Assessing trauma and mental health in refugee children and youth: a systematic review of validated screening and measurement tools

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

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

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.

Cross-culturally adapting the GHQ-12 for use with refugee populations: Opportunities, dilemmas, and challenges

This article discusses the opportunities, dilemmas, and challenges involved in the cross-cultural adaptation (CCA) of psychological scales for use with refugee populations. It draws on insights derived from an attempt to adapt the 12-item General Health Questionnaire (GHQ-12) to the particular culture and context of Eritrean refugees residing in Israel. Multiple techniques including expert translations, a focus-group discussion, a survey, and piloting, were employed to attain a cross-cultural and conceptually equivalent measure. During the CCA process, the research team encountered issues pertaining to conceptual non-equivalence, the structure of the measure's responses and scoring system, and acceptability. These issues required the team to move beyond semantic translation by adapting certain items. This study demonstrates the compromises which need to be made in the adaptation process and indicates the potential bias which each of these compromises introduces. Despite its limitations, CCA does appear to significantly improve detection of mental health symptoms in refugee populations. Overall, the results of the present study provide support for the notion that the sensitive and appropriate assessment of individuals from refugee backgrounds requires adopting a rigorous, systematic, and contextual approach to instrument adaptation, with an emphasis on the integration of idioms of distress as well as the adaptation of Likert-type scales.

Young children's development after forced displacement: a systematic review

OBJECTIVES

To examine the impact of displacement experiences on 0- to 6-year-old children's social-emotional and cognitive development, as well as influencing factors on reported outcomes.

STUDY DESIGN

We systematically searched MEDline, Psyndex, Cochrane Library, Web of Science, Elsevier, TandF, Oxford Journal of Refugee Studies, Journal of Immigrant & Refugee Studies, and Canada's Journal on Refugees for existing literature regarding social-emotional and cognitive outcomes in children directly exposed to forced displacement due to political violence. Results were synthesized in the discussion and displayed using harvest plots.

RESULTS

Our search generated 9,791 articles of which 32 were selected for review and evaluation according to NICE criteria. Included studies provided results for 6,878 forcibly displaced children. Measured outcomes were diverse and included areas such as peer relations, prosocial behavior, family functioning, play, intelligence, learning performance, and language development. Repeated exposure to adverse experiences, separation from parents, parental distress, as well as duration and quality of resettlement in the host country were reported as influencing factors in the reviewed studies.

CONCLUSION

As protective factors like secure and stable living conditions help to promote children's development, we call for policies that enhance participation in the welcoming society for refugee families. Early integration with low-threshold access to health and educational facilities can help to mitigate the wide-ranging negative consequences of forced displacement on young children's development.

Exploring Mental Health and Development in Refugee Children Through Systematic Play Assessment

To evaluate a standardized play observation as a measure of young children's mental health and development in a clinical and refugee population. We conducted individual play observations with 70 refugee children aged 3- to 6-years and compared them to a clinical group of 111 age-matched children regarding their level of play development, social interaction during play, traumatic re-enactments, and emotionless-cold play. Additionally, we assessed children's mental health, social-emotional development and markers of adversity by parent and educator report as well as their IQ-test scores and learning performance and related these factors to the play variables. Play variables were significantly correlated with IQ-test scores (r = 0.184, p = 0.037), learning performance (r = 0.208, p = 0.010) and vocabulary (r = 0.208, p = 0.021) in the comparison group and with social-emotional development in educator report (r = 0.368, p = 0.011), time spent in Germany (r = 0.342, p < 0.001) and parental distress (r = - 0.292, p = 0.034) in the refugee group. Children with more parent-reported adverse experiences showed less social-interactive play in the overall sample (r = - 0.178, p = 0.011). Our child-centered approach to standardized play observation augments information obtained from parent and educator reports and can provide valuable insights in subgroups where other commonly used tests are not available or applicable.

Negative and protective experiences influencing the well-being of refugee children resettling in Germany: a qualitative study

OBJECTIVE

Conflict, forced migration and searching for safety in a foreign land are all experiences common to refugee children. They experience potentially traumatic events that are distinct from the general population, yet current adverse childhood experience (ACE) studies do not cover these events. Studies that do examine refugee children's experiences typically focus on a single stage of migration or adversities from the community, offering insight into only a fraction of their realities. This study aimed to identify potentially traumatising and protective experiences subjectively perceived as influencing refugee children's well-being from all stages of migration and all socio-ecological levels.

DESIGN

Qualitative study with thematic analysis of semi-structured individual and group interviews. Themes were organised within a socio-ecological model.

SETTING

Non-profit organisations, youth welfare facilities and societies that organise civic engagement for refugee families in the Rhine-Neckar region in Germany provided rooms where interviews could be conducted.

PARTICIPANTS

Refugee parents and children who spoke one of the four most common languages of those seeking asylum in Germany in 2018 were included. This study excluded refugees who were not fleeing a conflict area. Forty-seven refugee parents and 11 children (aged 8-17 years) from Syria, Iraq, Palestine, Afghanistan and Eritrea participated.

RESULTS

Eight major themes emerged from interviews including six reflecting potentially negative experiences and two potentially protective themes. These themes evolved from experiences such as family dispersion, displacement, rigorous immigration and national policies, as well as constructive parenting and community support.

CONCLUSION

It is increasingly important to identify these diverse experiences as the refugee population continues to grow, and the increased prevalence of poor health outcomes in refugee children continues to be widely documented. Identifying ACEs specifically relevant to refugee children could contribute to understanding potential pathways and could further serve as a starting point for tailored interventions.

The refugee and asylum seeker mental health treatment screener (RAS-MT-screener): Feasibility and psychometric properties of a questionnaire detecting refugees' and asylum seekers' need and urgency for mental health treatment

OBJECTIVE

Refugees and asylum seekers are highly vulnerable to the development of mental health problems, yet oftentimes their need is underestimated. We aimed to develop a culturally sensitive screening tool for primary care settings assessing the urgency and need for mental health treatment to close this gap.

