A 6-year follow-up study of Cambodian refugee adolescents traumatized as children

Post-traumatic stress disorder in refugee minors in an outpatient care center: prevalence and associated factors

Due to their likelihood for experiencing a number of traumatic events, refugee minors have an increased risk of developing post-traumatic stress disorder (PTSD). However, the prevalence of PTSD in refugee children varies widely between studies, and it remains somewhat unclear what factors increase children's risk of PTSD. This study aimed to assess the prevalence of PTSD in a clinical outpatient sample of refugee minors, and to evaluate the association of different risk factors with a PTSD diagnosis. N = 417 refugee minors were recruited from an outpatient clinical center in Hamburg, Germany. The median age was 15.4 years and 74.6% of the minors were male. As part of the standard diagnostic process, their social history and a potential PTSD diagnosis using the Module K of the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) was assessed. The predictive value of age, gender, number of interpersonal traumatic events, un-/accompanied status, presence of family member in the host country, flight duration, residence status, and time since arrival in the host country were investigated using logistic regression analysis. The prevalence of PTSD among the young refugee patients was 61.6%. Significant predictors of a PTSD diagnosis were number of interpersonal traumatic life events, age, residence status, and time since arrival in the host country. The prediction model explained 33.8% of variance of the outcome with the number of interpersonal traumatic events having the largest contribution (20.8%). The high prevalence of PTSD among refugee minors in outpatient care emphasizes the need to establish appropriate care structures and train specialists in the treatment of PTSD.

The relationship of pre- and post-resettlement violence exposure to mental health among refugees: a multi-site panel survey of somalis in the US and Canada

BACKGROUND

A large body of research highlights the lasting impact of pre-resettlement violence on the mental health of refugees after resettlement. However, there is limited research on violence exposure after resettlement and its association with mental health. We examine the association of pre- and post-resettlement violence with post-resettlement mental health symptoms in a survey of Somali refugees in the US and Canada.

METHODS AND FINDINGS

We collected survey data from 383 Somalis across five cities in the US and Canada (Boston, MA; Minneapolis, MN; Lewiston, NC; Portland, ME; Toronto, Canada). Wave 1 data were collected between May 2013 and January 2014, while Wave 2 was collected between June 2014 and August 2015. Data from both waves were used to examine whether the association of past violence exposures persists across time and with more recent violence exposures. The War Trauma Screening Scale assessed exposure to any pre- and post-resettlement violence at Wave 1, while the My Exposure to Violence scale assessed any past-year violence exposure at Wave 2. Mental health outcomes included symptoms of depression and anxiety (Hopkins Symptom Checklist) and post-traumatic stress symptoms (Harvard Trauma Questionnaire). Separate linear regression models at Waves 1 and 2 examined the relationship of past violence exposure to standardized scores of mental health symptoms. Participants were 22 years of age, on average. Fifty-six percent of our sample had been exposed to violence after resettlement by Wave 2. At Wave 1, the associations of pre- and post-resettlement violence with mental health were comparable in magnitude across depression [β = 0.39, 95% CI (0.21 0.57) vs. β = 0.36, 95% CI (0.10 0.62)], anxiety [β = 0.33, 95% CI (0.12 0.55) vs. β = 0.38, 95% CI (0.01 0.75)], and PTSD [β = 0.55, 95% CI (0.37 0.72) vs. β = 0.47, 95% CI (0.21 0.74)]. At Wave 2, pre-resettlement violence was associated with depressive symptoms only [β = 0.23, 95% CI (0.06 0.40)], while past-year exposure to violence had the largest association with all mental health outcomes [depression: β = 0.39, 95% CI (0.17 0.62); anxiety: β = 0.46, 95% CI (0.01 0.75); PTSD: β = 0.67, 95% CI 0.46 0.88)].

CONCLUSIONS

Our study is the first to examine refugees' exposure to post-resettlement violence across time, finding that Somali refugees' exposure is both persistent and prevalent after resettlement. Post-resettlement violence had a larger association with mental health than pre-resettlement exposure by Wave 2. Our study highlights the urgent need to understand the role of post-resettlement violence exposure for refugees in the US and Canada.

DSM-5-Based ASD Models: Assessing the Latent Structural Relations with Functionality in War-Exposed Individuals

There is a dearth of studies investigating the latent structure of Acute Stress Disorder (ASD) following the changes in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5). To date, there is no consensus on the best representation of ASD. This study addressed this gap by examining four latent ASD models in a sample of war-exposed individuals (N = 424). Investigation on the relationship of the best-fitting model to functionality in the latent level was also conducted. The five-factor model, composed of intrusion, avoidance, numbing, dysphoric arousal, and anxious arousal factors, yielded the best-fitting model. Latent associations between the factors of the model and functionality suggest that symptoms of functionality do not significantly affect the factor structure of ASD. These findings have implications for understanding the underlying mechanism of ASD and can inform the development of more nuanced trauma-related interventions, particularly addressing ASD symptoms and functionality separately.

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.

The Strengths and Difficulties Questionnaire as a Mental Health Screening Tool for Newly Arrived Pediatric Refugees

Many refugee children have exposure to trauma prior to arrival and during resettlement. Mental health screening in primary care among resettled refugee children is needed. The Strengths and Difficulties Questionnaire (SDQ) was used to screen refugee children age 4-18 years at their Domestic Medical Examination and three other primary care visits in their first year of resettlement. We tested the association between time and SDQ score or intervention/referral, and differences based on geographic origin. SDQ scores were highest upon arrival (Ps < .0005). Referrals were most common at the six-month visit compared to arrival and one month (Ps < .01). Iraqi children had higher SDQ scores at all visits (Ps < .03). The SDQ can be used in primary care to screen newly arrived refugee children. Practitioners should screen at arrival to identify difficulties. Those with difficulties continuing at six months may need an intervention or referral.

Supporting Syrian families displaced by armed conflict: A pilot randomized controlled trial of the Caregiver Support Intervention

BACKGROUND

The impact of armed conflict and displacement on children's mental health is strongly mediated by compromised parenting stemming from persistently high caregiver stress. Parenting interventions for refugees emphasize the acquisition of parenting knowledge and skills, while overlooking the deleterious effects of chronic stress on parenting. War Child Holland's Caregiver Support Intervention (CSI) aims to strengthen parenting by lowering stress and improving psychosocial wellbeing among refugee parents, while also increasing knowledge and skill related to positive parenting. The CSI is a nine-session group intervention delivered by non-specialist providers.

OBJECTIVE

We describe the findings of a two-arm pilot randomized controlled trial of the CSI with Syrian refugees in Lebanon. The primary aim was to test the feasibility of our study methodology prior to conducting a definitive RCT.

