ArticleLiterature Review

Preventive mental health interventions for refugee children and adolescents in high-income settings

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Abstract

The mental health of refugee children and adolescents is a multifaceted phenomenon that needs to be understood and addressed across multiple sectors that influence all potential determinants of health, including housing, education, economic opportunities, and the larger policy and political context including immigration. The current state of interventions to address mental health problems in refugee children is limited and even more so for prevention programmes. This Review describes interventions of note that are delivered to individuals as well as parenting and school interventions, and broader socioeconomic and cultural interventions. Few studies aim to assess impact across multiple domains of the refugee experience. The multidimensional and collective character of challenges facing refugee children and families calls for comprehensive psychosocial interventions through which healing the psychological wounds of war is complemented by restoring and supporting the social and physical environment so that it is one in which children and their families can thrive.

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... There is a well-documented need for more responsive promotion and prevention programming for young newcomers, especially for refugee youth in the context of mental health and healthy development (Eruyar et al., 2018;Fazel & Betancourt, 2018;Hansson et al., 2010;Hettich et al., 2020;Marshall et al., 2016). Of the small evidence base that exists, individual and group interventions that have most commonly been employed are creative expression (i.e., art, music, and drama) and cognitive behavioural principles, which aim to reduce trauma-related impairment and improve mental health and social-emotional functioning (Sullivan & Simonson, 2016;Tyrer & Fazel, 2014). ...
... Additionally, barriers prevent youth from accessing these types of services (Valibhoy et al., 2017;Wood & Newbold, 2012). Even less research has been devoted specifically to parenting and family interventions (see Fazel & Betancourt 2018), as well as teacher-led (e.g., Gormez et al., 2017) and peer-based health promotion interventions (e.g., Im & Rosenberg 2016), despite the benefits these types of supports could have in enhancing youths' mental health and healthy adjustment. ...
... Research has shown that positive and supportive relationships offer protective benefits for newcomer youth. These include successful adjustment, academic engagement, sense of belonging, emotional support, and a sense of safety, while also acting as a buffer against immigration stress and engagement in risk behaviour, and mitigating the effects of school violence (Fazel & Betancourt, 2018;Sanchez et al., 2019;Suárez-Orozco et al., 2009). The importance of connectedness and development of social networks has also been highlighted in a recent review of psychosocial interventions for adolescent refugee youth (Hettich et al., 2020). ...
Article
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Background There is a well-documented need for more responsive promotion and prevention programming for young immigrants and refugees in the context of mental health and healthy development. Incorporating the voice of newcomers in the development of promotion and prevention efforts could assist in producing culturally-relevant materials and improve program outcomes. Objective Our goal was to utilize youth voice to identify considerations for developing programming to support newcomer youths’ healthy development. Methods We employed mixed methods and analyzed data using concept mapping. A total of 37 newcomers between the ages of 14 and 22 participated in focus groups to share their ideas for creating programming that would focus on relationships and well-being. Relevant responses were collated, cleaned, and generated into unique statements, and then sorted individually by 26 youth into thematically similar categories. We used multidimensional scaling and hierarchal cluster analysis to produce a concept map. Results Six concepts, in rank order of importance, emerged as follows: create a space for sharing; discuss relational issues; teach strategies for adjusting to a new country; teach wellness skills; have feel-good activities; and plan for diversity. Conclusions Participants’ lived experience and their own attendance in programming at newcomer organizations assisted them in brainstorming what types of activities, topics, and skills would be helpful for other newcomer youth, as well as considerations for facilitators implementing such programming. Promotion and prevention efforts intended for newcomer youth may benefit by incorporating ideas from the concept map.
... This sleep-item has shown to be of importance in understanding PTSD symptoms in URMs in previous studies using the CATS [22]. The etiology of mental health in URMs is complex and needs to be understood and addressed across multiple sectors that could potentially influence their mental health [42]. Hence, several mechanisms may explain the differences in symptom load across studies, such as differences in the level of exposure, time since leaving country of origin, perceived social support, level of support accommodation provided in the host country and access to targeted intervention, as well as individual traits such as cultural competence and the larger policy and political context [12,19,42]. ...
... The etiology of mental health in URMs is complex and needs to be understood and addressed across multiple sectors that could potentially influence their mental health [42]. Hence, several mechanisms may explain the differences in symptom load across studies, such as differences in the level of exposure, time since leaving country of origin, perceived social support, level of support accommodation provided in the host country and access to targeted intervention, as well as individual traits such as cultural competence and the larger policy and political context [12,19,42]. ...
... Rights reserved. [42]. A systematic review shows for instance that supportive living arrangements are important to promote well-being and improve mental health for URMs [13], with one study demonstrating that lower social support from mentors increase the risk of prolonged symptoms of PTSD [44]. ...
Article
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Building knowledge on how child welfare services (CWS) should tailor services for unaccompanied refugee minors (URMs) is important. URMs and youth in foster care are high-risk groups taken care of by the CWS in Norway. Little is known on whether knowledge gained from youth in foster care can inform services for URMs, and if these groups are comparable in terms of experiences of potential traumatic events (PTEs) and post-traumatic stress disorder (PTSD) symptom load. Eighty-one URMs reported PTEs and PTSD-symptoms using an adapted version of the Child and Adolescent Trauma Screen (CATS). Responses were described and compared with a sample of 303 youth in foster care in linear regression models. We present relative risks (RR) and standardized mean differences (SMD) for the PTEs and the PTSD subscale and total score between the groups in forest plots. URMs had experienced a mean (standard deviation) of 6.4 (3.4) PTEs and 43.9% reported to have PTSD-symptoms at or above the clinical cut off. Compared to the foster youth, URMs reported more exposures of interpersonal violence outside of the family (RRs ranging from 66.4 [95%CI 18.1; 243.5) to 1.3 (1.0, 1.5)], and more PTSD-symptoms in the re-experiencing subscale [SMD = 0.3 (95% CI 0.1, 0.6)]. The frequency and types of PTEs and the PTSD-symptom load and profile among URMs and youth in foster care differed. Findings underscore the importance of qualified and targeted care for URMs, and that this care should differ to that of other high-risk groups in the CWS.
... The adjustment of children after adverse events can be influenced by the parent-child relationship (El-Khani et al., 2020;Fazel & Betancourt, 2018). Refugee and asylum seeker parents are at risk of developing stress-related symptoms, and mental health problems can undermine their parenting skills, the parent-child relationship, and family functioning (Sangalang et al., 2017;Van Ee et al., 2016). ...
... Moreover, these parents are often forced to leave their social support networks behind, causing feelings of loneliness and isolation (Stewart et al., 2015). A well-functioning parent-child relationship, family system, and social support system can play an important protective role in families' adjustment after hardship (Betancourt & Khan, 2008;El-Khani et al., 2020;Fazel & Betancourt, 2018). ...
... Asylum seeker families face several continuous stressors, such as uncertainty, concerning their asylum status and financial difficulties. Fazel and Betancourt (2018) stated that, as a result, it might be difficult to prioritize other concepts such as mental health. Although several participants found FAME useful, some added that FAME could not address these important continuous stressors, as the program does not offer any practical solutions. ...
Article
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This study evaluated the feasibility of Family Empowerment (FAME), a preventive multifamily program for asylum seeker families in the Netherlands. FAME aims to reinforce the parent–child relationship, family functioning, and social support. We used an uncontrolled pre‐test–post‐test design, embedded in a mixed‐methods approach. FAME was offered to 46 asylum seeker families, mostly originating from Eritrea, Armenia, or Syria. Twenty‐seven parents gave consent to participate in this study. Program integrity and evaluations of participating parents and trainers were assessed. Family functioning and parental symptoms of depression and anxiety were measured pre‐ and post‐FAME. Six participants completed all assessments. Most participants valued gathering with multiple families. Although FAME might coincide with decreases in anxiety and depression, the program had a limited impact on family functioning. Possibly, the aims of FAME did not align with some families’ current needs. Lessons learned and recommendations to further improve interventions for refugee families are discussed.
... It is likely that such alterations in family dynamics can exacerbate trauma symptoms. Generally, the refugee parenting experience is characterized by disruptions which can affect established roles (gender, parent-child roles), family structure and hierarchies (Fazel and Betancourt, 2018;Williams, 2010). ...
... As pointed out by Daud et al. (2008), parenting is not the sole aspect to consider, and evaluations of parenting in trauma-affected samples should not be reduced to judgements of whether the parent is a "good enough" parent. Being a parent who has been through life-threatening events is in itself threatening to the notion of family as a secure base (Daud et al., 2008), and dealing with one's own traumatic experiences and handling parenting responsibilities at the same time should be recognized as an extraordinary task (Fazel and Betancourt, 2018). In addition to past trauma, worries over family members in insecure conditions are a continuous stressor among Somali refugees (Betancourt et al., 2015). ...
... Longitudinal research is needed to establish causal pathways in trauma transmission and clarify risk and protective factors. The mental health of children cannot be isolated to one or several individual factors, but are linked to basic conditions of e.g., political status, economic status, access to education which constitute general determinants of health (Fazel and Betancourt, 2018). ...
Article
The rates of posttraumatic stress syndrome (PTSD) are high among refugee populations. At the same time, evidence is emerging of intergenerational transmission of psychopathology. The objective of this study was to examine the current knowledge on risk and protective factors for adverse mental health outcomes in the non-exposed offspring of trauma-affected refugees. A systematic search was undertaken from 1 January 1981 to 5 February 2021 (PubMed, Embase, PSYCInfo). Studies were included if they reported on families of trauma-exposed refugee parents and mental health outcomes in their non-exposed children. The search yielded 1415 results and twelve articles met inclusion criteria. The majority of studies emphasized the negative effects of parental mental health symptoms. There was substantial evidence of an association between parental PTSD and increased risk of psychological problems in offspring. Parenting style was identified as both a potential risk and protective factor. Risk/protective factors at the individual and family level were identified, but findings were inconclusive due to sample sizes and study designs. There is a need for evidence-based interventions aimed at improving child outcomes, especially by improving parental mental health and reinforcing parenting skills. Future research should aim to incorporate broader aspects of child development.
... Caregivers can play a central role in promoting resilience among children exposed to adversity (Masten & Palmer, 2019). Several effective parenting programs exist for child internalizing and externalizing problems (Kazdin et al., 2018;Sandler et al., 2014), and research is beginning to show the efficacy of these programs among refugee families (see reviews by Fazel & Betancourt, 2018;Perera et al., 2018). Furthermore, several parenting programs have been successfully implemented and evaluated in low-and middle-income countries (LMICs; see meta-analysis of eleven studies by McCoy et al., 2020), as well as within conflict zones (see meta-analysis of three studies by Toufaili, 2021), indicating that, while relatively rare, such programs can be delivered and evaluated effectively even in challenging settings. ...
... Historically high levels of displacement and its consequences on children's outcomes have led to recent calls for caregiving interventions to buffer the effects on child development (El-Khani et al., 2018;Fazel & Betancourt, 2018). However, little is known about the effectiveness of these programs across a range of outcomes and across the diverse settings and contexts in which displaced individuals reside. ...
