War experiences and distress symptoms of Bosnian children

Psychological and environmental factors influencing resilience among Ukrainian refugees and internally displaced persons: a systematic review of coping strategies and risk and protective factors

Background

There is much discussion in the literature about the link between traumatic events related to war and mental illness. However, in comparison, mental health has been more researched than protective factors such as coping methods, which are the primary factors to build resilience in these circumstances. This review examines the psychological and environmental elements that influence the resilience of Ukrainian refugees and IDPs by analyzing coping strategies and risk and protective factors.

Methods

A literature search was conducted on PsycINFO, Pubmed, Scopus, and Science Direct, with 259 articles screened and 13 determined as eligible for inclusion. Inclusion criteria were: (1) studies on adult Ukrainian refugees and/or IDPs; (2) original, peer-reviewed studies; and (3) studies written in English or Italian language. Single-case reports and qualitative studies were excluded, as well as those studies written in any other language, and any studies for which the full-text version could not be obtained (i.e., conference abstracts). Two reviewers independently reviewed titles and abstracts, reviewed relevant articles' full text, and extracted the data.

Results

A diverse range of individual and socio-environmental risk and protective factors were identified, influencing the resilience of Ukrainian refugees and IDPs, as well as five main categories of coping strategies: emotion-focused strategies, problem-focused strategies, avoidance, faith-based strategies, and the ones based on sense of belonging.

Discussion

War trauma and associated stressors can lead to distressing physical and psychological reactions, which persist even after leaving the war zone. Many individual and socio-environmental risk factors, such as mental disorders, financial security, having relatives wounded or displaced, and an unfamiliar environment could influence the risk and severity of psychological difficulties, emphasizing the importance of coping strategies, social connections, faith, and cultural resilience.

Conclusion

This systematic review underscores the complex range of coping strategies and factors influencing the resilience of Ukrainian refugees and IDPs. Social connections and inclusive community interventions play vital roles in improving their psychological well-being, while longitudinal studies and culturally sensitive support are needed to address their unique challenges and strengths. Implementing collaborative care models can provide comprehensive support by integrating mental health services with primary healthcare and community-based organizations.

The COVID-19 Pandemic and Early Child Cognitive Development: A Comparison of Development in Children Born During the Pandemic and Historical References

Objective

To characterize cognitive function in young children under 3 years of age over the past decade, and test whether children exhibit different cognitive development profiles through the COVID-19 pandemic.

Study Design

Neurocognitive data (Mullen Scales of Early Learning, MSEL) were drawn from 700 healthy and neurotypically developing children between 2011 to 2021 without reported positive tests or clinical diagnosis of SARS-CoV-2 infection. We compared MSEL composite measures (general cognition, verbal, and non-verbal development) to test if those measured during 2020 and 2021 differed significantly from historical 2011-2019 values. We also compared MSEL values in a sub-cohort comprising infants 0-16 months of age born during the pandemic vs. infants born prior. In all analyses, we also included measures of socioeconomic status, birth outcome history, and maternal stress.

Results

A significant decrease in mean population MSEL measures was observed in 2021 compared to historical references. Infants born during the pandemic exhibited significantly reduced verbal, non-verbal, and overall cognitive performance compared to children born pre-pandemic. Maternal stress was not found to be associated with observed declines but a higher socioeconomic status was found to be protective.

Conclusions

Results reveal a striking decline in cognitive performance since the onset of the COVID-19 pandemic with infants born since mid-2020 showing an average decrease of 27-37 points. Further work is merited to understand the underlying causative factors.

A meta-analysis of school-based interventions for student refugees, migrants, and immigrants

How do mental health practitioners and educators support child migrants, child immigrants, child refugees, and their families? This article examines the scope of current interventions for these populations. A meta-analysis of interventions used in schools over the last two decades is discussed to provide an overview of the current evidence base in this area worldwide. Recommendations are made to facilitate the application of these interventions to support child-migrants, child-immigrants, and child-refugees in the schools, and their families.

The Effects of a Reading-Based Intervention on Emotion Processing in Children Who Have Suffered Early Adversity and War Related Trauma

Early adversity and trauma can have profound effects on children's affective development and mental health outcomes. Interventions that improve mental health and socioemotional development are essential to mitigate these effects. We conducted a pilot study examining whether a reading-based program (We Love Reading) improves emotion recognition and mental health through socialization in Syrian refugee (n = 49) and Jordanian non-refugee children (n = 45) aged 7-12 years old (M = 8.9, 57% girls) living in Jordan. To measure emotion recognition, children classified the expression in faces morphed between two emotions (happy-sad and fear-anger), while mental health was assessed using survey measures of optimism, depression, anxiety, distress, and insecurity. Prior to the intervention, both groups of children were significantly biased to interpret ambiguous facial expressions as sad, while there was no clear bias on the fear-anger spectrum. Following the intervention, we found changes in Syrian refugee children's bias in emotion recognition away from sad facial expressions, although this returned to pre-intervention levels 2 months after the end of the program. This shift in the bias away from sad facial expressions was not associated with changes in self-reported mental health symptoms. These results suggest a potential positive role of the reading intervention on affective development, but further research is required to determine the longer-term impacts of the program.