METHODS

We recruited 78 families (151 parents), who were randomized to the CSI or a waitlist control group. Data were collected at baseline and post-intervention.

RESULTS

Randomization was successful, retention was high (99 %), as was intervention completion (95 % among women, 86 % among men). Implementation fidelity was excellent. Blinding was largely, though not completely effective. The CSI group showed significantly increased parental warmth and responsiveness, decreased harsh parenting, lowered stress and distress, improved psychosocial wellbeing, and improved stress management. CSI parents reported increased child psychosocial wellbeing. Control families showed no significant change on any variable.

CONCLUSIONS

Findings demonstrate the feasibility of our methodology for a definitive RCT, and suggest that the CSI shows promise as a scalable approach to strengthening parenting in refugee communities. Trial registration # ISRCTN33665023.

1-year follow-up of the mental health and stress factors in asylum-seeking children and adolescents resettled in Germany

Background

Asylum-seeking children and adolescents (ASCs) who have resettled in Western countries show elevated rates of psychological distress, including Posttraumatic Stress Symptoms (PTSS), depression, and anxiety. Most longitudinal data suggest a relatively stable course of symptoms during the first years in exile. However, no longitudinal examination of the mental health of ASCs, who resettled in Europe in the wake of the 2015–17 European migrant crisis, has been conducted so far.

Methods

A prospective cohort study looked at 98 ASCs who resettled in southern Germany throughout 2015–17. They mainly came from Afghanistan, Syria, Eritrea, and Iraq. Baseline assessments were undertaken 22 months, on average, after resettlement, and follow-up assessments 1 year thereafter. Seventy-two ASCs could be secured for the follow-up. The measures included self-report questionnaires screening for PTSS, depression, anxiety, externalizing behavior, and post-migration factors that were administered in an interview-like setting. Results were analyzed using hierarchical multiple regression analysis.

Results

Participating ASCs reported on average eight potentially traumatic experiences and high levels of psychological distress at baseline that had significantly declined at follow-up. At follow-up, rates of clinically significant symptoms ranged from 9.7% (externalizing behavior) to 37.5% (PTSS). There was considerable individual variation in symptom change resulting in multiple mental health trajectories. ASCs whose asylum applications had been rejected presented significantly more symptoms than ASCs whose asylum applications had been accepted between assessments. Baseline psychopathology and asylum status predicted follow-up symptom severity.

Conclusions

In contrast to earlier studies, the symptom severity in this sample of ASCs in Germany ameliorated between assessments. Decisions on the asylum applications of ASCs are thought to contribute to the course of symptoms. Since levels of psychological distress were still high, dissemination and implementation of appropriate treatments for ASCs is crucial.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7263-6) contains supplementary material, which is available to authorized users.

Mental health needs and services for migrants: an overview for primary care providers

BACKGROUND

The objective of this article is to present an overview of the burden, spectrum of diseases and risk factors for mental illness among subgroups of migrants, namely, immigrants, refugees and individuals with precarious legal status. This expert review summarises some of the implications for primary care services in migrant receiving countries in the global North.

METHODS

A broad literature review was conducted on the epidemiology of mental health disorders in migrants and the available evidence on mental health services for this population focusing on key issues for primary care practitioners in high-income countries.

RESULTS

Although most migrants are resilient, migration is associated with an over-representation of mental disorder in specific subpopulations. There is a general consensus that stress-related disorders are more prevalent among refugee populations of all ages compared to the general population. Relative to refugees, migrants with precarious legal status may be at even higher risk of depression and anxiety disorders. Persistence and severity of psychiatric disorders among migrant populations can be attributed to a combination of factors including severity of trauma exposures during the migration process. Exposure to stressors after resettlement, such as poverty and limited social support, also impacts mental illness. Services for migrants are affected by restricted accessibility and should address cultural and linguistic barriers to and issues in the larger social environment that impact psychosocial functioning.

CONCLUSION

There is substantial burden of mental illness among some migrant populations. Primary care providers seeking to assist individuals need to be cognizant of language barriers to and challenges of working with interpreters as well as sensitive to cultural and social contexts within the diagnosis and service delivery process. In addition, best practices in screening migrants and providing intervention services for mental disorders need to be sensitive to where individuals and families are in the resettlement trajectory.

Review: How should child mental health services respond to the refugee crisis?

BACKGROUND

Child mental health services and related agencies are faced with an increasing challenge in responding to the influx of refugee children around the world. There is strong evidence on the prevalence and complexity of these children's mental health problems and broader needs.

AIMS

To review the research literature on risk and protective factors, and associated mental health interventions for refugee children.

METHODS

Peer-reviewed studies were included for the period 2004-2017; if they included refugee, asylum-seeking or internally displaced children under 18 years; and adopted a quantitative design. Vulnerability and protective factors for refugee children were considered in this context, followed by the respective types of interventions at pre-, peri- and postmigration stage, and across high- and low-/middle-income countries. Eighty-two peer-reviewed studies fulfilled the selection criteria.

RESULTS

The existing body of literature is largely based on identifying risk factors among children with mental health problems and predominantly designing trauma-focused interventions to reduce their symptomatic distress. Recent research and services have gradually shifted to a broader and dynamic resilience-building approach based on ecological theory, that is at child, family, school, community and societal level. There is increasing evidence for the implementation and effectiveness of multimodal interventions targeting all these levels, despite the methodological constraints in their evaluation.

CONCLUSIONS

In high-income countries, child mental health services need to collaborate with all agencies in contact with refugee children, establish joint care pathways, and integrate trauma-focused interventions with family and community approaches. In low- and middle-income countries, where specialist resources are sparse, resilience-building should aim at maximising and upskilling existing capacity. A six-dimensional psychosocial model that applies to other children who experience complex trauma is proposed.

Adjustment of refugee children and adolescents in Australia: outcomes from wave three of the Building a New Life in Australia study

BACKGROUND

High-income countries like Australia play a vital role in resettling refugees from around the world, half of whom are children and adolescents. Informed by an ecological framework, this study examined the post-migration adjustment of refugee children and adolescents 2-3 years after arrival to Australia. We aimed to estimate the overall rate of adjustment among young refugees and explore associations with adjustment and factors across individual, family, school, and community domains, using a large and broadly representative sample.

METHODS

Data were drawn from Wave 3 of the Building a New Life in Australia (BNLA) study, a nationally representative, longitudinal study of settlement among humanitarian migrants in Australia. Caregivers of refugee children aged 5-17 (N = 694 children and adolescents) were interviewed about their children's physical health and activity, school absenteeism and achievement, family structure and parenting style, and community and neighbourhood environment. Parent and child forms of the Strengths and Difficulties Questionnaire (SDQ) were completed by caregivers and older children to assess social and emotional adjustment.