Article
Full-text available
Globally, an estimated 79.5 million individuals have been displaced, nearly 40% of whom are children. Parenting interventions may have the potential to improve outcomes for displaced families. To investigate this, we conducted a systematic review to identify the types of caregiver or parenting interventions that have been evaluated among displaced families, to assess their efficacy across a range of contexts, and to describe their cultural and contextual adaptations. The review followed PRISMA guidelines. At stage one, all articles describing caregiver/parenting interventions for forcibly displaced families were included to provide a scoping review of the state of the literature. At stage two, only randomized controlled trials (RCTs) and quasi-experimental designs were included, allowing for quantitative analysis of program effects. A total of 30 articles (24 studies) were identified in stage one. 95.8% of these articles were published in the past 10 years. Of these, 14 articles (10 studies) used an RCT or quasi-experimental design to assess program efficacy or effectiveness. Relative to control groups, those assigned to caregiving programs showed significant, beneficial effects across the domains of parenting behaviors and attitudes, child psychosocial and developmental outcomes, and parent mental health. Cultural adaptations and recruitment and engagement strategies are described. The evidence base for caregiving programs for displaced families has expanded in recent years but remains limited. Caregiving/parenting programs show promise for reducing the negative effects of forced displacement on families, but future studies are needed to understand which programs show the greatest potential for scalability.
... As with any mental health intervention for children, it is important to involve refugee parents in their children's therapeutic processes and to listen to their points of view during the research development process (Yaylaci, 2018). The impact of family-level processes has, however, not been researched enough within the context of interventions for refugee children (Fazel & Betancourt, 2018). ...
... While the importance of involving refugee parents in their children's mental health interventions has been reiterated (Bosqui & Marshoud, 2018;Ehntholt & Yule, 2006;Fazel & Betancourt, 2018;Pacione et al., 2013), not many descriptions of refugee parental engagement can be found in art therapy case studies and research. Parents have been described as unavailable for meetings due to their survival predicament (de Freitas Girardi et al., 2020;Kalaf & Plante, 2019), language barriers and logistic difficulties due to the need for interpreters (Schottelkorb et al., 2012), and culturally-related perceptions of therapy (O'shea et al., 2000), such as experiencing it as too intrusive (Baraitser, 2014;Kalaf & Plante, 2019) or not as important as academic achievements. ...
Conference Paper
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"This paper seeks to explore the topic of art therapy interventions with refugee and asylum-seeking children and their parents, with a specific focus on how art therapists engage displaced parents in their child’s therapy process. Preliminary literature review findings, in preparation for a comprehensive scoping review, suggest that there is a research-practice gap on the topic of engaging refugee and asylum-seeking parents in their children’s art therapy processes. Flexible methods practiced in the field in the past 10 years, primarily funded and run by nongovernmental organizations (NGOs), are not necessarily reflected in the few research papers published about creative arts therapies interventions for refugee and asylum-seeking children. Out of 106 publications (including grey literature such as NGO manuals and reports, book chapters, case studies, and conference papers), a significant amount refers to creative arts therapies as part of multi-level and interdisciplinary interventions developed for refugees and asylum-seekers. Among these, most publications found are manuals and reports describing case vignettes or multi-level practice guidelines, rather than peer-reviewed publications about research. These literature review findings form the first stage of a larger research project which seeks to develop evidence-based guidelines regarding parent-child art therapy among refugees and asylum-seekers, using the first two phases of the Medical Research Council’s (MRC) recommendations for complex intervention development. In doing so, the research seeks to address the global need for evidence-based, culturally humble, and resilience-focused psychosocial support interventions for displaced populations."
... In the past few years, along with the significant increase in the number of refugees, seeking for effective ways to improve their health status and wellbeing has been accelerated. In this respect, many researchers have considered psychological health in ASCA from different aspects, especially its risk factors (5)(6)(7)(8). ...
... For instance, in the European countries, the prevalence of posttraumatic stress disorder (PTSD) among asylum seeking children and adolescents was reported between 20 and 84% (9). Similarly, several studies identified a high prevalence of other mental and psychological problems such as depression and anxiety in asylum seeking children and adolescents (5,10,11). ...
Article
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From 2015 to 2016, about 1. 3 million refugees arrived in Europe. Half of them were children under the age of 18. The combination of (specially forced) migration and adolescence increase the risk of psychological problems among refugees including asylum-seeking children and adolescents. Therefore, along with the significant increase in the number of refugees, investigating effective ways to improve their health status has grown. The planned project aims to improve self-care and self-development among asylum-seeking adolescents aged 15–18. With the long-term goal of improving wellbeing and quality of life, this multi-method study aims to develop a self-care and self-development intervention guidebook for asylum-seeking adolescents. The SC-SD4ASA project will focus on three main work packages: 1. assessment of needs and knowledge concerning self-care and self-development; 2. development of a guidebook to promote self-care and self-development for asylum-seeking adolescents; and 3. assessment of the guidebook fidelity, reliability, and validity. For the first work package, an intra-triangulation approach including three qualitative methods [in-depth interviews, focus group discussions and photographic means (photovoice)] will be used. The collected data will be analyzed using cross-cultural and multilingual approach to thematic analysis, known as meta-theme analysis. The results of the first stage will be utilized for developing the guidebook in the second (main) work packages. The guidebook fidelity will be assessed based on the National Institutes of Health Behavior Change Consortium fidelity framework in the last workplan. Empowering asylum-seeking adolescents with self-care /self-development skills can help them to sustain their wellbeing and better manage the challenges in their new situation. When successfully implemented, a guidebook will be developed to support all individuals involved in planning, managing, and promoting health among asylum-seeking adolescents that can be used for future self-care/self-development programs in practice.
... This is often due to the complexity and or intensity of the intended intervention imposing such a requirement to ensure fidelity of its implementation. This can prove as an impediment to reaching volatile or hard to reach areas with training and information in countries where conflict is active or where safety for non-nationals may be compromised [32]. ...
... Prior to the COVID-19 pandemic, there was already insufficient reach of evidencebased family skills programmes in humanitarian contexts [26,32]. Recognition was already taking shape in the family skills field that technology-based and online formats would be a key path to expanding engagement with families globally [39]. ...
Article
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A supportive environment with nurturing caregivers is essential for the healthy development of children. For children who have been exposed to extreme stress, such as humanitarian contexts, the need for strong, healthy, nurturing caregiver relationships may assume even greater importance. Much research has been building to position family skills interventions as a key tool in encouraging safe and supporting relationships between caregivers and children, thus preventing many problem behaviours and poor mental health. While there is substantial evidence of the effectiveness of family skills interventions in high-income and stable contexts, evidence of interventions that have been tested in humanitarian and challenging settings, such as contexts of refugee and displacement, are far fewer. Despite the role that family skills interventions can play in protecting children from current and future challenges, there is a significant lack of such interventions being utilised in humanitarian settings. We put forward seven likely reasons for this lack of uptake. Furthermore, the Strong Families programme, a UNODC family skills intervention, is presented as an example of an intervention that aims to bridge this gap of interventions that meet the need for humanitarian and contexts of extreme stress. More research is needed to unpack the content, delivery mechanisms and reach of family skills programmes to further aid programme developers in investing in efforts that might provide significant sustained impact for families in humanitarian contexts.
... A recent trial with Syrian refugees in Lebanon showed how combining TF-CBT and a parent-training program had much better effect on both parental and child health as compared to only TF-CBTor the control group [71]. These all suggest that reducing daily stress and providing integrated, multi-level or stepped-care approaches with different levels of support are important investments in the future health of refugee children [59,72]. ...
Article
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Almost half of the world’s forcibly displaced population are children, most commonly originating from Syria, Iraq and Afghanistan. Health disparities are well documented, especially for mental health, but not consistent across groups, time or context. Despite high exposure to trauma and stress, refugee children also show remarkable resilience. An ecological model of refugee health including both risk and resilience factors is therefore recommended. The model also includes the dynamic inter-relationship of past traumatic experiences, ongoing daily stressors and the disruptions of basic systems affecting both the individual and families as a whole, offering a framework to better understand the health disparities and appropriate interventions for refugee children.
... Multiple mental health interventions for refugee youth exist, including models implemented in schools and with peers, interventions that address services access and contextual factors, and some that focus on parenting (Fazel & Betancourt, 2018;Frounfelker et al., 2020). However, many interventions have not been tested using rigorous methods and do not necessarily employ evidence-based principles (Pfeiffer et al., 2018). ...
Article
Transnational migration of refugees is associated with poor mental health, particularly among children. We conducted a pilot trial of the Family Strengthening Intervention for Refugees (FSI-R), using a community-based participatory research (CBPR) approach to deliver a home-based intervention “for refugees by refugees” to improve family functioning and child mental health. N = 80 refugee families in the Greater Boston area participated in the study ( n = 40 Somali Bantu families; n = 40 Bhutanese families) with n = 41 families randomized to care-as-usual. Of the 39 families who received FSI-R, n = 36 caregivers and children completed qualitative exit interviews. We present findings from these interviews to identify the mechanisms through which a family-strengthening intervention for refugees can be acceptable, feasible, and effective at improving family functioning and children's mental health outcomes. Authors applied Grounded Theory to code interview transcripts and detailed field notes and used an iterative process to arrive at final codes, themes, and a theoretical framework. The greatest contributors to acceptability and feasibility included flexibility in scheduling intervention sessions, the interventionist being a community member, and improvements to family communication and time spent together. All of these factors were made possible by the CBPR approach. Our findings suggest that given the socio-political context within the U.S. and the economic challenges faced by refugee families, the successful implementation of such interventions hinges on culturally-grounding the intervention design process, drawing heavily on community input, and prioritizing community members as interventionists.
... Examples of stressful life events include exposure to violence, loss of loved ones, separation from parents, lack of access to basic necessities and discrimination (Fazel & Stein, 2002;Lustig et al., 2004). Stressful life events are a major risk factor for the development of mental health problems (Bean et al., 2007a;Fazel et al., 2012;Fazel & Betancourt, 2018;Heptinstall et al., 2004;Porter & Haslam, 2005;Reed et al., 2012). A recent meta-analysis showed high prevalence rates of post-traumatic stress disorder [PTSD] (23%), anxiety (16%) and depression (14%) among refugee and asylum-seeking children and adolescents (Blackmore et al., 2020). ...
Article
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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.
... Forced displacement of populations is a worldwide phenomenon which presents a pressing need for governments and aid organisations to respond to, especially in terms of healthcare and welfare (Fazel and Betancourt, 2018). The mental health of displaced populations has been an important area of clinical work and research to understand how the intersection of biological, psychological, social, and cultural factors explains individual responses which vary on a spectrum from successful integration to chronic mental illness. ...
... Schools are natural environments to provide psychosocial support for minors [10][11][12][13]. Nevertheless, targeted school-based interventions have been criticized for their inability to cover the full range of multi-faceted problems refugee youth face in their everyday life [14][15][16][17]. Multi-layered or triad intervention models may match more accurately than single interventions with the needs of adolescents exposed to traumatic war experiences and refugee-related stress [18][19][20]. ...
