Mental health problems and help-seeking behaviours of Syrian refugee adolescents: mediating role of self-stigma.

BACKGROUND: Although common mental health problems have been widely studied with self-stigma, few studies have focused on the mediating effect of self-stigma in the relationship between mental health problems and help-seeking behaviours of refugee adolescents. Therefore, the purpose of the present study was to examine whether self-stigma mitigates the adverse effects of stress, anxiety, and depression symptoms on the help-seeking behaviours of Syrian adolescents living in Turkey. METHODS: The participants of this study included 488 Syrian refugee adolescents (boys, 63.73%; girls, 3627%) living in Turkey. Participants completed the Depression Anxiety Stress Scale and General Help-Seeking Scale and Self-Stigma of Seeking Psychology Help Scale. RESULTS: The findings revealed that stress (ß = 0.19, p < 0.01), anxiety (ß = 0.12, p < 0.05), and depression (ß = 0.17, p < 0.01) had significant and positive predictive effects on self-stigma, but not on help-seeking behaviours. Also, self-stigma (ß = -0.12, p < 0.01) had a significant negative predictive effect on help-seeking behaviours. With regard to the indirect effects, the findings showed that self-stigma fully mediated the associations between stress - help-seeking [effect = -0.05, 95% confidence interval (CI) -0.11 to -0.01], anxiety - help-seeking (effect = -0.04, 95% CI -0.09 to -0.01)], and depression - help-seeking (effect = -0.05, 95% CI -0.12 to -0.01). CONCLUSIONS: Our findings highlight the potential negative effects of self-stigma on the help-seeking behaviours of Syrian refugee adolescents, both directly and indirectly. These results can be used to develop and implement effective and efficient interventions to address the unmet mental health needs of refugee adolescents.

Youth-led co-production of mental health promotion in Pakistan: intergenerational influences.

Youth with mental health needs face barriers in seeking and accessing help, especially in resource-constrained settings in Majority World Countries. Community engagement is thus important for mental health promotion, particularly in addressing stigma. Engagement can be enhanced by involving peer educators and by relating to intergenerational experiences in the sociocultural context of the community. The aim of this study was to explore how intergenerational experiences and perspectives can inform the co-production of youth-led mental health promotion in a Majority World Country, Pakistan. We recruited 11 families (one grandmother, mother and granddaughter in each family) as advisers from two disadvantaged areas of Karachi, and 14 peer educators. Training for peer educators included seminars, experiential activities, three participatory workshops with family advisers and supervision. A sub-sample of family advisers and peer educators attended four focus groups, and peer educators completed reflective diaries following each activity. Data were integrated and subjected to thematic codebook analysis. The three themes related to enabling and hindering factors towards co-production of mental health promotion, incorporation of intergenerational resilience and cascading knowledge to communities. The findings highlighted potential benefits of youth-led mental health promotion that contextualizes intergenerational experiences for those communities. Peer educator roles should be supported by training, and mental health promotion should be integrated within local service systems.

What Should Personalised Mental Health Support Involve? Views of Young People with Lived Experience and Professionals from Eight Countries.

Research demonstrates that young people value mental health support that is tailored to their needs and preferences, rather than a "one size fits all" offer, which is often not equitably accessible (National Children's Bureau, 2021). Understanding young people's lived experiences across different sociocultural contexts is important. The aim of this research was to conduct an international qualitative study on the views of young people with lived experience and professionals, on proposed aspects of personalised support for anxiety and/or depression. Participatory action focus groups were conducted with N = 120 young people with lived experience of anxiety and/or depression (14-24 years) and with N = 63 professionals in Brazil, India, Kenya, Pakistan, Portugal, South Africa, Turkey, and the United Kingdom. Data were analysed using the rigorous and accelerated data reduction (RADaR) technique. Overall, although some country-specific differences were found in terms of what aspects of support young people found to be most important, individual preferences were considered stronger, furthering the view that support should be personalised to the needs of the individual young person. Young people experiencing anxiety and/or depression should be able to choose for themselves which aspects of support they would prefer in their own care and support plans, with families and mental health professionals providing guidance where appropriate, rather than removing the young person from the decision-making process altogether. It should also be ensured that the aspects of personalised support can be understood by young people and professionals from different contexts, including marginalised and minoritised groups and communities.

Feasibility evaluation of psychosocial intervention for internally displaced youth in Kenya.