Youth in Northern Ireland: Linking Violence Exposure, Emotional Insecurity, and the Political Macrosystem

Growing up in the aftermath of armed conflict puts youth at a higher risk for psychopathology—particularly in societies like Northern Ireland which continue to be characterized by intergroup tension and cyclical violence. This risk may be heightened during adolescence, when youth are beginning to explore their identities and are becoming more aware of intergroup dynamics in both their immediate communities and the broader society. It is also during this stage when youth increasingly witness or engage in antisocial behavior and sectarian activities. A series of studies in Belfast conducted by Cummings et al. (2014, Child Dev Perspect, 12(1), 16–38; 2019, J Clin Child Adolesc Psychol, 48(2), 296–305) showed that adolescents’ exposure to sectarian violence resulted in heightened emotional insecurity about the community and subsequent adjustment problems. Though the impact of direct exposure to violence is well documented, few studies have accounted for the influence of sectarianism that occurs outside of one's immediate environment. These influences may include the general climate surrounding events that are not experienced firsthand but are nonetheless salient, such as the overarching levels of tension between groups or societal discourse that is threatening to one's identity. These higher‐level influences, often referred to collectively as the macrosystem, are a necessary component to consider for adequately assessing one's socio‐developmental environment. Yet, measurement at this level of the social ecology has proven elusive in past work. The current study advances research in this area by using newspaper coding as a method of measuring the political macrosystem in Northern Ireland and assessing whether a tense or threatening climate serves as an added risk factor for youth living in Belfast.

In the current study, we measured sectarian violence at the level of the macrosystem by systematically collecting and coding newspaper articles from Northern Ireland that were published between 2006 and 2011 (N = 2,797). Each article was coded according to its level of overall political tension between Catholics and Protestants, threat to Catholics, and threat to Protestants. When aggregated, these assessments reflected the overarching trends in Catholic–Protestant relations during this period. In order to assess the association between these sociopolitical trends and the direct experiences of adolescents, the newspaper coding was linked with five waves of survey data from families (N = 999) in socioeconomically disadvantaged areas of Belfast. Using a series of multilevel moderation analyses, we then tested whether intergroup tension and ingroup threat moderated the relation between adolescents’ direct exposure to violence and their emotional insecurity. These analyses were followed by a thematic analysis of the coded newspaper articles in order to provide further context to the findings.

The results indicated that adolescents’ response to direct exposure to sectarian violence varied based on the political climate at the time of their interview. Overall, the adolescents’ emotional insecurity about the community increased with exposure to sectarian violence. During periods when the sociopolitical climate was characterized by high levels of intergroup political tension, this relation was slightly weaker—regardless of the adolescents’ ingroup (i.e., Protestant vs. Catholic). During periods when the sociopolitical climate was coded as threatening, this relation was weaker for Catholic adolescents. That is, high levels of macro‐level threat—particularly events coded as threatening for Protestants—seemed to be a protective factor for Catholic adolescents. Group differences were also found based on the adolescents’ cumulative amount of exposure to sectarian violence. As threat in the macrosystem increased, Catholic adolescents who were directly exposed to higher than average levels of sectarian violence became more emotionally secure, while Catholics with little to no exposure to violence became more insecure. Contrastingly, Protestant adolescents directly exposed to higher than average levels of sectarian violence were more insecure than Protestants with little to no violence exposure.

A thematic analysis of the newspaper articles revealed the categories of events that were viewed by coders as politically tense and threatening. Five primary themes emerged: ineffective policing and justice, family and community unrest, memories of violence, destabilized leadership, and organized paramilitary activity. Many of the articles coded as most threatening reported on a spike in attacks organized by dissident republican groups—that is, members of the Catholic community with, particularly hardline views. This may be pertinent to the finding that associations between sectarian violence exposure and emotional insecurity were exacerbated during this time for Protestants but not for Catholics. Findings from the thematic analysis provide a deeper examination of the context of events taking place during the study period, as well as their potential bearing on interpretation of the macro‐level effects.

In conclusion, these findings illustrate how one's response to the immediate environment can vary based on shifts in the political macrosystem. The current study thus contributes conceptually, empirically, and methodologically to the understanding of process relations between multiple levels of the social ecology and adolescent functioning. These results may further inform the design of future interventions and policies meant to lessen the impact of political violence. The methods used here may also be useful for the study of other contexts in which macrosystem effects are likely to have a salient impact on individual wellbeing.

Trauma exposure, mental health and tobacco use among vulnerable Syrian refugee youth in Jordan

BACKGROUND

Little is known about tobacco use among youth exposed to armed conflicts, or the influence of trauma on tobacco use in this context. This study examined patterns of smoking by tobacco product and gender among Syrian refugee youth living in host communities in Jordan and assessed the associations of post-traumatic stress disorder (PTSD) and depression symptoms, trauma exposure and social support with current smoking status in boys and girls.

METHODS

Syrian refugee students (mean [standard deviation] age = 14.9 [1.33] years) were identified through the public school system. Data were collected using an online Arabic questionnaire that included questions about demographics, trauma exposure, current smoking (cigarette and waterpipe), PTSD, depression and perceived social support. Logistic regression was used to assess the adjusted effects of independent variables on current smoking status.

RESULTS

One in 7 boys and one in 14 girls were current smokers, with boys reporting greater tobacco use than girls. Among boys, current smokers reported significantly higher family member loss and lower perceived family social support than nonsmokers; among girls, current smokers also reported significantly higher family member loss as well as greater PTSD symptoms and lower perceived significant other/special person social support.

CONCLUSIONS

Tobacco use is established among this vulnerable group. The findings highlight the potential role of psychosocial support for tobacco prevention and cessation strategies.

Constructing Invisible Walls through National and Global Policy

Worldwide 37,000 people are forced to flee their homes every day due to conflict and persecution. The factors that lead people to leave their home countries often originate with economic deprivation and violence, escalated to a level that becomes a struggle for survival. Climate change, as it has accelerated over the last three to four decades and negatively impacted natural resources, contributes to a parallel increase in strife and migration. The US response to migration has been to construct an “Invisible Wall” of isolationist and xenophobic policies, many of which are especially harmful to children and their families. The southern US border is perhaps the most high profile location of the Invisible Wall’s construction, fortified by federal policies and a withdrawal from international cooperation. Global reengagement on climate change and migration, US ratification of the Convention on the Rights of the Child, and destruction of the Invisible Wall will help to create a world where children can thrive.