METHOD

Items for the screening tool were selected out of an item pool generated by a group of clinical experts based on the data obtained from n = 307 asylum seekers in a refugee state registration and reception center in Germany. Out of these, n = 111 attended a psychosocial walk-in clinic, and clinicians' ratings of urgency and need for mental health treatment were added.

RESULTS

The resulting questionnaire comprised 8 items assessing urgency and 13 items assessing need for mental health treatment. Sensitivity was =0.74 and specificity =0.70. Participants of clinical and non-clinical samples differ highly significantly (p < .001). Cross-cultural validity was shown by comparing measurement invariance for different countries of origin.

CONCLUSION

The RAS-MT-Screener is a clinically and cross-culturally valid screening tool in primary care settings for the urgency and need for mental health treatment with acceptable psychometric properties. Future research on its external and construct validity is warranted.

Cognitive evaluation in unaccompanied refugee children: a systematic review

OBJECTIVE

This study aims to identify what existing literature has shown about possible cognitive alterations in unaccompanied refugee children.

DATA SOURCES

The search was performed in the Web of Science, PsycInfo, Scopus, and PubMed databases, including articles published in any year and in any language. The research was submitted to the Prospero protocol (ID: CRD42021257858), and the quality of the included articles was evaluated using the Mixed Methods Appraisal Tool.

DATA SYNTHESIS

Memory and attention are the main topics identified, largely because they are related to symptoms of post-traumatic stress disorder. However, low specificity was observed in the conduction of cognitive assessments, leading to relevant inconsistencies in the collected data.

CONCLUSIONS

The use of psychological assessment instruments that are either poorly adapted or not adapted at all to the populations studied casts doubt on the validity of the data produced so far.

Diagnostic test accuracy of screening tools for post-traumatic stress disorder among refugees and asylum seekers: A systematic review and meta-analysis

Background

Refugees and asylum seekers often experience traumatic events resulting in a high prevalence of post-traumatic stress disorder (PTSD). Undiagnosed PTSD can have detrimental effects on resettlement outcomes. Immigration medical exams provide an opportunity to screen for mental health conditions in refugee and asylum seeker populations and provide links to timely mental health care.

Objective

To assess the diagnostic accuracy of screening tools for PTSD in refugee and asylum seeker populations.

Methods

We systematically searched Medline, Embase, PsycINFO, CENTRAL and CINAHL up to 29 September 2022. We included cohort-selection or cross-sectional study designs that assessed PTSD screening tools in refugee or asylum seeker populations of all ages. All reference standards were eligible for inclusion, with a clinical interview considered the gold standard. We selected studies and extracted diagnostic test accuracy data in duplicate. Risk of bias and applicability concerns were addressed using QUADAS-2. We meta-analyzed findings using a bivariate random-effects model. We partnered with a patient representative and a clinical psychiatrist to inform review development and conduct.

Results

Our review includes 28 studies (4,373 participants) capturing 16 different screening tools. Nine of the 16 tools were developed specifically for refugee populations. Most studies assessed PTSD in adult populations, but three included studies focused on detecting PTSD in children. Nine studies looked at the Harvard Trauma Questionnaire (HTQ) with diagnostic cut-off points ranging from 1.17 to 2.5. Meta-analyses revealed a summary point sensitivity of 86.6% (95%CI 0.791; 0.917) and specificity of 78.9% (95%CI 0.639; 0.888) for these studies. After evaluation, we found it appropriate to pool other screening tools (Posttraumatic Stress Disorder Checklist, the Impact of Event Scale, and the Posttraumatic Diagnostic Scale) with the HTQ. The area under the curve for this model was 79.4%, with a pooled sensitivity of 86.2% (95%CI 0.759; 0.925) and a specificity of 72.2% (95%CI 0.616; 0.808).

Conclusions

Our review identified several screening tools that perform well among refugees and asylum seekers, but no single tool was identified as being superior. The Refugee Health Screener holds promise as a practical instrument for use in immigration medical examinations because it supports the identification of PTSD, depression, and anxiety across diverse populations. Future research should consider tool characteristics beyond sensitivity and specificity to facilitate implementation in immigration medical exams.

Registration

Open Science Framework: 10.17605/OSF.IO/PHNJV.

Coping and Resilience: PTSD Screening and Brief Intervention for Underrepresented Students at a Public University

The undetected and untreated PTSD symptoms (difficulty paying attention, nightmares and difficulty sleeping, irritability or aggression, flashbacks, diminished interest in activities, self-destructive behavior, and feeling isolated) of college students may interfere with their relationships, well-being, learning, and academic success. To examine the feasibility, acceptability, and impact of providing a short-term trauma-specific evidence-based group intervention, Coping & Resilience (C&R), an adaptation of Cognitive Behavioral Intervention for Trauma in Schools (CBITS) was implemented at a large urban public university. Fifty college students (54 percent male, 90 percent students of color), with a mean PTSD symptom score of 34 at pretest (considered in the moderate range of symptom severity) participated in C&R groups. As expected, student PTSD symptoms improved after group participation. A Quade test showed a significant decrease in the scores from pretest to follow-up for PTSD and two subscales (intrusion and avoidance). Large public universities serving underrepresented students are uniquely positioned to become trauma- and resilience-informed systems and to provide trauma support services to promote student well-being.

Screening Tools for Mental Disorders Among Female Refugees: a Systematic Review

Female refugees are particularly vulnerable to mental disorders but assessment may be complex and challenging. Various screening tools have been developed for this population, but little is known about their usefulness. The main aim is to examine the literature on the effectiveness of screening tools for mental health problems among female refugees. Systematic review of PubMed, PsycINFO and Embase to locate all published work. Comprehensive search terms were used and inclusion and exclusion criteria were formulated. The initial search yielded 877 articles, of which 757 were removed after titles and abstracts were reviewed. Then, 121 full-text versions of articles were examined and 96 excluded according to the criteria. A total of 25 articles were included in this systematic review in accordance with the PRIMSA guidelines. Twenty screening tools were evaluated. There is a lack of tools used to screen refugee women, and in particular those in emergency settings. Cultural factors may not be accounted for in the development of screening instruments. Further research in this field can help inform public health policies to address social, educational and occupational inclusion for refugee women in different contexts.