BACKGROUND: There is limited evidence on the cultural appropriateness of first-stage psychosocial interventions for youth with mental health problems who experience conflict and disadvantage in low- and middle-income countries (LMIC). AIMS: To evaluate the feasibility of such an intervention (Writing for Recovery - WfR) among youth with emerging emotional problems following internal displacement in Kenya. METHOD: Fifty-four youth aged 14-17 years were randomly allocated to a six-session intervention or a waiting list control group. They completed measures of stressful life events; post-traumatic stress, depressive and anxiety symptoms; quality of life; and free text on their experience of the intervention. RESULTS: Young participants reported high levels of trauma exposure and emotional problems. The intervention was perceived as flexible and culturally acceptable, with reported short-term impact. This was found to have promising post-intervention effect in reducing post-traumatic stress, but not depressive or anxiety symptoms; and in enhancing quality of life scores. CONCLUSIONS: Similar psychosocial interventions that can be delivered by paraprofessionals are important for resource-constrained LMIC settings, but need to be integrated within a comprehensive scaled service model.

Youth and professional perspectives of mental health resources across eight countries.

Introduction: Youth mental health support and services vary across sociocultural contexts. It is important to capture the perspectives of youth with lived experiences for planning needs-led interventions and services, especially in Global South Countries (GSC), with limited specialist resources and representative literature. Methods: The aim was to establish how youth with lived experiences of anxiety and depression viewed external support in different countries, and how these views were juxtaposed with those of professionals. We involved 121 youth aged 14-24 years and 62 professionals from different disciplines in eight countries, predominantly from the Global South. Two youth and one professional focus group was facilitated in each country. The data were analysed through a codebook thematic approach. Results: Youth across all countries largely valued informal support from family, peers and community, whilst those from GSC had limited access to structural support. They related lived experiences to therapeutic engagement and processes, in contrast with professionals who focused on outcomes and service delivery. Mental health awareness and integration of interventions with social support were considered essential by both youth and professionals, especially in disadvantaged communities. Conclusion: The mental health needs of youth in disadvantaged GSC communities can be best met through multi-modal interventions addressing these needs across their socioecology and positioned within a stepped care model. Youth with lived experiences should be involved in service planning, implementation and monitoring.

Associations among resilience, hope, social support, feeling belongingness, satisfaction with life, and flourishing among Syrian minority refugees.

To date, research on refugee mental health has mainly focused on understanding the absence of psychopathology rather than on their well-being and associated positive aspects. The aim of this study was to examine the role of resilience, hope, belongingness, and social support in predicting satisfaction with life and flourishing among 361 minority Syrian refugees living in Iraq (age range = 18-60 years, mean = 32.57, SD = 10.05). Participants completed the Brief Resilience Scale, Adult Hope Scale, Multidimensional Scale of Perceived Social Support Scale, General Belongingness Scale, Satisfaction With Life Scale, and Flourishing Scale. Males reported significantly higher levels of resilience, belongingness, and flourishing compared to females. Demographic variables (age, gender, and economic level), resilience, hope, belongingness, and social support were correlated with life satisfaction and flourishing scores. While controlling for sociodemographic characteristics, resilience and hope were associated with life satisfaction and flourishing scores. However, belongingness and social support were only associated with flourishing scores. The findings suggest that equipping refugees with positive psychological resources could promote increased levels of life satisfaction and flourishing and thus enhance preventive psychosocial programs.

Implementation of child mental health service improvement plans in four low- and middle-income countries: stakeholders' perspectives.

Children in low- and middle-income countries (LMIC) have high levels of unmet mental health needs, especially in disadvantaged communities. To address this gap, we developed a child mental health service improvement programme. This was co-facilitated using interprofessional principles and values in four countries, South Africa, Kenya, Turkey and Brazil. Eighteen stakeholders from different professions were interviewed after six months on their perspectives on enabling factors and challenges they faced in implementing service plans. Participants valued the holistic case management approach and scaled service model that underpinned the service plans. Emerging themes on participants' priorities related to service user participation, integrated care, and different levels of capacity-building. We propose that an integrated care model in LMIC contexts can maximize available resources, engage families and mobilize communities. Implementation requires concurrent actions at micro-, meso- and macro-level.

Developing a case mix classification for child and adolescent mental health services: the influence of presenting problems, complexity factors and service providers on number of appointments.

