Is Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) Effective in Reducing Trauma Symptoms among Traumatized Refugee Children? A Systematic Review

Psychotherapists' readiness to treat PTSD: the influence of refugees' country of origin

Background: Previous research suggests that psychotherapists' readiness to treat traumatized patients varies according to patient and therapist characteristics, including the patient's refugee background.Objective: This study aims to examine the relationship between psychotherapists' readiness to treat patients with symptoms of post-traumatic stress disorder and various patient and therapist characteristics, including refugee background and country of origin.Method: In our vignette study with a nationwide online survey in Germany (N = 871), we assessed the readiness of licensed psychotherapists (LPTs) and therapists in training (PiTs) to treat patients with PTSD. Vignettes described patients with PTSD who differed in gender, refugee background, and country of origin (Syria vs. Ukraine). Participants rated treatment readiness and expected treatment success based on the vignette they received.Results: Treatment readiness and expected success were significantly lower for refugee patients. There was no difference in treatment readiness between refugees from Syria and Ukraine, but therapists expected less therapeutic success for Syrian patients compared to Ukrainian patients. Gender did not influence the results.Conclusions: The study shows that refugee background and country of origin influence psychotherapists' readiness to treat PTSD and their expectations of treatment success. These findings highlight potential reasons for the undertreatment of refugees and suggest opportunities for intervention and training, such as informing therapists about effective treatments for refugee patients.

Effectiveness of trauma-focused treatments for refugee children: a systematic review and meta-analyses

ABSTRACTBackground: Prevalence of posttraumatic stress disorder (PTSD) in refugees is higher compared to the general population, and barriers in accessing mental health care are often experienced. With staggering numbers of people seeking refuge around the world, and 40% being 18 years or younger, effective trauma-focused therapies for refugee children with PTSD are highly needed.Objective: A systematic review and meta-analyses were conducted to provide an overview of, and to analyse, intervention studies using PTSD measures in young refugees, assessing treatment effectiveness and addressing efforts to mitigate barriers to mental health care.Method: Eleven databases were searched for studies evaluating trauma-focused treatments (TFT) for refugee children (0-18). Meta-analyses were conducted for all included studies grouped together; and second, per intervention type, using posttreatment measures and follow-up measures. Pooled between-group effect sizes (ESs) and pre-post ESs, using a random-effects model were calculated.Results: A total of 47 studies was retrieved, with 32 included in the meta-analyses. The narrative review highlighted positive outcomes in reducing posttraumatic stress symptoms for CBT-based interventions, EMDR therapy, KIDNET, and other treatments such as art therapy. Meta-analyses revealed medium pooled pre-post ESs for CBT-based interventions (ES = -.55) and large for EMDR therapy (ES = -1.63). RCT and CT studies using follow-up measures showed promising outcomes for KIDNET (ES = -.49). High heterogeneity of the included studies limited interpretation of several other combined effects. Results should be interpreted with caution due to the generally low quality of the included studies. All studies addressed efforts to minimize treatment barriers.Conclusion: More high-quality studies are urgently needed to inform treatment recommendations. Evidence-based therapies, such as CBT-based interventions, EMDR therapy, and KIDNET, demonstrate promising findings but need further replication. Strategies to overcome barriers to treatment may be necessary to reach this population.

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

BackgroundGlobally, there is an increasing trend of forcibly displaced people, of which over 40% are children. Unaccompanied asylum-seeking children (UASC) are at risk of experiencing psychological distress and developing mental health difficulties. However, in the UK, the approach from statutory mental health services is inconsistent across different geographical areas.AimThis report outlines recommendations for statutory mental health services in the UK in relation to working with UASC.MethodA rapid evaluation method was adopted including interviewing fifteen key informants as well as reviewing existing clinical guidelines. Key informants included clinicians, service managers, social workers and commissioners from Local Authorities, National Health Services, and third sector partners. Recommendations were synthesised using narrative synthesis.Results and conclusionExisting service provision and barriers to the implementation of interventions were summarised and compared against existing guidelines. The report presents recommendations on assessments, screening tools, and psychological interventions for developing a pathway for UASC within statutory services.

Challenges and facilitators in treating unaccompanied young refugees with posttraumatic stress disorder in a dissemination trial: a qualitative study with psychotherapists

BACKGROUND

Unaccompanied young refugees (UYRs) report high rates of post-traumatic stress, depression and anxiety, and low mental health service utilization. Studies have examined the experiences of psychotherapists and refugees in psychotherapy, focusing on barriers. Our stepped-care approach aims to reduce barriers through comprehensive support, such as training and case consultation for psychotherapists and interpreters, and treatment recommendations for UYRs.

METHODS

A qualitative design with semi-structured interviews was employed, with 20 psychotherapists, of whom 13 were females. All psychotherapists participated in the 'BETTER CARE' project, which included trauma-focused cognitive-behavioral therapy training and case consultations. We analyzed psychotherapists' initial worries, challenges, and facilitators in treating UYRs with posttraumatic stress disorder, and compared the responses of completers' and non-completers' psychotherapists, following a mix of deductive and inductive coding.