Differences in psychiatric care utilization between refugees, non-refugee migrants and Swedish-born youth

BACKGROUND

The study aimed to examine differences in, and characteristics of psychiatric care utilization in young refugees who came to Sweden as unaccompanied or accompanied minors, compared with that of their non-refugee immigrant and Swedish-born peers.

METHODS

This register-linkage cohort study included 746 688 individuals between 19 and 25 years of age in 2009, whereof 32 481 were refugees (2896 unaccompanied and 29 585 accompanied) and 32 151 non-refugee immigrants. Crude and multivariate Cox regression models yielding hazard ratios (HR) and 95% confidence intervals (CI) were conducted to investigate subsequent psychiatric care utilization for specific disorders, duration of residence and age at migration.

RESULTS

The adjusted HRs for psychiatric care utilization due to any mental disorder was significantly lower in both non-refugee and refugee immigrants when compared to Swedish-born [aHR: 0.78 (95% CI 0.76-0.81) and 0.75 (95% CI 0.72-0.77, respectively)]. Within the refugee group, unaccompanied had slightly lower adjusted risk estimates than accompanied. This pattern was similar for all specific mental disorders except for higher rates in schizophrenia, reaction to severe stress/adjustment disorders and post-traumatic stress disorder. Psychiatric health care utilization was also higher in immigrants with more than 10 years of residency in Sweden entering the country being younger than 6 years of age.

CONCLUSIONS

For most mental disorders, psychiatric health care utilization in young refugees and non-refugee immigrants was lower than in their Swedish-born peers; exceptions are schizophrenia and stress-related disorders. Arrival in Sweden before the age of 6 years was associated with higher rates of overall psychiatric care utilization.

Practitioner competencies for working with refugee children and young people: A scoping review

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.

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

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

The posttraumatic stress interview for children (KID-PIN): development and validation of a semi-structured interview of PTSD symptoms among displaced children in the Middle East

BACKGROUND

In populations affected by mass disaster such as armed conflict and displacement, children are at risk of developing mental ill-health, in particular post-traumatic stress disorder (PTSD). Valid and reliable screening instruments are needed to assess the severity of PTSD symptoms among children and to identify individuals in need of treatment.

METHOD

In the context of an ongoing war in the Middle East, we developed the KID-PIN as a semi-structured interview for PTSD symptoms that can be administered by trained paraprofessionals. To achieve a culturally and contextually appropriate instrument, the development was based on open-ended interviews with affected children and involved both local and international experts. Using the KID-PIN and instruments for constructs associated with PTSD, 332 Iraqi and Syrian displaced children were interviewed. A subset of the sample (n = 86) participated in validation interviews based on experts applying the Clinician-Administered PTSD Scale for DSM-5-Child/Adolescent Version (CAPS-CA-5).

RESULTS

The KID-PIN demonstrated excellent internal consistency (Cronbach's alpha = 0.94) with good convergent validity. Confirmatory factor analyses of the KID-PIN showed an acceptable fit with the DSM-5 and other common models; the best fit was reached with the Hybrid model. Receiver operating characteristic analyses indicated that the cut-off score of 28 or higher on the KID-PIN is the optimum cut-off for a probable PTSD diagnosis.

CONCLUSION

The utility of the newly developed KID-PIN as a screening instrument for PTSD in children is supported by the measure's high internal consistency and good convergent and structural validity, as well as its diagnostic accuracy.

Impact of war and forced displacement on children's mental health-multilevel, needs-oriented, and trauma-informed approaches

The infliction of war and military aggression upon children must be considered a violation of their basic human rights and can have a persistent impact on their physical and mental health and well-being, with long-term consequences for their development. Given the recent events in Ukraine with millions on the flight, this scoping policy editorial aims to help guide mental health support for young victims of war through an overview of the direct and indirect burden of war on child mental health. We highlight multilevel, need-oriented, and trauma-informed approaches to regaining and sustaining outer and inner security after exposure to the trauma of war. The impact of war on children is tremendous and pervasive, with multiple implications, including immediate stress-responses, increased risk for specific mental disorders, distress from forced separation from parents, and fear for personal and family's safety. Thus, the experiences that children have to endure during and as consequence of war are in harsh contrast to their developmental needs and their right to grow up in a physically and emotionally safe and predictable environment. Mental health and psychosocial interventions for war-affected children should be multileveled, specifically targeted towards the child's needs, trauma-informed, and strength- and resilience-oriented. Immediate supportive interventions should focus on providing basic physical and emotional resources and care to children to help them regain both external safety and inner security. Screening and assessment of the child's mental health burden and resources are indicated to inform targeted interventions. A growing body of research demonstrates the efficacy and effectiveness of evidence-based interventions, from lower-threshold and short-term group-based interventions to individualized evidence-based psychotherapy. Obviously, supporting children also entails enabling and supporting parents in the care for their children, as well as providing post-migration infrastructures and social environments that foster mental health. Health systems in Europe should undertake a concerted effort to meet the increased mental health needs of refugee children directly exposed and traumatized by the recent war in Ukraine as well as to those indirectly affected by these events. The current crisis necessitates political action and collective engagement, together with guidelines by mental health professionals on how to reduce harm in children either directly or indirectly exposed to war and its consequences.

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

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

Factors associated with posttraumatic growth among healthcare workers at an academic-medical center: A correlational study

PURPOSE

Posttraumatic growth (PTG) can occur after experiencing traumatic events. Our purpose was to examine factors associated with PTG experiences of healthcare workers within an academic-medical center.

DESIGN AND METHODS

A correlational study was conducted using a convenience sample of 479 healthcare workers at a large academic-medical center.

FINDINGS

Having children living at home, serving the pediatric population, longer duration of alcohol abstinence, and having received treatment for trauma were significantly associated with greater PTG scores. Compared to nondirect care staff, advance practice providers, nursing staff, social work/psychologists, and pharmacy staff had significantly lower PTG scores.