Background: Case-mix classification is a focus of international attention in considering how best to manage and fund services, by providing a basis for fairer comparison of resource utilization. Yet there is little evidence of the best ways to establish case mix for child and adolescent mental health services (CAMHS).Aim: To develop a case mix classification for CAMHS that is clinically meaningful and predictive of number of appointments attended and to investigate the influence of presenting problems, context and complexity factors and provider variation.Method: We analysed 4573 completed episodes of outpatient care from 11 English CAMHS. Cluster analysis, regression trees and a conceptual classification based on clinical best practice guidelines were compared regarding their ability to predict number of appointments, using mixed effects negative binomial regression.Results: The conceptual classification is clinically meaningful and did as well as data-driven classifications in accounting for number of appointments. There was little evidence for effects of complexity or context factors, with the possible exception of school attendance problems. Substantial variation in resource provision between providers was not explained well by case mix.Conclusion: The conceptually-derived classification merits further testing and development in the context of collaborative decision making.

What do young people who self-harm find helpful? A comparative study of young people with and without experience of being looked after in care.

BACKGROUND: Self-harm amongst young people is an increasing problem, with looked-after young people at higher risk. Despite this, little research exists on what young people who self-harm find helpful. METHOD: One hundred and twenty-six 11-21 year olds (53 who had experience of the care system and 73 who did not) were recruited from the community and NHS. All participants had self-harmed in the past 6 months. Participants completed an Audio Computer-Assisted Self-interview (ACASI) regarding their views about the support they had received, how helpful it was, and what further help they felt they needed. RESULTS: Looked-after young people reported the three most helpful sources of support were Child and Adolescent Mental Health Services (CAMHS), friends and pets and the least helpful were CAMHS, Accident and Emergency (A&E) and Social services. For non-looked-after young people, CAMHS, counselling and Harmless (user-led support service for self-harm) were most helpful and CAMHS, cognitive behavioural therapy (CBT) and general practitioner (GP) were the least. Compared with the other group, more looked-after young people had received help from A&E and CAMHS, whereas more non-looked-after young people had accessed GPs, parents, psychological therapies, self-help books and websites. More looked-after young people found support groups helpful, and more non-looked-after young people reported that distraction techniques, medication and their siblings were helpful. CONCLUSION: Young people who self-harm have mixed views about CAMHS. Differences in the pattern of access and preferences for support between looked-after and non-looked-after young people should be reflected in service availability and commissioning. KEY PRACTITIONER MESSAGE: Little is known about what young people who self-harm find helpful, particularly for looked-after young people. CAMHS was named amongst the most helpful and the least helpful services by both looked-after and non-looked-after young people. Social services and A&E were frequently cited amongst the least helpful sources of support. Young people report finding informal support helpful, including family and friends. There appears to be a need for explorations of the reasons behind the apparent negative perception of statutory services in young people, and what is required to shift that.

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.

Psychological Trait Resilience Within Ecological Systems Theory: The Resilient Systems Scales.

This project describes the development of the Resilient Systems Scales, created to address conceptual and methodological ambiguities in assessing the ecological systems model of resilience. Across a number of samples (total N = 986), our findings suggest that the Resilient Systems Scales show equivalence to a previously reported assessment (Maltby, Day, & Hall, 2015 ) in demonstrating the same factor structure, adequate intercorrelation between the 2 measures of resilience, and equivalent associations with personality and well-being. The findings also suggest that the Resilient Systems Scales demonstrate adequate test-retest reliability, compare well with other extant measures of resilience in predicting well-being, and map, to varying degrees, onto positive expression of several cognitive, social, and emotional traits. The findings suggest that the new measure can be used alongside existing measures of resilience, or singly, to assess positive life outcomes within psychology research.

Interprofessional training on resilience-building for children who experience trauma: Stakeholders' views from six low- and middle-income countries.

Children exposed to multiple adversities are at high risk of developing complex mental health and related problems, which are more likely to be met through integrated interprofessional working. Combining the expertise of different practitioners for interprofessional care is especially pertinent in low- and middle-income countries (LMIC) in the absence of specialist resources. The aim of this study was to work with practitioners who deliver care to vulnerable children in six LMIC (Turkey, Pakistan, Indonesia, Kenya, Rwanda, and Brazil) to understand their perspectives on the content of an interprofessional training programme in building resilience for these children. Seventeen participants from different professional backgrounds, who were in contact with vulnerable children were interviewed. A thematic analytic framework was used. Four themes were identified, which were the benefits of a tiered approach to training, challenges and limitations, perceived impact, and recommendations for future training. The findings indicate the importance of co-ordinated policy, service, and training development in an interprofessional context to maximize resources; the need for cultural adaptation of skilled-based training and interventions; and the usefulness of new technologies to enhance accessibility and reduce costs in LMIC.

Potential barriers in the therapeutic relationship in unaccompanied refugee minors in mental health.