RESULTS

Sound adjustment according to the SDQ was observed regularly among young refugees, with 76-94% (across gender and age) falling within normative ranges. Comparison with community data for young people showed that young refugees had comparable or higher adjustment levels than generally seen in the community. However, young refugees as a group did report greater peer difficulties. Bivariate and multivariate linear regression analyses showed that better reported physical health and school achievement were associated with higher adjustment. Furthermore, higher school absenteeism and endorsement of a hostile parenting style were associated with lower adjustment.

CONCLUSIONS

This is the first study to report on child psychosocial outcomes from the large, representative longitudinal BNLA study. Our findings indicate sound adjustment for the majority of young refugees resettled in Australia. Further research should examine the nature of associations between variables identified in this study. Overall, treating mental health problems early remains a priority in resettlement. Initiatives to enhance parental capability, physical health, school achievement and participation could assist to improve settlement outcomes for young refugees.

Prevalence of and risk factors for mental disorders in refugees

Given the increasing numbers of refugees worldwide, the prevalence of their mental disorders is relevant for public health. Prevalence studies show that, in the first years of resettlement, only post-traumatic stress disorder (PTSD) rates are clearly higher in refugees than in host countries' populations. Five years after resettlement rates of depressive and anxiety disorders are also increased. Exposure to traumatic events before or during migration may explain high rates of PTSD. Evidence suggests that poor social integration and difficulties in accessing care contribute to higher rates of mental disorders in the long-term. Policy and research implications are discussed.

Effect of relocation after a natural disaster in Armenia: 20-year follow-up

BACKGROUND

This study is a 20-year follow-up of individual's relocated from their home after the devastating earthquake in Armenia in 1988.

METHODS

Ninety-seven subjects who were exposed to the earthquake and thirty-seven subjects who were not exposed to the earthquake were administered the Symptom Checklist-90-R (SCL 90) and the UCLA PTSD Reaction in 2008. The exposed subjects comprised three groups: subjects who stayed in the earthquake city; those who relocated and returned; and a group who left permanently but were visiting family at the time of the study.

RESULTS

The Stayed group had significantly higher scores on the SCL-90-R when compared to the other three groups. The Stayed group and the Relocated group had significantly higher scores for partial and full PTSD than the Left group and the comparison group.

CONCLUSION

Permanent relocation to another country where one is able to start a new life in a safe environment provides the best adaptation for recovery when the destruction and delay in reconstruction lasted as long as it did in Armenia.

A Systematic Review of Longitudinal Risk and Protective Factors and Correlates for Posttraumatic Stress and Its Natural History in Forcibly Displaced Children

BACKGROUND

Posttraumatic stress (PTS) results in significant distress or functional impairment. Prevalence studies report higher rates of PTS in forcibly displaced children (FDC). Current evidence deriving mainly from cross-sectional studies is unable to make causal attributions. Given rising rates of forcible displacement reported by the United Nations High Commissioner for Refugees (UNHCR) in 2014, there is increasing need to determine the best policies and practice for engaging mental health needs of FDC.

METHODS

This systematic review identifies (1) longitudinal risk and protective factors and correlates for PTS and (2) its natural history in FDC, contributing to research identifying vulnerable subgroups and malleable factors for PTS and understanding its natural history. No meta-analysis was conducted due to heterogeneity; results were analyzed through narrative synthesis.

RESULTS

Eleven longitudinal studies were identified. All but one were prospective cohort designs. They identified prevalence rates between 20% and 48.7% at baseline, 10% and 48.3% at 1 year ( k = 7), 18% and 48% at 2-3 years ( k = 2), 8% and 38% at 6 years ( k = 2), and 35% at 12 years using nine measurement methods in seven independent samples. Evidence from multiple associations supported the following risk factors: exposure to traumatic stressors or other stress, older age, and prior psychopathology. Evidence predominantly supported the stability of PTS with some decline.

CONCLUSION

While results should be interpreted with caution given small or unrepresentative samples, they suggest regular mental health screenings should be conducted for FDC, who are a vulnerable subgroup with variable onset and remission. Risk associations with prior psychopathology also suggest that screening upon arrival may be advisable for early intervention and prevention.

Effects of maternal traumatic distress on family functioning and child mental health: An examination of Southeast Asian refugee families in the U.S

BACKGROUND

The psychological effects of trauma are well-documented among refugee adults and children alone, yet less research has attended to the intergenerational transmission of trauma within refugee families. Additionally, there is considerable diversity between refugee populations as well as within-group variation in the experiences and effects of refugee trauma.

OBJECTIVE

The current study examines the longitudinal effects of maternal traumatic distress on family functioning and child mental health outcomes among Southeast Asian refugee women and their adolescent children. Given the potential for variation in these effects, we also explore group differences in these relationships by ethnicity and child nativity.

METHODS

Longitudinal data were collected from a random sample of 327 Southeast Asian refugee mothers and their children in the United States. We employed structural equation modeling to examine associations between latent variables representing maternal traumatic distress, family functioning, and child mental health outcomes (i.e., depressive symptoms, antisocial and delinquent behavior, and school problems). We then tested for group differences in these associations by ethnicity (Cambodian and Vietnamese subgroups) and child nativity (U.S.-born and foreign-born children).

RESULTS

We found maternal traumatic distress was indirectly linked to child mental health outcomes, and that child nativity was associated with these paths while ethnicity was not. For foreign-born children, maternal traumatic distress was associated with diminished family functioning a year later, which was associated with increased school problems at the two-year mark. Maternal traumatic distress was indirectly associated with depressive symptoms and antisocial and delinquent behavior, respectively, after accounting for family functioning. For all children, weaker family functioning was significantly associated with poorer mental health.

CONCLUSIONS

Findings suggest that refugee parents' trauma can adversely affect family relationships and the mental health of children. Interventions that address parental trauma and support intergenerational relationships may enhance mental health within refugee communities for future generations.

The mental health of civilians displaced by armed conflict: an ecological model of refugee distress

Early research on the mental health of civilians displaced by armed conflict focused primarily on the direct effects of exposure to war-related violence and loss. Largely overlooked in this war exposure model were the powerful effects of ongoing stressors related to the experience of displacement itself. An ecological model of refugee distress is proposed, drawing on research demonstrating that mental health among refugees and asylum seekers stems not only from prior war exposure, but also from a host of ongoing stressors in their social ecology, or displacement-related stressors. Implications of this model for addressing the mental health and psychosocial needs of refugees and other displaced populations are considered.