RESULTS

Psychotherapists expressed worries similar to those documented in the literature on barriers (such as organizational challenges, emotional stress, and uncertainty about working with interpreters) prior to participating in the project. Major facilitators were the components offered by the project, such as online training, workshop and case consultations. In addition, support from the facility and caregivers and the provision of skilled interpreters who translated accurately and transparently, as well as patients' treatment readiness and language proficiency, were seen as facilitators or, when lacking, as challenges. Completers' psychotherapists were more likely to emphasize the positive aspects of the project, a positive therapeutic alliance and patients' trusting relationship with the interpreters as facilitators. In contrast, non-completers' psychotherapists were more likely to encounter structural difficulties, such as the lack of primary caregivers, greater distances, and grief symptoms among patients.

CONCLUSIONS

Our findings indicate that enhancing the knowledge of psychotherapists, caregivers, and interpreters through specialized training is important for effective trauma treatment with UYRs. This training should result in increased patient readiness, caregiver support, and fostering a cooperative treatment environment, while also building a trusting relationship between patient, psychotherapist, and interpreter. As initial worries were largely unconfirmed, and completers' psychotherapists benefited more from the projects' offers, we recommend similar approaches.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017453. Registered on 11 December 2019.

Investigating factors influencing utilization of trauma-focused cognitive behavioral therapy among unaccompanied young refugees: an exploratory analysis

BACKGROUND

Unaccompanied young refugees (UYRs) exhibit elevated levels of mental distress, including posttraumatic stress symptoms (PTSS), depression and anxiety. Despite the considerable psychological burden, UYRs frequently lack access to mental health care (MHC). The factors that contribute to higher rates of treatment utilization among UYR remain poorly understood. Untreated PTSS can result in chronic impairment, underscoring the importance of identifying these factors. The aim of this study is to investigate factors associated with the intention and actual utilization of MHC of UYRs living in child and youth welfare facilities in Germany.

METHOD

This study is part of the multi-site project BETTER CARE which aims to implement a stepped and collaborative care approach. A sample of N = 139 UYRs who had received a treatment recommendation for trauma-focused cognitive behavioral therapy (TF-CBT) was analyzed. Binomial logistic regression was performed to identify factors predicting the likelihood of intention to seek MHC. In addition, the association between intention to seek MHC and actual utilization was determined using a chi square test.

RESULTS

The results demonstrated a significant correlation between age (η = 0.25, p <.01), length of stay in Germany (η = 0.28, p <.01), and severity of PTSD symptoms (η = 0.26, p <.01) with intention to use MHC. In the logistic regression analysis, PTSD emerged as a significant predictor of intended use (B = 2.66, p <.05). The utilization of MHC was found to be closely associated with the initial intention to use (χ²(1) = 88.846, p <.001).

CONCLUSIONS

The findings contribute to an expanding body of literature on the mental health requirements and service utilization patterns among UYRs, offering insights for policymakers, mental health professionals, and child welfare services striving to enhance care for this vulnerable population.

Trauma focused-cognitive behavioral therapy training effectiveness in promoting professional development of psychotherapists working with unaccompanied minors in Greece: a non-blinded randomized control trial

The need to develop psychotherapists' skills to respond to current treatment challenges, such as addressing trauma due to the refugee crisis, is increasing. However, there is a dearth of evidencebased training for psychotherapists who work with refugees, especially in frontline countries. A randomly selected sample of 80 clinicians working with unaccompanied minors (UAMs) in Greek accommodation centers nationwide participated in an intensive trauma-focused cognitive behavioral therapy (TF-CBT) training (n=44) or a control-group (n=36) and completed the Professional Quality of Life Scale, the Work and Meaning Inventory and a questionnaire to assess knowledge and therapeutic skills, in pre-andpost measurements. Clinicians with 1-3 years of experience with refugees reported higher burnout (p=0.012, M=25.78 vs M=22.04) and secondary traumatic stress than those with less than a year (p=0.014, M=22.03 vs M=18.04). Positive meaning at work increased in both groups at post-test (TF-CBT group: p=0.019, M=15 vs M=13.6, and control group: p<0.001, M=15.17 vs M=13.42). The TF-CBT training group outperformed the control group in knowledge and skills (p=0.021, M=10.15 vs M=8.75) and identified a lower number of children with post-traumatic stress disorder symptoms (p=0.009, M=6.94 vs M=4.33) post-training. This study provides preliminary evidence on TF-CBT training effectiveness in equipping psychotherapists to work with UAMs, while their professional quality of life warrants further research.