Background: Unaccompanied refugee minors present with disproportionately high prevalence of emotional and psychological morbidities. However, their utilization of mental health services has been shown to be significantly poorer than the indigenous population of the country they seek asylum in. Despite this, there is limited research exploring their perspectives on the barriers they face. Aims: This research aims to understand unaccompanied refugee minors' and their carers' perceptions of the barriers to utilize mental health services and to explore issues perceived to be related to poor engagement with services. Methods: Semi-structured interviews with 15 unaccompanied refugee minors and their carers were conducted. This was to elicit their views, perceptions and beliefs based on their experience of receiving treatment from a specialist mental health service in the UK. Results: Thematic analysis was used and the findings were categorised into two broad themes; the participants' perceptions of the intervention and perceptions of the professionals. Salient aspects of these are discussed. Conclusions: The findings have potential to stimulate further research into gaining a better understanding of the barriers these young people face in accessing help, and may contribute to developing services that are more efficient in engaging this vulnerable group and meeting their specific needs.

Mental health problems of Syrian refugee children: the role of parental factors.

War-torn children are particularly vulnerable through direct trauma exposure as well through their parents' responses. This study thus investigated the association between trauma exposure and children's mental health, and the contribution of parent-related factors in this association. A cross-sectional study with 263 Syrian refugee children-parent dyads was conducted in Turkey. The Stressful Life Events Questionnaire (SLE), General Health Questionnaire, Parenting Stress Inventory (PSI-SF), Impact of Events Scale for Children (CRIES-8), and Strengths and Difficulties Questionnaire were used to measure trauma exposure, parental psychopathology, parenting-related stress, children's post-traumatic stress symptoms (PTSS), and mental health problems, respectively. Trauma exposure significantly accounted for unique variance in children's PTSS scores. Parental psychopathology significantly contributed in predicting children's general mental health, as well as emotional and conduct problems, after controlling for trauma variables. Interventions need to be tailored to refugee families' mental health needs. Trauma-focused interventions should be applied with children with PTSD; whilst family-based approaches targeting parents' mental health and parenting-related stress should be used in conjunction with individual interventions to improve children's comorbid emotional and behavioural problems.

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

BACKGROUND: Child mental health services and related agencies are faced with an increasing challenge in responding to the influx of refugee children around the world. There is strong evidence on the prevalence and complexity of these children's mental health problems and broader needs. AIMS: To review the research literature on risk and protective factors, and associated mental health interventions for refugee children. METHODS: Peer-reviewed studies were included for the period 2004-2017; if they included refugee, asylum-seeking or internally displaced children under 18 years; and adopted a quantitative design. Vulnerability and protective factors for refugee children were considered in this context, followed by the respective types of interventions at pre-, peri- and postmigration stage, and across high- and low-/middle-income countries. Eighty-two peer-reviewed studies fulfilled the selection criteria. RESULTS: The existing body of literature is largely based on identifying risk factors among children with mental health problems and predominantly designing trauma-focused interventions to reduce their symptomatic distress. Recent research and services have gradually shifted to a broader and dynamic resilience-building approach based on ecological theory, that is at child, family, school, community and societal level. There is increasing evidence for the implementation and effectiveness of multimodal interventions targeting all these levels, despite the methodological constraints in their evaluation. CONCLUSIONS: In high-income countries, child mental health services need to collaborate with all agencies in contact with refugee children, establish joint care pathways, and integrate trauma-focused interventions with family and community approaches. In low- and middle-income countries, where specialist resources are sparse, resilience-building should aim at maximising and upskilling existing capacity. A six-dimensional psychosocial model that applies to other children who experience complex trauma is proposed.

A sequence analysis of patterns in self-harm in young people with and without experience of being looked after in care.