Posttraumatic stress and depression in Yazidi refugees

AIM

The aim of this investigation was to determine the frequency of mental pathologies in children and adolescents of the Yazidi minority group who immigrated to Turkey from Iraq. The refugees were asked about preventive and risk factors that occurred before and after their immigration.

SUBJECTS AND METHODS

The sample comprised 55 children and adolescents (30 males and 25 females) who were Yazidi refugees and had settled in the Uçkuyular, Oğuz, Onbaşı, and Uğurca villages of Batman, Turkey. The study was conducted 9 months after the refugees had immigrated. The participants were evaluated in their native language through a semistructured interview titled "Reliability and Validity of Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version - Turkish Version". A sociodemographic form was prepared so that investigators could understand their traumatic experiences before and after the migration and their current social conditions. All the interviews were conducted in the participants' native language without the help of translators. The investigators filled out the sociodemographic forms.

RESULTS

Posttraumatic stress disorder (PTSD) was detected in 20 children (36.4%), depression in 18 (32.7%), nocturnal enuresis in six (10.9%), and anxiety in four (7.3%). The following factors were found to be associated with depression: witnessing violence and/or death, being a girl, having older parents, being the elder child, and having multiple siblings (P<0.05). Risk factors for PTSD, depression, and comorbid conditions included witnessing violence and/or death (P<0.05). Four participants were observed to have both PTSD and depression (7.3%).

CONCLUSION

Most of the refugee children had experienced serious traumatic events in their home country. PTSD, depression, and comorbid mental problems are frequently seen in refugee children.

The Mental Health of Refugee Children

Refugee children are generally considered to be at high risk for mental health problems because of the extreme stressors they experience in the pre- and post-migration periods. This paper summarizes current knowledge on the manifestations of emotional disorder among refugee children and on the associated risk and protective factors. Special attention is given to the interaction of culture with the specific family, social and cultural context of refugee children. Intervention and preven tion services, as well as the implementation of community programs, are discussed.

Child Psychiatry and the Developing World: Recent Developments

ABSIRACT: The authors examine the growth and role of child psychiatry in the developing world over the last 25 years. They review national epidemiologi cal studies of the prevalence of child psychiatric disorders, culture-specific symptoms of maladjustment and the evidence for culture-specific parenting patterns. They consider the impact of social change on psychiatric disorders in the Third World, identify ing specific protective factors (e.g. gender, intelli gence, special schooling, social skills) and vulner ability factors (e.g. poor diet). The authors then examine the role of culturally sensitive intervention strategies. Training programs for child psychiatrists in the developing world must encompass both medical and public health models. The review closes with a brief discussion of urgent research questions and a summary of the most pressing clinical requirements for child psychiatry in the developing world.

Refugee Trauma

Epidemiological studies and theoretical models of refugee trauma based on ethnographic, biomedical and sociopolitical perspectives have focused on a variety of cultural and ethnic groups since World War II. Subjective distress and problems in psychosocial functioning are influenced by individual, fam ily, cultural and social variables. Refugees are at risk for developing psychiatric illness resulting from pre-migration, migration and post-migration experiences. This paper reviews biological, psychological and sociocultural models for recog nizing, conceptualizing and treating the psychiatric problems of traumatized refugees. The treatment approach of the Oregon Indochinese Psychiatric Program is summarized.

Bereavement Responses among Palestinian Widows, Daughters and Sons Following the Hebron Massacre

In February 1994, an Israeli settler shot Muslim worshippers at the Ibrahime Mosque at Hebron, West Bank. Fifty-three people were killed, and 200 injured. The Derogatis Symptom Checklist-Revised (SCL-90-R), a 90-item 5-point self-administered discomfort scale was administered to all surviving widows ( n=23), daughters ( n=12), and sons ( n=26). Statistically significant different results occurred in 3 of 9 subscales. Widows scored higher somatization than the daughters, who scored higher than the sons. Daughters scored higher phobia than the widows, who scored higher than the sons. Widows scored higher anxiety than the daughters, who scored higher than the sons. Culturally-and-religiously-proscribed gender and familial roles appear to contribute to the different bereavement response patterns. No respondents sought professional mental health counseling.

Exploring communication of traumatic experiences from Khmer Rouge genocide survivors to their offspring: In-depth interviews with both generations

BACKGROUND

Traumatic events experienced by parents who have survived genocide influence mental health among their offspring. This study aims at exploring how the communication of traumatic events between Khmer Rouge survivors and their offspring was perceived by both generations.

METHODS

Qualitative interviews were performed with six Khmer Rouge survivors and with six young people representing the second generation and were analysed using a content analysis approach.

DISCUSSION

Parents felt that informing their children was important to instill gratitude for living a better life and to empower them. Among children, this was met with empathy but sometimes also disbelief and at times they blamed their parents for being too submissive.

CONCLUSION

The study discloses the complexity, pros and cons of intergenerational sharing of trauma.

Familial separations, coping styles, and PTSD symptomatology in resettled refugee youth

Youth from refugee backgrounds have been found to experience high rates of posttraumatic stress disorder (PTSD), even after years of resettlement. The present study sought to investigate how familial separations and coping styles act as correlates of PTSD symptoms in resettled refugee youth (N = 50). Participants (Mage = 16.63; range: 12-21) completed self-report questionnaires assessing PTSD symptoms and their use of coping styles, and engaged in a semi-structured interview designed by the authors to investigate their resettlement and adaptational experiences in Australia. Youth who were separated from immediate family members demonstrated significantly more PTSD symptoms than their counterparts, and there was a relationship between avoidant coping and PTSD, although this diminished once the confound between scales was controlled for. This study found evidence for the integrity of the family unit as a correlate of PTSD in refugee youth, but no evidence of a relationship between coping style and family separations.

Fostering Resilience: Protective Agents, Resources, and Mechanisms for Adolescent Refugees' Psychosocial Well-Being

BACKGROUND

Adolescent refugees face many challenges but also have the potential to become resilient. The purpose of this study was to identify and characterize the protective agents, resources, and mechanisms that promote their psychosocial well-being.

METHODS

Participants included a purposively sampled group of 73 Burundian and Liberian refugee adolescents and their families who had recently resettled in Boston and Chicago. The adolescents, families, and their service providers participated in a two-year longitudinal study using ethnographic methods and grounded theory analysis with Atlas/ti software. A grounded theory model was developed which describes those persons or entities who act to protect adolescents (Protective Agents), their capacities for doing so (Protective Resources), and how they do it (Protective Mechanisms). Protective agents are the individuals, groups, organizations, and systems that can contribute either directly or indirectly to promoting adolescent refugees' psychosocial well-being. Protective resources are the family and community capacities that can promote psychosocial well-being in adolescent refugees. Protective mechanisms are the processes fostering adolescent refugees' competencies and behaviors that can promote their psychosocial well-being.