Psychopathology and Associated Risk Factors Among Forcibly Displaced Syrian Children and Adolescents

More than half of the 2.7 million registered Syrian refugees in Turkey are under 18 years of age. This study investigates prevalence of psychopathology and associated risk factors in refugee children in Turkey. Of a total of 218 children aged 9-15 years, 56.2% lost someone important to them, 55.1% saw dead or wounded people, 70.4% witnessed explosions or gun battles, 42.5% witnessed people being tortured and 25.6% personally experienced cruelty/torture during war. Prevalence of PTSD was 18.3% and that of anxiety-related disorders were as high as 69.0%. Death of an important person (p = .032) and male gender (p = .040) were associated with PTSD; whilst exposure to cruelty or torture (p = .014) and increasing duration of refuge (p = .042) were significantly associated with development of anxiety disorders. Findings of the present study reveals existence of the expected but unspoken mental health needs among the Syrian children in Turkey.

Mental Health Outcomes for Youth Living in Refugee Camps: A Review

Currently, there are approximately 10.8 million child refugees worldwide. Youth living in refugee camps face a wide range of difficulties placing them at risk for trauma exposure and negative mental health outcomes. However, little is known about the mental health functioning of these youth. The present review provides a systematic review of mental health outcomes for refugee/displaced youth residing in refugee camps. Twenty studies were included in the present review. Among these studies, the prevalence of mental health disorders varied greatly with some studies reporting null effects for disorders like posttraumatic stress disorder and others reporting prevalence as high as 87%. Levels of anxiety, somatic symptoms, depression, and aggression also varied across studies. The results point to the significant need for more research on the mental health of youth residing in refugee camps. Despite the wide range of measurement approaches, the evidence points to a fairly consistent finding of a range of maladjustment problems for youth living in refugee camps. Implications for improving the methodology for investigating mental health are discussed.

Trauma-Informed Psychoeducation for Somali Refugee Youth in Urban Kenya: Effects on PTSD and Psychosocial Outcomes

The current study developed and implemented a trauma-informed psychoeducation (TIPE) intervention that is culturally relevant to urban Somali refugees in Nairobi, Kenya. A total of 141 Somali refugee youth completed 12 sessions of peer-led TIPE intervention. A series of pre- and post-tests revealed that TIPE made positive impacts on PTSD symptoms and psychosocial factors, with a differential effect observed according to baseline PTSD symptom report. Participants with high baseline PTSD scores (i.e. above clinical threshold) reported a significant decrease in PTSD symptoms and increase in perceived social support. In the meantime, those with no to mild baseline PTSD symptoms showed an increase in self-awareness of trauma responses and thus PTSD symptom report within the range of normalcy. This research supports the effect of a culturally relevant psychoeducation intervention in addressing the high mental health and psychosocial needs of the marginalized urban Somali refugee community in low resource settings.

An evaluation of a common elements treatment approach for youth in Somali refugee camps

BACKGROUND

This paper reports on: (1) an evaluation of a common elements treatment approach (CETA) developed for comorbid presentations of depression, anxiety, traumatic stress, and/or externalizing symptoms among children in three Somali refugee camps on the Ethiopian/Somali border, and (2) an evaluation of implementation factors from the perspective of staff, lay providers, and families who engaged in the intervention.

METHODS

This project was conducted in three refugee camps and utilized locally validated mental health instruments for internalizing, externalizing, and posttraumatic stress (PTS) symptoms. Participants were recruited from either a validity study or from referrals from social workers within International Rescue Committee Programs. Lay providers delivered CETA to youth (CETA-Youth) and families, and symptoms were re-assessed post-treatment. Providers and families responded to a semi-structured interview to assess implementation factors.

RESULTS

Children who participated in the CETA-Youth open trial reported significant decreases in symptoms of internalizing (d  =  1.37), externalizing (d  =  0.85), and posttraumatic stress (d  =  1.71), and improvements in well-being (d  =  0.75). Caregivers also reported significant decreases in child symptoms. Qualitative results were positive toward the acceptability and appropriateness of treatment, and its feasibility.

CONCLUSIONS

This project is the first to examine a common elements approach (CETA: defined as flexible delivery of elements, order, and dosing) with children and caregivers in a low-resource setting with delivery by lay providers. CETA-Youth may offer an effective treatment that is easier to implement and scale-up versus multiple focal interventions. A fullscale randomized clinical trial is warranted.

Are Children or Adolescents More at Risk for Posttraumatic Stress Reactions Following Exposure to Violence?: Evidence From Post-Genocide Rwanda

Whether children or adolescents exhibit higher levels of posttraumatic stress symptoms (PTSS) in response to violence is an unresolved research question. We examine this issue in UNICEF's 1995 National Trauma Survey (NTS) of 8-19-year-olds (n = 942) who survived the Rwandan Genocide and lived and attended schools in the community. PTSS were assessed with a symptom checklist based on DSM-IV indexed using an overall score comprising the sum of scores on all items and mean item scores of each of five distinct factors identified in a factor analysis within this sample. Eighty percent of the sample had witnessed massacres; 25%, rape/sexual mutilation. The overall symptom score among children was significantly (p < 0.05) lower than among adolescents. Among the five separate factors, this direct association of age with symptom levels held for two: re-experiencing (p < 0.001) and dysphoric arousal (p < 0.05), but not for the remaining three: avoidance, numbing, and anxious arousal. This discordance in factorial response to violence may help explain prevailing inconsistencies in the age-PTSS association reported to date.