OBJECTIVES: Young people in the public care system ('looked-after' young people) have high levels of self-harm. DESIGN: This paper reports the first detailed study of factors leading to self-harm over time in looked-after young people in England, using sequence analyses of the Card Sort Task for Self-harm (CaTS). METHODS: Young people in care (looked-after group: n = 24; 14-21 years) and young people who had never been in care (contrast group: n = 21; 13-21 years) completed the CaTS, describing sequences of factors leading to their first and most recent episodes of self-harm. Lag sequential analysis determined patterns of significant transitions between factors (thoughts, feelings, behaviours, events) leading to self-harm across 6 months. RESULTS: Young people in care reported feeling better immediately following their first episode of self-harm. However, fearlessness of death, impulsivity, and access to means were reported most proximal to recent self-harm. Although difficult negative emotions were salient to self-harm sequences in both groups, young people with no experience of being in care reported a greater range of negative emotions and transitions between them. For the contrast group, feelings of depression and sadness were a significant starting point of the self-harm sequence 6 months prior to most recent self-harm. CONCLUSIONS: Sequences of factors leading to self-harm can change and evolve over time, so regular monitoring and assessment of each self-harm episode are needed. Support around easing and dealing with emotional distress is required. Restricting access to means to carry out potentially fatal self-harm attempts, particularly for the young persons with experience of being in care, is recommended. PRACTITIONER POINTS: Self-harm (and factors associated with self-harm) can change and evolve over time; assessments need to reflect this. Looked-after young people reported feeling better after first self-harm; fearlessness of death, access to means, and impulsivity were reported as key in recent self-harm. Underlying emotional distress, particularly depression and self-hatred were important in both first and most recent self-harm. Looked-after young people should undergo regular monitoring and assessment of each self-harm episode and access to potentially fatal means should be restricted. The CaTS would have clinical utility as an assessment tool Recruiting participants can be a significant challenge in studies with looked-after children and young people. Future research with larger clinical samples would be valuable.

Use, acceptability and impact of booklets designed to support mental health self-management and help seeking in schools: results of a large randomised controlled trial in England.

Mental health booklets may provide a low-cost means of promoting mental health self-management and help seeking in schools. The aim of the study was to assess the (a) use, (b) acceptability and (c) impact of booklets for students in primary (10-11 years) and secondary school (12-13 years) alone and in conjunction with funding for targeted mental health support. This was a 2 × 2 factorial cluster randomized controlled trial, in which 846 schools in England were randomly allocated to receive/not receive: (1) booklets for students containing information on mental health self-management and help seeking, and (2) funding for mental health support as part of a national mental health initiative. 14,690 students (8139 primary, 6551 secondary) provided self-report on mental health, quality of life (baseline and 1 year follow-up) and help seeking (follow-up). (a) Approximately, 40 % primary school students and 20 % secondary school students reported seeing the booklets. (b) Of these, 87 % of primary school students reported that the booklet was 'very helpful' or 'quite helpful', compared with 73 % in secondary school. (c) There was no detectable impact of booklets on mental health, quality of life or help seeking, either alone or in conjunction with additional funding through the national mental health initiative. Lack of discernable impact of booklets underscores the need for caution in adopting such an approach. However, it is feasible that the impact was obscured by low uptake or that booklets may be more effective when used in a targeted way.

Editorial: Global child mental health - emerging challenges and opportunities.

Children in low- and middle-income countries (LMIC), particularly those living in disadvantaged and conflict-ridden communities, are faced with extensive unmet health and social care needs (UNICEF, ). A substantial body of research has also provided evidence specifically relating to children's mental health, thereby increasing our understanding regarding the impact of cumulative and interlinked risk factors such as war, conflict and displacement, natural disasters, poverty, child labour and other forms of exploitation. Attempts to improve children's mental health in LMICs is, however, constrained by a range of factors including stigma relating to mental illness, limited policy input as reflected by the low level of specialist resources, lack of contextualised evidence regarding culturally appropriate psychosocial interventions (Patel & Rahman, ), and underrepresentation of LMICs in the research literature (Helal, Ahmed, & Vostanis, ).

Exploring the challenges of meeting child mental health needs through community engagement in Kenya.

BACKGROUND: Despite growing evidence on the extent of child mental health problems in low-middle-income countries, the gap between need and provision remains high. Previous research in high income countries has demonstrated that evidence-based interventions can be scaled-up through community consultation, particularly by engaging key stakeholders. AIMS: This study aimed to explore community stakeholders' views on children's mental health needs and culturally acceptable interventions in Kenya, to ascertain how to integrate global service standards with culturally-specific expectations. METHODS: Focus groups were conducted with community stakeholders (seven young people 14-17 years, seven parents, nine teachers and 11 other professionals). These participants were recruited from an urban community of internally displaced and disadvantaged families in Nakuru. RESULTS: Results indicated that Kenya faced similar challenges in meeting mental health needs as in other countries, including economic constraints, limited knowledge, stigma and systemic issues, but that these were manifested in culturally specific ways that were linked to societal and professional's attitudes and local context. CONCLUSIONS: Stakeholders' views are important in informing the planning, delivery and evaluation of interventions. However, for such interventions to be sustained, a clear therapeutic framework, evidence-base and sociocultural adaptation are likely to be important factors.