RESULTS

Eight family and community capacities were identified that appeared to promote psychosocial well-being in the adolescent refugees. These included 1) finances for necessities; 2) English proficiency; 3) social support networks; 4) engaged parenting; 5) family cohesion; 6) cultural adherence and guidance; 7) educational support; and 8) faith and religious involvement. Nine protective mechanisms identified were identified and grouped into three categories: 1) Relational (supporting, connecting, belonging); 2) Informational (informing, preparing), and; 3) Developmental (defending, promoting, adapting).

CONCLUSIONS

To further promote the psychosocial well-being of adolescent refugees, targeted prevention focused policies and programs are needed to enhance the identified protective agents, resources, and mechanisms. Because resilience works through protective mechanisms, greater attention should be paid to understanding how to enhance them through new programs and practices, especially informational and developmental protective mechanisms.

Cross-cultural findings on community violence exposure and internalizing psychopathology: comparing adolescents in the United States, Russia, and Belgium

The study aimed to investigate cross-cultural differences in the relation between community violence and psychopathology. A self-report survey was conducted in a representative sample of 3,309 14-17 year old adolescents from urban communities in the US (N = 1,343), Belgium (N = 946) and Russia (N = 1,009). In all three countries, boys reported higher prevalences of violence exposure and more victimization by community violence than girls. Controlling for involvement in antisocial behavior, levels of psychopathology increased along with severity of exposure to community violence (from no exposure to witnessing to victimization). The associations between community violence and internalizing problems were similar across countries and gender. Current findings suggest that the relationships between community violence and adolescent mental health are not culture bound and that they follow similar dynamics in different populations. Clinical implications and directions are discussed.

Treating childhood trauma

This review begins with the question "What is childhood trauma?" Diagnosis is discussed next, and then the article focuses on treatment, using 3 basic principles-abreaction, context, and correction. Treatment modalities and complications are discussed, with case vignettes presented throughout to illustrate. Suggestions are provided for the psychiatrist to manage countertransference as trauma therapy proceeds.

Trauma history and psychopathology in war-affected refugee children referred for trauma-related mental health services in the United States

There is an increasing need to deliver effective mental health services to refugee children and adolescents across the United States; however, the evidence base needed to guide the design and delivery of services is nascent. We investigated the trauma history profiles, psychopathology, and associated behavioral and functional indicators among war-affected refugee children presenting for psychological treatment. From the National Child Traumatic Stress Network's Core Data Set, 60 war-affected refugee children were identified (51.7% males, mean age = 13.1 years, SD = 4.13). Clinical assessments indicated high rates of probable posttraumatic stress disorder (30.4%), generalized anxiety (26.8%), somatization (26.8%), traumatic grief (21.4%), and general behavioral problems (21.4%). Exposure to war or political violence frequently co-occurred with forced displacement; traumatic loss; bereavement or separation; exposure to community violence; and exposure to domestic violence. Academic problems and behavioral difficulties were prevalent (53.6% and 44.6%, respectively); however, criminal activity, alcohol/drug use, and self-harm were rare (all < 5.45%). These findings highlight the complex trauma profiles, comorbid conditions, and functional problems that are important to consider in providing mental health interventions for refugee children and adolescents. Given the difficulties associated with access to mental health services for refugees, both preventive and community-based interventions within family, school, and peer systems hold particular promise.

Trajectories of internalizing problems in war-affected Sierra Leonean youth: examining conflict and postconflict factors

Three waves of data from a prospective longitudinal study in Sierra Leone were used to examine internalizing trajectories in 529 war-affected youth (ages 10-17 at baseline; 25% female). Latent class growth analyses identified 4 trajectories: A large majority of youth maintained lower levels of internalizing problems (41.4%) or significantly improved over time (47.6%) despite very limited access to care, but smaller proportions continued to report severe difficulties 6 years postwar (4.5%) or their symptoms worsened (6.4%). Continued internalizing problems were associated with loss of a caregiver, family abuse and neglect, and community stigma. Despite the comparative resilience of most war-affected youth in the face of extreme adversity, there remains a compelling need for interventions that address family- and community-level stressors.

The impact of political violence on psychosocial functioning of individuals and families: the case of palestinian adolescents

BACKGROUND

  The impact of political violence on the psychosocial functioning of adolescents and their families was compared for surveyed populations from two regions of Palestine.

METHOD

  A randomly-selected sample of 971 adolescents (521 from the West Bank and 450 from the Gaza Strip regions, 42% male/57% female) completed scales measuring traumatic event, post-traumatic stress disorder (PTSD), peer relations, mental health, aggression, and family functioning.

RESULTS

  (1) West Bank participants reported a significantly higher level of exposure to political violence and significantly more aggression, mental health symptoms, problems in family and social functioning; (2) Participants exposed to greater political violence reported higher levels of depression, hostility, paranoid ideation, and PTSD; (3) Economic status and level of parental education were related to reduced levels of mental health symptoms and greater family functioning; (4) There were gendered differences.

CONCLUSIONS

  The study provides a starting point to begin to compare the experiences and outcomes between Palestinian adolescents in the West Bank and Gaza Strip and a basis for considering implications for service delivery and policy makers concerned with the well being of Palestinian communities.

Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors

We undertook a systematic search and review of individual, family, community, and societal risk and protective factors for mental health in children and adolescents who are forcibly displaced to high-income countries. Exposure to violence has been shown to be a key risk factor, whereas stable settlement and social support in the host country have a positive effect on the child's psychological functioning. Further research is needed to identify the relevant processes, contexts, and interplay between the many predictor variables hitherto identified as affecting mental health vulnerability and resilience. Research designs are needed that enable longitudinal investigation of individual, community, and societal contexts, rather than designs restricted to investigation of the associations between adverse exposures and psychological symptoms. We emphasise the need to develop comprehensive policies to ensure a rapid resolution of asylum claims and the effective integration of internally displaced and refugee children.

Trauma, exile and mental health in young refugees

OBJECTIVE

To review evidence of trauma and exile-related mental health in young refugees from the Middle East.

METHOD

A review of four empirical studies: i) a qualitative study of 11 children from torture surviving families, ii) a cohort study of 311 3-15-year-old asylum-seeking children, iii) a qualitative study of 14 members of torture surviving families and iv) a follow-up study of 131 11-23-year-old refugees.