PRACTICE IMPLICATIONS

Understanding the positive psychological changes that occur in workers after trauma experiences may provide insight to guide interventions that promote healthcare worker wellbeing.

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

In 2019, more than 25.9 million children under 18 were displaced due to unending political conflicts. Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) has a high level of empirical evidence to support its efficacy in processing trauma and behavioral problems in non-refugee children. Yet, little is known about its long-term effectiveness in refugee children. This study conducted a systematic review that assessed the evidence of the effectiveness of TF-CBT in reducing trauma symptoms among refugee children under 18 years of age. A systematic review was conducted from peer-reviewed literature databases (12 databases): PsycINFO, PubMed, Scopus, Google Scholar, ProQuest Dissertations and Theses (PQDT), Cochrane Library, MEDLINE, PROSPERO, EBSCOHost, Campbell Collaboration Library of Systematic Reviews, Social Sciences Index, and grey literature sources published from 1990 to 2019. The search yielded 1650 articles, and 4 peer reviewed studies were identified that met inclusion criteria and yielded a sample size of 64 refugee children from 21 different countries. All 4 studies provided evidence that supported TF-CBT's effectiveness in decreasing trauma symptoms and sustainment during the follow-up assessment among refugee children participants. Despite TF-CBT effectiveness for trauma symptoms treatment, there is still limited evidence to suggest that TF-CBT is effective for all refugee children due to the pilot nature of the studies, and its underutilization in traumatized refugee children from different cultural backgrounds. Future studies should conduct more TF-CBT interventions with diverse refugee children to provide more empirical support for its effectiveness with that population.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40653-021-00370-0.

Persistence of antidepressant use among refugee youth with common mental disorder

BACKGROUND

The objective of this study was to investigate whether persistence of antidepressant use differs between refugee youth and Swedish-born youth after a diagnosis of a common mental disorder (CMD), and if clinical and sociodemographic factors are associated with antidepressant discontinuation.

METHODS

Youth aged 16-25 years, with an incident diagnosis of CMD (depression, post-traumatic stress disorder (PTSD), anxiety disorders) accessing specialized healthcare in Sweden 2006-2016 were included. New users were identified with a one-year washout period. Refugees (N=1575) were compared with Swedish-born youth (N=2319). Cox regression models [reported as adjusted Hazard Ratios (HRs) with 95% confidence intervals (CIs)] were used to investigate factors associated with discontinuation of antidepressant use.

RESULTS

Among youth (mean age 20.9 years, SD 2.7, 50% females), the median duration of antidepressant use differed considerably between refugee (101 days, IQR 31-243) and Swedish-born youth (252 days, IQR 101-558). Refugees were more likely to discontinue treatment (HR 1.61, 95% CI 1.47-1.77). Factors associated with an increased risk for discontinuation in refugees included ≤5 years duration of formal residency (HR 1.28, 95% CI 1.12-1.45), antidepressant type, and dispensing lag (time from prescription to dispensing) of >7 days (1.43, 1.25-1.64), whereas PTSD (0.78, 0.64-0.97) and anxiolytic use (0.79, 0.64-0.96) were associated with a lower discontinuation risk.

LIMITATIONS

Only persons treated in specialized healthcare could be included.

CONCLUSION

The relatively short treatment durations among refugee youth suggest that antidepressant treatment may not be optimal in CMD, and better monitoring of treatment as well as transcultural education of healthcare personnel are warranted.

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

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

Health screening among children newly granted asylum in Denmark

AIM

To describe the findings and recommendations of the general health assessment (GHA) of newly resettled refugee children in Denmark.

METHODS

This cross-sectional study included children (aged <18 years) undergoing GHA from 2017 to 2019 at a university hospital Section of Immigrant Medicine. GHA was offered to all refugees newly resettled in the Municipality of Copenhagen. It comprised of a structured questionnaire, clinical examination, blood test and recommendations.

RESULTS

In the study period, 107 children were eligible, 100 children had a GHA performed and of whom all were included in the study. Trauma was reported in 61% (n = 61/100) of children. The median duration of the asylum-seeking process was 18 months (IQR: 8-24), and the highest number of relocations was nine. Latent tuberculosis (n = 2/100 [2%]) was the only infectious disease diagnosed. Specific recommendations for follow-up were frequent and included referral to specialist departments (n = 26/100 [26%]), suggestions for family doctor (n = 96/100 [96%]) and for municipality (n = 62/100 [62%]).

CONCLUSION

Self-reported trauma was frequent among 100 newly resettled refugee children. For most children, the asylum process was protracted and included several relocations. Specific follow-up recommendations were given to the vast majority. GHA may contribute to improving health, which could possibly support integration for the child and family.

The Child Behavior Checklist as a Screening Instrument for PTSD in Refugee Children

Thousands of refugees who have entered Europe experienced threatening conditions, potentially leading to post traumatic stress disorder (PTSD), which has to be detected and treated early to avoid chronic manifestation, especially in children. We aimed to evaluate and test suitable screening tools to detect PTSD in children. Syrian refugee children aged 4-14 years were examined using the PTSD-semi-structured interview, the Kinder-DIPS, and the Child Behavior Checklist (CBCL). The latter was evaluated as a potential screening tool for PTSD using (i) the CBCL-PTSD subscale and (ii) an alternative subscale consisting of a psychometrically guided selection of items with an appropriate correlation to PTSD and a sufficient prevalence (presence in more than 20% of the cases with PTSD). For both tools we calculated sensitivity, specificity, and a receiver operating characteristic (ROC) curve. Depending on the sum score of the items, the 20-item CBCL-PTSD subscale as used in previous studies yielded a maximal sensitivity of 85% and specificity of 76%. The psychometrically guided item selection resulted in a sensitivity of 85% and a specificity of 83%. The areas under the ROC curves were the same for both tools (0.9). Both subscales may be suitable as screening instrument for PTSD in refugee children, as they reveal a high sensitivity and specificity.