Article
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Background Schools are natural environments in which to enhance young people’s social and emotional skills, mental health, and contact between diverse groups, including students from refugee and immigrant backgrounds. A layered or tiered provision of services is recommended as it can be effective to meet the needs of war-affected adolescents who variably show mental health problems (such as posttraumatic stress disorder (PTSD)). The current protocol describes the study design for a multi-layered intervention model. The study will test the effectiveness of two interventions: a teacher-training intervention In-Service Teacher Training (INSETT) combined with targeted cognitive-behavioral treatment-based Teaching Recovery Techniques (TRT) and a classroom-focused preventive intervention Peer Integration and Enhancement Resources (PIER). We analyze, first, whether the interventions are effective in decreasing psychological distress and increasing positive resources, i.e., prosocial behavior and resilience among refugee and immigrant students. Second, we analyze which student-, school-, and parent-related factors mediate the possible beneficial changes. Third, we look at which groups the interventions are most beneficial to. Methods A three-arm cluster RCT with parallel assignment, with a 1:1:1 allocation ratio, is applied in 16 schools that agreed to participate in the Refugees Well School interventions and effectiveness study. Schools were randomized to three conditions of two active interventions and a waiting list control condition. Students, their parents, and teachers in intervention and control schools participated in the study at baseline before the interventions, after the interventions, and at 6 to 12 months after the interventions. The primary effectiveness criterion variables are psychological distress (SDQ) symptoms, resilience (CYRM-12), and prosocial behavior (SDQ). Discussion The current study presents a recommended universal approach of layered interventions aiming to reduce psychological distress and increase resilience among refugee and immigrant students. A combination of promotive, preventive, and targeted interventions may offer a holistic, ecological intervention package for schools to better address the needs of the whole group. Trial registration ISRCTN ISRCTN64245549 . Retrospectively registered on 10 June 2020
... In the past, it was already found difficult to reach caregivers, in humanitarian contexts, with evidence-based family skills programmes [89][90][91], despite their significant needs. As part of our secondary objective, we compared the effect of the Strong Families programme on different ethnicities, namely in families from Iran and those who have migrated from Afghanistan to Iran in the past. ...
Article
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Caregivers have a key role in protecting children’s wellbeing, and, with appropriate skills, can prevent a multitude of negative social outcomes, particularly in challenged or humanitarian settings. Accordingly, the Strong Families programme was designed as a light touch family skills programme, with a focus of supporting caregiving during stressful situations. To evaluate the short-term impact of the Strong Families programme, we performed a time-convenience, randomized, controlled trial in Iran. A total of 292 families (63% from Iranian decent, 39% from Afghan decent, and 1% other), with children aged eight to twelve years, were recruited through ten centers in Iran and allocated to an intervention (n = 199) or waitlist/control group (n = 93). The two groups did not differ demographically at baseline. We assessed families prospectively, through three scales, PAFAS (parenting and family adjustment scales), SDQ (strengths and difficulties questionnaire), and CYRM-R (child and youth resilience measure). Caregivers in the intervention group improved (highly) statistically significantly on all but one PAFAS subscales (parental consistency, coercive parenting, positive encouragement, parental adjustment, family relationships, and parental teamwork), which was not noted in the waitlist group. On the SDQ, there were (highly) significant positive changes in scores in the intervention group on all sub-scales and the “total difficulty scale“, whereas the waitlist/control group also improved on three (prosocial, conduct problems, and hyperactivity) of the five SDQ subscales. Children originating from Afghanistan improved significantly on the overall resilience scale of the CYRM-R in the intervention group, but not in the waitlist/control group. Overall, all our stratified results of the different scales reflect an accentuated improvement in families with higher levels of problems at baseline. Our comparative results indicated a strong alignment of the strong families programme with its intended short-term impact, per its logical frame on parenting practices and family management skills, children behaviour, caregivers and children mental health, and capacity to cope with stress. We postulate that the potential nudging or diffusion of knowledge (cross-contamination between intervention and waitlist/control group) at the community level could explain improvements in the waitlist/control group on some indicators, however, further research on this is recommend.
... Therefore, at the same time that adolescent refugees are going through the turbulent childhood-to-adulthood phase of life, they are likely to also be shouldering the burden of traumatic and stressful experiences from before they fled, during their migration, and after their arrival in the host country (O'Donnell and Roberts 2015;Given-Wilson et al. 2016;Garcia and Birman 2020). Experiences such as interpersonal violence, loss of loved ones, and abuse during their migration have been vastly reported (Fazel et al. 2012;Fazel et al. 2014, Fazel andBetancourt 2017). Not only must young refugees overcome the implications of these difficulties while simultaneously adjusting to new cultures and languages, they must also contend with multiple stressors, such as worries about their loved ones left behind in their countries of origin, fears of being sent back, social isolation, and bureaucratic difficulties such as the asylum-seeking process itself (Fazel et al. 2012;Given-Wilson et al. 2016;Silove et al. 2017;Juang et al. 2018). ...
Article
In this cross-sectional study, we explored the association of salutogenic variables— resilience and quality of life (QOL)—with posttraumatic stress (PTS) and depressive symptoms of 55 refugees who came to Germany as minors from various disputed Middle East and Africa countries. Results revealed that 53 per cent of participants showedaclinicallyrelevantlevelofPTS,and32percentscoredintheclinicalrange for depression.Levels of resilienceandQOLweremoderate.Regressionmodelsrevealed that resilience was the only significant variable associated with PTS over and above traumatic events and demographic variables. Pre-migration traumatic events and QOL were found to be significant variables associated with depression. life was found to mediate the relation between resilience and depression. Pre- and peri-traumatic events were not associated with resilience or QOL. Post-migration stressors were negatively associated with resilience and QOL. These findings suggest that the impact of forced migration on the young adults’ adjustment should be investigated not only in terms of psychological symptoms, but also in terms of resilience and QOL. In addition, therapeutic interventions should focus not only on diminishing psychological difficulties, but also in helping theseyoungrefugees increase, build, and maintain resilience and QOL. Keywords: refugees, PTS, depression, resilience, quality of life Introduction
... There is limited work on adapted interventions for resettled refugee and immigrant populations (Ballard, Wieling, & Forgatch, 2018;Fazel & Betancourt, 2018;Sim, Bowes, Maignant, Magber, & Gardner, 2021;Slobodin & de Jong, 2015), but several approaches have been proposed as part of the adaptation process for parenting programs delivered among other diverse populations. Approaches to adapting evidence-based programs for new cultural or ethnic groups vary in both the framework used to guide the adaptations and adaptation process and the extent of the adaptations that are made (Baumann et al., 2015;Kumpfer et al., 2017;Mejia, Calam, & Sanders, 2017); however, there are some similarities across approaches (Mejia et al., 2017). ...
Article
Social workers can promote resiliency among refugee families by referring them to evidence-based programs to reduce the stressors of resettlement. The purpose of this study was to complete a structured adaptation process with the SafeCare® program for implementation in a refugee resettlement community. Participants included 21 members of an adaptation team made up of administrators, supervisors, and family service providers from three community agencies and community health workers. Quantitative findings suggested that content, process, and literacy-related adaptations were necessary to ensure cultural relevance of program materials. Qualitative feedback suggested the adaptation approach was a meaningful process that engaged community members and resulted in an acceptable and feasible curriculum for delivery in the refugee resettlement community, which will be further tested in a forthcoming implementation trial. The multi-pronged, community-engaged approach to SafeCare adaptation is presented as a potential framework for other programs that could benefit refugee children and their families.
... Heightened levels of post-traumatic stress disorder (PTSD), anxiety, and depression are common in migrant and refugee children and adolescents [7][8][9]. These disorders are even more pronounced among refugee adolescents, as they carry multiple burdens of traumatic war and migration experiences [10]. ...
Article
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Background: Schools are considered natural environments in which to enhance students' social-emotional skills and mental health in general, but they can be especially important for students with refugee and immigrant backgrounds. The current study tested the effectiveness of two school-based interventions in enhancing the mental health and wellbeing of adolescents of native, refugee, and immigrant backgrounds. It further analyzed the role of age, gender, daily stressors, and discrimination in affecting the interventions' effectiveness. Methods: A three-arm cluster RCT with parallel assignment was applied among the 16 schools. Schools were randomized to three conditions of two active interventions and a waiting-list control condition. Students (n = 1974) filled in an online questionnaire at baseline before the interventions, after the interventions, and at follow-up an average of 9 months after the interventions. The effectiveness criteria were internalizing and externalizing problems, resilience, and prosocial behavior. Results: Interventions were generally not effective in decreasing mental health problems and increasing psychosocial resources. The expected positive intervention effects were dependent on students' age and gender and exposure to socioeconomic daily stressors. Conclusion: Interventions enhancing teacher awareness and peer relationships at school should be carefully tailored according to the strengths and vulnerabilities of participating students, especially their daily stress exposure, but also age and gender.
... [7,13,14] When a refugee or asylum-seeking child arrives at a new school, there are a number of important factors to consider when it comes to the mental health of the child concerned. These can be grouped into three main areas: understanding the past experience of the child and their family -both with regards to their previous education as well as their other experiences; determining and addressing their needs through a thorough and appropriate assessment [15,16] and finally working out how best to welcome them into the school community so that they feel a sense of belonging in their new environment. [2] We will discuss each of these areas in turn. ...
Chapter
The interface between mental health and schools has become a major focus of policy and practice. School attendance is important and impacts a range of outcomes, from academic performance, to children and young people's mental health. In this book, experts from the education and mental health sectors have collaborated to produce a practical guide to mental health and attendance at school that will be of interest to both researchers and practitioners across this inter-disciplinary field. The book covers topics such as the importance of a multidisciplinary approach, terminology and socio-political considerations, school attendance problems in relation to emotional, behavioural and neurodevelopmental disorders, special educational needs, school factors and influences and attendance of vulnerable children. Its aim is to offer practical advice and key information to practitioners from both clinical and educational sectors so that they can work more effectively to enable children and young people to thrive.
... Such studies identified that war-related pre-migration traumas and stress are associated with a higher prevalence of posttraumatic stress disorder (PTSD) and depression in refugee children (Rousseau & Gagnon, 2020;Hadfield, Ostrowski, & Ungar, 2017;Bronstein & Montgomery, 2011). Pre-migration traumatic experiences can interact with post-migration stressors, such as low socioeconomic status and poverty, to heighten the mental health vulnerabilities of immigrant children and youth (Fazel & Betancourt, 2018). These findings demonstrate that childhood experiences of war can have longterm mental health consequences that may outlast the period of resettlement and well into adulthood, unless the resettlement process is accompanied by the provision of specialized child mental health services and supports. ...
Article
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African immigrant children experience some of the poorest mental health outcomes in Canada, yet limited research has systematically mental health determinants among this growing demographic. Our participatory action research project (PAR) explored, from the perspectives of parents, the factors influencing the mental health of African immigrant children in Alberta, Canada. The project utilized an intersectionality theoretical lens to collect and analyze data from a sample of 81 African immigrant parents who participated in nine conversation cafés and five focus groups. This PAR approach provided an ideal structure to engage parents and generate knowledge on the factors influencing their children’s mental health. Parents identified racial discrimination, limited mental health awareness, limited access to mental health supports, changing family dynamics, parental absenteeism, and unresolved pre-migration trauma as factors influencing their children’s mental health. These factors were perceived as contributing to children’s experiences of material deprivation, social problems, and emotional difficulties. Our findings suggest that interventions to overcome these factors and enhance the mental health of African immigrant children must target transformation of the family, community, and cultural systems within which their lives are embedded, as well as the policies and institutions that produce and reproduce child mental health vulnerabilities.
... In Ontario, the location of the present study, there is an underutilization of both acute care and outpatient mental health treatment services for immigrant youth relative to long-term residents (Saunders et al., 2018). Explanations for this underutilization include stigma around mental illness, linguistic obstacles, and lack of cultural sensitivity of service providers (Fazel & Betancourt, 2018;Hodes, 2010). As a result, youth who could benefit from but do not use mental health services are left to address troubling experiences as they interact with challenges that arise in their daily lives (Soberano et al., 2018). ...
Article
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The purpose of the study was to identify barriers to accessing mental health services by migrant youth in a middle-sized central Canadian city. We asked participants, “What would stop you from talking to someone about mental health stress?”. We interviewed 30 youth aged 16 to 22 who migrated from 10 different countries and lived in Canada for an average of 29 months. The data was analyzed using group concept mapping. The participants identified five concepts: fear of being misunderstood or ignored, desire for confidentiality, lack of trust and understanding, talking about it as not appropriate, and fear of the disclosure process. We compare these results with the literature.