Sleep quality among internally displaced Georgian adolescents and population-based controls

Sleep problems in children and adolescents are a significant public health concern and may be linked to a variety of psychoemotional difficulties. This study aimed to evaluate sleep quality and associated factors in conflict-affected Georgian adolescents after 9 months of forced displacement. Thirty-three internally displaced adolescents (mean age 11.4 years) and 33 adolescents (mean age 10.8 years) from the general population completed the Epworth Sleepiness Scale and the Children's Depression Inventory (CDI). Parents completed the Children's Sleep-Wake Scale and provided information on their socioeconomic status (SES) and the adolescents' sleep behavior, academic performance, and peer social relationships. The groups differed significantly in sleep quality, peer relationships, SES, and CDI scores. In the internally displaced group, the only significant predictor of sleep quality was SES, which increased the predictive capacity of the model (demographic and psychosocial variables) by 20% in the hierarchical analyses. The most significant predictor in the non-internally displaced group was CDI. This research indicates that displacement may affect sleep quality and psychosocial functioning. The importance of family SES as a contributing factor to displaced adolescents' poor sleep quality is highlighted. An integrated approach designed to improve the psychosocial environment of internally displaced adolescents is needed for their protection.

Nutritional and Mental Health Status of Afghan Refugee Children in Peshawar, Pakistan: A Descriptive Study

The study sought to ascertain and describe the physical and mental health states of Afghan refugee children after the terrorist attack on September 11, 2001 in the US and the aerial bombing of Afghanistan that followed. A cross-sectional survey was carried out in four refugee camps in Peshawar, Pakistan from February to March 2002, and comparisons among camps were made. A total of 70 males (mean age SD = 9.81 ±1.98 years old) and 30 females (7.94 ±2.07) answered a self-developed questionnaire on demographic data, traumatic events experience, living environment in the camps, and physical and mental health, through interviews. Anthropometric measures were measured and physical symptoms including anaemia and edema were assessed. Severe malnutrition was not shown and there were no significant differences in most nutritional and physical states among the camps. Nevertheless, in the newer camps more children experienced war related traumatic events. Mental symptoms were prevalent in all camps, though the characteristics of the symptoms differed among the camps. Asia Pac J Public Health 2005; 17(2): 93-98.

Identifying Priorities for Mental Health Interventions in War-Affected Youth: A Longitudinal Study

BACKGROUND

War-affected youth often suffer from multiple co-occurring mental health problems. These youth often live in low-resource settings where it may be infeasible to provide mental health services that simultaneously address all of these co-occurring mental health issues. It is therefore important to identify the areas where targeted interventions would do the most good.

METHODS

This analysis uses observational data from 3 waves of a longitudinal study on mental health in a sample of 529 war-affected youth (24.2% female; ages 10-17 at T1, 2002) in Sierra Leone. We regressed 4 mental health outcomes at T3 (2008) on internalizing (depression/anxiety) and externalizing (hostility/aggression) problems and prosocial attitudes/behaviors and community variables at T2 (2004) controlling for demographics, war exposures, and previous mental health scores at T1, allowing us to assess the relative impact of potential mental health intervention targets in shaping mental health outcomes over time.

RESULTS

Controlling for baseline covariates at T1 and all other exposures/potential intervention targets at T2, we observed a significant association between internalizing problems at T2 and 3 of the 4 outcomes at T3: internalizing (β = 0.27, 95% confidence interval [CI]: 0.11-0.42), prosocial attitudes (β = -0.20, 95% CI: -0.33 to -0.07) and posttraumatic stress symptoms (β = 0.22, 95% CI: 0.02-0.43). No other potential intervention target had similar substantial effects.

CONCLUSIONS

Reductions in internalizing may have multiple benefits for other mental health outcomes at a later point in time, even after controlling for confounding variables.

Feasibility and efficacy of a peer-led recovery group program for war-related trauma in Libya

After 42 years under the brutal rule of Colonel Muammar al-Gaddafi, the people of Libya rose up on 17 February 2011 and demanded change. The 9-month civil war that followed resulted in the deaths of approximately 15,000 Libyans. This study reports on the feasibility and efficacy of a 10-week peer-led group-based recovery intervention for war-related trauma implemented at the Garyounis internally displaced person camp outside of the city of Benghazi. The results of this preliminary assessment show that the use of peers to lead recovery groups for war-related trauma is not only feasible but also appears to be highly efficacious in reducing posttraumatic stress disorder symptoms in civilians. The reported subjective experiences of those involved in facilitating the groups suggest that the use of peers, rather than mental health professionals, is a realistic option to minimize the long-term effects of war-related trauma.

The validity of the DSM-IV PTSD criteria in children and adolescents: a review

OBJECTIVE

DSM-V is on its way and doubts have been raised regarding the validity of pediatric PTSD. It is the goal of the current review to critically review the empirical literature on PTSD in youth.

METHOD

A search of PsycINFO, PubMed and reference lists was conducted. Empirical information considered relevant regarding the validity of the criteria was collected.

RESULTS/CONCLUSIONS

The validity of the symptom criteria and clusters varies, with the Avoidance/Numbing cluster outperforming the Re-experiencing-and Arousal cluster. Factor analytic findings suggest that Arousal criterion D4 should be placed within the Re-experiencing cluster, and that the Avoidance/Numbing cluster should be split up. Some non-DSM-IV PTSD symptoms, among which guilt, have considerable validity in trauma-exposed youth and their inclusion in DSM-V PTSD should be considered. As for preschool children, alternative criteria are recommended that are more developmentally sensitive.

The Impact of Terrorism on Children: A Two-Year Experience

Objectives:

To review and analyze the cumulative two-year, Israeli experience with medical care for children victims of terrorism during the prehospital and hospital phases.

Methods:

Data were collected from the: (1) Magen David Adom National Emergency Medical System Registry (prehospital phase); (2) medical records from the authors’ institutions (pediatric triage); and (3) Israel Tr auma Registry (injury characteristics and utilization of in-hospital resources). Statistical analyses were performed as appropriate.