Survival states as indicators of learning performance and biological stress in refugee children: a cross-sectional study with a comparison group

BACKGROUND

Our goal was to accurately detect young children at risk for long-term psychiatric disturbances after potentially traumatic experiences in the course of relocation. In addition to detailed assessment of parent-rated parent and child symptomatology, we focused on disruptive behaviors in the education environment summarized as survival states, as these frequently lead to clinical referral.

METHODS

We screened 52 refugee children aged 3-7 (M = 5.14 years, SD = 1.17) for symptoms of Posttraumatic Stress Disorder (PTSD) with the Child and Adolescent Trauma Screening (CATS) in parent rating. The parents' mental health was assessed using the Refugee Health Screener (RHS-15). Furthermore, the child's educators were asked to evaluate the pathological survival states of the child and we made a general assessment of the children's symptoms with the Strengths and Difficulties Questionnaire (SDQ) rated by parents and educators. Children in the refugee sample completed a working memory learning task (Subtest Atlantis from the Kaufmann Assessment Battery for Children, KABC-II) and delivered saliva samples for testing of the cortisol level.

RESULTS

The parental rating of their child's PTSD symptoms was significantly related to their own mental well-being (r = .50, p < .001). Children with survival states in educator ratings exhibited weaker learning performance (F = 3.49, p < .05) and higher evening cortisol levels (U = 113, z = - 1.7, p < .05, one-tailed).

CONCLUSIONS

Survival states are promising indicators for children's learning performance and distress level complementary to parent rating of child PTSD, which is highly intercorrelated with the parents' own symptom load.

TRIAL REGISTRATION

Trial registration number: DRKS00021150 on DRKS Date of registration: 04.08.2020 retrospectively registered.

A pilot study on ecological momentary assessment in asylum-seeking children and adolescents resettled to Germany: Investigating compliance, post-migration factors, and the relation between daily mood, sleep patterns, and mental health

Background

Asylum-seeking children and adolescents (ASCs) resettled to western countries show elevated levels of psychological distress. While research on the mental health of ASCs is increasing, less is known about their day-to-day living experiences such as their daily mood, sleep patterns, and post-migration factors. Moreover, no examination in situ, using smartphone-assisted ecological momentary assessment (EMA), has been conducted up to now among ASCs. Furthermore, we do not know if screening measures succeed in reflecting the daily mood of ASCs experienced in everyday life.

Methods

We undertook a smartphone-assisted EMA study over a two-week period with 3 measurements a day. Participants were N = 40 ASCs from 10 different countries who had resettled to Germany. They completed standardized questionnaires screening for history of trauma and clinical symptoms (post-traumatic stress symptoms, depression, and anxiety) that were carried out in interview-like settings, and they participated in the subsequent EMA where they rated mood, sleep parameters, and post-migration factors on a daily basis. Multilevel models of clinical symptoms, daily mood, and sleep parameters were computed based on a total of 680 measurements.

Results

The multiply traumatized and highly distressed participants reported different levels of discrimination, and various social activities and contacts in the EMA. The overall compliance rate was shown to be 40.5%. Higher PTSS and anxiety scores were associated with lower levels of daily mood and poorer outcomes of some sleep parameters. Depression scores were not associated with any of the variables assessed in the EMA.

Conclusions

Smartphone-assisted EMA among ASCs resettled to Germany proved to be implementable despite a rather low compliance rate. Not only do ASCs show high symptom levels, they are also affected by these symptoms in their daily lives. The results emphasize the need for concise screenings and psychological treatment for this high-risk population. Limitations include the convenient nature of the sample and the lack of a comparison group.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

The health status of newly arrived asylum-seeking minors in Denmark: a nationwide register-based study

OBJECTIVES

Asylum-seeking minors are known to be at increased risk of physical and mental diseases compared to both native children and adult asylum seekers. We present a nationwide register-based study based on the health assessment of 7210 newly arrived minors in Danish asylum centres from 1 January 2011 to 31 December 2015.

METHODS

We describe socio-demographic characteristics, trauma history and symptoms of physical and mental health. To associate the reporting of traumatic events and signs of anxiety or depression, we performed logistic regression analysis.

RESULTS

We found a high, albeit varying, prevalence of traumatic experiences, sleeping and eating problems, and head- and toothache. In the subgroup that was assessed for need of urgent support, more than two of every five minor scored above the threshold. In the subgroup examined by a doctor, one of every four had at least one abnormal finding.

CONCLUSIONS

The prevalence of trauma and mental health symptoms and the association of the two were striking. Our findings underline that timely recognition and appropriate treatment of childhood traumas should be given high priority in the receiving communities.

Asylum-Seeking Children with Medical Complexity and Rare Diseases in a Tertiary Hospital in Switzerland

The aim of this study was to assess the characteristics of asylum-seeking children with medical complexity visiting a tertiary care hospital in Switzerland, detailing their underlying medical conditions and management. Asylum-seeking patients with frequent visits between January 2016 and December 2017 were identified using administrative and electronic health records. Of 462 patients, 19 (4%) fulfilled the inclusion criteria with 811 (45%) visits. The age of the 19 patients ranged from 0 to 16.7 years (median of 7 years) with two main age groups identified: < 2 years and > 12 years. Nine (47%) patients originated from Syria. A total of 34/811(4%) visits were hospital admissions, 66/811 (8%) emergency department visits and 320/811(39%) outpatient department visits. In children < 2 years genetic diseases (5/8; 63%) and nutritional problems (6/8; 75%) were most common; in adolescents, orthopedic diseases (4/8; 50%) and mental health problems (4/8; 50%). Asylum-seeking children with medical complexity represent a small but important group of patients requiring frequent medical consultations. The high proportion of young patients with genetic diseases and severe nutritional problems suggests that new strategies are required in the management of this specific group of asylum-seeking children. This could be achieved by improved co-ordination between hospital and non-hospital care exploring options for integrated care.