... For instance, strong peer supports and connections with adults have been shown to relate to positive emotional health among children in the general population whose parents had severe depression [69]. School-based interventions for refugee children's emotional health have mostly focused on addressing specific conditions such as depression or anxiety rather than universally promoting emotional health through enhancing school contexts such as teacher-student support or climate [70]. Another example of an initiative that leveraged multisectoral collaboration and intervention across various social contexts including schools, healthcare, housing, and employment is the 'Welcoming Cities' initiative in regions within the United States [71]. ...
Article
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Background Refugee children face numerous challenges associated with pre-migration trauma and post-migration adaptation. Much research pertaining to refugee children’s well-being focuses on psychiatric symptoms. Relatively few studies have examined how social context factors—such as perceptions of peer belonging, and support from adults at home and at school—contribute to the emotional health of refugee children. Informed by social–ecological theories emphasizing dynamic interactions between the contexts in which children develop, we examined associations between social context factors and emotional health in refugee children. Methods Data were drawn from a population-based data linkage in British Columbia, Canada. The analytic sample included 682 grade 4 students (Mage 9.2 years; 46.3% female) with a refugee background who responded to the Middle Years Development Instrument (MDI) during the 2010/2011–2016/2017 school years. The MDI is a self-report survey of children’s social and emotional competencies and social context factors completed at school. Regression analyses were used to examine associations of social context factors (school climate, supportive adults at school and at home, and peer belonging) with indicators of emotional health (life satisfaction, self-concept, optimism, and sadness). Refugee generation status (first/second) was considered through stratification and testing of interactions with social context factors. Results Perceived supportive school climate, support from adults in school and at home, and peer belonging were each independently associated with better emotional health. Results were similar for first- and second-generation children. Conclusion Taken together, results suggest a unique role of the school context to refugee children’s emotional health. School-based programming that promotes positive school climate can be considered as an important approach to support newcomer refugee children and their families.
... We have often worked with families who sometimes face daily affairs that take up time, such as compulsory registrations, having to bring children to school, and meetings with institutions such as school, the council for refugees, and immigration and naturalization services. As a result of the aforementioned issues, it can be difficult to prioritize research, recruitment and inclusion (Fazel & Betancourt, 2018). ...
Article
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Researchers who are aiming to conduct high quality mental health research in resettled refugee populations are likely to experience multiple challenges in their work. To our knowledge, there is no overview of these challenges and their implications for the quality of research from a researchers’ perspective. We conducted a systematic literature search to further complete the overview of challenges. Lastly, we placed the findings of the thematic analysis and the literature search in a conceptual framework derived from the social ecological model of Bronfenbrenner. Our findings indicate that common research challenges, such as high drop-out rate or low treatment fidelity, must be understood in the light of multiple levels such as the individual, microsystem, mesosystem, exosystem and macrosystem level. This will help future researchers to increase the understanding of the complex interplay of factors that play a role when facing challenges in their work and to create possibilities for improvement.
... Such findings fit well with the construct of belonging as both an individual feeling of familiarity and a resource that resists forms of social exclusion (Antonsich, 2010). Though we know little about how belonging may be linked with broader wellbeing for adult refugees, among children and youth belonging has been found to prevent mental illness and promote resilience, wellbeing and achievement (Fazel & Betancourt, 2018). ...
Article
This interpretive qualitative study investigated relationships and relational processes that facilitate social connection in a group therapy intervention for Syrian refugees in Jordan. Drawing from grounded theory analytical methods, a core relational process, sharing stories eases pain, was derived from the data to explain how group members came to develop close, caring relationships, which led to other psychosocial benefits. The findings fill a gap in the group treatment literature specific to refugees and advance understanding of group relationships as an active ingredient promoting change. Findings also suggest that group-based treatment may be uniquely suited to address some of the broader social-relational consequences of conflict and forced migration.
... The number of forcibly displaced people worldwide reached 79.5 million at the end of 2019, with about half of them being children (UNHCR, 2020). Eventhough many conflict-affected children manifest resilience (Sleijpen, Haagen, Mooren, & Kleber, 2016), evidence suggests an increased risk of developing poor mental health outcomes (Fazel & Betancourt, 2018). However, studies focusing on adolescent refugees are limited. ...
Article
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Background Refugee youth experience hardships associated with exposure to trauma in their homelands and during and after displacement, which results in higher rates of common mental disorders. The World Health Organization (WHO) developed Problem Management Plus (PM+), a non-specialist-delivered brief psychological intervention, for individuals who have faced adversity. PM+ comprises problem-solving, stress management, behavioural activation and strengthening social support. However, it does not include an emotional processing component, which is indicated in trauma-exposed populations. Objective This pilot randomized controlled trial (RCT) aims to evaluate the feasibility and acceptability of PM+, adapted to Syrian, Eritrean and Iraqi refugee youth residing in the Netherlands, with and without a newly developed Emotional Processing (EP) Module. Methods Refugee youth (N = 90) between 16 and 25 years of age will be randomized into PM+ with care-as-usual (CAU), (n = 30), PM+ with Emotional Processing (PM+EP) with CAU (n = 30) or CAU only (n = 30). Inclusion criteria are self-reported psychological distress (Kessler Psychological Distress Scale; K10 > 15) and impaired daily functioning (WHO Disability Assessment Schedule; WHODAS 2.0 > 16). Participants will be assessed at baseline, one-week post-intervention and three-month follow-up. The main outcome is the feasibility and acceptability of the adapted PM+ and PM+EP. The secondary outcomes are self-reported psychological distress, functional impairment, post-traumatic stress disorder (PTSD) symptom severity and diagnosis, social support, and self-identified problems. The pilot RCT will be succeeded by a process evaluation including trial participants, participants’ significant others, helpers, and mental health professionals (n = 20) to evaluate their experiences with the PM+ and PM+EP programmes. Results and Conclusion This is the first study that evaluates the feasibility of PM+ for this age range with an emotional processing module integrated. The results may inform larger RCTs and implementation of PM+ interventions among refugee youth. Trial Registration Registered to Dutch Trial Registry, NL8750, on 3 July 2020. Medical Ethical Committee of the Amsterdam University Medical Centre, location Vrije Universiteit Medical Centre, Protocol ID: 2020.224, 1 July 2020.
... S evere traumatic experiences of torture and war have ramifications across generations. 1 Children whose parents have suffered severely traumatizing experiences are a vulnerable group 2 and may be at increased risk of developing mental health issues. 3 Torture and cumulative exposure to traumatic events are consistent predictors of post-traumatic stress disorder (PTSD) and depression. 4 Poor mental health among refugees postresettlement may also be associated with pre-displacement sociodemographic factors, such as gender, education and pre-flight socioeconomic status (SES). ...
Article
Background Young refugees and descendants of refugees have different preconditions for learning than their peers without refugee background. Children growing up in families where parents have suffered torture and war trauma may represent a particularly vulnerable group. This study investigates whether children of torture survivors living in Denmark achieved different test scores throughout primary and secondary school compared to children of non-traumatized parents. Methods Using data from a national school test programme, tests from Grades 2–8 were compared for children whose parents had been treated for torture and war trauma as to their peers. Referral to specialized rehabilitation clinics was used to identify the traumatized parent group. The mean score difference was estimated using multilevel linear regression, and outcomes were measured within groups of parental region of origin to allow for region-specific effects. The odds of missing a test were also estimated with multilevel logistic regression. Results The study included 854 467 children [median age (interquartile range) =12 (3.3)] of which 7809 were children of the trauma-exposed parents. The analysis revealed that children of torture survivors achieved test scores between −6% (95% CI: −0.13, 0.00) and −38% (95% CI: −0.44, −0.32) of a standard deviation compared to children of non-traumatized parents, adjusted for the main effect of region of origin. They were also more likely to miss a test [OR=4.95 (95% CI: 4.30, 5.71)]. Conclusions The findings indicate that risk factors for poorer school performance cluster in children of traumatized refugee parents, and reveal the possible adverse educational effects of trauma across generations.
... Policy-makers urgently need to address the appalling circumstances UYRs have to deal with, particularly in Greece and Italy. Next to tackling these material stressors, adequate social support and care is needed in order to mitigate the negative impact of SLEs and prevent the development of psychiatric conditions such as posttraumatic stress disorder (Fazel & Betancourt, 2018). Particularly, policies and the broader public need to promote inclusive practices and fight racism and discrimination. ...
Article
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Previous research has shown the drastic impact of daily stressors on the mental health of unaccompanied young refugees (UYRs). This longitudinal study contributes to existing literature by distinguishing different kinds of daily stressors and examining their impact over time, in relation to stressful life events, legal status, and contact with family. We recruited N = 189 UYRs from diverse backgrounds in Greece, Italy, and Belgium, and conducted two additional waves of interviews, accompanying them for approximately 2 years on their migratory and settlement trajectories throughout Europe. Data were analyzed via growth curve modeling. Results showed that both material and social stressors have a long-term negative effect on anxiety and depression symptoms, while stressful life events only have a significant effect in the beginning of UYRs' trajectories. Having long-term documents and contact with family alleviate symptoms of depression. We discuss how these findings relate to previous research and what they imply for policy-makers and practitioners in the field. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... Thus, relational therapies could potentially have even greater impact in conditions like those faced by the Syrian child refugees in our sample. Indeed, social isolation, disruption of community ties, and the loss of social capital and relational networks can all augment self-perceived vulnerability, allowing traumatic memories to be reactivated and symptoms produced (Fazel & Betancourt, 2018). Accordingly, we may conclude that prevalently clinically-informed and symptoms-oriented interventions cannot sufficiently address the underlying conditions that maintain and-most probably-will continue to increase, children's vulnerability. ...
Article
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The ongoing war in Syria has led to the displacement of 12 million people since 2011, with minors representing 40% of all refugees. Syrian children living in refugee camps are at risk of developing a wide range of mental health problems, given their previous and ongoing exposure to episodes of violence, disruption of family ties, and discontinuous access to education. In this study, we drew on the salutogenic paradigm to investigate whether, and to what extent, high/low levels of resilience were associated with other indicators of mental health and post-traumatic response in Syrian children living in refugee camps. The sample was composed of 311 Syrian children living in Jordanian refugee camps as a consequence of the war in Syria. We administered quantitative self-report measures to assess participants' exposure to trauma, individual levels of resilience, and mental health, performing discriminant analysis to examine the association between resilience and trauma/ mental health. Syrian children living in Jordanian refugee camps reported intense exposure to traumatic events. The linear discriminant equation supported adoption of the function [Wilk's Lambda (Λ = 0.827)]: lower levels of resilience were associated with trauma symptoms (re-experiencing, avoidance, and hyperarousal) and emotional problems, while higher levels of resilience were associated with pro-social behaviours. The findings of the present study suggest that resilience acts as a protective factor buffering children from the consequences of trauma and challenging life conditions. We discuss the implications for interventions designed to promote the wellbeing and mental health of children living in refugee camps.
... Prior to the COVID-19 pandemic, there were already insufficient opportunities to reach caregivers in humanitarian contexts with evidence-based family skills programmes [32,60]. This is particularly alarming given the aforementioned significant needs of families in these contexts [25]. ...