RESULTS

The reactions of the children were not necessarily post-traumatic stress disorder specific. Seventy-seven per cent suffered from anxiety, sleep disturbance and/or depressed mood at arrival. Sleep disturbance (prevalence 34%) was primarily predicted by a family history of violence. At follow-up, 25.9% suffered from clinically relevant psychological symptoms. Traumatic experiences before arrival and stressful events in exile predicted internalizing behaviour, witnessing violence and frequent school changes in exile predicted externalizing behaviour. School participation, Danish friends, language proficiency and mother's education predicted less long-term psychological problems.

CONCLUSION

Psychological problems are frequent in refugee children, but the extents are reduced over time in exile. Traumatic experience before arrival is most important for the short-term reaction of the children while aspects of life in exile are important for the children's ability to recover from early traumatization.

Trauma and resilience in young refugees: A 9-year follow-up study

The aim of the present study was to assess and understand the long-term trajectory of psychological problems among young Middle Eastern refugees in Denmark. Participants were 131 young refugees from the Middle East (76 girls, 55 boys; mean age = 15.3 years) from 67 families. They were assessed first on arrival in Denmark in 1992–1993 and again 8–9 years later. The high prevalence of psychological problems at arrival was considerably reduced by the time of follow-up, but it was still somewhat higher than what has been found in most community studies using the same assessment tools. Groups of children differed in showing low levels of symptoms at arrival that were stable (spared) or increased (reacting) and high levels at arrival that persisted (traumatized) or decreased (adapted). The number of types of traumatic experiences before arrival distinguished the spared and the traumatized young refugees and the number of types of stressful events after arrival the adapted and the traumatized, also after corrections for age, sex, specific traumatic events, parents' education and health, and the social situation of the young refugees. The study emphasizes the importance of environmental factors for healthy long-term adaptation after traumatic experiences related to war and other organized violence.

Analysis of trauma exposure, symptomatology and functioning in Jewish Israeli and Palestinian adolescents

BACKGROUND

There has been no reported research comparing Jewish Israeli and Palestinian adolescents regarding the effect of ongoing political violence on adolescent psychosocial, family, post-traumatic stress disorder (PTSD) and aggression problems.

AIMS

To compare Israeli and Palestinian responses regarding the relationship between exposure to traumatic events and psychosocial, behavioural, emotional and family problems.

METHOD

A cluster sample of youths aged 14-18 years, including 442 Jewish Israeli adolescents in Ariel, Haifa and Tel-Aviv, and 450 Palestinian adolescents in Gaza cities, villages and refugee camps were surveyed in 2006 using our Traumatic Events Questionnaire (TEV), the Brief Symptoms Inventory (BSI), the PTSD Symptom Scale - Interview (PSS-I), the Index of Peer Relations scale (IPR), Buss-Perry Aggression Questionnaire (BPAQ) and the MacMaster Family Assessment Device (FAD).

RESULTS

Palestinian respondents had higher scores in the TEV, BSI, PSS-I and BPAQ questionnaires, and greater problems in functioning as revealed in the IPR and FAD. The social functioning of the adolescents with their peers predicted mental health symptoms and PTSD symptoms. Lower socioeconomic status predicted mental health symptoms, PTSD, pathology of participants' family functioning and the social functioning of the adolescents with their peers. Parents' education positively effected the FAD score and the avoidance item on the PSS-I, and religiosity improved the score on the FAD. Females reported more symptoms on the BSI and PSS-I than males, and males more symptoms on the FAD and IPR than females.

CONCLUSIONS

Both respondent groups had significant emotional and behavioural problems. Individual and community treatment, and community and social development, are likely to be useful for both populations, particularly Palestinians.

Safe enough to sleep: sleep disruptions associated with trauma, posttraumatic stress, and anxiety in children and adolescents

Sleep disturbance is an essential symptom of posttraumatic stress disorder, and recent evidence suggests that disrupted sleep may play an important role in the development of posttraumatic stress disorder following traumatic stress. The authors review several aspects of sleep as it relates to posttraumatic stress disorder. First, there is an association between traumatic stress and different components of disrupted sleep in children and adolescents. Second, sleep disruption appears to be a core feature of other pediatric anxiety disorders, and the authors consider if this preexisting sleep vulnerability may explain in part why preexisting anxiety disorders are a risk factor for developing posttraumatic stress disorder following a traumatic event. Third, the authors consider attachment theory and the social context of trauma and sleep disruption. This article concludes with a consideration of the therapeutic implications of these findings.

Prevalence of mental disorders among children exposed to war: a systematic review of 7,920 children

Worldwide, millions of children are affected by armed conflict. However, data on the prevalence of mental disorders among these children is sparse. We aimed to determine the prevalence of mental disorders among children affected by war using a systematic review and meta-regression analysis. We systematically reviewed existing literature to identify studies on prevalence of post-traumatic stress disorder (PTSD), anxiety, depression and psychosis among children exposed to armed conflict. We searched electronic databases and references listed in studies to obtain eligible studies. We pooled studies using the random-effects method and explored heterogeneity using meta-regression analysis. Seventeen studies met our inclusion criteria. Studies included 7,920 children. Sample sizes ranged from 22 to 2,976. Four studies were conducted during a conflict and others during post-conflict. All the studies reported PTSD as the primary outcome ranging from 4.5 to 89.3%, with an overall pooled estimate of 47% (9% CI: 35-60%, I2 = 98%). Meta-analysis heterogeneity was attributable to study location (OR 1.33, 95% CI: 1.27-1.41), method of measurement (OR 1.36, 95% CI: 1.29-1.44) and duration since exposure to war (coefficient 0.17, 95% CI: 0.94-0.25). In addition, four studies reported elevated depression that allowed pooling (43%, 95% CI: 31-55%) and three studies reported elevated anxiety disorders allowing pooling (27%, 95% CI: 21-33%). Our systematic review suggests a higher prevalence rate of mental disorders among children exposed to conflict than among the general population. Given the number of current conflicts, there is a paucity of information regarding mental disorders among children affected by war.

Mental health problems in separated refugee adolescents

PURPOSE

As migration and separation from parents are widely recognized as important risk factors for the mental health of adolescents, this study aims to investigate mental health problems in refugee adolescents separated from their parents compared to their accompanied peers, all living in Belgium.

METHODS

One thousand two hundred ninety-four adolescents--10% of them refugee adolescents separated from both parents--completed three self-report questionnaires (Hopkins Symptoms Checklist-37A, Stressful Life Events, and Reaction of Adolescents to Traumatic Stress) on the prevalence of traumatic experiences, anxiety, and depression symptoms, externalizing problems, and posttraumatic stress.

