDI. Only 46% of the present CIDI diagnoses were predicted by the HSCL-25. Comorbidity between CIDI diagnoses was found more than four times as often in the concordant cases (case agreed upon by both instruments) than in the discordant CIDI cases. Concordant cases had more depression and panic/generalized anxiety disorders. Neither the anxiety nor the depression subscales improved the prediction of anxiety or depression. The receiver operating characteristic (ROC) curves confirmed that the HSCL-25 gave best information about depression. Except for phobia it predicted best for men. Optimal HSCL-25 cut-off was 1.67 for men and 1.75 for women. Of the discordant HSCL-25 cases, one-third reported no symptoms in the CIDI, one-third reported symptoms in the CIDI anxiety module, and the rest had symptoms spread across the modules. With the exception of depression, the HSCL-25 was insufficient to select individuals for further investigation of diagnosis. The two instruments to a large extent identified different cases. Either the HSCL-25 is a very imperfect indicator of the chosen CIDI diagnoses, or the dimensions of mental illness measured by each of the instruments are different and clearly only partly overlapping.
The goal of this paper is to provide researchers who are not experts in psychometric theory with a concise guide to instrument selection, development and evaluation. Issues of context - factors related to the setting or population in which an instrument will be used - and psychometrics - the functioning of an instrument within a given context - are reviewed and discussed. Finally, four categories or types of instruments, and the psychometric analyses that are necessary for establishing the reliability and validity of each type, are described.
In a world with numerous refugees and increased concern for their well-being, governmental and non-governmental organisations are asking researchers for accurate estimates describing the extent of psychopathology in displaced populations. Although exact numbers are sought, the researcher soon learns
Worldwide, 300?000 children are currently used as child soldiers in armed conflicts. We interviewed 301 former child soldiers who had been abducted by the northern Ugandan rebellion movement Lord's Resistance Army. All the children were abducted at a young age (mean 12.9 years) and for a long time (mean 744 days). Almost all the children experienced several traumatic events (mean six events); 233 (77%) saw someone being killed, and 118 (39%) had to kill someone themselves. 71 children also filled in the impact of event scale--revised to assess their post-trauma stress reactions. 69 (97%) reported post-traumatic stress reactions of clinical importance. The death of a parent, especially of the mother, led to an important increase in score for avoidance symptoms (mother alive 16.4, mother not alive 21.6; p=0.04), with a high increase for girls (from 15.1 to 25.8), but almost no change for boys (from 17.7 to 17.4; p=0.02). Our findings shed light on the nature of severe trauma experienced by this group of children, and show a high rate of post-traumatic stress reactions.
This paper describes the effect of pre-migration and post-migration experiences on the mental health of a sample of 40 refugee children aged 8-16 who lived in London with at least one parent or a refugee relative. Children's post-traumatic stress disorder (PTSD) and depression symptoms were assessed with standardised self-report measures (Impact of Event Scale and Depression Self-Rating Scale for Children, respectively). Information regarding past and present experiences were gathered during an interview with parents. There was a significant correlation between the number of pre-migration traumas experienced by the families and the children's PTSD scores. There was also a significant correlation between the families' number of post-migration stresses and children's depression scores. Higher PTSD scores were significantly associated with the pre-migration experience of violent death of family members and the post-migration experience of an insecure asylum status. Higher depression scores were significantly associated with insecure asylum status and severe financial difficulties. The clinical implications of these findings are discussed.
The Hopkins Symptom Checklist depression scale (HSCL-D) and the Harvard Trauma Questionnaire (HTQ) have been used extensively in international studies, particularly among refugees and conflict-affected populations. Like many other screening measures, however, the HSCL-D and HTQ have not been subjected to extensive epidemiologic testing, particularly among communities not affected by war. The present study examined the psychometric properties of the HSCL-D and HTQ by comparing the measures with the Structured Clinical Interview for DSM-IV (SCID) among ethnic Cambodians living in Surin, Thailand, a community that was spared the long period of mass violence that affected Cambodia proper. The PTSD data of the HTQ were then contrasted with those obtained from a refugee clinic. The main finding was that in the Surin study, the screening measures showed greater agreement with the SCID in identifying noncases (negative prediction) than cases (positive prediction). In contrast, in the earlier clinic study, the HTQ showed high positive and moderately low negative prediction. The results support previous observations that clinical interviews such as the SCID may be more conservative in identifying cases. We raise the possibility, however, that structured interviews may perform differently across clinic and community populations. In particular, clinicians may be more accurate in identifying cases than noncases in highly symptomatic clinic populations, with the converse applying in low prevalence community populations. These issues warrant further investigation to specify more clearly the value of using the two approaches to case identification.
The objective of this study is to make comparisons of the severity of the psychological distress, behavioral problems and traumatic stress reactions, and experiences of unaccompanied refugee minors (URMs) with immigrant/refugee (I/R) and Dutch (native) adolescents with parental caregivers (N = 3273). Self-report questionnaires were administered. Most assessments took place at school. URMs consistently reported significantly higher scores for internalizing problems, traumatic stress reactions, and stressful life events than all other groups. Gender appears to play an important role in the native and I/R samples in reporting psychological distress, behavioral problems, and traumatic stress reactions. Older age was significantly related to higher scores only in the URM group. Natives scored higher on externalizing problems than the other groups. URMs reported to have experienced twice as many stressful life events than I/Rs and natives. URMs appear to be at significantly higher risk for the development of psychopathology than refugee adolescents living with a family member, immigrants, or Dutch adolescents.
The objective of this study is to provide preliminary psychometric properties of the Hopkins Symptom Checklist-37 (HSCL-37A) for refugee adolescents. The HSCL-37A is a modification of the well-known HSCL-25 and assesses symptoms of internalizing and externalizing problems that have been associated with reactions to trauma. Four independent heterogeneous samples (N=3890) of unaccompanied refugee minors, immigrants, and native Dutch and Belgian adolescents were assessed at school. The confirmative factor analyses, per language version, support the two-factor structure of internalizing and externalizing behavior. The total and subscales show good internal consistency and acceptable test-retest reliability in spite of the heterogeneous sample populations. The construct, content, and criterion validity of the HSCL-37A were also examined and found to be good. The findings of this study suggest that the HSCL-37A is a reliable and valid instrument to be used among culturally diverse refugee adolescents to assess emotional distress and maladaptive behaviors.
To investigate the level of posttraumatic stress and depressive symptoms, and background risk and protective factors that might increase or ameliorate this distress amongst unaccompanied asylum-seeking children and adolescents (UASC).
Cross-sectional survey carried out in London. Participants were 78 UASC aged 13-18 years, predominantly from the Balkans and Africa, compared with 35 accompanied refugee children. Measures included self-report questionnaires of war trauma, posttraumatic stress and depressive symptoms.
UASC had experienced high levels of losses and war trauma, and posttraumatic stress symptoms. Predictors of high posttraumatic symptoms included low-support living arrangements, female gender and trauma events, and increasing age only amongst the UASC. High depressive scores were associated with female gender, and region of origin amongst the UASC.
UASC might have less psychological distress if offered high-support living arrangements and general support as they approach the age of 18 years, but prospective studies are required to investigate the range of risk and protective factors.
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