Article
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Child psychosocial recovery interventions in humanitarian contexts often overlook the significant effect that caregivers can have on improving children’s future trajectory. We enhanced the well-established, evidenced-based child trauma recovery programme Teaching Recovery Techniques (TRT) intervention with parenting sessions, i.e., TRT + Parenting (TRT + P), which aims to improve parent mental health and their ability to support their children’s mental health. We describe the findings of a three-arm randomised controlled trial comparing enhanced TRT + P vs. TRT and waitlist. The primary aim was to test if children in the enhanced arm of the programme show improved child and caregiver mental health. We recruited 119 Syrian refugee children and one of their caregivers in Beqaa Valley in Lebanon. They were randomised to the TRT, TRT + P, or waitlist control group. Data were collected at baseline and 2 weeks and 12 weeks post intervention. Training of facilitators was via remote training from the United Kingdom. Results showed a highly consistent pattern, with children in the enhanced TRT + P group showing the greatest levels of improvement in behavioural and emotional difficulties compared to children in the TRT or waitlist control groups. Caregivers in the TRT + P group also reported significant reductions in depression, anxiety, and stress. Findings indicate that the addition of the evidence-based parenting skills components has the potential to enhance the effects of interventions designed to improve children’s mental health in contexts of trauma, conflict, and displacement. Implications for COVID-19 remote learning are also discussed.
Article
Children make up over half of the world's migrants and refugees and face a multitude of traumatic experiences prior to, during, and following migration. Here, we focus on migrant children emigrating from Mexico and Central America to the United States and review trauma related to migration, as well as its implications for the mental health of migrant and refugee children. We then draw upon the early adversity literature to highlight potential behavioral and neurobiological sequalae of migration‐related trauma exposure, focusing on attachment, emotion regulation, and fear learning and extinction as transdiagnostic mechanisms underlying the development of internalizing and externalizing symptomatology following early‐life adversity. This review underscores the need for interdisciplinary efforts to both mitigate the effects of trauma faced by migrant and refugee youth emigrating from Mexico and Central America and, of primary importance, to prevent child exposure to trauma in the context of migration. Thus, we conclude by outlining policy recommendations aimed at improving the mental health of migrant and refugee youth.
Article
Globally, individuals and communities that are marginalized based on their identities are at heightened risk for exposure to traumatic stress and socioeconomic hardship. Marginalization and disproportionate risk for many types of adversities correspond with disparities in physical health, mental health, and overall well-being. Together, the 12 empirical studies, one systematic review, and commentary in this special issue of the Journal of Traumatic Stress highlight the impact of discrimination and disproportionate adversity among groups marginalized based on race, ethnicity, nativity, caste, gender identity, sexual orientation, economic status, and medical status. Although most studies in this issue focus on the United States, the articles that focus on disparities and risk factors in India, El Salvador, Uganda, and Burundi provides a multicontinent global perspective. The global perspective, including the impact of the global pandemic, invites further examination of how disproportionate exposure to traumatic stress and adversity are associated with inequitable burden and health disparities worldwide. This special issue further highlights the developmental and multigenerational burden of systemic marginalization by including studies of children, young adults, adults, and parent-child dyads. Pathways for change and intervention are illustrated through a liberatory consciousness perspective, with one study utilizing liberatory media skills (e.g., positive media images and messages) to mitigate the adverse effects of trauma exposure on at-risk young adults of color. Worldwide, research on the effects of trauma, stress, and adversities must examine contextual factors (e.g., economic hardship), marginalization (e.g., discrimination, identity factors), and the differential impact on health among individuals and communities.
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Background Schools are considered as natural environments to enhance students’ social-emotional skills in general and mental health and affiliation among students with refugee and immigrant background. A layered or tiered provision of services are recommended as they can be effective to meet the needs of war-affected adolescents’ who variably show posttraumatic stress disorder (PTSD). The current study tests the effectiveness of multi-layered interventions integrating targeted cognitive-behavioral treatment-based TRT (Teaching Recovery Techniques), a class-room focused preventive intervention PIER (Peer Integration and Enhancement Resources), and a whole school psychoeducative teacher-led intervention INSETT (In Service Teacher Training) in enhancing the wellbeing of children in their school environments. We analyze first, whether the interventions are effective in decreasing symptoms of PTSD and psychological distress and increasing positive resources i.e. prosocial behavior and resilience among refugees and immigrant students. Second, we analyze which student-, school- and parent-related factors mediate the possible beneficial changes, and third, we look at which groups benefit the interventions most. Methods A three-arm cluster RCT with parallel assignment, with approximately 1:1 allocation ratio, is applied among 16 schools that agreed to participate in the Refugees Well School interventions and effectiveness study. Schools were randomized to three conditions of two active interventions and a waiting-list control condition. Students, their parents, and teachers in intervention and control schools participate at baseline before the interventions, after the interventions, and at 6 to 12 months after the interventions. The primary effectiveness criterion variables are psychological distress (SDQ) symptoms, resilience (CYRM-12), executive functioning (AEFI) and prosocial behavior (SDQ). PTSD (CRIES-8) symptoms are used as outcome variable in one of the interventions (TRT). Discussion The current study provides a recommended universal approach of layered interventions aiming to reduce psychological distress and increase resilience among migrated students. Combination of promotive, preventive and targeted interventions may offer a holistic, ecological intervention package for schools to better address the needs of the whole group. Trial registration ISRCTN, identifier: ISRCTN64245549. Registered 10. June 2020. Retrospectively registered, http://www.isrctn.com/ISRCTN64245549
Article
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Background Children who have been forcibly displaced are likely to experience psychosocial challenges given they may be dealing with past trauma and challenges of adapting to their new environment. Effective psychosocial interventions are needed to promote psychosocial wellbeing. Literature identifies the ages of 6–12 years (middle childhood), as key to addressing psychosocial development. To date, systematic reviews identifying effective psychosocial interventions for children have focused on adolescents. Aim We conducted a systematic review and meta-analysis to: 1) identify psychosocial interventions conducted in middle childhood with forcibly displaced children; 2) summarize the characteristics of the included interventions; 3) identify the methodological quality of the studies; and 4) identify effectiveness of the interventions. Method A comprehensive literature search was conducted across four databases and supplementary literature. Study design was classified according to the National Health and Medical Research Council Hierarchy of Evidence. Methodological quality was assessed using the QualSyst appraisal checklist. Intervention approaches were classified into activity codes using the ‘Who is Where When doing What’ (4Ws) tool. Intervention effects were explored through meta-analysis. Results Nineteen studies with 2386 children met the eligibility criteria. A total of 19 intervention approaches were identified. The interventions found to be most promising were Narrative Exposure Therapy for children and adolescents (KidNET), Cognitive Behavioural Therapy, Child-Centred Play Therapy, Eye Movement Desensitization and Reprocessing, and creative interventions. Unstructured play or education alone did not produce a beneficial intervention effect. Conclusions Middle childhood presents a unique opportunity to address psychosocial wellbeing with forcibly displaced children. While psychological-based activities in this review demonstrated effectiveness for symptom reduction, future intervention options should expand to include strengths- and resilience-based. Further research evaluating the effectiveness of psychosocial intervention for forcibly displaced children is required using randomised control designs, greater sample sizes, and longitudinal data.
Article
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Approximately half of the world's displaced population are children and a significant proportion of these are unaccompanied asylum-seeking children (UASC). UASC are the most vulnerable of all refugee populations. Up to 90% of UASC have been subjected to exploitation, including trafficking or being drafted into military groups. Having survived the perils of flight, UASC are confronted with continued challenges, including the uncertainties regarding their residential rights in host counties. Unsurprisingly, the prevalence of mental health problems is higher amongst UASC than in any other refugee group. Yet, Mental Health and Psychosocial Support (MHPSS) appears to neither reach nor engage UASC. This begs for re-examination of what and how MHPSS is offered. Despite high levels of adversity, UASC often have considerable resilience, and make remarkable recoveries. However, literature exploring their resources or their own views of what helps or hinders recovery is scarce. In this narrative review, we explore individual and systemic factors promoting recovery in UASC. We consider theoretical understanding of resilience, emerging data and user perspectives. From these we deduct four areas of resilience in UASC: Individual factors - prosocial behaviour, problem-solving skills; Lifetime relationships - positive early family relationships, connection with family and country of origin, positive peer and adult relationships in host country; Acculturation - integration of own and new culture, positive relationships with prosocial institutions; Care arrangements - supported but less restrictive living arrangements. We suggest, MHPSS may need to focus on enhancing social networks, including connectedness with positive relationships in the home-country, life-history work with a focus on resource-building experiences in addition to trauma, and promoting integration of old and new cultural values. We also conclude that despite growing data, there is a gap in both eliciting user perspectives and understanding adaptive resources, especially those emerging during early development and within their cultural setting. Supplementary information: The online version contains supplementary material available at 10.1007/s40653-021-00385-7.
Article
Research indicates that refugee and asylum seeker children and young people often require specialised psychological support. Competencies have been established as helpful in guiding the training, education and ongoing professional development of practitioners working in specialised areas. To date there has been no comprehensive review of the literature concerning practitioner competencies for working with refugee or asylum seeker children and young people. This scoping review therefore aimed to synthesise all literature regarding practitioner competencies that are considered important for working in the area of mental health with refugee and asylum seeker children and young people. Literature was sourced from PsycINFO, Scopus, and PubMed. Studies were included if they: a) were published in peer-reviewed journals, b) were published in English, c) were published in the last 25 years, d) collected primary data, e) related to children and/or young people (defined as aged under 25) with refugee or asylum seeker backgrounds, and f) discussed practitioner competencies (in relation to refugee or asylum seeker children or young people). Nine articles met criteria and a deductive thematic analysis identified six key competencies: 1) knowledge of the complexity of needs of refugees; 2) use of holistic approaches; 3) ability to work in co-ordination with others in the child's network; 4) ability to build therapeutic relationships; 5) seeking feedback; and 6) cultural competency. Further empirical research that directly aims to identify practitioner competencies, from both the practitioner and client perspective, will support the challenging work done by practitioners working with refugee and asylum seeker children and young people.
Article
Nearly 5.6 million Syrian refugees have been displaced by the country's civil war, of which roughly half are children. A digital analysis of features in children's drawings potentially represents a rapid, cost-effective, and non-invasive method for collecting information about children's mental health. Using data collected from free drawings and self-portraits from 2480 Syrian refugee children in Jordan across two distinct datasets, we use LASSO machine-learning techniques to understand the relationship between psychological trauma among refugee children and digitally coded features of their drawings. We find that children's drawing features retained using LASSO are consistent with historical correlations found between specific drawing features and psychological distress in clinical settings. We then use drawing features within LASSO to predict exposure to violence and refugee integration into host countries, with findings consistent with anticipated associations. Results serve as a proof-of-concept for the potential use of children's drawings as a diagnostic tool in human crisis settings.