RESULTS

Refugee adolescents separated from both parents experienced the highest number of traumatic events compared to accompanied refugee adolescents. Risk factors influencing the development of serious mental health problems (anxiety, depression, and posttraumatic stress) are separation from parents, high number of traumatizing events experienced, and gender. Despite the fact that refugee adolescents living only with their mother experienced more traumatizing events compared to adolescents living with both parents, they have fewer mental health problems than refugee adolescents living with their father.

CONCLUSIONS

This study confirms the importance of the availability of parents to adolescents who have to deal with migration experiences, because separated refugee adolescents are at higher risk to experience multiple traumatic experiences and to develop severe mental health problems. Reception and care structures should provide more adequate preventive and curative interventions to these at-risk groups, and government policies should consider these adolescents primarily as "minors" rather than just "refugees."

Unaccompanied refugee children and adolescents: the glaring contrast between a legal and a psychological perspective

Unaccompanied refugee children and adolescents are a vulnerable group: they live not only in a relatively difficult situation as minor refugees staying in another country, but also face other risks due to the absence of their parents, such as traumatic experiences, exploitation or abuse. The difficult living situation of these unaccompanied refugee children and adolescents might therefore threaten their emotional well-being, resulting in important emotional and behavioural problems. This 'psychological' perspective shows the necessity of a strongly elaborated reception and care system for these children and adolescents in order to meet their specific situation and needs. Nevertheless, the case study of unaccompanied refugee minors living in Belgium, as explored in this paper, shows that the legal perspective on these youths - considering them as 'refugees' and 'migrants', not as 'children' - is predominantly the starting point to build the care system on. Moreover, this legal perspective contrasts sharply with the psychological perspective, as such that these children and adolescents do not receive appropriate support and care as they need.

Asylum grant rates following medical evaluations of maltreatment among political asylum applicants in the United States

Although many individuals applying for political asylum allege maltreatment and sometimes torture in their countries of origin, the utility of medical evaluations in asylum adjudication has not been documented. This study compares the asylum grant rate among US asylum seekers who received medical evaluations from Physicians for Human Rights (PHR), with rates among asylum seekers who did not receive PHR evaluations. Retrospective analysis was carried out on all asylum cases referred to PHR between 2000 and 2004 for medical evaluations for which adjudication outcome was available. Basic demographic information was obtained: age, sex, country of origin, English language ability, US region where adjudication occurred, whether legal representation was pro bono, type of evaluation, provision of oral court testimony, and whether asylum seekers were in detention. Cases were analyzed descriptively and with chi square tests. Between 2000 and 2004, 1663 asylum seekers received medical evaluations from PHR; the adjudication status (either granted or denied) was determined in 746 cases at the time of the study. Of these cases, 89% were granted asylum, compared to the national average of 37.5% among US asylum seekers who did not receive PHR evaluations. Medical evaluations may be critical in the adjudications of asylum cases when maltreatment is alleged.

Shattered Shangri-la: differences in depressive and anxiety symptoms in students born in Tibet compared to Tibetan students born in exile

OBJECTIVE

As a result of ongoing political tensions within Tibetan regions of the People's Republic of China, several thousand Tibetans escape across the Himalayas every year to seek refuge in India and Nepal. Prior studies have found a high prevalence of depressive and anxiety symptoms in these refugees, many of whom are young and have been exposed to significant trauma. However, it is not known whether depressive and anxiety symptoms are more prevalent in these refugees than in ethnic Tibetans born and raised in the relative political and social stability of exile communities in North India and Nepal.

METHODS

We conducted a cross-sectional survey of a convenience sample of 319 students attending school at the Tibetan Children's Villages in Northern India to test the a priori hypothesis that adolescents and young adults who escaped from Tibet to India would demonstrate increased depressive and anxiety symptoms when compared to ethnic Tibetans born and raised in exile. The Hopkins Symptom Checklist-25 (HSCL-25) was used to measure depressive and anxiety symptoms. In addition, demographic information on age, sex, country of birth and frequency of family contact was collected.

RESULTS

Students born in Tibet had higher mean HSCL-25 depressive and anxiety symptom scores than did ethnic Tibetans born in exile. Female students demonstrated higher depressive and anxiety scores, as did those with limited contact with immediate family. After adjusting for sex, age and frequency of family contact, being born in Tibet was associated with increased HSCL-25 depressive and anxiety symptom scores (depression: F[2, 316] = 29.96, P < 0.0001; anxiety: F[4, 316] = 43.57, P < 0.0001).

CONCLUSIONS

The experience of being raised in Tibet and escaping to India appears to be a risk factor for increased depressive and anxiety symptoms when compared to being born and raised within an exile community in India or Nepal.

Psychosocial intervention for war-affected children in Sierra Leone

BACKGROUND

There are no psychosocial interventions to address both educational needs and psychological distress among displaced children in post-conflict settings.

AIMS

To assess the psychosocial status of displaced children enrolled in the Rapid-Ed intervention; and to determine whether the Rapid-Ed intervention alleviated traumatic stress symptoms that interfere with learning among war-affected children in Sierra Leone.

METHOD

A randomly selected sample of 315 children aged 8-18 years who were displaced by war were interviewed about their war experiences and reactions to the violence before and after participating in the 4-week Rapid-Ed intervention combining basic education with trauma healing activities.

RESULTS

High levels of intrusion, arousal and avoidance symptoms were reported at the pre-test interviews conducted 9-12 months after the war. Post-test findings showed statistically significant decreases in intrusion and arousal symptoms (P<0.0001), a slight increase in avoidance reactions (P<0.0001) and greater optimism about the future.

CONCLUSIONS

The findings suggest potential for combining basic education with trauma healing activities for children in post-conflict settings, but confirmatory studies using a control group are needed. Conducting research in post-conflict settings presents unique challenges.

Mental health of Bosnian refugee children: a comparison of clinician appraisal with parent, child and teacher reports

This study compares clinician appraisal of Bosnian refugee children with independent parent, child and teacher reports. From whom and by what means can children "at risk" be reasonably identified? Forty-eight Bosnian refugee children (aged 7-20), resettled in Sweden 1994-95, were assessed clinically by means of a semi-structured interview. Thereafter, standardized mental health questionnaires were administered to parents (Achenbach's Child Behavior Checklist), children (Achenbach's Youth Self-Report and Macksoud's Posttraumatic Stress Reaction Checklist) and teachers (clinician designed School Competence Scale and Achenbach's Teacher's Report Form). On clinician interview, nearly half of the children (48%) were identified with one or more mental health problem "demanding further attention". Depressiveness was the single most prevalent symptom (31%); followed by post-traumatic stress (23%), and anxiety-regressiveness (15%). At the same time, 75% of the children were rated by teachers as "quite competent" in school. Parent, child and clinician appraisals of primary school children showed broad similarities. Teachers reported a similar prevalence of child distress, but identified different symptoms and different children demanding attention. Evaluation of teenage youths showed greater disparity: teenagers labeled their own symptoms more often as post-traumatic stress reactions and teachers identified few youths in need of attention. Inter-relatedness among parent, child and clinician appraisals supports the robustness of our semi-structured interview. At the same time, apartness of teacher report underscores the need to incorporate an outside-world vantage point in the process of risk assessment. Also, a more concrete presentation of post-traumatic stress reactions and a higher "further attention" threshold for inward emotional problems seem called for.