Renal Crisis in Children during Armed Conflict

Armed conflicts continue to occur in some regions of the globe, mostly in developing countries. These man-made disasters affect all segments of the population; however, some groups are more vulnerable and suffer more seriously from the unfavorable consequences of such conflicts. Among these, the pediatric population deserves special attention because they cannot protect themselves, and hence carry a higher threat of injuries and probability of death during conflicts. In addition, children who do survive the disaster are more prone to exploitation. Pediatric victims, including those who sustain acute kidney injury or those suffering from chronic kidney disease before armed conflicts, face higher risks of morbidity and mortality as a result of treatment problems, specifically limited dialysis options. Displaced children, forced to flee their homes as a result of armed conflicts, are also at risk for various health problems because they may not find ideal circumstances for disease treatment. Making preparations in anticipation of armed conflicts, such as disaster-relief scenarios and action plans, may be useful to decrease the death toll in these children, who are dependent on their caregivers for survival. Adopting principles of disaster nephrology may contribute to improved survival chances of pediatric kidney patients in chaotic circumstances.

Risk of childhood psychiatric disorders in children of refugee parents with post-traumatic stress disorder: a nationwide, register-based, cohort study

BACKGROUND

Children of refugees are often exposed to the consequences of parental post-traumatic stress disorder (PTSD), potentially leaving them vulnerable to intergenerational transmission of psychopathology. The present study aimed to determine whether parental PTSD is associated with childhood psychiatric morbidity among children of refugees.

METHODS

This study is a two-generation nationwide cohort study using the Danish Immigration Services database. We followed up children younger than 18 years with at least one refugee parent until psychiatric contact, end of the study, their 18th birthday, emigration, or death. We excluded children if their parents were diagnosed only with psychiatric diagnoses other than PTSD or if they had received a psychiatric contact before parental PTSD diagnosis. Information on parental PTSD and offspring psychiatric morbidity was obtained from the Danish Psychiatric Central Research Register. We used Cox proportional hazards regression models to assess the risk of psychiatric contacts among children of refugees with PTSD compared with children of refugees with no psychiatric diagnosis.

FINDINGS

Between Jan 1, 1995, and Dec 31, 2015, 102 010 refugees obtained residency permission in Denmark and 62 239 biological children of refugees were born in Denmark before Dec 31, 2015. 51 793 were eligible and included in the study (median follow-up 7·15 years [IQR 3·37-11·78]); of these, 1307 (2·5%) children had a psychiatric contact. 7486 (14·5%) children of refugees were exposed to parental PTSD. Parental PTSD significantly increased the risk of psychiatric contact in offspring (hazard ratio 1·49 [95% CI 1·17-1·89] for paternal PTSD, p=0·0011; 1·55 [1·20-2·01] for maternal PTSD, p=0·00084) after adjustment for sociodemographic variables.

INTERPRETATION

Children of refugees exposed to parental PTSD are at increased risk of psychiatric morbidity. Targeted screening and interventions are necessary to prevent psychiatric morbidity and ensure access to adequate care.

FUNDING

Section for Immigrant Medicine, Department of Infectious Diseases, Copenhagen University Hospital Hvidovre.

Common mental disorders among young refugees in Sweden: The role of education and duration of residency

BACKGROUND

Studies investigating risks of common mental disorders (CMDs) in refugee youth are sparse. The current study examined health care use due to CMDs in unaccompanied and accompanied refugee youth and Swedish-born, and the role of education and residency duration.

METHODS

This longitudinal cohort study included 746,517 individuals (whereof 36,347 refugees) between 19 and 25 years, residing in Sweden in 2009. Refugees were classified as unaccompanied/accompanied. Risk estimates of CMDs, measured as health care use and antidepressant treatment, between 2010-2016 were calculated as adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Highest attained education in 2009, and residency duration were examined as potential modifiers.

RESULTS

Compared to Swedish-born youth, refugees had a lower risk of treated major depressive and anxiety disorders (aHR): 0.67 (95% CI 0.63-0.72) and 0.67 (95% CI 0.63-0.71) respectively), but a higher risk for posttraumatic stress disorders (PTSD). Compared to Swedish-born, unaccompanied had a nearly 6-fold elevated risk for PTSD (aHR: 5.82, 95% CI 4.60-7.34) and accompanied refugees had a 3-fold risk of PTSD (aHR: 3.08, 95% CI 2.54-3.74). Rates of PTSD decreased with years spent in Sweden. The risk of CMDs decreased with increasing education.

LIMITATIONS

The study lacked information on pre-migration factors. There may further be a potential misclassification of untreated CMDs.

CONCLUSION

Refugees had a lower risk of treated depressive and anxiety disorders but a higher risk for PTSD. In refugees, the rates of anxiety disorders increased slightly over time whereas the rates of PTSD decreased. Last, low education was an important predictor for CMDs.

Psychological morbidity among forcibly displaced children-a literature review

In 2018, nearly 75 million people were displaced from their place of origin of which 20.4 million are considered as refugees. Children constitute over half of this population. A review of the currently available literature regarding the psychological impact of forced displacement on children was performed with the concept examined under three stages of flight: pre-migration, intra-migration and post-migration. The resilience of children despite adversities is explored. Post-traumatic stress disorder (PTSD), depression and anxiety are the most commonly studied effects of forced migration on children. Rates range from 20 to 52.7%, 23 to 44.1% and 38.3 to 69% respectively. PTSD is associated with pre-migration disturbances such as witnessing death or torture of relatives, assaults and separation from family. Intra-migration difficulties relate to the hazardous journey, length of detention, type of facility and failed asylum application. Post-migration difficulties highlighted are insecure asylum status, housing worries, multiple relocations and poor acculturation technique and are more related to depression and anxiety. Despite these challenges and the tremendous horror witnessed, the majority of children report good functionality in their host countries in the long-term. The purpose of this report is to provide an overview of the factors contributing to the manifestation of mental health issues in child refugees as well as to examine mechanisms which enhance successful resettling in the host society. Health and social care providers must understand the complex interplay between the damaging effects of displacement, and the innate protective factors that persecuted children possess. Management should involve a holistic approach that considers children, families and native communities.