Chapter
By the end of 2019, the United Nations High Commissioner for Refugees (UNHCR) reported over 80 million displaced persons worldwide: 50% being children and youth below the age of 18 (2020). Of those displaced persons, 20.4 million fall under UNHCR’s mandate, which protects individuals who have well-founded fears of being persecuted in their country of origin. UNHCR refugees are eligible for permanent resettlement. When resettled, children and youth are quickly transitioned into schools where educators and school communities have the potential to stabilize their lives, provide them with safe spaces, and offer them rich learning opportunities. Pre-service and in-service teacher professional development, however, does not adequately address the psychosocial and social-emotional needs of refugee newcomers who have experienced mass violence. Creating spaces that support students’ sense of safety and belongingness in the school and classroom will support mental health and well-being. When war-affected students feel safe and a sense of belonging in their schools and classrooms, they are more likely to voluntarily share details of their lived experiences during pre-, trans-, and post-migration. This chapter discusses an educator’s role when faced with a student’s trauma story.KeywordsTrauma storyTrauma-informed teaching practicesWar-affected refugeesSLIFE
Article
Background: Children born to migrant parents have higher rates of language difficulties, intellectual disability and autism. This study explores the relationship between migration, ethnicity and reasons for early years referrals to community paediatrics in a diverse multi-cultural population in a city in south west England. Methods: Observational retrospective study from a community paediatric service serving a multi-cultural urban population from June 2012 to February 2016. We tested associations of ethnicity and parental birth origin with reason for referral (developmental or non-developmental) for children under 5 years old and estimated crude rate ratios for referrals using population census data. Results: Data were available for 514 children (52% white or mixed race, 16% Asian, 21% African diaspora, and 11.5% Somali); 53% had two UK-born parents while 22% had two migrant (non-UK-born) parents. Referrals were for developmental reasons in 307 (60%) including 86 for possible autism. Parental birth origin and ethnicity were associated with reason for referral (p < 0.001). Children from African diaspora, Asian or Somali backgrounds had more than twice the rate (rate ratio [RR] 2.37, 95% CI 1.88-2.99, p < 0.001) of developmental referrals compared with white or mixed-race children. Children of Somali or African diaspora ethnicity were, respectively, six-times (RR 5.99, 95% CI 3.24-10.8, p < 0.001) and four times (RR 4.23, 95% CI 2.44-7.29, p < 0.001) more likely to be referred for possible autism spectrum than their white or mixed-race peers. Developmental referral as a proportion of all referrals was twice as high among children with one migrant parent (20.4%) and three times as high among children with two migrant parents (29.5%), compared with children whose parents were both UK-born (10.7%). Conclusions: This study supports the importance of ethnicity and parental migration as factors in young children experiencing developmental difficulties, especially concerns about social communication or autism.
Article
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Background: An unprecedented number of people around the world are experiencing forced displacement due to natural or man-made events. More than 50% of refugees worldwide are children or adolescents. In addition to the challenges of settling in a new country, many have witnessed or experienced traumatic events. Therefore, refugee children and adolescents are at risk of developing mental health problems such as post-traumatic stress disorder, and require appropriate and effective support within communities. Objectives: To assess the effectiveness and acceptability of community-based interventions (RCTs only) in comparison with controls (no treatment, waiting list, alternative treatment) for preventing and treating mental health problems (major depression, anxiety, post-traumatic stress disorder, psychological distress) and improving mental health in refugee children and adolescents in high-income countries. Search methods: Databases searches included the Cochrane Common Mental Disorders Controlled Trials Register (all available years), CENTRAL/CDSR (2021, Issue 2), Ovid MEDLINE, Embase, six other databases, and two trials registries to 21 February 2021. We checked reference lists of included study reports. SELECTION CRITERIA: Studies of any design were eligible as long as they included child or adolescent refugees and evaluated a community-based mental health intervention in a high-income country. At a second stage, we selected randomised controlled trials. Data collection and analysis: For randomised controlled trials, we extracted data relating to the study and participant characteristics, and outcome data relating to the results of the trial. For studies using other evaluation methods, we extracted data relating to the study and participant characteristics. W derived evidence on the efficacy and availability of interventions from the randomised controlled trials only. Data were synthesised narratively. Main results: We screened 5005 records and sought full-text manuscripts of 62 relevant records. Three randomised controlled trials were included in this review. Key concerns in the risk of bias assessments included a lack of clarity about the randomisation process, potential for bias is outcome measurement, and risk of bias in the selection of results. Primary outcomes There was no evidence of an effect of community-based interventions when compared with a waiting list for symptoms of post-traumatic stress (mean difference (MD) -1.46, 95% confidence interval (CI) -6.78 to 3.86: 1 study; low-certainty evidence), symptoms of depression (MD 0.26, 95% CI -2.15 to 2.67: 1 study; low-certainty evidence), and psychological distress (MD -10.5, 95% CI -47.94 to 26.94; 1 study; very low-certainty evidence). There were no data on adverse events. Secondary outcomes Three trials reported on short-term changes in child behaviour, using different measures, and found no evidence of an effect of the intervention versus a waiting list (low to very low certainty). None of the trials reported on quality of life or well-being, participation and functioning, or participant satisfaction. Authors' conclusions: There is insufficient evidence to determine the efficacy and acceptability of community-based mental health interventions for refugee children and adolescents.
Many migrant children experience abuse and neglect in their home country, abuse during their migration journey, and cultural dislocation in their final destination. It has been well documented that adverse childhood experiences (ACEs) such as those experienced by migrant children can lead to long-term physical and psychological negative effects including the development of complex trauma (C-PTSD). Using a composite of similar cases treated by the author, Maria, a Mexican refugee, is presented in order to explore treatment options for refugee children and the challenges involved in treating this population. We demonstrate how Trauma Systems Therapy for Refugees (TST-R) can be used to treat C-PTSD in migrant children. We also discuss using art therapy, role-playing, psychodynamic psychotherapy, narrative exposure therapy and psychoeducation in an environment that takes into account the cultural background of the child’s country of origin how to approach the time limited treatment that is sometimes necessary when working with refugees.
Article
The COVID-19 pandemic has greatly impacted the lives of many around the world, particularly refugee and immigrant communities. In the United States, millions of children and youth had to quickly shift from in-person to remote learning, encountering new challenges and uncertainties in their overall educational experiences. This study explored some of the impacts of the COVID-19 pandemic on the educational, socialization, and mental and emotional health and wellbeing of Rohingya refugee youth from Myanmar resettled in the United States. Through in-depth qualitative interviews with 15 Rohingya refugees ages 12-17, we found that Rohingya youth’s experiences with COVID-19 pandemic presented both challenges and opportunities. The challenges included unavailability of personal space to conduct school work, difficulties adjusting to online school due to computer literacy levels, and familial responsibilities that often conflicted with their schooling, as well as feelings of boredom and sadness that consequently impacted their emotional and mental health state. Youth also noted opportunities such as spending more time with their parents who were unable to work due to the pandemic as well as feeling helpful in acting as caregivers to their siblings and in working alongside their parents. Implications for policymakers and educators are also discussed.
Article
Objective: The objective of this review was to identify, critically appraise, and synthesize qualitative evidence on the experiences of nurses providing care within various health care delivery environments to involuntary migrant women who are experiencing pregnancy, birth or postpartum. Introduction: Nurses are central to providing care to populations experiencing inequities. These populations include forcibly displaced, pregnant and/or mothering women who have migrated involuntarily. Most of these women are ethnically diverse and often experience poverty and low literacy. This review is focused on the experiences of nurses providing care to these women. Inclusion criteria: The authors of this review considered qualitative, peer-reviewed studies published in academic journals between January 2000 and January 2021. Studies and study abstracts published in English that examined nurses providing care to involuntary migrant maternal women were included. Methods: Information sources that were systematically searched for this review included: CINAHL (EBSCO), PsycINFO (EBSCO), and MEDLINE (EBSCO). Final searches were conducted in January 2021 using language within database thesauruses such as CINAHL headings and MeSH terms as well as keywords related to qualitative inquires on experiences of nurses caring for involuntary migrant maternal women. An intersectionality lens was applied within all review methods. Study selection was conducted by two reviewers screening titles and abstracts that aligned with the inclusion criteria. The review followed the JBI approach for critical appraisal, data extraction, and data synthesis. Results: Twenty-three qualitative studies were included in this review. Qualitative methodologies within these studies included case study, ethnography, interpretive descriptive, and grounded theory. Nine studies considered the sex of participating nurses and three studies considered participant history of migration. One hundred and fifteen verbatim findings were pooled into four categories and aggregated into the following two synthesized findings: i) Nurses integrate cultural and linguistic diversity within practice; and, ii) Nurses assess for inequities resulting from forced migration on maternal women. Study quality was rated as moderate on ConQual scoring where dependability was rated as moderate and credibility was rated as high. Conclusions: Key implications are made within nursing education programming, nursing practice, and policy analysis. In the realm of nursing education, integration of migrant status as a health determinant will enhance nurses' skills in assessing migrant status and understanding how varying statuses contribute to barriers among involuntary migrant women accessing health services. Providing ongoing education to nurses centered on trauma and violence-informed practice is recommended. With regard to nursing practice, review findings revealed the need for creative solutions to overcome language barriers. Innovative approaches for nurses working across language barriers in acute and community health contexts when interpreter services are not available needs further exploration and protocol integration. Examination of clinical care pathways is needed for inclusion of involuntary migrant women, and exploring assessment strategies targeting how migrant status contributes to limited health service accessibility. For policy, organizations need to build policies that promote examination of migrant status and its health impacts among involuntary migrant maternal women exposed to migration-related trauma and violence to support nurses in their care provision. Systematic review registration number: PROSPERO CRD42019137922.
Article
Objective To explore the experiences of how Syrian refugee youth resettled in Canada negotiate and facilitate a sense of belonging within their school environment. Method Semi-structured interviews in English were conducted with nine Syrian refugee youths aged 16 to 18. The content of the interviews was analysed through Interpretive Phenomenological Analysis. Results Participants identified a variety of factors which helped them or became hurdles for within this process. Three themes of language proficiency, shared experiences, and school environment were described. Overall, it was apparent that schools with robust policies, such as having trained teachers and language support programmes, were important in facilitating belonging. Peers who were from the same sociocultural background or were migrants themselves often were highlighted as important individuals as they acted as cultural brokers. Conclusion Syrian refugee youth within this study actively found ways to facilitate belonging within their school environments, even if there was a lack of structural support in the forms of inadequate language programmes or poor school policies. This study’s findings also iterate that Syrian refugee youth are active agents in their environments, as they engage in various opportunities to socialize, integrate, and thrive in their new environments.
Chapter
Children are more vulnerable than adults but have greater adaptive potential. They need thinking about in the context of their families and communities even if separated from them. Effects of adversity vary according to the developmental stage at which they occur, and subsequent development can also be compromised. Key developmental stages are considered, attending to what harms can be sustained, and what may be protective. Post-migration factors affecting outcome are also reviewed, including poor housing, poverty, bullying, racism, isolation, and prolonged uncertainty. Intervention requires building a relationship and a network of support, and possibly sequential episodes of care with incremental and ‘portable’ gains: meeting basic needs first by attending to accommodation, safety, links with schools and language skills. Age-appropriate explanations are essential. Some specific interventions are reviewed. The chapter concludes by revisiting the need for support and protection, and understanding developmental needs and family dynamics. This can promote healthy development and reduce intergenerational transmission of trauma.
Article
This study reviewed the literature on family-based mental health interventions for refugees across migration contexts and settings to identify types of interventions and intervention components, implementation approaches and to assess effectiveness. The review used a systematic approach, and ten intervention studies were retained for analysis. The findings identified three primary types of family-based mental health interventions used with diverse refugee communities in settings in the Global North and South-parenting groups, multiple family groups and home visiting interventions. Findings indicated that non-specialized or peer providers were frequently utilized to deliver the interventions though additional details on the workforce and workforce development strategies are needed to better understand how to sustain and support such providers. The findings suggest that family-based mental health interventions are potentially effective for improving a range of child and caregiver mental health outcomes and improving family processes and functioning among refugee families. However, the empirical evidence is quite limited to date, with a need for additional rigorous studies, especially with refugee families in humanitarian settings, to further build the evidence base.