A gender-oriented comparison between the mental health profiles of Bulgarian immigrants forcibly migrated to Turkey and the native population 15 years after migration

Background. The considerable problem of the migration of people, mainly from developing or undeveloped countries to developed countries, is a worldwide issue. The aims of this study were to compare, according to gender, scores obtained pertaining to mental symptom distributions of Bulgarian immigrants arriving in one city of west Turkey in 1989 with those of native-born citizens, as well as to the scores obtained from the scales of anxiety, hopelessness, job and life satisfaction. Methods. During the period of study between 1 February and 31 April 2003, short symptom inventory, state and trait anxiety scales, and hopelessness, job, and life satisfaction scales were collected from 85 immigrants living in a district where immigrants are prevalent. The results of 98 of the native population living in the same district were also collected during the same period. Data were analyzed using chi-square, t, Mann-Whitney U-tests, and percent ratios.

RESULTS

Upon comparison of the scores of both immigrant women and native women, and immigrant men and native men, no differences were found between scores obtained from the subscales of short symptom inventory, state and trait anxiety scales, and hopelessness and job satisfaction scales (p>0.05). The only observable difference was between scores obtained from the life satisfaction scale (p<0.01 and p<0.05, respectively). The depression subscale of the short symptom inventory revealed a difference in the scores of immigrant women compared to immigrant men, as did the somatization subscale for native-born women when compared to native men (p<0.05 and p<0.05, respectively).

CONCLUSIONS

That both male and female immigrants had low scores for life satisfaction forces us to draw the conclusion that their expectations, necessities, desires and wishes were not entirely fulfilled. The reason for their being no observable differences between the other scale scores may be attributed to the fact that the immigrant women and men share not only the same ethnic origin, but also historical and cultural ties with those in Turkey. An alternative view could be that those entering the country may have adapted to the environment after the passage of 15 years. Furthermore, the significant difference seen between immigrant women and men, and native women and men in terms of symptoms of depression and somatization, respectively, may be explained through the notion that women perceived migration to be more different, and that native women more readily accepted the thought of physical illness according to mental disorders. Further studies are needed to better explain some of these results.

Course and predictors of mental health of unaccompanied refugee minors in the Netherlands: one year follow-up

This epidemiological investigation addresses the prevalence, course, and predictors of the psychological distress and behavioral problems of unaccompanied refugee minors living in the Netherlands. The legal guardians, teachers and minors themselves all reported on the mental health of the refugee minors (n=582) at baseline and follow-up approximately 12 months later. The self-reported psychological distress of refugee minors was found to be severe (50%) and of a chronic nature (stable for one year) which was confirmed by reports from the guardians (33%) and teachers (36%). The number of self-reported experienced adverse life events were strongly related to the severity of psychological distress. Baseline psychopathology was the largest predictor of psychological distress at follow-up reported by all informants accounting for 22-51% of the variance. The present study, which used a population-based sample, further enlarges the knowledge of mental health among refugee adolescents. The investigation is unique because of the large sample size, the longitudinal nature of the study, the use of multiple informants, and the culturally diverse sample.

Immigrants and refugees: the psychiatric perspective

Psychiatric studies of immigrants have yielded contradictory findings regarding rates of mental illness. Current evidence suggests that rates of schizophrenia (and probably other disorders) among immigrant groups are low compared with native-born populations when sending and receiving countries are socially and culturally similar. The rates for immigrants are higher when sending and receiving countries are dissimilar, probably because of multiple social problems faced by immigrants in the receiving country. Refugees who flee their own country because of fears of violence or starvation often have had extremely traumatic experiences, which may result in PTSD and sometimes chronic impairment. Asylum seekers who arrive illegally to seek refuge in a foreign country also may have multiple traumas and experience further distress from their uncertain residency and legal status. Although much is known about the effects of migration, competent culturally sensitive services for migrants remain inadequate to meet the need.

Practitioner review: assessment and treatment of refugee children and adolescents who have experienced war-related trauma

BACKGROUND

Increasingly clinicians are being asked to assess and treat young refugees, who have experienced traumatic events due to war and organised violence. However, evidence-based guidance remains scarce.

METHOD

Published studies on the mental health difficulties of refugee children and adolescents, associated risk and protective factors, as well as effective interventions, particularly those designed to reduce war-related post-traumatic stress disorder (PTSD) symptoms, were identified and reviewed. The findings are summarised.

RESULTS

Young refugees are frequently subjected to multiple traumatic events and severe losses, as well as ongoing stressors within the host country. Although young refugees are often resilient, many experience mental health difficulties, including PTSD, depression, anxiety and grief. An awareness of relevant risk and protective factors is important. A phased model of intervention is often useful and the need for a holistic approach crucial. Promising treatments for alleviating symptoms of war-related PTSD include cognitive behavioural treatment (CBT), testimonial psychotherapy, narrative exposure therapy (NET) and eye movement desensitisation and reprocessing (EMDR). Knowledge of the particular needs of unaccompanied asylum-seeking children (UASC), working with interpreters, cross-cultural differences, medico-legal report writing and the importance of clinician self-care is also necessary.

CONCLUSION

More research is required in order to expand our limited knowledge base.

Validation of the multiple language versions of the Reactions of Adolescents to Traumatic Stress questionnaire

The objective of this study was to assess the preliminary psychometric properties of the Reaction of Adolescents to Traumatic Stress questionnaire (RATS) for refugee adolescents. Four independent heterogeneous adolescent population samples (N = 3,535) of unaccompanied refugee minors, immigrants, and native Dutch and Belgian adolescents were assessed at school. The confirmatory factor analyses, per language version, support the three-factor structure of intrusion, avoidance/numbing, and hyperarsoual. The total and subscales of the RATS show good internal consistency and good (content, construct, and criterion) validity. The RATS, in this study, was found to be a reliable and valid instrument for assessing posttraumatic stress reactions of culturally diverse adolescents.