Introduction:

During the recent wave of violence in Israel and the surrounding region, hundreds of children have been exposed to and injured by terrorist attacks. There is a paucity of data on the epidemiology and management of terror-related trauma in the pediatric population and its effects on the healthcare system. This study focuses on four aspects of terrorism-related injuries: (1) tending to victims in the prehospital phase; (2) triage, with a description of a modified, pediatric triage algorithm; (3) characteristics of trauma-related injuries in children; and (4) utilization of in-hospital resources.

Results:

During the study period, 41 mass-casualty events (MCEs) were managed by Magen David Adom. Each event involved on average, 32 regular and nine mobile intensive care unit ambulances with 93 medics, 19 paramedics, and four physicians. Evacuation time was 5–10 minutes in urban areas and 15–20 minutes in rural areas. In most cases, victims were evacuated to multiple facilities. To improve efficiency and speed, the Magen David Adom introduced the use of well-trained “first-responders” and volunteer, off-duty professionals, in addition to “scoop and run” on-the-scene management. Because of differences in physiology and response between children and adults, a pediatric triage algorithm was developed using four categories instead of the usual three. Analysis of the injuries sustained by the 160 children hospitalized after these events indicates that most were caused by blasts and penetration by foreign objects. Sixty-five percent of the children had multiple injuries, and the proportion of critical to fatal injuries was high (18%). Compared to children with non-terrorism-related injuries, the terrorism-related group had a higher rate of surgical interventions, longer hospital stays, and greater needs for rehabilitation services.

Conclusion:

Terrorism-related injuries in children are severe and increase the demand for acute care. The modifications in the management of pedi-atric casualties from terrorism in Israel may contribute to the level of preparedness of medical and paramedical personnel to cope with future events. Further studies of other aspects of traumatic injuries, such as its short- and long-term psychological consequences, will provide a more comprehensive picture of the damage inflicted on children by acts of terrorism.

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

Children and adolescents who are forcibly displaced represent almost half the world's internally displaced and refugee populations. We undertook a two-part systematic search and review of the evidence-base for individual, family, community, and societal risk and protective factors for the mental health outcomes of children and adolescents. Here we review data for displacement to low-income and middle-income settings. We draw together the main findings from reports to identify important issues and establish recommendations for future work. We draw attention to exposure to violence as a well established risk factor for poor mental health. We note the paucity of research into predictor variables other than those in the individual domain and the neglect of other variables for the assessment of causal associations, including potential mediators and moderators identifiable in longitudinal work. We conclude with research and policy recommendations to guide the development and assessment of effective interventions.

Emergency safe spaces in Haiti and the Solomon Islands

This paper provides background information on emergency Safe Spaces for children and specific information for responses in Haiti and the Solomon Islands. In 2007, both countries experienced natural disasters that resulted in internal displacement of thousands of people. The Save the Children Alliance created Safe Spaces for children living in camps for internally displaced persons. The project sought to accomplish 'B-SAFE' strategies through emergency education, psychosocial, and protection interventions. The B-SAFE strategies are to (B)uild relationships, cooperation, and respect among peers; to (S)creen for high-risk children and youth; (A)ctive, structured learning and life saving information; to (F)acilitate children's natural resilience and a return to normalcy; and to (E)stablish a sense of security and self-esteem. The project made use of child and parent surveys and observation tools that measured B-SAFE indicators. Analysed data demonstrated an improvement in children's behavior participating in the programme.

Establishing the boundaries and building bridges: a literature review on ecological theory: implications for research into the refugee parenting experience

Currently an ecological model for conceptualizing and capturing the refugee parenting experience is lacking. After an extensive review of the literature related to the usages of Bronfenbrenner's ecological model of child development, a gap was found in knowledge and research centred on describing the environment of pre-resettlement (i.e. pre-flight, flight, migration, camp) contexts and their impact on refugee parents and carer experiences. The culture of the refugee parenting experience may be characterized by disruptions in and alterations to family structure and organization; values and norms; and gender roles. This paper begins by examining the definition and usages of existing ecological frameworks in the 20th and 21st century. Particular attention is drawn to the gaps in the existing literature and an ecological model is offered. The paper concludes with a discussion of the implications for practice. The outcomes of this paper suggest the need for practitioners, policymakers and researchers to engage and develop culturally competent, relevant and appropriate interventions (i.e. reconciling differing beliefs and behaviours concerning child-rearing practices; affirming positive parenting practices of these families during engagement protocols and processes; adopting a strengths-based orientation) in the area of child protection whilst at the same time safeguarding and promoting the welfare of children within pre- and post-resettlement contexts.

Depression and post-traumatic stress disorder among Haitian immigrant students: implications for access to mental health services and educational programming

BACKGROUND

Previous studies of Haitian immigrant and refugee youth have emphasized "externalizing" behaviors, such as substance use, high risk sexual behavior, and delinquency, with very little information available on "internalizing" symptoms, such as depression and anxiety. Analyzing stressors and "internalizing" symptoms offers a more balanced picture of the type of social and mental health services that may be needed for this population. The present study aims to: 1) estimate the prevalence of depression and post-traumatic stress disorder (PTSD) among Haitian immigrant students; and 2) examine factors associated with depression and PTSD to identify potential areas of intervention that may enhance psychosocial health outcomes among immigrant youth from Haiti in the U.S.

METHODS

A stratified random sample of Haitian immigrant students enrolled in Boston public high schools was selected for participation; 84% agreed to be interviewed with a standardized questionnaire. Diagnosis of depression and PTSD was ascertained using the best estimate diagnosis method.

RESULTS

The prevalence estimates of depression and PTSD were 14.0% and 11.6%; 7.9% suffered from comorbid PTSD and depression. Multivariate logistic regression demonstrated factors most strongly associated with depression (history of father's death, self-report of schoolwork not going well, not spending time with friends) and PTSD (concern for physical safety, having many arguments with parents, history of physical abuse, and lack of safety of neighborhood).