Article
Importance: Refugee children and adolescents are at increased risk of mental health difficulties, but little is known about how the characteristics of the neighborhood in which they resettle may affect vulnerability and resilience. Objective: To test whether neighborhood socioeconomic disadvantage is associated with risk of psychiatric disorders among refugee children and adolescents and examine whether the association differs by sex, age at arrival, and family structure. Design, setting, and participants: This quasi-experimental register-based cohort study included refugees in Denmark aged 0 to 16 years at the time of resettlement from 1986 to 1998. A refugee dispersal policy implemented during those years assigned housing to refugee families in neighborhoods with varying degrees of socioeconomic disadvantage in a quasi-random (ie, arbitrary) manner conditional on refugee characteristics observed by placement officers. Cox proportional hazard models were used to examine the association between neighborhood disadvantage and risk of psychiatric disorders, adjusting for relevant baseline covariates. Exposures: A neighborhood disadvantage index combining information on levels of income, education, unemployment, and welfare assistance in the refugees' initial quasi-randomly assigned neighborhood. Main outcomes and measures: First-time inpatient or outpatient diagnosis of a psychiatric disorder before age 30 years. Results: Median (IQR) baseline age in the sample of 18 709 refugee children and adolescents was 7.9 (4.7-11.7) years; 8781 participants (46.9%) were female and 9928 (53.1%) were male. During a median (IQR) follow-up period of 16.1 (10.2-20.8) years, 1448 refugees (7.7%) were diagnosed with a psychiatric disorder (incidence rate, 51.2 per 10 000 person-years). An increase of 1 SD in neighborhood disadvantage was associated with an 11% increase in the hazard of a psychiatric disorders (hazard ratio [HR], 1.11; 95% CI, 1.03-1.21). This association did not differ between male and female individuals, refugees who arrived at different ages, or those from single- vs dual-parent households. In secondary analyses using prescribed psychiatric medication as the outcome, a similar association with neighborhood disadvantage was found (HR, 1.08; 95% CI, 1.03-1.14). Conclusions and relevance: In this cohort study, neighborhood disadvantage was associated with an increase in risk of psychiatric disorders. The results suggest that placement of refugee families in advantaged neighborhoods and efforts to enhance the neighborhood context in disadvantaged areas may improve mental health among refugee children and adolescents.
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Pre- and post-migration stressors can put resettled refugee children at risk of poor mental health outcomes. The Family Strengthening Intervention for Refugees (FSI-R) is a peer-delivered preventative home visiting program for resettled refugees that aims to draw upon families’ strengths to foster improved family communication, positive parenting, and caregiver-child relationships, with the ultimate goal of reducing children’s risk of mental health problems. Using an explanatory sequential mixed methods design, this study draws upon qualitative interviews with caregivers (n = 19) and children (n = 17) who participated in a pilot study of the FSI-R intervention in New England, as well as interventionists (n = 4), to unpack quantitative findings on mental health and family functioning from a randomized pilot study (n = 80 families). Most patterns observed in the quantitative data as published in the pilot trial were triangulated by qualitative data. Bhutanese caregivers and children noted that children were less shy or scared to speak up after participating in the FSI-R. Somali Bantu families spoke less about child mental health and underscored feasibility challenges like language barriers between caregivers and children. Interventionists suggested that families with higher levels of education were more open to implementing behavior change. In both groups, families appreciated the intervention and found it to be feasible and acceptable, but also desired additional help in addressing broader family and community needs such as jobs and literacy programs.
Article
Background: Unaccompanied refugee minors (URMs) are a population at risk of mental health problems and a population with whom the therapeutic alliance can be difficult to set up. The therapeutic alliance's quality can impact the result and effectiveness of psychotherapeutic interventions. The aim of the present study was to gather URMs' points of view about mental health services and mental health professionals (MHP) in the host country. A summary of interviews conducted with URMs will allow a better understanding of their perception and expectations. Methods: Seven databases were searched with English and French keywords. In the end, nine studies were selected. Results: The review of the interviews shows that URMs do not have a clear perception of MHP - it seems difficult for them to trust MHP, but also to understand the value of sharing past painful experiences to reduce current symptoms. They can have a negative perception of mental health and consider that this is not a priority. URMs prefer to focus on day-to-day problems, do activity-based interventions and do group sessions to value social interactions. Conclusions: Clinical and methodological implications are discussed. The development of an instrument to evaluate therapeutic care for URMs could be interesting for future research and for clinicians.
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Background: Torture survivors face multiple problems, including psychological difficulties, whether they are refugees or remain in the country where they were tortured. Provision of rehabilitation varies not only with the needs of survivors and resources available, but also with service models, service provider preferences and the local and country context. Despite increasing efforts in research on effectiveness of psychological interventions with torture survivors, results are inconclusive. Methods: We undertook a Cochrane systematic review of psychological, social and welfare provision, with meta-analysis to best estimate efficacy. The process raised conceptual, methodological and ethical issues of relevance to the wider field. Findings: We searched very widely, but rejected hundreds of papers which recommended treatment without providing evidence. We found nine randomised controlled trials, from developed and under-resourced settings. All conceptualised survivors' problems in psychiatric terms, using outcomes of post-traumatic stress symptoms, distress, and quality of life, by self-report, with or without translation or unstandardised interpretation, and with little mention of cultural or language issues. None used social or welfare interventions. Four related studies used narrative exposure therapy (NET) in a brief form, and without ensuring a safe setting as recommended. Five used mixed methods, including exposure, cognitive behavioural therapy, and eye movement desensitisation. Combined, the studies showed no immediate improvement in PTSD, distress, or quality of life; at six months follow-up, a minority showed some improvement in PTSD and distress, although participants remained severely affected. Conclusions: While applauding researchers' commitment in running these trials, we raise ethical issues about exposure in particular, and about the effects of shortcomings in methodology, particularly around assessment using unfamiliar cultural frameworks and language, and the lack of concern about dropout which may indicate harm. The issues addressed aid interpretation of existing research, and guide clinical practice as well as future studies evaluating its effectiveness.
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Children and adolescents are a vulnerable group to develop post-traumatic stress symptoms after natural or man-made disasters. In the light of increasing numbers of refugees under the age of 18 years worldwide, there is a significant need for effective treatments. This meta-analytic review investigates specific psychosocial treatments for children and adolescents after man-made and natural disasters. In a systematic literature search using MEDLINE, EMBASE and PsycINFO, as well as hand-searching existing reviews and contacting professional associations, 36 studies were identified. Random- and mixed-effects models were applied to test for average effect sizes and moderating variables. Overall, treatments showed high effect sizes in pre-post comparisons (Hedges' g = 1.34) and medium effect sizes as compared with control conditions (Hedges' g = 0.43). Treatments investigated by at least two studies were cognitive-behavioural therapy (CBT), eye movement desensitization and reprocessing (EMDR), narrative exposure therapy for children (KIDNET) and classroom-based interventions, which showed similar effect sizes. However, studies were very heterogenic with regard to their outcomes. Effects were moderated by type of profession (higher level of training leading to higher effect sizes). A number of effective psychosocial treatments for child and adolescent survivors of disasters exist. CBT, EMDR, KIDNET and classroom-based interventions can be equally recommended. Although disasters require immediate reactions and improvisation, future studies with larger sample sizes and rigorous methodology are needed.
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Objectives: Unemployment and temporary employment are known to impact psychological health. However, the extent to which the effect is altered by migration-related and sociodemographic determinants is less clear. The purpose of this study was to investigate whether the association between employment status and psychological distress differs between immigrants and Swedish-born and to what extent, the association is modified by gender and reason for immigration. Design: Cross-sectional survey study. Participants and setting: Data from public health surveys undertaken in 2002, 2006 and 2010 from random samples of Stockholm County residents, Sweden, were used to analyse a weighted sample of 51 118 individuals aged 18-64 (43 444 Swedish-born, 4055 non-refugees, 3619 refugees). According to their activity in the labour market, the participants were categorised into permanently/self-employed, temporarily employed and unemployed. Outcomes measures: Associations between self-reported employment and psychological distress measured by a 12-item version of the General Health Questionnaire were explored across individuals with different migration status and reasons for immigration using logistic regression and pairwise comparisons. The analyses were stratified by gender and adjusted for age, socioeconomic characteristics and survey year. Results: Unemployment was associated with elevated likelihood of psychological distress across the study population, regardless of migration status and gender. Fully adjusted models revealed nearly a 3-fold higher odds of distress in unemployed Swedish-born (OR 3.05, 95% CI 2.66 to 3.51), non-refugees (OR 3.51, 95% CI 2.44 to 5.05) and refugees (OR 2.91, 95% CI 2.20 to 3.85) when compared with permanently/self-employed. Temporary employment also increased the likelihood of distress, particularly among refugees and Swedish-born. Conclusions: The effect of unemployment on increased likelihood of poor psychological well-being overcomes gender-specific and migration-specific differences and is equally pronounced for Swedish-born, non-refugees and refugees. Exclusion from the labour market appears to be a major determinant of psychological health inequalities in contemporary Sweden.
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Objective: To conduct a randomized controlled trial assessing the impact of a family-based intervention delivered to Burmese migrant families displaced in Thailand on parenting and family functioning. Participants and procedures: Participants included 479 Burmese migrant families from 20 communities in Thailand. Families, including 513 caregivers and 479 children aged 7 to 15 years, were randomized to treatment and waitlist control groups. The treatment group received a 12-session family-based intervention delivered to groups of families by lay facilitators. Adapted standardized and locally derived measures were administered before and after the intervention to assess parent-child relationship quality, discipline practices, and family functioning. Results: Compared with controls, intervention families demonstrated improved quality of parent-child interactions on scales of parental warmth and affection (Effect size (ES) = 0.25 caregivers; 0.26 children, both p < 0.05) and negative relationship quality (ES = -0.37, p < 0.001 caregivers; -0.22 children, p < 0.05). Both children and caregivers also reported an effect on relationship quality based on a locally derived measure (ES = 0.40 caregivers, p < .001; 0.43 children, p < .05). Family functioning was improved, including family cohesion (ES = 0.46 caregivers; 0.36 children; both p < 0.001) and decreased negative interactions (ES = -0.30 caregivers, p < 0.01; -0.24 children, p < 0.05). Family communication also improved according to children only (ES = 0.29, p < 0.01). Caregivers, but not children, reported decreased harsh discipline (ES = -0.39, p < 0.001), and no effects were observed on use of positive discipline strategies. Treatment attendance was high, with participants attending a mean of 9.7 out of 12 sessions. Conclusion: The intervention increased protective aspects of family well-being for migrant children and caregivers in a middle-income country. The strongest effects were on parent-child relationship quality and family functioning, while results were mixed on changes in discipline practices. Results suggest that a behavioral family-based approach implemented by lay providers in community settings is a promising intervention approach for strengthening families in highly stressed contexts. Trial registration: Clinicaltrials.gov: NCT01668992.
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Refugees frequently experience symptoms of posttraumatic stress and depression, which impede their acculturation in the new host country where they are resettling. There are few longitudinal studies investigating predictors of mental health and acculturation during the early postmigration period. We conducted a longitudinal study of 298 Iraqi refugees, assessing them upon arrival to the U.S. and 1 year after migration. Premigration trauma was associated with increased PTSD and depressive symptoms at baseline, and with decreased acculturation 1 year later. Resilience was associated with depressive symptoms at 1-year follow-up, but not with other resettlement outcomes (PTSD symptoms, English-language skills, or acculturation). PTSD and depressive symptoms at baseline predicted the same symptoms at 1-year follow-up, but not any other resettlement outcomes. The number of chronic diseases at baseline predicted worse PTSD and depressive symptoms, acculturation, and English language skills at 1-year follow up. Postmigratory exposure to daily stressors and less social support predicted worse 1-year outcomes. Results suggest that interventions that aim to improve mental health and promote acculturation among refugees should assess their history of trauma, chronic disorders, and psychological symptoms soon after migration, and promptly provide opportunities for social support.