Mental Health of Refugee Children and Youth: Epidemiology, Interventions, and Future Directions

The number of refugee youth worldwide receives international attention and is a top priority in both academic and political agendas. This article adopts a critical eye in summarizing current epidemiological knowledge of refugee youth mental health as well as interventions aimed to prevent or reduce mental health problems among children and adolescents in both high- and low-to-middle-income countries. We highlight current challenges and limitations of extant literature and present potential opportunities and recommendations in refugee child psychiatric epidemiology and mental health services research for moving forward. In light of the mounting xenophobic sentiments we are presently witnessing across societies, we argue that, as a first step, all epidemiological and intervention research should advocate for social justice to guarantee the safety of and respect for the basic human rights of all refugee populations during their journey and resettlement. A constructive dialogue between scholars and policy makers is warranted.

Asylum seeking children and adolescents in Australian immigration detention on Nauru: a longitudinal cohort study

INTRODUCTION

Immigration detention has a profound and negative impact on the physical health, mental health, development and social-emotional well-being of children, adolescents and their families. Australian clinicians will report results from detailed health and well-being assessments of asylum seeking children and adolescents who have experienced prolonged immigration detention.

METHODS AND ANALYSIS

This is a national, multicentre study with a longitudinal cohort design that will document health and well-being outcomes of the children and adolescents who have been detained in offshore detention on the remote island of Nauru. Outcome measures will be reported from the time arrival in Australia and repeated over a 5-year follow-up period. Measures include demographics, residency history and refugee status, physical health and well-being outcomes (including mental health, development and social-emotional well-being), clinical service utilisation and psychosocial risk and protective factors for health and well-being (eg, adverse childhood experiences). Longitudinal follow-up will capture outcomes over a 5-year period after arrival in Australia. Analysis will be undertaken to explore baseline risk and protective factors, with regression analyses to assess their impact on health and well-being outcomes. To understand how children's outcomes change over time, multilevel regression analysis will be utilised. Structural equation modelling will be conducted to explore the correlation between baseline factors, mediational factors and outcomes to assess trajectories over time.

ETHICS AND DISSEMINATION

This research project was approved by the Sydney Children's Hospitals Network Human Research Ethics Committee. Subsequent site-specific approvals have been approved in 5 of the 11 governing bodies where the clinical consultations took place. In order to ensure this research is relevant and sensitive to the needs of the cohort, our research team includes an asylum seeker who has spent time in Australian immigration detention. Results will be presented at conferences and published in peer-reviewed Medline-indexed journals.

Pediatric Healthcare Utilization in a Large Cohort of Refugee Children Entering Western Europe During the Migrant Crisis

: Background: Currently, half of the population displaced worldwide is children and adolescents. Little is known on healthcare demand in underage migrants.

MATERIALS AND METHODS

We analyzed healthcare utilization in n = 1.411 children and adolescents living in a large German refugee reception in 2015-2016.

RESULTS

The mean age of all included refugees was 9 years (60.8% male). The majority came from the eastern Mediterranean region. During a mean camp inhabitance of 34 days, 57.6% needed primary healthcare, with a significant inverse correlation of healthcare seeking frequency with age and duration of camp inhabitance. Infants and unaccompanied minors displayed particular high demands for medical help.

DISCUSSION

Our analysis showed that pediatric primary healthcare in pediatric and adolescent refugees are most sought during the first period upon arrival with particular demand in infants, toddlers, and unaccompanied minors. Based on this data, future care taking strategies should be adapted accordingly.

Measuring subjective well-being in an understudied population of young Western-African IDPs and refugees

Purpose

The purpose of this paper is to report a real-life empirical case and discuss some caveats emerged in measuring subjective well-being (SWB) in an understudied population of adolescents refugees from West Africa.

Design/methodology/approach

During the process of translation and cultural adaptation of the subjective well-being assessment scale in the target population, the model of measurement presented some weakness with regard to content validity criteria.

Findings

This leads to a partial revision of the model and the development of new locally-based domains of SWB.

Originality/value

Context-specific factors’ robustness showed the dynamic and culture-informed nature of the SWB construct. Practical and theoretical implications of using quantitative questionnaires in non-western contexts characterized by high grades of insecurity and instability will be discussed.

Management of mental health conditions in refugee youth: An overview for the psychiatric-mental health nurse practitioner

TOPIC

In 2017, there were a total of 70 million forcibly displaced individuals or refugees, worldwide. Unfortunately, over 50% of refugees are under the age of 18 years. Refugee youth are at-risk for a variety of mental health conditions.

PURPOSE

The purpose of this report is to provide psychiatric-mental health nurse practitioners (PMHNPs) with an understanding of unique cultural implications in refugee youth, risk factors towards the development of psychiatric illness, and means to identify those at-risk for sequelae or those meeting diagnostic criteria. Also presented are foundational treatment and management implications to ensure the provision of culturally sensitive and efficacious care to this unique population.

SOURCES USED

Utilizing PubMed, CINAHL, and PsycINFO, a literature review was conducted to identify relevant publications pertaining to mental health issues in refugee youth spanning from 2013 to present. Reference lists of identified articles were also searched.

CONCLUSIONS

A variety of risk and protective factors are discussed, spanning from premigration, during flight, and postsettling periods. PMHNPs must be proficient in screening and diagnosis of mental health conditions in refugee youth and implementation of pharmacological and psychotherapeutic interventions. PMHNPs must also be well versed in community-based resources that can be utilized to promote optimal outcomes.

Complexities of conducting research in adolescent refugees resettling in Australia

Adolescent refugees resettling in Australia are a vulnerable and marginalised population. Dedicated research to help better understand their health-care needs remains scarce. There are multiple complexities which may deter health professionals from conducting research with this population. Health-care system barriers, such as lack of adolescent- and refugee-specific health-care services, complicate comprehensive data collection. Limited investigator knowledge pertaining to culturally appropriate research in a population with limited English proficiency or a history of trauma can have an impact on adolescent participation and retention in research studies. Additional ethical and legal issues relating to adolescent consent and confidentiality, which include suicidality and physical or sexual abuse, can arise during research and cause potential harm to adolescents if not managed appropriately. This article highlights current knowledge and understanding relating to these issues along with recommendations to address barriers and safeguard adolescents, with the aim of promoting high-quality research that will benefit resettling adolescent refugees.