CONCLUSIONS

A significant level of depression and PTSD was observed. Stressors subsequent to immigration, such as living in an unsafe neighborhood and concern for physical safety, were associated with an increased risk of PTSD and should be considered when developing programs to assist this population. Reducing exposure to these stressors and enhancing access to social support and appropriate school-based and mental health services may improve educational attainment and psychosocial health outcomes among Haitian immigrant youth.

Family Contexts and Schooling Disruption among Orphans in Post-Genocide Rwanda

This study examines the relationship between orphan status and schooling disruption in post-genocide Rwanda. The results indicate that while non-orphans have more favorable schooling outcomes in two-parent than in single-parent families, the reverse is true among Rwandan orphans. In single-mother households, paternal orphans, i.e. orphans with only a living mother, have better outcomes than their orphan and non-orphan counterparts. In contrast, paternal orphans have worse outcomes than other children in two-parent households, especially in households headed by males. Maternal orphans are more likely to experience schooling disruptions than non-orphans regardless of family structure. The maternal-orphan disadvantage is nevertheless greater in female-headed than in male-headed households. As expected, non-related orphans are more disadvantaged than orphans related to their household heads. However, non-related orphans have a greater disadvantage in two-parent than in single-parent households. The results also suggest that within households, the provision of childcare to children below schooling age is an impediment to orphan's schooling. These impediments are, however, greater for double-orphans than paternal or maternal orphans.

Access to mental health for asylum seekers in the European Union. An analysis of disparities between legal rights and reality

The article explores some of the issues surrounding access to mental health care for asylum seekers, using Belgium as a case in point. Asylum and immigration issues have become increasingly pressing in Europe, with member states seeking a common European Asylum System and establishing minimum standards for the reception of asylum seekers. The EU measures have fallen short of providing and implementing clear guidelines. Significant discrepancies continue to exist between member states, notably policies on health care for refugees, and in particular mental healthcare. Access to mental health care is identified as crucial, yet for many the right to access is theoretical only, and in reality care is often inaccessible. Access should refer not only to the availability, but also the quality and efficacy of care. Refugees are a particularly vulnerable population, and access in the fullest sense of the term should be an essential element in the reception of asylum seekers.

Effectiveness of a school-based group psychotherapy program for war-exposed adolescents: a randomized controlled trial

OBJECTIVE

To evaluate the comparative effectiveness of a classroom-based psychoeducation and skills intervention (tier 1) and a school-based trauma- and grief-focused group treatment (tier 2) of a three-tiered mental health program for adolescents exposed to severe war-related trauma, traumatic bereavement, and postwar adversity.

METHOD

A total of 127 war-exposed and predominantly ethnic Muslim secondary school students attending 10 schools in central Bosnia who reported severe symptoms of posttraumatic stress disorder (PTSD), depression, or maladaptive grief and significant impairment in school or relationships were randomly assigned to one of two experimental conditions. These included either an active-treatment comparison condition (tier 1), consisting of a classroom-based psychoeducation and skills intervention alone (n = 61, 66% girls, mean age 16.0 years, SD 1.13) or a treatment condition composed of both the classroom-based intervention and a 17-session manual-based group therapy intervention (tier 2), trauma and grief component therapy for adolescents (n = 66, 63% girls, mean age 15.9 years, SD 1.11). Both interventions were implemented throughout the school year. Distressed students who were excluded from the study due to acute risk for harm (n = 9) were referred for community-based mental health services (tier 3).

RESULTS

Program effectiveness was measured via reductions in symptoms of PTSD, depression, and maladaptive grief assessed at pretreatment, posttreatment, and 4-month follow-up. Analysis of mean-level treatment effects showed significant pre- to posttreatment and posttreatment to 4-month follow-up reductions in PTSD and depression symptoms in both the treatment and comparison conditions. Significant pre- to posttreatment reductions in maladaptive grief reactions were found only in the treatment condition. Analyzed at the individual case level, the percentages of students in the treatment condition who reported significant (p <.05) pre- to posttreatment reductions in PTSD symptoms (58% at posttreatment, 81% at 4-month follow-up) compare favorably to those reported in controlled treatment efficacy trials, whereas the percentages who reported significant reductions in depression symptoms (23% at posttreatment, 61% at follow-up) are comparable to, or higher than, those found in community treatment settings. Lower but substantial percentages of significant symptom reduction were found for PTSD (33% at posttreatment, 48% at follow-up) and depression symptoms (13% at posttreatment; 47% at follow-up) in students in the comparison condition. The odds of significant symptom reduction were higher for PTSD symptoms at both posttreatment and 4-month follow-up and for maladaptive grief at posttreatment (no follow-up was conducted on maladaptive grief). Rates of significantly worsened cases were generally rare in both the treatment and comparison conditions.

CONCLUSIONS

A three-tiered, integrative mental health program composed of schoolwide dissemination of psychoeducation and coping skills (tier 1), specialized trauma- and grief-focused intervention for severely traumatized and traumatically bereaved youths (tier 2), and referral of youths at acute risk for community-based mental health services (tier 3) constitutes an effective and efficient method for promoting adolescent recovery in postwar settings.

The well being of children living in chronic war zones: The Palestinian—Israeli case

The paper presents a comprehensive review and integration of available studies on the effects of severe traumatic experiences on children, especially in the context of short and enduring exposure to harsh events and adversities, as they relate to children who live in violent war zones, in particular in Israel and the Palestinian territories. The review focuses on the role of risk and protective factors in determining the debilitating and damaging effects as well as resiliencies of short term and chronic catastrophic experiences on the future well being of children and emerging adults.