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The last decade has been marked by increasing attention to rigor in the evaluation of interventions that seek to promote the mental health and psychosocial well-being of children in crisis contexts. One of the key markers of such rigor has been the increased adoption of strong quasi-experimental designs, where children receiving an intervention are compared to children not receiving the intervention. Although usually not randomly assigned to such conditions, children in the ‘intervention’ and ‘comparison’ groups are generally assumed to have had similar experiences other than in relation to exposure to the intervention. The use of such designs—when planned and implemented on a sound ethical basis—can significantly strengthen the capacity to make appropriate attribution of any changes observed by exploring the counterfactual case: what happens when there is no intervention? This question is usually supplementary to questions about the outcomes observed in children receiving the services being evaluated and crucial to inference regarding such outcomes. However, this paper argues that data from comparison groups has major value in its own right. Indeed, it represents a major untapped source of reflection on processes of resilience in humanitarian contexts. We use as a foundation for our analysis 3 studies completed over the last decade which examined the impact of protective and psychosocial interventions for war-affected children in Sierra Leone and Uganda. The interventions considered include programs fostering reintegration of formerly abducted children, prompting structured activities in schools, and establishing child-friendly spaces in refugee settlements. In each case, however, our focus is not on the group that received greatest attention in the original reports—the children receiving the intervention—but on those that did not. Analysis indicates the powerful forces which promote recovery in situations of conflict and the need for interventions to be more mindful that their core function is to bolster such engagement and not seek to drive recovery.
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Treatment of post-traumatic stress disorder (PTSD) in refugees and asylum seekers resettled in high-income countries presents specific challenges. This systematic review examined the effectiveness of psychosocial interventions for this group. We searched the Cochrane Central Register of randomised trials, CINAHL, EMBASE, PILOTS, PsycINFO, PubMed and Web of Science up to July 2016. Studies included randomised and controlled clinical trials comparing psychosocial interventions with waiting list or treatment as usual in adult refugees and asylum seekers with PTSD resettled in high-income countries. PTSD symptoms post-intervention was the primary outcome. We computed standardized mean differences (SMD) with 95% confidence intervals (CI). This study is registered with PROSPERO: CRD42015027843. Twelve studies were included in the meta-analysis. Psychosocial interventions were effective in decreasing PTSD symptoms relative to control groups (SMD -1·03, 95% CI -1·55 to -0·51; number needed to treat 4·4; I² 86%; 95% CI 77 to 91). Narrative exposure therapy, a manualized short-term variant of cognitive behavioural therapy with a trauma focus, was the best-supported intervention (5 RCTs, 187 participants, SMD -0·78, 95% CI -1·18 to -0·38, I² 37%; 95% CI 0 to 77). Methodological quality of the included studies was limited. Overall, psychosocial interventions for asylum seekers and refugees with PTSD resettled in high-income countries were found to provide significant benefits in reducing PTSD symptoms. Yet, the number of studies is small and their methodological quality limited, so that more rigorous trials should be conducted in the future.
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Background The majority of survivors of mass violence live in low- and middle-income countries (LMICs). Aims To synthesise empirical findings for psychological interventions for children and adolescents with post-traumatic stress disorder (PTSD) and/or depression in LMICs affected by mass violence. Methods Randomized controlled trials with children and adolescents with symptoms of PTSD and/or depression in LMICs were identified. Overall, 21812 hits were found through July 2016 in Medline, PsycInfo, and Pilots databases, 21 met the inclusion criteria and were reviewed according to PRISMA guidelines. Findings Twenty-one studies were included. Active treatments for PTSD yielded large pre-treatment to post-treatment changes (g=1.15) and a medium controlled effect size (g=0.57), respectively. Effect sizes were similar at follow-up. Active treatments for depression produced small to medium effect sizes. Finally, after adjustment for publication bias, the imputed uncontrolled and controlled effect sizes for PTSD were medium and small, respectively. Interpretation Psychological interventions may be effective in treating pediatric PTSD in LMICs. It appears that more targeted approaches are needed for depressive responses.
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Background: Preventative and treatment programs for people at risk of developing psychological problems after exposure to war trauma have mushroomed in the last decade. However, there is still much contention about evidence-based and culturally sensitive interventions for children. The aim of this study was to examine the efficacy of the Teaching Recovery Techniques in improving the emotional and behavioral outcomes of war-affected children resettled in Australia. Methods and Findings: A cluster randomized controlled trial with pre-test, post-test, and 3-month follow-up design was employed. A total of 82 participants (aged 10–17 years) were randomized by school into the 8-week intervention (n = 45) or the waiting list (WL) control condition (n = 37). Study outcomes included symptoms of post-traumatic stress disorder, depression, internalizing and externalizing problems, as well as psychosocial functioning. A medium intervention effect was found for depression symptoms. Participants in the intervention condition experienced a greater symptom reduction than participants in the WL control condition, F(1, 155) = 5.20, p = 0.024, partial η² = 0.07. This improvement was maintained at the 3-month follow-up, F(2, 122) = 7.24, p = 0.001, partial η² = 0.20. Conclusions: These findings suggest the potential benefit of the school and group-based intervention on depression symptoms but not on other outcomes, when compared to a waiting list control group. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12611000 948998.
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Over the past several decades, an increasing number of refugee children and families have involuntarily migrated to countries around the world to seek safety and refuge. As the refugee population increases, it is becoming more important to understand factors that promote and foster resilience among refugee youth. The present review examines the past 20 years of resilience research with refugee children to identify individual, family, school, community, and societal factors fostering resilience. This review highlights various factors that promote resilience among refugee children, including social support (from friends and community), a sense of belonging, valuing education, having a positive outlook, family connectedness, and connections to home culture. Recommendations for interventions and programs to promote resilience as well as future directions for resilience research are discussed.
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Decision-making regarding an asylum request of a minor requires decision-makers to determine the best interests of the child when the minor is relatively unknown. This article presents a systematic review of the existing knowledge of the situation of recently arrived refugee children in the host country. This research is based on the General Comment No. 14 of UN Committee on the Rights of the Child. It shows the importance of knowing the type and number of stressful life events a refugee child has experienced before arrival, as well as the duration and severity of these events. The most common mental health problems children face upon arrival in the host country are PTSD, depression and various anxiety disorders. The results identify the relevant elements of the best interests of the child assessment, including implications for procedural safeguards, which should promote a child rights-based decision in the asylum procedure.
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Purpose Studies show a high level of mental health problems among refugee children. This study examined whether a subset of refugee children living in Denmark accessed psychiatric healthcare services more than those born in the country. Methods This study compared 24,427 refugee children from Asia, The Middle East, Sub-Saharan Africa and former Yugoslavia, who obtained residency in Denmark between 1 January 1993 and 31 December 2010 with 146,562 Danish-born children, matched 1:6 on age and sex. The study looked at contacts with psychiatric hospitals as well as psychologists and psychiatrists in private practice. Results Between 1 January 1996 and 30 June 2012, 3.5 % of the refugee children accessed psychiatric healthcare services compared to 7.7 % of the Danish-born children. The rate ratio of having any first-time psychiatric contact was 0.42 (95 % CI 0.40–0.45) among refugee boys and 0.35 (95 % CI 0.33–0.37) among refugee girls, compared to Danish-born children. Figures were similar for those accessing private psychologists or psychiatrists, emergency room, inpatient and outpatient services. Conclusions Refugee children used fewer psychiatric healthcare services than Danish-born children. This may indicate that refugee children experience barriers in accessing psychiatric healthcare systems and do not receive adequate assessment of their mental health and subsequent referral to specialist services.
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This study examined mental health problems among children of Iraqi refugees, most of whom were Christian. Exposure to potentially traumatic events was hypothesized to predict more symptoms of depression and traumatic stress. Moreover, youth reports of supportive relationships with parents and positive feelings about school were examined in relation to mental health problems. These promotive factors were expected to mitigate the hypothesized association between traumatic event exposure and mental health problems. Participants were 211 youth recruited from agencies and programs serving Iraqi refugees in a large metropolitan area in the United States. The hypotheses were partially supported. Youth who reported experiencing more potentially traumatic events endorsed more traumatic stress and depression symptoms. After accounting for exposure to potentially traumatic events and other covariates, youth who reported more positive feelings about school endorsed fewer symptoms of traumatic stress, and youth who reported more supportive relationships with parents endorsed fewer symptoms of depression. In addition, there was an interaction between potentially traumatic events and relationships with parents when predicting depression symptoms. Youth endorsed higher levels of depression symptoms when they reported less supportive relationships, regardless of the amount of traumatic event exposure, whereas youth endorsed lower levels of depression symptoms when they reported more supportive relationships with parents, but only at low levels of traumatic event exposure. Otherwise, the main effects were not qualified by interactions between potentially traumatic event exposure and the promotive factors. The findings from this study have implications for future research, policy, and practice with children of refugees.
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Background: Gender based violence (GBV) remains one of the most serious threats to the health and safety of women and girls worldwide. The problem is even more pronounced in refugee populations where women and girls are at increased risk of violence. In 2015, UNHCR reported the highest number of forcibly displaced people in recorded history. Despite growing need, there have been few rigorous evaluations of interventions aimed at primary GBV prevention and no systematic reviews of GBV prevention efforts specifically focused on refugee populations; reviews to date have primarily examined prevention of conflict related sexual violence, with very limited focus on other forms of GBV such as intimate partner violence Methods: This study reviewed the scientific literature addressing strategies for primary prevention of GBV and their effectiveness among refugee populations over the past ten years (2006 to 2015). Narrative content analysis methods were used to extract findings related to prevention activities/programs recommended by the global humanitarian community, such as sociocultural norms change, rebuilding family and community support structures, improving accountability systems, designing effective services and facilities, working with formal and traditional legal systems, monitoring and documenting GBV, and/or engaging men and boys in GBV prevention and response. Results: Study findings indicate that a range of GBV prevention activities recommended by the global humanitarian community are currently being applied in a variety of settings. However, there remains a limited body of evidence on the effectiveness of GBV prevention programs, interventions, and strategies, especially among refugee populations. Conclusion: Commonly agreed upon standards or guidelines for evaluation of GBV prevention programming, and publication of evaluations conducted using these guidelines, could assist humanitarian stakeholders to build and disseminate an evidence base of effective GBV prevention interventions, programs and strategies. Evaluation of GBV prevention efforts, especially among refugee populations, must be given higher priority to justify continuation or revision of recommended GBV activities/programs being implemented in diverse humanitarian settings.
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The purpose of the present research review is to identify effective, high quality school-based interventions for immigrant students with disabilities or academic and behavioral problems. A systematic review of the literature was conducted to synthesize international research studies. Initial and criteria-based selection processes yielded six intervention studies published between 1975 and 2010. Two of the studies are academic interventions while four are behavioral interventions. Three studies were conducted in the United States while the remaining three in Israel, Canada, and Norway. The identified studies were evaluated against the quality indicators of special education research. Three experimental studies met the minimum criteria for acceptable methodological rigor. The results show an urgent need for methodologically robust intervention studies in the field of special education for immigrant students. Implications for research and practice are discussed.