Prevention of psychological distress and promotion of resilience amongst unaccompanied refugee minors in resettlement countries

AIM

As increasing numbers of unaccompanied refugee minors (URMs) are arriving in Europe, there is a need to investigate which factors promote psychological resilience and improve their mental health. This review aims to identify preventive post settlement influences, including living arrangements, access to mental health services, and effective treatments that may improve mental health outcomes.

METHODS

A systematic literature review was conducted of published papers in any language for children (<18 years) entering a host country, unaccompanied and seeking asylum. Specific studies were eligible if they examined any treatment or nontreatment influences on mental health or psychological resilience for the URM. Thirteen published quantitative studies were identified.

RESULTS

URMs in more supportive living arrangements including foster care had lower risk of PTSD and lower depressive symptoms compared with those in semi-independent care arrangements. URMs living in reception settings that restricted freedom had more anxiety symptoms. Regarding help seeking, one study found only 30% of URMs had foster parents or guardians who could detect a mental health need. Two papers found the URMs had low levels of contact with mental health services despite the high prevalence of psychiatric symptoms. URMs were less likely than accompanied children to receive trauma-focused interventions, cognitive therapy, or even practical assistance with basic social needs. With regard to treatment evaluation, only case series were identified. Three studies found cognitive behavioural therapy improved PTSD symptoms and mental health outcomes. A less structured approach (mental health counselling alone) did not improve functional health outcomes.

CONCLUSION

Higher support living arrangements with low restrictions are associated with lower psychological distress. Most URMs are not receiving psychological interventions, and there is a dearth of studies evaluating treatment effectiveness for this group. There is an urgent need for more research to investigate pathways to mental health services and treatment efficacy in this vulnerable group.

Addressing Marginality and Exclusion: The Resettlement Experiences of War-Affected Young People in Quebec, Canada

Accessing meaningful forms of support can be an onerous experience for young people resettling from war-affected contexts. In addition to facing linguistic and financial barriers in this process, these young people negotiate care systems that are often structurally and culturally insensitive to their unique needs, values, beliefs, and intersectional experiences of oppression. Drawing on interviews with 22 young people from war-affected areas living in Quebec, Canada, this paper critically examines how dominant cultural norms and social relations in Quebec's health, social and educational services network shape their experiences in seeking care, healing and belonging. Alternative care systems and approaches, as proposed by the participants, are then explored. The findings emphasize the need for spaces and care services where war-affected young people's identities and lived realities are validated and represented.

Trauma and resilient functioning among Syrian refugee children

Following the civil war in Syria, there has been a growing interest in the impact of war, violent conflict, and refuge on the development and mental health of refugee children in general and Syrian refugee children in particular. The objective of this paper is threefold: (a) to critically review the existing literature on the psychological functioning of Syrian refugee children, with a particular focus on those residing in the urban areas or camps in Turkey; (b) to identify the main theoretical and methodological problems of this emerging literature; and (c) to suggest guidelines for how to improve research and practice in this field. The reviewed literature predominantly focuses on psychological trauma, trauma-related symptomatology or other maladaptive functioning in children, and psychosocial interventions conducted toward alleviating these issues. This paper will summarize the research findings in the above-mentioned topics to discern what can be known from the existing literature on Syrian refugee children.

Psychiatric screening and interventions for minor refugees in Europe: an overview of approaches and tools

Currently hundreds of thousands of minor refugees entered Europe. This group has been exposed to traumatic events pre-, during, and post-migration and is at increased risk of developing psychiatric disorders. In this article, we describe the results of our literature search on screening and interventions for post-traumatic stress disorder (PTSD) in minor refugees, in order to make recommendations for clinical practice. Results show that studies on diagnostic accuracy of assessment instruments and efficacy of mental healthcare interventions in this population are lacking. Traumatic experiences pre-flight, during the flight and at resettlement, superimposed by parental PTSD, and other contextual factors, might lead to more than 25% of minor refugees developing PTSD.

CONCLUSION

To enhance the number of minor refugees recognized with PTSD, we recommend the use of a brief screening instrument. A public health approach, focusing on environmental supportive factors is the first step in treatment for this group, followed by short-term psychological group interventions focusing on psycho-education and stress reduction. Minor refugees with no improvement in PTSD symptoms by these interventions need referral to specialized mental health care services. Mental health providers should be culturally competent. What is Known: • Post-traumatic stress disorder, anxiety, sleeping problems, and depression are the most common psychiatric disorders in minor refugees. • Evidence based methods on screening and interventions in minor refugees with psychiatric disorders are lacking. What is New: • In the absence of validated screening tools a best practice reliable, quick and child-friendly tool is presented. • A layered system for mental health care and psychosocial support in minor refugees is explained.

Disparities in access to care in marginalized populations

PURPOSE OF REVIEW

The current article reviews recent literature related to three groups whose health is affected by barriers to the healthcare system: refugee and immigrant populations; youth who are lesbian, gay, bisexual, transgender, queer, or questioning; and those with mental health problems.

RECENT FINDINGS

Refugee and immigrant populations are increasing worldwide, and recent work has focused on improving their access to mental, dental, and preventive care. Lesbian, gay, bisexual, transgender, queer, or questioning youth have unique healthcare needs but frequently lack a support system and may not be forthcoming about their sexuality or sex identity. A rising number of children are being diagnosed with mental health disorders, but due to multiple factors, youth are not receiving the care they need.

SUMMARY

Pediatric healthcare providers should be aware of the unique challenges faced by youth displaced from their country of origin, who are lesbian, gay, bisexual, or transgender or are questioning their sexuality or sex identity, and who struggle with mental health disorders. Toolkits, other educational resources, and novel technological advances can assist pediatricians in ensuring optimal health care of these at-risk groups.