Trauma exposure and the drug endangered child

This study examines the differences in trauma exposure and the response to those events between drug endangered children (DEC) and non-drug endangered children involved in the child welfare system. This data represents the experiences of 1,127 children randomly selected from the state's child protective service database and represents 20% of all open cases during 2005-2006. Archival data were analyzed to determine the presence of exposure using DSM-IV-TR posttraumatic stress disorder (PTSD) Criterion A1, and whether or not the child's response to exposure met PTSD Criterion A2. Results reveal high rates of trauma exposure in the DEC group and indicate that trauma exposure and trauma response did significantly vary across groups. Implications for the assessment and treatment of child welfare-involved children are drawn.

Psychosocial Effects of War Experiences among Displaced Children in Southern Darfur

This study focused on assessing the psychosocial effects of the long standing, high intensity, and guerrilla-style of warfare among displaced children in Southern Darfur. The goal was to better understand the etiology, prognosis, and treatment implications for traumatic reactions, depression, and grief symptoms in this population. Three hundred thirty-one children aged 6–17 from three IDP Camps were selected using a quota sampling approach and were administered a Demographic Questionnaire, Child Post Traumatic Stress Reaction Index, Child Depression Inventory, and the Expanded Grief Inventory. Forty-three percent were girls and 57% were boys. The mean age of the children was 12 years. Results found that children were exposed to a very large number of war experiences with no significant differences between genders for types of exposure, including rape, but with older children (13–17 years) facing a larger number of exposures than younger children (6–12 years). Out of the 16 possible war experiences, the mean number was 8.94 ( SD = 3.27). Seventy-five percent of the children met the DSM-IV criteria for PTSD, and 38% exhibited clinical symptoms of depression. The percentage of children endorsing significant levels of grief symptoms was 20%.

Increased exposure to war experiences led to higher levels of: 1) traumatic reactions; 2) depression; and 3) grief symptoms. Of the 16 war experiences, abduction, hiding to protect oneself, being raped, and being forced to kill or hurt family members were most predictive of traumatic reactions. Being raped, seeing others raped, the death of a parent/s, being forced to fight, and having to hide to protect oneself were the strongest predictors of depressive symptoms. War experiences such as abduction, death of one's parent/s, being forced to fight, and having to hide to protect oneself were the most associated with the child's experience of grief. In addition to Total Grief, Traumatic Grief, Existential Grief, and Continuing Bonds were measured in these children. Although trauma, depression, and grief often exist as co-morbid disorders, the mechanisms and pathways of these is less understood. In this study we used Structural Equation Modeling to better understand the complex interaction and trajectories of these three symptoms evolving from war exposure and loss. This study is the first of its kind to assess the psychosocial effects of war experiences among children currently living in war zone areas within Sudan. It identifies some of the most prevalent war-related atrocities and their varying impact on the children's psychological well-being and overall adjustment. Implications for planning mental health interventions are discussed.

Emotional and behavioural problems in migrant adolescents in Belgium

Refugee and migrant adolescents may be at increased risk for the development of emotional and behavioural problems. Since studies on this topic are rather scarce and results inconsistent, this large-scale screening study aims at investigating the prevalence of emotional and behavioural problems in recently arrived migrant adolescents in Belgium, compared to Belgian peers. About 1,249 migrant adolescents and 602 Belgian adolescents filled in four self-report questionnaires on the prevalence of emotional and behavioural problems, traumatic experiences and symptoms of post-traumatic stress. Migrant adolescents experienced more traumatic events than their Belgian peers, and show higher levels of peer problems and avoidance symptoms. On the contrary, non-migrant adolescents reveal more symptoms of anxiety, externalizing problems and hyperactivity. Factors influencing the prevalence of emotional and behavioural problems are the number of traumatic events experienced, gender and the living situation. Although migrant and non-migrant adolescents don't differ much in the prevalence of emotional and behavioural symptoms, attention should be given to the screening and support of risk groups within the population of migrant adolescents, such as girls, those who experienced a lot of traumatic events and unaccompanied refugee children and adolescents.

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.

Adolescents caught between fires: Cognitive emotion regulation in response to war experiences in Northern Uganda

This study aimed to assess the prevalence of war experiences and the use of specific cognitive emotion regulation strategies in response to these experiences among 294 formerly abducted adolescents at three rehabilitation centres in Uganda. Cognitive strategies were measured by Cognitive Emotion Regulation Questionnaire (CERQ). Symptoms of psychopathology were measured by the Impact of Events Scale-Revised (IES-R) and the Youth Self-Report (YSR). Relationships were studied by means of descriptive statistics, correlations and Multiple Regression Analyses. Strong relationships were found between specific cognitive emotion regulation strategies and posttraumatic stress (PTS), Internalizing and Externalizing symptoms. The results may have implications for intervention strategies.

Traumatized refugee children: the case for individualized diagnosis and treatment

The first 131 traumatized refugee children evaluated and treated in a child specialty clinic indicated a wide variety of trauma including war-related traumas (21%) for areas of recent conflict and domestic violence (28%) predominantly occurring in patients from Mexico and Latin America. Clinical diagnoses indicate PTSD was common (63%) in the war trauma group but was found less (25%) in the domestic violence group. Otherwise, the refugee clinic population showed a wide variety of diagnoses, including 20% having learning or cognitive disability or clear mental retardation. The traumatized refugee children had a similar prevalence of PTSD and depression to a comparable group of American child psychiatry patients. Refugee children have faced a variety of traumas and have a variety of diagnoses. All traumatized refugee children need an individualized evaluation and treatment plan. Trauma focused therapy is not appropriate for all refugee children.

Trauma exposure in pre-school children in a war zone

BACKGROUND

There has been little reported research into the effect of war on the behaviour and emotional well-being of pre-school children.

AIMS

To investigate the relationship between exposure to war trauma and behavioural and emotional problems among pre-school children.

METHOD

A total of 309 children aged 3-6 years were selected from kindergartens in the Gaza Strip, and were assessed by parental reports in regard to their exposure to war trauma, using the Gaza Traumatic Checklist, and their behavioural and emotional problems, using the Behaviour Checklist (BCL) and the Strengths and Difficulties Questionnaire (SDQ).

RESULTS

Pre-school children were exposed to a wide range of traumatic events. The total number of traumatic events independently predicted total BCL and SDQ scores. Exposure to day raids and shelling of the children's houses by tanks were significantly associated with total behavioural and emotional problems scores.

CONCLUSIONS

Direct and non-direct exposure to war trauma increases the risk of behavioural and emotional problems among pre-school children, which may present as non-specific psychopathology.

Event-list construction and treatment of exposure data in research on political violence

Event lists are commonly applied for measuring exposure to various kinds of potentially stressful and traumatizing life events. Before making general conclusions about the psychological effects of exposure to such events, problematic issues related to the use of event-list data need to be discussed and resolved. This article focuses on issues related to the construction and application of event lists for measuring exposure to political violence such as issues related to reliability, the applicability of the additive assumption, whether to weight event-list items, and the possible consequences of incomplete event lists. Alternative future approaches to these measurement issues are also discussed.

The impact of terrorism on children and adolescents: terror in the skies, terror on television

Terrorist attacks and their aftermath have had a powerful impact on children and their families. Media and television exposure of terrorist events throughout the world has increased during the past few years. There is increasing concern about the effects of this exposure on children who witness these violent images. To develop a proactive and strategic response to reactions of fear, clinicians, educators, and policy makers must understand the psychologic effects of media coverage of terrorism on children. Previous research has focused on media coverage of criminal violence and war. Recent studies have examined the effect of remote exposure of terrorist attacks and have shown a significant clinical impact on children and families.

Psychosocial support for war-traumatized child and adolescent refugees: evaluation of a short-term treatment program

OBJECTIVE

The purpose of this study was to evaluate a newly designed psychosocial treatment program for war traumatized child and adolescent refugees. The program was designed to reduce emotional distress and improve psychosocial functioning.

METHOD

Ten young Kosovan refugees (mean age 13.3 years) residing in Germany participated in the manual based intervention program. This multimodal program consists of individual, family and group sessions using a psychoeducational approach beside trauma and grief focusing activities, creative techniques and relaxation. Kind and severity of traumatic experiences were gathered by interviewing the child and their caretakers using the Harvard Trauma Questionnaire (HTQ). Psychiatric diagnoses (Schedule for Affective Disorders and Schizophrenia for School-Age Children, K-SADS) were assessed prior to the intervention. Post-traumatic symptomatology (HTQ), emotional problems (Diagnostic System for Psychological Disorders, DYSIPS) and the overall psychosocial functioning (Child Global Assessment Scale, CGAS) were assessed before and after the 12-week intervention.

RESULTS

Following the intervention the degree of overall psychosocial functioning increased substantially in 9 of 10 participants. Furthermore, post-traumatic, anxiety and depressive symptoms were reduced significantly. The rate of post-traumatic stress disorder (PTSD) diagnoses fell from 60% to 30%. The number of patients with PTSD and a high rate of comorbid symptoms (depression and anxiety) as well as a history of severe traumatization remained at 30%.

CONCLUSIONS

This study suggests that the psychosocial treatment program specified for war traumatized adolescents may be useful for the relief of psychiatric sequelae and for an improvement in overall psychosocial functions, but not for the subgroup of severely traumatized patients with complex psychiatric disturbances.

PTSD and depression in refugee children: associations with pre-migration trauma and post-migration stress

This paper describes the effect of pre-migration and post-migration experiences on the mental health of a sample of 40 refugee children aged 8-16 who lived in London with at least one parent or a refugee relative. Children's post-traumatic stress disorder (PTSD) and depression symptoms were assessed with standardised self-report measures (Impact of Event Scale and Depression Self-Rating Scale for Children, respectively). Information regarding past and present experiences were gathered during an interview with parents. There was a significant correlation between the number of pre-migration traumas experienced by the families and the children's PTSD scores. There was also a significant correlation between the families' number of post-migration stresses and children's depression scores. Higher PTSD scores were significantly associated with the pre-migration experience of violent death of family members and the post-migration experience of an insecure asylum status. Higher depression scores were significantly associated with insecure asylum status and severe financial difficulties. The clinical implications of these findings are discussed.

Childhood reactions to terrorism-induced trauma: a review of the past 10 years

OBJECTIVE

To summarize the literature about the clinical presentation and treatment interventions of childhood reactions to terrorism-induced trauma.

METHOD

The literature on children's responses to terrorist activities was reviewed.

RESULTS

Over the past 10 years, more research has emerged on the subject of terrorism in children. Many of the effects of terrorism-induced trauma are similar to the effects of natural and man-made trauma. Children's responses include acute stress disorder, posttraumatic stress disorder, anxiety, depression, regressive behaviors, separation problems, sleep difficulties, and behavioral problems. However, several aspects of terrorist attacks result in unique stressors and reactions and pose specific challenges for treatment. The unpredictable, indefinite threat of terrorist events, the profound effect on adults and communities, and the effect of extensive terrorist-related media coverage exacerbates underlying anxieties and contributes to a continuous state of stress and anxiety. Intervention strategies include early community-based interventions, screening of children at risk, triage and referral, and trauma-loss-focused treatment programs.

CONCLUSIONS

Advances have been made in the research of childhood reactions to terrorism-induced trauma. Further research is needed to identify children at risk and to determine the long-term impact on children's development. Although the preliminary results of interventions developed to help children are promising, outcome data have not been examined, and further research is needed to evaluate their effectiveness.