Treating children traumatized by war and Tsunami: a comparison between exposure therapy and meditation-relaxation in North-East Sri Lanka

Research on psychotherapy for refugees in Germany: A systematic review on its transdisciplinary and transregional opening

Recently, an increasing amount of research has focused on adapting psychotherapy concepts for refugees moving to Germany. For a long time, research from disciplines like anthropology and cultural studies has problematized the eurocentrism of psychology's theoretical premises and methodologies. Currently, scholarship around Global Mental Health and decolonization emphasizes how knowledge production from various disciplines and regions relates to this topic and could contribute to improving respective approaches. Consequently, this review aims at evaluating the actual transdisciplinary and transregional opening of studies on psychotherapeutic interventions for refugees in Germany. It provides a theoretically as well as empirically informed basis for looking at disciplinary premises, practices, and boundaries as well as the regional locatedness of respective research. Fourteen relevant studies, published between January 1, 2007 and March 4, 2022, were identified by systematically searching the databases PubPsych and Web of Science. The studies were reviewed regarding study design, choice and characterization of target groups, regional origin and target group specific adaptations of the therapeutic concepts, integration of elements from and connections to other disciplines, and use of references to scholarship from the Global South. The findings show a pronounced focus on the development of trauma therapy approaches and moreover a broad variety of concept adaptations in response to the assumed characteristics, situations, and needs of the target groups. While the findings reveal a complex transregional pattern of development and adaptation of the therapeutic concepts, transdisciplinary opening and reference to the Global South appear scarce.

The impact of mental health and psychosocial support programmes on children and young people's mental health in the context of humanitarian emergencies in low- and middle-income countries: A systematic review and meta-analysis

Humanitarian emergencies pose a significant global health challenge for children and young people's mental and psychological health. This systematic review investigates the effectiveness of mental health and psychosocial support (MHPSS) programmes delivered to children and young people affected by humanitarian emergencies in low- and middle-income countries (LMICs). Twelve electronic databases, key websites and citation checking were undertaken. Forty-three randomised controlled trials (RCTs) published in English between January 1980 and May 2023 were included in the review. Overall, the findings suggest that cognitive behavioural therapy may improve depression symptoms in children and young people affected by humanitarian emergencies. Narrative exposure therapy may reduce feelings of guilt. However, the impact of the other MHPSS modalities across outcomes is inconsistent. In some contexts, providing psychosocial programmes involving creative activities may increase the symptoms of depression in children and young people. These findings emphasise the need for the development of MHPSS programmes that can safely and effectively address the diverse needs of children and young people living in adversarial environments.

Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials

BACKGROUND

Existing clinical trials of cognitive behavioural therapies with a trauma focus (CBTs-TF) are underpowered to examine key variables that might moderate treatment effects. We aimed to determine the efficacy of CBTs-TF for young people, relative to passive and active control conditions, and elucidate putative individual-level and treatment-level moderators.

METHODS

This was an individual participant data meta-analysis of published and unpublished randomised studies in young people aged 6-18 years exposed to trauma. We included studies identified by the latest UK National Institute of Health and Care Excellence guidelines (completed on Jan 29, 2018) and updated their search. The search strategy included database searches restricted to publications between Jan 1, 2018, and Nov 12, 2019; grey literature search of trial registries ClinicalTrials.gov and ISRCTN; preprint archives PsyArXiv and bioRxiv; and use of social media and emails to key authors to identify any unpublished datasets. The primary outcome was post-traumatic stress symptoms after treatment (<1 month after the final session). Predominantly, one-stage random-effects models were fitted. This study is registered with PROSPERO, CRD42019151954.

FINDINGS

We identified 38 studies; 25 studies provided individual participant data, comprising 1686 young people (mean age 13·65 years [SD 3·01]), with 802 receiving CBTs-TF and 884 a control condition. The risk-of-bias assessment indicated five studies as low risk and 20 studies with some concerns. Participants who received CBTs-TF had lower mean post-traumatic stress symptoms after treatment than those who received the control conditions, after adjusting for post-traumatic stress symptoms before treatment (b=-13·17, 95% CI -17·84 to -8·50, p<0·001, τ2=103·72). Moderation analysis indicated that this effect of CBTs-TF on post-traumatic stress symptoms post-treatment increased by 0·15 units (b=-0·15, 95% CI -0·29 to -0·01, p=0·041, τ2=0·03) for each unit increase in pre-treatment post-traumatic stress symptoms.

INTERPRETATION

This is the first individual participant data meta-analysis of young people exposed to trauma. Our findings support CBTs-TF as the first-line treatment, irrespective of age, gender, trauma characteristics, or carer involvement in treatment, with particular benefits for those with higher initial distress.

FUNDING

Swiss National Science Foundation.

Barriers and facilitators to the implementation of mental health and psychosocial support programmes following natural disasters in developing countries: A systematic review

Climate change is leading to more frequent and intense natural disasters, with developing countries particularly at risk. However, most research concerning mental health and natural disasters is based in high-income country settings. It is critically important to provide a mental health response to such events, given the negative psychosocial impacts they elicit. The aim of this systematic review is to explore the barriers and facilitators to implementing mental health and psychosocial support (MHPSS) following natural disasters in developing countries. Eight databases were searched for relevant quantitative and qualitative studies from developing countries. Only studies reporting barriers and/or facilitators to delivering MHPSS in response to natural disasters in a low- or middle-income country were included and full texts were critically appraised using the McGill University Mixed Methods Appraisal Tool. Reported barriers and facilitators were extracted and analysed thematically. Thirty-seven studies were included in the review, reflecting a range of natural disaster settings and developing countries. Barriers to implementing MHPSS included cultural relevance, resources for mental health, accessibility, disaster specific factors and mental health stigma. Facilitators identified included social support, cultural relevance and task-sharing approaches. A number of practical approaches can be used to facilitate the implementation of MHPSS in developing country settings. However, more research is needed on MHPSS in the developing country natural disaster context, especially in Africa, and international policies and guidelines need to be re-evaluated using a decolonial lens.

Effectiveness of Psychotherapy for Internalising Symptoms in Children and Adolescents When Delivered in Routine Settings: A Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to examine the effectiveness of psychological interventions for internalising disorders in youth when delivered in routine settings. Secondary aims were to examine the effectiveness of cognitive behavioural therapy and determine moderators of treatment response. The study was pre-registered (PROSPERO 2020 CRD42020202776). Databases were systematically searched (PsycINFO, Medline, Embase, PubMed, ERIC) in December 2022 and screened according to the PRISMA 2020 statement. Inclusion: School aged participants (4-18 years) with a primary internalising disorder; psychotherapy delivered in a routine setting (e.g. outpatient clinic, school) by setting staff; compared psychotherapy to any control in a randomised controlled trial; reported pre-to-post or pre-to-follow-up comparisons on the primary disorder according to child, parent or independent evaluator report; and was published in English. Risk of bias was assessed using the ROB 2.0 Cochrane tool. Results were synthesised using random effects to pool estimates. Risk ratios were used to analyse dichotomous data and standardised mean differences (SMD) for continuous data. Forty-five studies were included (N = 4901 participants; M = 13 years; range 8-16; SD = 2.5). Nine used waitlist control, 17 treatment as usual, 4 placebo; 15 compared psychotherapy to active control. Psychotherapy was associated with small significant effects pre- to post-treatment compared to non-active controls for anxiety (SMD =  - 0.24 to 0.50) and depression (SMD =  - 0.19 to 0.34) with effects differing by informant. Psychotherapy led to small significant pre-to-post-benefits in youth internalising disorders in routine settings. Results are limited by reporter type and follow-up.

A Scoping Review of Trauma-Informed Pediatric Interventions in Response to Natural and Biologic Disasters

A scoping review was performed of trauma-informed psychological interventions to treat anxiety, depression, and posttraumatic stress symptoms in youth in response to natural/biologic disasters. The specific aims were to identify psychosocial interventions used in response to natural/biologic disasters, report the interventions' effectiveness, describe limitations, and provide treatment recommendations and future directions. Of the 45 studies extracted, 28 were on natural disasters and 17 on biologic disasters with the majority related to the COVID-19 pandemic. The most commonly implemented interventions were Cognitive Behavioral Therapy (CBT), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and eye movement desensitization and reprocessing (EMDR). The UCLA Posttraumatic Stress Disorder Reaction Index (UCLA PTSD-RI) and the Strengths and Difficulties Questionnaire (SDQ) were the most frequently used measures. Methodological rigor was varied, with 60% randomized, controlled trials. Overall, there was a significant decrease in posttraumatic stress symptoms, distress, anxiety, and depression regardless of whether the participant received CBT, TF-CBT, or EMDR. Generally, there was not a significant decrease in anxiety and depression with yoga, cognitive fear-reduction, emotion-based drawing, and community health education. Recommendations for future directions include larger-scale studies with group and on-line interventions that include younger children with moderation analyses by gender and race/ethnicity.

Post-Traumatic Stress Disorder/Developmental Trauma Disorder/Complex Post-Traumatic Stress Disorder and Complementary and Integrative Medicine/Functional Medicine

Response to PTSD treatments differ based on the age the abuse occurred, the type of abuse, and the chronicity of the abuse. Even when modifications to treatment are made based on the developmental age when the abuse occurred, therapies may be insufficient. In addition, when diagnostic criteria are modified to identify more children, some children continue to escape detection. Developmental Trauma Disorder, (akin to the RDoC), may be more suitable to identify epigenetic and inflammatory effects of early abuse that may be responsible for the nonresponsive to treatment. Complementary and Integrative Medicine interventions (meditation, EFT, EMDR, PUFAs, etc.) may reverse these effects.

Efficacy of psychological interventions for PTSD in distinct populations - An evidence map of meta-analyses using the umbrella review methodology

We aimed at mapping the meta-analytic evidence base on the efficacy of psychological treatments for posttraumatic stress disorder (PTSD) in specific populations. We conducted a systematic search until January 2022 in MEDLINE, PsycINFO, PTSDpubs, Web of Science, and the Cochrane Database of Systematic Reviews for meta-analyses of randomized controlled trials. We contrasted all eligible meta-analyses irrespective of overlapping datasets to present a comprehensive overview of the state of research. Reporting quality was assessed using the AMSTAR 2 tool and certainty of evidence was assessed using established umbrella review criteria. Nine meta-analyses with distinct adult populations (51 unique trials) and four with children and adolescents (24 unique trials) were included. Reporting quality of meta-analyses was heterogeneous with risk of bias assessment being rated lowest. The certainty of evidence on the efficacy of psychological interventions for adult populations was thoroughly weak because of small samples and large heterogeneity. In war- and conflict-affected youth, the certainty of evidence was suggestive. Our review highlights the need to improve quality of meta-analyses on treatment efficacy for PTSD. More importantly, however, the findings demonstrate the need for new large-scale trials on the efficacy of treatments for PTSD in distinct populations in order to increase certainty of evidence and to identify potential differences in treatment responses.

Hypervigilance or shutdown? Electrophysiological processing of trauma-unrelated aversive stimuli after traumatic life events

Post-Traumatic Stress Disorder (PTSD) research indicates that hyper-reactivity to trauma-related stimuli reflects reduced prefrontal cortex (PFC) modulation of amygdala reactivity. However, other studies indicate a dissociative "shutdown" reaction to overwhelming aversive stimuli, possibly reflecting PFC over-modulation. To explore this, we used an Event-Related Potential (ERP) oddball paradigm to study P3 responses in the presence of the following: 1. Trauma-unrelated morbid distractors (e.g., "injured bear") related to the Rorschach inkblot test, and 2. Negative distractors (e.g., "significant failure"), among participants with high post-traumatic stress symptoms (PTS; n = 20), low PTS (n = 17), and controls (n = 15). Distractors were presented at 20% frequency amongst the more frequent (60%) neutral standard stimuli (e.g., "desk lamp") and the equally frequent (20%) neutral trauma-unrelated target stimulus ("golden fish"). P3 amplitudes were high in the presence of morbid distractors and low in the presence of negative distractors only amongst the control group. Possible mechanisms underlying the lack of P3 amplitude modulation after trauma are discussed.

A systematic review of evidence-based interventions for child and adolescent mental health problems in low- and middle-income countries

BACKGROUND

Treatments for mental health problems in childhood and adolescence have advanced in the last 15 years. Despite advances in research, most of the evidence on effective interventions comes from high-income countries, while evidence is scarce in low- and middle-income countries (LMICs), where 90% of world's children and adolescents live. The aim of this review was to identify evidence-based interventions tested in LMICs to treat or prevent child and adolescent mental health problems.

METHODS

We conducted a systematic review of seven major electronic databases, from January 2007 to July 2019. We included randomised or non-randomised clinical trials that evaluated interventions for children or adolescents aged 6 to 18 years living in LMICs and who had, or were at risk of developing, one or more mental health problems. Results were grouped according to the studied conditions. Due to the heterogeneity of conditions, interventions and outcomes, we performed a narrative synthesis. The review was registered at PROSPERO under the number CRD42019129376.

FINDINGS

Of 127,466 references found through our search strategy, 107 studies were included in narrative synthesis after the eligibility verification processes. Nineteen different conditions and nine types of interventions were addressed by studies included in the review. Over 1/3 of studied interventions were superior to comparators, with psychoeducation and psychotherapy having the highest proportion of positive results. One-third of studies were classified as presenting low risk of bias.

INTERPRETATION

This review shows that different interventions have been effective in LMICs and have the potential to close the mental health care gap among children and adolescents in low-resource settings.

The effectiveness of therapeutic interventions on psychological distress in refugee children: A systematic review

OBJECTIVE

To systematically review existing research exploring the effectiveness of psychological interventions in reducing symptoms of distress amongst refugee and asylum-seeker children.

METHOD

Six databases were searched to identify English studies presenting original empirical quantitative data (published before September 2022) testing the efficacy of psychological interventions for children from refugee and asylum-seeking backgrounds. Quality of studies were assessed through the Appraisal Tool for Cross-Sectional Studies as well as the Cochrane Risk of Bias Tool. Relevant data were extracted to facilitate a narrative synthesis.

RESULTS

Seventy-one eligible articles were identified (n > 10,000). A number of cognitive-behavioral, psychosocial, and trauma-focused interventions that catered specifically to children and their families were identified. A synthesis of these results suggest that interventions may assist in the reduction of various psychopathologies, although the effects were mixed across intervention types.

CONCLUSIONS

While the review yielded promising findings, most findings were derived from small pilot and empirical studies, leading to difficulties with drawing conclusions. There remains a need for studies using more rigorous research methodologies to expand and ratify this valuable knowledge base.

CLINICAL SIGNIFICANCE

 Forced displacement is at an all-time high. Many children are being forced to seek asylum and refuge, and they become vulnerable to the development of poor mental health, with limited understanding surrounding how to appropriately intervene. This review aims to equip clinicians with increased knowledge and confidence in working therapeutically alongside clients from refugee or asylum-seeking background, with the goal of fostering positive mental health and wellbeing.

Trauma-Sensitive Mindfulness for War Refugees: Communication of Preliminary Findings

Mindfulness and meditation was explored with the view to support the use of trauma-sensitive mindfulness (TSM) in clinical practice with survivors of war refugees in the treatment of post-traumatic stress disorders. The following questions were explored: (1) How are mindfulness and meditation defined? (2) What are the practices and perceived value of mindfulness practices? (3) What are the evidence and non-evidence-based treatments for post-traumatic stress disorder (PTSD)? (4) What are the possibilities of using TSM to support war-traumatised refugees in the treatment of PTSD in a refugee camp setting? Findings that measured currently actioned interventions for war-traumatised refugees did not account for psychological support that could be implemented in a refugee camp setting on a once-off basis. In response to the gaps and limitations highlighted, the study suggests an adaptation of the TSM intervention and professional development of practitioners in the art of TSM therapy.

Adaptations of evidence-based trauma-focused interventions for children and adolescents: a systematic review

BACKGROUND

Rates of potentially traumatic events (PTEs) and other forms of adversity among children are high globally, resulting in the development of a number of evidence-based interventions (EBIs) to address the adverse outcomes stemming from these experiences. Though EBIs are intended to be delivered according to set parameters, these EBIs are frequently adapted. However, little is known about existing adaptations of EBIs for children who experienced PTEs or other adversities. As such, this review aimed to determine: (1) why existing EBIs designed to address PTEs and other adversities experienced by children are adapted, (2) what processes are used to determine what elements should be adapted, and (3) what components of the intervention are adapted.

METHODS

Nine academic databases and publicly available search engines were used to identify academic and grey literature. Initial screening, full-text review, data extraction, and quality determinations were completed by two members of the research team. Data were synthesized narratively for each adapted EBI by research question.

RESULTS

Forty-two studies examining the adaptations of nine different EBIs were located, with Trauma-Focused Cognitive Behavioral Therapy and Cognitive Behavioral Intervention for Trauma in Schools being the most commonly adapted EBIs. Most frequently, EBIs were adapted to improve fit with a new population and to address cultural factors. Most commonly, researchers in combination with others made decisions about adapting interventions, though frequently who was involved in these decisions was not described. Common content adaptations included the addition of intervention elements and the tailoring/tweaking/refining of intervention materials. Common contextual adaptations included changes to the intended population, changes to the channel of treatment delivery, and changes to who administered the intervention.

CONCLUSIONS

Most published studies of EBI adaptions have been developed to improve fit and address cultural factors, but little research is available about adaptations made by clinicians in day-to-day practice. Efforts should be made to evaluate the various types of adaptations and especially whether adaptations improve access to services or improve child outcomes in order to ensure that all children exposed to trauma can access effective treatment.

TRIAL REGISTRATION

The protocol for this systematic review was published with PROSPERO (CRD42020149536).

Associations between therapist factors and treatment efficacy in randomized controlled trials of trauma-focused cognitive behavioral therapy for children and youth: A systematic review and meta-analysis

Previous research suggests that the effect of therapist factors on patient outcomes is significant. Yet, to date, no reviews have explored the potential effects of therapist characteristics on treatment outcomes for children and youth with posttraumatic stress disorder (PTSD). This systematic review and meta-analysis aimed to summarize the professional characteristics of trial therapists delivering trauma-focused cognitive behavioral interventions (TF-CBT) for child PTSD in clinical trials and understand the association between treatment efficacy and therapist factors. Systematic searches for randomized controlled trials (RCTs) published through November 3, 2020, were conducted; 40 RCTs were included in the full review. PTSD treatment outcome data were extracted from each publication along with any available data regarding trial therapists. Subgroup analyses were conducted to compare the outcomes of interventions conducted by different types of therapists. All therapist groups yielded significant effects for TF-CBT relative to active and passive control conditions, with the largest effect size, Hedges' g = -1.11, for RCTs that used clinical psychologists and psychiatrists. A significant moderating effect was found when comparing the treatment outcomes of clinical psychologists and psychiatrists versus other professionals, p = .044; however, this effect was no longer apparent when only studies with an active control arm were included. Further moderator analyses demonstrated no significant differences regarding therapists' educational and professional backgrounds and PTSD treatment outcomes. The current RCT evidence for TF-CBT for children and youth with PTSD does not suggest that therapist educational or professional background influences treatment efficacy. Limitations and implications for future research are discussed.

Factors Influencing Improvement of Trauma-Related Symptoms Among Somali Refugee Youth in Urban Kenya

Somali refugee youth present with a heightened risk for common mental disorders (CMDs), and yet few studies have discussed factors influencing mental health outcomes after psychosocial interventions. This study aimed to identify key factors that contribute to the improvement of CMD symptoms among Somali youth displaced in urban Kenya. Logistic regression analyses revealed that trauma exposure and emotional coping predict overall symptom improvement, pointing to a differential intervention effect on those with differing levels of religious belief and attitudes toward violence. This study provides insights into how psychosocial factors likely contribute to positive intervention outcomes in Somali refugee youth.

Trauma-focused cognitive behavioral therapy for children and youth in low and middle-income countries: A systematic review

BACKGROUND

Trauma-focused cognitive behavioral therapy (TF-CBT) has been identified as a gold standard treatment for childhood posttraumatic stress disorder (PTSD) in Western countries. More recently, TF-CBT has emerged in the literature as an area of interest for children and youth affected by conflict and war in low- and middle-income countries (LMIC).

METHODS

The present systematic review assesses the current evidence base of TF-CBT for children and youth in LMIC, with a focus on conflict-affected countries. A total of 143 articles were identified, of which 11 articles, representing 1,354 participants, met the proposed inclusion criteria.

RESULTS

Results showed that the majority of the studies identified were conducted in low-resource community settings in East or Central Africa (n = 8). It was also found that cultural considerations were taken into account in TF-CBT delivery to meet the needs of local populations. Additionally, measures were translated and validated for local use.

CONCLUSIONS

Findings of outcome data indicated that TF-CBT was effective in treating trauma-related symptoms and improving psychosocial functioning in children and adolescents in LMICs. Given the limited number of published literature available in this area, further studies are needed to conclude when and for whom trauma-focused interventions are most relevant.

Trauma-focused treatments for refugee children: study protocol for a randomized controlled trial of the effectiveness of KIDNET versus EMDR therapy versus a waitlist control group (KIEM)

BACKGROUND

Prevalence of posttraumatic stress disorder (PTSD) in refugees is reportedly higher in comparison to the general population. Refugee children specifically are often coping with trauma and loss and are at risk for mental health difficulties. With staggering numbers of people seeking refuge around the world and 50% being 18 years or younger, research examining the effects of trauma-focused therapies for refugee children with PTSD is highly needed. Both Eye Movement Desensitization and Reprocessing (EMDR) therapy and the child version of Narrative Exposure Therapy (KIDNET) have been used for refugees, although these treatment methods have not been systematically compared. The aim of the current study is to investigate the effectiveness of EMDR and KIDNET, compared to a waitlist control group and with each other, offered to refugee children.

METHODS

A randomized controlled three-arm trial has been designed. The primary outcome is PTSD diagnosis and symptom severity assessed with the Clinician-Administered PTSD Scale for Children DSM5 (CAPS-CA-5) at baseline (T1), 1 month post-treatment, or after 8 weeks of waiting (T2) and 3 months follow-up (T3). Additionally, instruments to assess posttraumatic stress symptoms, behavioral and emotional problems, and quality of life perception in children aged 8-18 are conducted at T1, T2, and T3.

DISCUSSION

This is the first RCT that examines the effectiveness of EMDR and KIDNET in refugee children aged 8-18 years specifically, compared to a waitlist control group intended to reduce PTSD diagnosis and severity of posttraumatic stress symptoms and comorbid complaints in a growing and challenging population.

TRIAL REGISTRATION

Dutch Trial Register NL40769 . Retrospectively registered on June 16, 2021.

The efficacy and acceptability of exposure therapy for the treatment of post-traumatic stress disorder in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Posttraumatic stress disorder (PTSD) is common among children and adolescents who have experienced traumatic events. Exposure therapy (ET) has been shown to be effective in treating PTSD in adults. However, its efficacy remains uncertain in children and adolescents.

AIMS

To evaluate the efficacy and acceptability of ET in children and adolescents with PTSD.

METHOD

We searched PubMed, EMBASE, Cochrane, Web of Science, PsycINFO, CINAHL, ProQuest, LILACS, and international trial registries for randomized controlled trials (RCTs) assessed ET in children and adolescents (aged ≤18 years) with PTSD up to August 31, 2020. The primary outcomes were efficacy (the endpoint score from PTSD symptom severity rating scales) and acceptability (all-cause discontinuation), secondary outcomes included efficacy at follow-up (score from PTSD scales at the longest point of follow-up), depressive symptoms (end-point score on depressive symptom severity rating scales) and quality of life/social functioning (end-point score on quality of life/social functioning rating scales). This study was registered with PROSPERO (CRD42020150859).

RESULT

A total of 6 RCTs (278 patients) were included. The results showed that ET was statistically more efficacious than control groups (standardized mean differences [SMD]: - 0.47, 95% confidence interval [CI]: - 0.91 to - 0.03). In subgroup analysis, exposure therapy was more efficacious for patients with single type of trauma (SMD: - 1.04, 95%CI: - 1.43 to - 0.65). Patients with an average age of 14 years and older, ET was more effective than the control groups (SMD: - 1.04, 95%CI: - 1.43 to - 0.65), and the intervention using prolonged exposure therapy (PE) (SMD: - 1.04, 95%CI: - 1.43 to - 0.65) was superior than control groups. Results for secondary outcomes of efficacy at follow-up (SMD: - 0.64, 95%CI: - 1.17 to - 0.10) and depressive symptoms (SMD: - 0.58, 95%CI: - 0.93 to - 0.22) were similar to the previous findings for efficacy outcome. No statistically significant effects for acceptability and quality of life/social functioning were found.

CONCLUSION

ET showed superiority in efficacy at post-treatment/follow-up and depressive symptoms improvement in children and adolescents with PTSD. Patients with single type of trauma may benefit more from ET. And ET is more effective in patients 14 years or older. Moreover, PE could be a better choice.

Systematic Review for the Medical Applications of Meditation in Randomized Controlled Trials

Background: Meditation has been increasingly adapted for healthy populations and participants with diseases. Its beneficial effects are still challenging to determine due to the heterogeneity and methodological obstacles regarding medical applications. This study aimed to integrate the features of therapeutic meditation in randomized controlled trials (RCTs). Methods: We conducted a systematic review of RCTs with meditation for populations with diseases using the PubMed database through June 2021. We analyzed the characteristics of the diseases/disorders, participants, measurements, and their overall benefits. Results: Among a total of 4855 references, 104 RCTs were determined and mainly applied mindfulness-based (51 RCTs), yoga-based (32 RCTs), and transcendental meditation (14 RCTs) to 10,139 patient-participants. These RCTs were conducted for participants with a total of 45 kinds of disorders; the most frequent being cancer, followed by musculoskeletal and connective tissue diseases and affective mood disorder. Seven symptoms or signs were frequently assessed: depressive mood, feeling anxious, quality of life, stress, sleep, pain, and fatigue. The RCTs showed a higher ratio of positive outcomes for sleep (73.9%) and fatigue (68.4%). Conclusions: This systematic review produced the comprehensive features of RCTs for therapeutic meditation. These results will help physicians and researchers further study clinical adaptations in the future as reference data.

The mental health and well-being of internally displaced female Yazidis in the Kurdistan Region of Iraq: a realist review of psychosocial interventions and the impact of COVID-19

BACKGROUND

Yazidis in the Kurdistan Region of Iraq have been exposed to recurrent traumatic experiences associated with genocide and gender-based violence (GBV). In 2014, ISIS perpetrated another genocide against the Yazidi community of Sinjar. Women and girls were held captive, raped and beaten. Many have been forced into displacement. Rates of post-traumatic stress disorder (PTSD) and suicide are high. Limited research has evaluated interventions delivered to this population.

METHODS

This review explores how the global evidence on psychosocial interventions for female survivors of conflict-related sexual violence applies to the context of the female Yazidi population. We used a realist review to explore mechanisms underpinning complex psychosocial interventions delivered to internally displaced, conflict-affected females. Findings were cross-referenced with eight realist, semi-structured interviews with stakeholders who deliver interventions to female Yazidis in the Kurdistan Region of Iraq. Interviews also allowed us to explore the impact of COVID-19 on effectiveness of interventions.

RESULTS

Seven mechanisms underpinned positive mental health outcomes (reduced PTSD, depression, anxiety, suicidal ideation): safe spaces, a strong therapeutic relationship, social connection, mental health literacy, cultural-competency, gender-matching and empowerment. Interviews confirmed relevance and applicability of mechanisms to the displaced female Yazidi population. Interviews also reported increased PTSD, depression, suicide and flashbacks since the start of the COVID-19 pandemic, with significant disruptions to interventions.

CONCLUSION

COVID-19 is just one of many challenges in the implementation and delivery of interventions. Responding to the mental health needs of female Yazidis exposed to chronic collective violence requires recognition of their sociocultural context and everyday experiences.

Psychological Interventions for Children Experiencing PTSD After Exposure to a Natural Disaster: A Scoping Review

Exposure to a natural disaster can have a myriad of significant and adverse psychological consequences. Children have been identified as a particularly vulnerable population being uniquely susceptible to post-disaster psychological morbidity, including post-traumatic stress disorder (PTSD). Without effective intervention, the impact of natural disasters on children's developmental trajectory can be detrimental, however, research is yet to find evidence to definitively establish the comparative efficacy or unequivocal superiority of any specific psychological intervention. A scoping review was undertaken according to the Preferred Reporting Items extension for Scoping Reviews Guidelines (PRISMA-ScR), to evaluate the current research regarding psychological interventions for children (below 18 years of age) experiencing PTSD after exposure to natural disasters, a single incident trauma. Fifteen studies involving 1337 children were included in the review. Overall, psychological interventions, irrespective of type, were associated with statistically significant and sustained reductions in PTSD symptomatology across all symptom clusters. However, whilst evidence supported the general efficacy of psychological interventions in this population, the majority of studies were considered retrospective field research designed in response to the urgent need for clinical service in the aftermath of a natural disaster. Consequently, studies were largely limited by environmental and resource constraints and marked by methodological flaws resulting in diverse and highly heterogeneous data. As such, definitive conclusions regarding the treatment efficacy of specific psychological interventions, and furthermore their ameliorative contributions constituting the necessary mechanisms of change remains largely speculative. As natural disasters can have a catastrophic impact on human lives, establishing levels of evidence for the efficacy of different psychological interventions for children represents a global public health priority.

A meta-analysis of dropout from evidence-based psychological treatment for post-traumatic stress disorder (PTSD) in children and young people

BACKGROUND

Despite the established evidence base of psychological interventions in treating PTSD in children and young people, concern that these trauma-focused treatments may 'retraumatise' patients or exacerbate symptoms and cause dropout has been identified as a barrier to their implementation. Dropout from treatment is indicative of its relative acceptability in this population.

OBJECTIVE

Estimate the prevalence of dropout in children and young people receiving a psychological therapy for PTSD as part of a randomized controlled trial (RCT).

METHODS

A systematic search of the literature was conducted to identify RCTs of evidence-based treatment of PTSD in children and young people. Proportion meta-analyses estimated the prevalence of dropout. Odds ratios compared the relative likelihood of dropout between different treatments and controls. Subgroup analysis assessed the impact of potential moderating variables.

RESULTS

Forty RCTs were identified. Dropout from all treatment or active control arms was estimated to be 11.7%, 95% CI [9.0, 14.6]. Dropout from evidence-based treatment (TFCBTs and EMDR) was 11.2%, 95% CI [8.2, 14.6]. Dropout from non-trauma focused treatments or controls was 12.8%, 95% CI [7.6, 19.1]. There was no significant difference in the odds of dropout when comparing different modalities. Group rather than individual delivery, and lay versus professional delivery, were associated with less dropout.

CONCLUSIONS

Evidence-based treatments for children and young people with PTSD do not result in higher prevalence of dropout than non-trauma focused treatment or waiting list conditions. Trauma-focused therapies appear to be well tolerated in children and young people.

Strategies for Delivering Mental Health Services in Response to Global Climate Change: A Narrative Review

This narrative review examined strategies for preparedness and response to mental health impacts of three forms of climate change from a services perspective: (1) acute and extreme weather events such as hurricanes, floods, and wildfires, (2) sub-acute or long-term events such as droughts and heatwaves; and (3) the prospect of long-term and permanent changes, including higher temperatures, rising sea levels, and an uninhabitable physical environment. Strategies for acute events included development and implementation of programs and practices for monitoring and treating mental health problems and strengthening individual and community resilience, training of community health workers to deliver services, and conducting inventories of available resources and assessments of at-risk populations. Additional strategies for sub-acute changes included advocacy for mitigation policies and programs and adaptation of guidelines and interventions to address the secondary impacts of sub-acute events, such as threats to livelihood, health and well-being, population displacement, environmental degradation, and civil conflict. Strategies for long-lasting changes included the implementation of evidence-based risk communication interventions that address the existing and potential threat of climate change, promoting the mental health benefits of environmental conservation, and promoting psychological growth and resilience.

Systematic review and meta-analyses of the long-term efficacy of narrative exposure therapy for adults, children and perpetrators

Objective: Narrative Exposure Therapy (NET) is a short-term trauma-focused intervention originally developed for treating survivors of war and torture. The neurobiological theoretical foundations of NET would suggest that the approach should have long term beneficial effects. We tested this assumption and also provided an extensive overview of all NET studies for adults, for children (KIDNET), and for perpetrators (Forensic Offender Rehabilitation NET; FORNET).Method: Following a systematic literature review, we conducted meta-analyses with all studies that had control conditions, and with all Randomized Controlled Trials (RCTs). We assessed between-groups short- (< 6 months) and long-term (≥ 6 months) effect sizes for symptoms of posttraumatic stress disorder (PTSD) and depression.Results: In a total of 56 studies from 30 countries comparing 1370 participants treated with NET to 1055 controls, we found large between group effect sizes regarding the reduction of PTSD symptoms in favor of NET. Analyses of RCTs with active controls yielded small to medium effect sizes in the short-term, and large effect sizes in the long-term.Conclusions: NET, KIDNET, and FORNET yield beneficial and sustainable treatment results for severely traumatized individuals living in adverse circumstances. Studies in highly developed health care systems comparing NET with other evidence-based trauma-focused interventions are needed.

Does cumulative exposure to traumatic stressors predict treatment outcome of community-implemented exposure-based therapy for PTSD?

Background: Posttraumatic Stress Disorder (PTSD) is associated with high levels of functional impairments such as difficulties in academic or occupational performance and in social relationships. With an increasing number of traumatic event types experienced (trauma load), PTSD risk increases in a dose-dependent manner. Accordingly, high rates of PTSD can impair the reconstruction process in post-conflict societies. In order to meet these high needs for mental health services in societies with little access to professional care, task shifting approaches and community-based interventions have been suggested. Narrative Exposure Therapy (NET) has been developed as a short and pragmatic exposure-based PTSD treatment that can be easily trained to lay personnel. Yet, it remains unclear whether NET can be effectively provided by trained lay counsellors even at high levels of trauma load. Objective: To investigate whether trauma load influences the treatment effectiveness of NET provided by trained and supervised local lay counsellors. Method: Linear mixed models were calculated to investigate the influence of trauma load on treatment effectiveness in a sample of N = 323 rebel war survivors from Northern Uganda with PTSD. Results: We found a strong reduction of PTSD symptoms following NET, which was not influenced by trauma load. However, individuals with higher levels of trauma load reported higher PTSD symptoms before therapy as well as 4 and 10 months following treatment completion compared to individuals with lower trauma load. Conclusions: Treatment with NET by lay counsellors is effective independent of trauma load. However, individuals with higher trauma load have a higher probability to show residual symptoms, which might require additional time, sessions or treatment modules.

The relationship between multiple exposures to violence and war trauma, and mental health and behavioural problems among Palestinian children and adolescents

The current study aims to investigate the effect of cumulative exposure to violence on mental health amongst children and adolescents living in the Gaza Strip. The sample consists of 1029 children and adolescents aged 11-17 years. Of them, 533 (51.8%) were female and 496 (48.2%) were male. War-traumatic events were measured using the War-Traumatic Events Checklist (W-TECh). Violence was derived from the Multicultural Events Schedule for Adolescents (M.E.S.A.) containing three domains: violence at home, violence in the neighbourhood, and violence at school. Emotional and behavioural problems were measured using the Strengths and Difficulties Questionnaire (SDQ). Posttraumatic Stress Disorder was measured using the Post-Traumatic Stress Disorders Symptoms Scale (PTSDSS). Finally, depression symptoms were measured by the Depression scale. Around two thirds of the children (64.5%, N = 665) reported that they were exposed to violence at home, 48.2% (N = 497) to violence in the neighbourhood, 78.2% (N = 806) to violence at school. In addition, boys significantly showed more exposure to violence compared to girls. Moreover, the prevalence of PTSD according to DSM-5 is 53.5% (N = 549). The results also showed that cumulative effect of exposure to violence in more contexts (political war trauma, violence at home, neighbourhood and/or school) predicted higher levels of PTSD, social and emotional problems, depression, and overall mental health problems amongst children. Cumulative exposure to violence may increase the propensity of developing mental health problems such as PTSD, emotional and behavioural problems, and depression symptoms and thus interventions should be targeted to these populations.

Psychological interventions for posttraumatic stress disorder and depression in refugees: A meta-analysis of randomized controlled trials

Millions of refugees around the globe suffer from posttraumatic stress disorder (PTSD) and/or depression. We conducted a meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of psychological interventions for PTSD and/or depression in refugees. The meta-analysis was registered on the PROSPERO database (CRD42017071384). A search using the Medline, PsycINFO, and PILOTS databases was conducted in January 2019, resulting in 17 RCTs, of which 14 were conducted with adult refugees (1,108 participants) and 3 with young refugees (<18 years; 151 participants). Further inclusion criteria were at least 10 participants completing an active psychological intervention for PTSD, depression, or both and less than 50% of participants receiving concurrent psychotropic drugs. Random effects models showed that active interventions for adult PTSD yielded a medium to large aggregated effect size (g = 0.77; 95% confidence interval [CI] [0.26, 1.28]) at posttreatment when compared with passive and active control conditions. Active interventions for adult depression also produced large controlled effect sizes at posttreatment (g = 0.82; 95% CI [0.24, 1.40]). The effects appeared to persist over the average follow-up period of 6 months. The findings suggest that psychological interventions can effectively reduce symptoms of both PTSD and depression in adult refugees. However, the considerable heterogeneity between studies indicates that the efficacy may vary significantly. Future studies should aim to explore the substantial heterogeneity in effect sizes between studies with adult refugees. Additionally, more trials with young refugees suffering from PTSD or depression are needed to determine treatment efficacy for this population.

Changes in Traumatic Memories and Posttraumatic Cognitions Associate with PTSD Symptom Improvement in Treatment of Multiply Traumatized Children and Adolescents

Refinement, targeting, and better dissemination of trauma-focused therapies requires understanding their underlying mechanisms of change. Research on such mechanisms among multiply traumatized children and adolescents is scarce. We examined the role of improvements in problematic qualities of traumatic memories and maladaptive posttraumatic cognitions in PTSD symptom reduction, in a randomized, pragmatic trial of narrative exposure therapy vs. treatment as usual with 40 participants 9-17 years old (48% female, 75% refugee background) repeatedly exposed to war or family violence related trauma. Posttraumatic cognitions, quality of traumatic memories and PTSD symptoms were assessed by self-report before and after treatment. Improvements in both quality of traumatic memories (r _MI = .36) and posttraumatic cognitions (r _MI = .46) correlated with symptom reduction. However, improvement during treatment was only significant for quality of traumatic memories (F _MI(11,333.56) = 4.77), not for posttraumatic cognitions. We detected no difference in effects of narrative exposure therapy and treatment as usual on cognitions or memories. We tentatively suggest problematic, overly sensory and incoherent quality of traumatic memories may be a useful target in the treatment of PTSD symptoms among multiply traumatized children and adolescents. Changing maladaptive posttraumatic cognitions, though important, may be challenging among those with severe, repeated trauma.

The efficacy of Narrative Exposure Therapy for Children (KIDNET) as a treatment for traumatized young refugees versus treatment as usual: study protocol for a multi-center randomized controlled trial (YOURTREAT)

BACKGROUND

Germany hosts a large number of refugees from war-affected countries. The integration of refugees, in particular young refugees from the Middle East, is one of the major current social challenges in Germany. Mental disorders, first of all post-traumatic stress disorder (PTSD) that results from war experiences, are common among young refugees and interfere with quality of life as well as functional integration. Evidence regarding effective treatment options for this population is scarce. In this trial, we aim to evaluate the pragmatic, short-term psychotherapy Narrative Exposure Therapy for Children (KIDNET) for the treatment of young refugees in Germany.

METHODS

In a rater-blinded, multi-center, randomized-controlled trial, KIDNET is compared to treatment as usual (TAU) within the general health care system. A total number of 80 young refugees who fulfill the diagnostic criteria of PTSD will be randomized to either KIDNET or TAU. Diagnostic interviews will take place at baseline before treatment as well as 6 and 12 months thereafter. They will assess exposure to traumatic events, PTSD and comorbid symptoms, as well as parameters of integration.

DISCUSSION

The results of this study should provide evidence regarding effective treatment options for young refugees in Germany, a population that has been understudied and received only limited access to mental health care so far. Next to the effects of treatment on mental health outcomes, integration parameters will be investigated. Therefore, this study should provide broad insights into treatment options for young refugees and their potential implications on successful integration.

TRIAL REGISTRATION

German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS), ID: DRKS00017222. Registered on 15 May 2019.

A Comparison of Narrative Exposure Therapy and Non-Trauma-Focused Treatment in Post-Traumatic Stress Disorder: A Systematic Review and Meta-Analysis

Background: Narrative Exposure Therapy (NET) is a relatively new treatment that may be beneficial as a standalone approach or as an adjunct for use in individuals who suffer from simple or complex Posttraumatic Stress Disorder (PTSD).Aims: The main objective of this review was to explore the effectiveness of NET in remediating PTSD symptoms as compared to Non Trauma-Focused-Therapy (NTFT).Methods: A systematic search in Medline, PsycINFO, EMBASE and The Cochrane Central Register of Controlled Trials (CENTRAL) was carried out. Reference lists of papers and grey literature were hand searched. Experimental studies that compare NET to NTFT with no preference to age, gender or nationality of participants that include a baseline and 3-6 month measurement of PTSD outcomes using tools with good psychometric properties were included. The search resulted in 10 randomised controlled trials. Data extraction, collection and analysis was then carried out by the authors.Results: In all of the studies, the difference in the PTSD symptoms' mean score after 3-6 months between the NET group and the NTFT group was in favour of NET. However, the level of significance was attained in six of the studies only. The overall effect size (standardised mean difference) of the trials is 0.684 in favour of NET (p < .001).Conclusions: NET was shown to be superior to NTFT in post-traumatic stress disorder. The most important recommendations are in relation to research and target the methodological limitations of existing studies in particular the small sample sizes, lack of blindness and inadequate rigour during the trials. More research is needed to further explore the benefits of NET for different populations and trauma-types.

Gender differences in response to war-related trauma and posttraumatic stress disorder - a study among the Congolese refugees in Uganda

BACKGROUND

The wars in the Democratic Republic of Congo have left indelible marks on the mental health and functioning of the Congolese civilians that sought refuge in Uganda. Even though it is clear that civilians who are exposed to potentially traumatizing events in war and conflict areas develop trauma-related mental health problems, scholarly information on gender differences on exposure to different war-related traumatic events, their conditional risks to developing PTSD and whether the cumulative exposure to traumatic events affects men and women differently is still scanty.

METHODS

In total, 325 (n = 143 males, n = 182 females) Congolese refugees who lived in Nakivale, a refugee settlement in the Southwestern part of Uganda were interviewed within a year after their arrival. Assessment included exposure to war-related traumatic events, and DSM-IV PTSD symptom severity.

RESULTS

Our main findings were that refugees were highly exposed to war-related traumatic events with experiencing dangerous flight as the most common event for both men (97%) and women (97%). The overall high prevalence of PTSD differed among women (94%) and men (84%). The highest conditional prevalence of PTSD in women was associated with experiencing rape. The dose-response effect differed significantly between men and women with women showing higher PTSD symptom severity when experiencing low and moderate levels of potentially traumatizing event types.

CONCLUSION

In conflict areas, civilians are highly exposed to different types of war-related traumatic events that expose them to high levels of PTSD symptoms, particularly women. Interventions focused at reducing mental health problems resulting from war should take the context of gender into consideration.

Five Applications of Narrative Exposure Therapy for Children and Adolescents Presenting With Post-Traumatic Stress Disorders

Narrative exposure therapy (NET) is an individual therapeutic approach that has an emerging evidence base for children. It was initially trialed with refugee and asylum seeking populations, in low, middle and high-income settings, utilizing either lay or professional therapists. The results of treatment trials for PTSD in refugee children with NET (or the child "KIDNET" adaptation) demonstrates how this is an effective intervention, is scalable and culturally dexterous. This paper describes, in five cases from clinical practice settings, the applicability of NET into broader, routine practice. The cases outlined describe the use of NET with adolescents with: autism spectrum disorders, psychotic symptoms, and intellectual disabilities; histories of forced abduction into child soldiering; complex physical health problems needing multiple interventions; and victims of childhood sexual abuse. The cases are discussed with regards to how the NET lifeline facilitated engagement in treatment, practical adaptations for those with intellectual disabilities and how NET, with its relatively short training for health professionals, can be modified to different contexts and presentations. The importance of improving access to care is discussed to ensure that young people are supported with their most complex and disruptive memories.

Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges

Post-traumatic stress disorder (PTSD) is arguably the most common psychiatric disorder to arise after exposure to a traumatic event. Since its formal introduction in the DSM-III in 1980, knowledge has grown significantly regarding its causes, maintaining mechanisms and treatments. Despite this increased understanding, however, the actual definition of the disorder remains controversial. The DSM-5 and ICD-11 define the disorder differently, reflecting disagreements in the field about whether the construct of PTSD should encompass a broad array of psychological manifestations that arise after trauma or should be focused more specifically on trauma memory phenomena. This controversy over clarifying the phenotype of PTSD has limited the capacity to identify biomarkers and specific mechanisms of traumatic stress. This review provides an up-to-date outline of the current definitions of PTSD, its known prevalence and risk factors, the main models to explain the disorder, and evidence-supported treatments. A major conclusion is that, although trauma-focused cognitive behavior therapy is the best-validated treatment for PTSD, it has stagnated over recent decades, and only two-thirds of PTSD patients respond adequately to this intervention. Moreover, most people with PTSD do not access evidence-based treatment, and this situation is much worse in low- and middle-income countries. Identifying processes that can overcome these major barriers to better management of people with PTSD remains an outstanding challenge.

Practitioner Review: Mental health problems of refugee children and adolescents and their management

BACKGROUND

Since 2010, the numbers of refugees have increased and around half are under 18 years of age. It is known that experience of organised violence, displacement and resettlement increases the risk for psychiatric disorders and psychosocial impairment. This review integrates recent research into the risk and protective factors for psychopathology with service and treatment issues.

METHODS

We draw on and critically evaluate key systematic reviews in the selected areas, innovative robust studies and relevant government reports.

RESULTS

Many refugee children show resilience and function well, even in the face of substantial adversities. The most robust findings for psychopathology are that PTSD, and posttraumatic and depressive symptoms are found at higher prevalence in those who have been exposed to war experiences. Their severity may decrease over time with resettlement, but PTSD in the most exposed may show higher continuity. More severe psychiatric disorders including psychosis may also occur. Service delivery needs to take into account socioeconomic and cultural influences but, given the high level of unmet need even in high-income countries, stepped care delivery is required. The evaluation of psychological interventions, often delivered in group settings, suggests that they can be effective for many distressed children; however, for the more impaired, a greater range of disorder-specific therapies will be required.

CONCLUSIONS

Child and adolescent mental health clinicians and service providers need to be aware of the specific needs of this population and systems for service delivery. There are significant knowledge gaps in understanding risk and vulnerability, service delivery and treatment effectiveness.

The Impact of Psychological Interventions on Posttraumatic Stress Disorder and Pain Symptoms: A Systematic Review and Meta-Analysis

OBJECTIVES

Posttraumatic stress disorder (PTSD) and pain often co-occur, introducing clinical challenges and economic burden. Psychological treatments are considered effective for each condition, yet it is not known which therapies have the potential to concurrently address PTSD and pain-related symptoms.

MATERIALS AND METHODS

To conduct a systematic review and meta-analysis, databases were searched for articles published between January 2007 and December 2017 describing results from clinical trials of interventions addressing PTSD and pain-related symptoms in adults. Two independent reviewers finalized data extraction and risk of bias assessments. A random-effects model was used for meta-analysis and to calculate pooled and subgroup effect sizes (ESs) of psychological-only (single modality) and multimodal interventions.

RESULTS

Eighteen trials (7 uncontrolled, 11 randomized controlled trials, RCTs), totaling 1583 participants, were included in the systematic review. RCT intervention types included exposure-based, cognitive-behavioral, and mindfulness-based therapies. Data from 10 RCTs (N=1, 35) were available for meta-analysis, which demonstrated moderate effect for reduced PTSD severity (ES=-0.55, confidence interval [CI]: -0.83, -0.26) and nonsignificant effect for pain intensity (ES=-0.14, CI: -0.43, 0.15) and pain interference (ES=-0.07, CI: -0.35, 0.20) outcomes. Findings from uncontrolled trials supported meta-analytic results from RCTs. Using GRADE assessment, the quality of evidence was deemed as moderate for RCTs and low for non-RCTs.

DISCUSSION

Findings indicated that the majority of the interventions appeared to have a greater impact on reducing PTSD rather than pain-related symptoms. There remains a need to further develop interventions that consistently impact PTSD and pain-related outcomes when these 2 conditions co-occur.

Undocumented asylum seekers with posttraumatic stress disorder in the Netherlands

Background: To date, most studies on the mental health of refugees in Europe have focused on the prevalence and treatment of psychopathology. Little is known about those who illegally reside in the host country, referred to, in the Netherlands, as undocumented asylum seekers. There are indications that mental health and psychosocial problems are more prevalent in this group than among refugees in general, with unsatisfactory treatment outcomes. Objective: To describe characteristics and mental health and psychosocial problems of undocumented asylum seekers, and to establish the need for, and feasibility of, a tailored treatment approach. Method: Based on a literature review and extensive clinical experience, common mental health and psychosocial problems and accessibility of care for undocumented asylum seekers are established, as well as the common treatment approach in the Netherlands. A tailored treatment programme and experiences with its implementation are described. Results: Mental health and psychosocial problems are highly prevalent among undocumented asylum seekers, and access to care is limited. In addition, treatment in the Netherlands, if provided, is mostly insufficient yet prolonged. Given the specific psychosocial problems and living conditions of undocumented asylum seekers, a necessary criterion to enable adequate and evidence-based treatment provision is acknowledgement of their distinct needs. A tailored treatment programme as currently implemented in the Netherlands appears to meet this criterion and be feasible under certain conditions. Collaboration between mental health care providers and involved social service and governmental parties by regular meetings, though complicated, is a relevant element. Conclusions: Even though undocumented asylum seekers are illegally residing in a country, medical ethics and the human rights perspective necessitate for adequate and evidence-based treatment for those among them with mental health problems. The tailored treatment approach presented here suggests that, notwithstanding factors complicating care provision which require specific attention, this is feasible.

Treating children and adolescents with multiple traumas: a randomized clinical trial of narrative exposure therapy

Background and Objective: Millions of children and adolescents worldwide suffer from post-traumatic stress disorder (PTSD) and other problems due to prolonged exposure to traumatizing events. Forms of cognitive-behavioural therapy are the most commonly used treatment for PTSD, but evidence from sophisticated studies in clinical settings among children is limited. Method: This multicentre, parallel, non-blinded, pragmatic randomized controlled trial assessed the effectiveness of narrative exposure therapy (NET) in traumatized children and adolescents. Fifty 9-17-year-old participants, who had experienced prolonged traumatic conditions in the form of refugeedom or family violence and suffered from PTSD symptoms, were randomized into NET (n = 29) and treatment as usual (TAU; n = 21) active control groups. The objective was to determine whether NET can be feasibly implemented within the existing healthcare system of a high-income country and whether it would reduce mental health problems, especially PTSD, and increase resilience, in children and adolescents with multiple traumas more effectively than TAU. We hypothesized that NET would be more effective than TAU in reducing symptoms and increasing resilience. Results: Analysis of variance revealed that PTSD and psychological distress, but not depression symptoms, decreased regardless of treatment group. Resilience increased in both groups. Within-group analyses showed that the decrease in PTSD symptoms was significant in the NET group only. The effect sizes were large in NET but small in TAU. Concerning PTSD symptom cut-off scores, the reduction in the share of participants with clinical-level PTSD was significant in the NET group only. Intention-to-treat analyses using linear mixed models confirmed these results. Conclusions: Despite its shortcomings, this study gives preliminary support for the safety, effectiveness, and usefulness of NET among multiply traumatized children and adolescents in clinical settings. Close attention must be paid to the implementation of the new intervention as an everyday tool in healthcare.

Impact and cultural acceptance of the Narrative Exposure Therapy in the aftermath of a natural disaster in Burundi

BACKGROUND

In the aftermath of natural disasters, affected populations are at risk of suffering from trauma-related mental health disorders such as posttraumatic stress disorder (PTSD) or depression. Particularly in poor post-conflict regions, these mental disorders have the potential to impair the ability of individuals to move on with their lives. We aimed to evaluate the feasibility, cultural acceptance, and effect of a trauma-focused psychotherapy, Narrative Exposure Therapy (NET), in the aftermath of a flood disaster in Burundi.

METHODS

Fifty-one individuals who were living in emergency camps overseen by the Burundian Red Cross in the aftermath of a flood disaster, and who had lost homes and close relatives, were invited to participate in semi-structured diagnostic interviews. Trained Burundian psychology students conducted these interviews, and six sessions of NET were offered to the 15 individuals most affected by trauma-related symptoms. An additional group of psychology students, blind to the treatment conditions, conducted three and 9 months follow-ups with them including also 25 participants who had reported significant but less severe trauma-related symptoms, assessing mental health symptoms, acceptance of NET, stigmatization due to trauma symptoms, and participants' economic well-being.

RESULTS

Between baseline and 9-months post-intervention assessment, symptoms of PTSD (Hedges' g = 3.44) and depression (Hedges' g = 1.88) improved significantly within participants who received NET and within those who received no treatment (Hedges' g_PTSD = 2.55; Hedges' g_depression = 0.72). Furthermore, those who received NET felt less stigmatized by their participation in the intervention than by the trauma-related mental health symptoms they experienced. Overall, participants reported that they would be willing to forego as much as 1 month's worth of income in exchange for receiving trauma-focused interventions in the months following the disaster.

CONCLUSIONS

Individuals severely affected by trauma-related mental health symptoms might benefit significantly from NET in the aftermath of natural disasters, while less affected individuals seem to recover spontaneously. Despite significant challenges conducting NET in emergency camps in the aftermath of natural disaster in a post-conflict country, such interventions are feasible, appreciated and might have long-lasting impacts on the lives of survivors if conducted with due respect to participants' privacy.

TRIAL REGISTRATION

UKCR2014 , the 19.06.2014, retrospectively registered.

Psychological and psychosocial interventions for refugee children resettled in high-income countries

Large numbers of refugee children are arriving in high-income countries. The evidence to date suggests that they have mental health needs that are higher than for the general population and that these are exacerbated by the numbers of traumatic events they have experienced and the post-migration stressors they continue to be exposed to. The importance of a thorough and thoughtful assessment is discussed. Treatments of note are described for post-traumatic stress disorder, family functioning, general mental health problems and school environments. Future opportunities to operationalise outcome measures, develop multimodal interventions and utilise implementation science methodology are considered.

A controlled trial of trauma-focused therapy versus problem-solving in Islamic children affected by civil conflict and disaster in Aceh, Indonesia

OBJECTIVE

To evaluate the relative efficacies of trauma-focused cognitive behavior therapy and problem-solving therapy in treating post-traumatic stress disorder in children affected by civil conflict in Aceh, Indonesia.

METHOD

A controlled trial of children with post-traumatic stress disorder ( N = 64) randomized children to either five individual weekly sessions of trauma-focused cognitive behavior therapy or problem-solving therapy provided by lay-counselors who were provided with brief training. Children were assessed by blind independent assessors at pretreatment, posttreatment and 3-month follow-up on post-traumatic stress disorder, depression and anger, as well as caregiver ratings of the child's post-traumatic stress disorder levels.

RESULTS

Intent-to-treat analyses indicated no significant linear time × treatment condition interaction effects for post-traumatic stress disorder at follow-up ( t(129.05) = -0.55, p = 0.58), indicating the two conditions did not differ. Across both conditions, there were significant reductions in post-traumatic stress disorder on self-reported ( t(131.26) = -9.26, p < 0.001) and caregiver-reported ( t(170.65) = 3.53, p = 0.001) measures and anger ( t(127.66) = -7.14, p < 0.001). Across both conditions, there was a large effect size for self-reported post-traumatic stress disorder (cognitive behavior therapy: 3.73, 95% confidence interval = [2.75, 3.97]; problem-solving: 2.68, 95% confidence interval = [2.07, 3.29]).

CONCLUSIONS

These findings suggest that trauma-focused cognitive behavior therapy and problem-solving approaches are comparably successful in reducing post-traumatic stress disorder and anger in treating mental health in children in a post-conflict setting. This pattern may reflect the benefits of non-specific therapy effects or gains associated with trauma-focused or problem-solving approaches.

Mind the gap: The role of mindfulness in adapting to increasing risk and climate change

It is becoming clear that increasingly complex global challenges cannot simply be solved by new technology or governments alone. We also need to develop new social practices and encourage a broader cultural shift towards sustainability. Against this background, this paper explores the role of mindfulness in adapting to increasing risk and climate change. Based on a literature review, it assesses current research on 'mindful climate adaptation', and explores how individual mindfulness is linked to climate adaptation. While in practice mindfulness-based approaches to climate adaptation have gained widespread recognition (e.g., by the United Nations), the results show that related research is scarce and fragmented. There is almost no research into the role of mindfulness in climate adaptation. At the same time, new scientific domains are opening up in cognate fields that illuminate the mindfulness-adaptation nexus from certain perspectives. These fields include: (1) disaster management; (2) individual well-being; (3) organisational management; (4) environmental behaviour; (5) social justice; and (6) knowledge production. As new concepts and approaches emerge, they require critical construct validation and empirical testing. The importance of further investigation is supported by a complementary empirical study, which shows that individual mindfulness disposition coincides with increased motivation to take (or support) climate adaptation actions. The paper concludes that mindfulness has the potential to facilitate adaptation at all scales (through cognitive, managerial, structural, ontological, and epistemological change processes) and should, therefore, become a core element in climate and associated sustainability research. Finally, it sketches the conceptual trajectories of the mindfulness-adaptation nexus and presents a pioneering, comprehensive framework for 'mindful climate adaptation'.

Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence

Mindfulness-based treatments for posttraumatic stress disorder (PTSD) have emerged as promising adjunctive or alternative intervention approaches. A scoping review of the literature on PTSD treatment studies, including approaches such as mindfulness-based stress reduction, mindfulness-based cognitive therapy and metta mindfulness, reveals low attrition with medium to large effect sizes. We review the convergence between neurobiological models of PTSD and neuroimaging findings in the mindfulness literature, where mindfulness interventions may target emotional under- and overmodulation, both of which are critical features of PTSD symptomatology. Recent emerging work indicates that mindfulness-based treatments may also be effective in restoring connectivity between large-scale brain networks among individuals with PTSD, including connectivity between the default mode network and the central executive and salience networks. Future directions, including further identification of the neurobiological mechanisms of mindfulness interventions in patients with PTSD and direct comparison of these interventions to first-line treatments for PTSD are discussed.

Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence

Mindfulness-based treatments for posttraumatic stress disorder (PTSD) have emerged as promising adjunctive or alternative intervention approaches. A scoping review of the literature on PTSD treatment studies, including approaches such as mindfulness-based stress reduction, mindfulness-based cognitive therapy and metta mindfulness, reveals low attrition with medium to large effect sizes. We review the convergence between neurobiological models of PTSD and neuroimaging findings in the mindfulness literature, where mindfulness interventions may target emotional under- and overmodulation, both of which are critical features of PTSD symptomatology. Recent emerging work indicates that mindfulness-based treatments may also be effective in restoring connectivity between large-scale brain networks among individuals with PTSD, including connectivity between the default mode network and the central executive and salience networks. Future directions, including further identification of the neurobiological mechanisms of mindfulness interventions in patients with PTSD and direct comparison of these interventions to first-line treatments for PTSD are discussed.

A Skill Set for Supporting Displaced Children in Psychological Recovery After Disasters

Helping children, adolescents, and families displaced following a natural disaster is a daunting task made more challenging by the relatively small research base to inform services and interventions. This paper describes the current literature pertaining to intervention practices used with displaced youth. Where gaps in the literature exist, we pull from the more general research on relocation and post-disaster intervention to assist practitioners in tailoring their efforts. Specifically discussed are ways to enhance youth resilience, to help youth build new social connections and adjust to change and uncertainty while coping with trauma-related symptoms, and to meet needs through the systems in which children are embedded. The need for focused attention to cultural factors is discussed with an emphasis on collaborating with culture brokers.