Psychological interventions for children with emotional and behavioral difficulties aged 5-12 years: An evidence review

In low- and middle-income countries (LMICs), children and families face a multitude of risk factors for mental health and well-being. These risks are even further exacerbated in humanitarian emergencies. However, access to effective mental health services in such settings is severely limited, leading to a large mental health treatment gap. Middle childhood (5-12 years) is a crucial period for human development during which symptoms of emotional distress often emerge, with one in three mental disorders developing prior to age 14. However, there is little evidence of effective psychological interventions for children in this developmental stage, and suitable for implementation within LMICs and humanitarian emergencies. We conducted this evidence review to inform the development of a new intervention package based on existing best practice for this age group, drawing insights from both global and LMIC resources. Our review synthesizes the findings of 52 intervention studies from LMICs and humanitarian settings; 53 existing systematic reviews and meta-analyses covering both LMICs and high-income countries, and 15 technical guidelines. Overall, there is limited high-quality evidence from which to draw recommendations for this age group; however, some promising intervention approaches were identified for children experiencing externalizing and internalizing symptoms, traumatic stress and a combination of difficulties. Several effective interventions utilize cognitive-behavioral techniques for children, in either group or individual format, and incorporate caregiver skills training into treatment, although the findings are mixed. Most evaluated interventions use specialists as delivery agents and are lengthy, which poses challenges for scale-up in settings where financial and human resources are scarce. These findings will inform the development of new psychological interventions for children in this age group with emotional and behavioral difficulties.

Upholding the Human Rights and Well-Being of Refugee Children Through Effective Clinical Care

Refugee children are often exposed to adversities and traumatic experiences that can harm the mental health and well-being of refugee children. These include human trafficking and exploitation and dangers in detention centers and refugee camps. All these adverse events can be traumatic and contribute to poor mental health, including posttraumatic stress, anxiety, depression, and substance use disorders. Therefore, the assessment of refugee children and adolescents should include screening and identification for these experiences, provision of evidence-based trauma treatment, and social supports to promote their well-being and thriving.

Rethinking mental healthcare for refugees

After several years of downturn in new resettlement, the United States is projected to admit 125,000 refugees in the current fiscal year. Refugee communities have known risks of developing mental health problems due to high rates of exposure to war and conflict-related trauma and chronic stressors associated with displacement and resettlement. In this commentary, we examine limitations in the current system of mental health care available to newly arriving refugee communities and make recommendations for expanding and redesigning services to better meet the needs of culturally diverse refugee communities. This includes drawing on public health and prevention frameworks to implement a continuum of services including basic services and security, trauma-informed prevention services to meet the needs of individuals, families and communities and specialized clinical care for those that need it. Across all services, we recommend robust engagement and partnership with refugee community leaders to design and deliver programs.

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

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

A systematic review and meta-analysis of trauma-focused cognitive behavioral therapy for children and adolescents

BACKGROUND

Among minors, posttraumatic stress symptoms (PTSS) are a common consequence of traumatic events requiring trauma-focused treatment.

OBJECTIVE

This meta-analysis quantified treatment effects of trauma-focused cognitive behavioral therapy (TF-CBT) with PTSS as primary outcome and symptoms of depression, anxiety, and grief as secondary outcomes.

PARTICIPANTS AND SETTING

Inclusion criteria for individual settings: (1) patients aged between 3 and 21, (2) at least one traumatic event, (3) minimum 8 sessions of (4) TF-CBT according to Cohen, Mannarino and Deblinger (2006, 2017), (5) a quantitative PTSS measure at pre- and post-treatment, (6) original research only. Inclusion criteria for group settings: had to involve (1) psychoeducation, (2) coping strategies, (3) exposure, (4) cognitive processing/restructuring, (5) contain some reference to the manual and no minimum session number was required.

METHODS

Searched databases were PsychInfo, MEDLINE, Cochrane Library, PTSDPubs, PubMed, Web of Science, and OpenGrey.

RESULTS

4523 participants from 28 RCTs and 33 uncontrolled studies were included. TF-CBT showed large improvements across all outcomes from pre- to post-treatment (PTSS: g = 1.14, CI 0.97-1.30) and favorable results compared to any control condition including wait-list, treatment as usual, and active treatment at post-treatment (PTSS: g = 0.52, CI 0.31-0.73). Effects were more pronounced for group settings. We give pooled estimates adjusted for risk of bias and publication bias, which initially limited the quality of the analyzed data.

CONCLUSIONS

TF-CBT is an effective treatment for pediatric PTSS as well as for depressive, anxiety, and grief symptoms. It is superior to control conditions, supporting international guidelines recommending it as a first-line treatment.

The inter-agency standing committee (IASC) guidelines on mental health and psychosocial support (MHPSS) in emergency settings: a critique

The bio-medical model of 'mental health' and 'mental illness' that relates to the relationship between wellbeing and distress informs psychopathology and dominates conceptualisation in many Western Educated Industrialised Rich Democratic (WEIRD) populations. This paper aims to critique the model, questioning the appropriateness of psychopathology as a conceptual framework when working as a Western trained clinician with populations such as in China, Japan, Asia, the Middle-East and Africa. The paper also considers the cultural appropriateness of western notions of psychopathology when working inter-culturally in relation to the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings, and the Review of the Implementation of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings.