Development and evaluation of a training program for interpreters in the field of trauma-focused cognitive behavioral therapy.

Background: The treatment of traumatized refugee minors is often challenging because of language barriers. International guidelines, therefore, recommend the use of language mediators. However, there is a scarcity of evaluated training programs that prepare language mediators to translate during psychotherapy developed specifically for this patient group, for instance trauma-focused cognitive behavioral therapy (TF-CBT). Methods: Based on an extensive literature review and in collaboration with an expert focus group, a one-day TF-CBT-specific online training program was developed for language mediators willing to work with minor refugees, and delivered on nine occasions between November 2020 and June 2021. The participants answered pre- and post-training questions about trauma- and TF-CBT-related knowledge and attitudes relevant to therapy, as well as the perceived usefulness of the training. Bayesian estimation was used to determine pre-post changes. Results: A total of 129 participants speaking 35 different languages participated in the training program. Analyses revealed 95% highest density intervals not containing the null with respect to knowledge gain (effect size median 0.28) and change in treatment-appropriate attitudes (effect size median 0.31). The participants rated the training as useful. Conclusion: The TF-CBT-specific training course was successfully carried out. It was likely to disseminate both knowledge gains and a shift toward more treatment-appropriate attitudes. It was perceived as useful by the participants. Given the scarcity of evaluated training programs for language mediators working with minor refugees, the results are promising. The limitations include the lack of both a control group and the verification of the results using an external outcome measure.

Screening for Posttraumatic Stress Symptoms in Young Refugees: Comparison of Questionnaire Data with and without Involvement of an Interpreter.

Background: The substantial number of young refugees who have arrived in Europe since 2015 requires rapid screening to identify those in need of treatment. However, translated versions of screening measures are not always available, necessitating the support of interpreters. The Child and Adolescent Trauma Screen (CATS) is a validated questionnaire for posttraumatic stress symptoms. Here, we report on the psychometric properties of the CATS in a sample of young refugees as a function of interpreter involvement. Methods: A total of N = 145 (Mage = 16.8, SD = 1.54; 93% male) were assessed with the CATS, with half of the screenings conducted with and half without interpreters. Post hoc analyses included calculating internal consistency using Cronbach's α. We used confirmative factor analysis to investigate the factor structure. Results: The CATS total scale showed good reliability (α = 0.84). Differences in psychometric properties between the interpreter vs. the no interpreter group were minor and tended to be in favor of the interpreter group. Results of a confirmatory factor analysis were acceptable after the exclusion of items with low item-scale correlations. Conclusions: The sample and the administration of the assessment represent the situation of young refugees in Germany, where resources are low and translated versions not always available. The CATS may be a helpful screening tool for clinicians working with young refugees, even when administered with an interpreter. Limitations include the post hoc design of the analysis without randomization of participants and the lack of a third comparison group using translated questionnaire versions.

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

BACKGROUND: Asylum-seeking children and adolescents (ASCs) resettled to western countries show elevated levels of psychological distress. While research on the mental health of ASCs is increasing, less is known about their day-to-day living experiences such as their daily mood, sleep patterns, and post-migration factors. Moreover, no examination in situ, using smartphone-assisted ecological momentary assessment (EMA), has been conducted up to now among ASCs. Furthermore, we do not know if screening measures succeed in reflecting the daily mood of ASCs experienced in everyday life. METHODS: We undertook a smartphone-assisted EMA study over a two-week period with 3 measurements a day. Participants were N = 40 ASCs from 10 different countries who had resettled to Germany. They completed standardized questionnaires screening for history of trauma and clinical symptoms (post-traumatic stress symptoms, depression, and anxiety) that were carried out in interview-like settings, and they participated in the subsequent EMA where they rated mood, sleep parameters, and post-migration factors on a daily basis. Multilevel models of clinical symptoms, daily mood, and sleep parameters were computed based on a total of 680 measurements. RESULTS: The multiply traumatized and highly distressed participants reported different levels of discrimination, and various social activities and contacts in the EMA. The overall compliance rate was shown to be 40.5%. Higher PTSS and anxiety scores were associated with lower levels of daily mood and poorer outcomes of some sleep parameters. Depression scores were not associated with any of the variables assessed in the EMA. CONCLUSIONS: Smartphone-assisted EMA among ASCs resettled to Germany proved to be implementable despite a rather low compliance rate. Not only do ASCs show high symptom levels, they are also affected by these symptoms in their daily lives. The results emphasize the need for concise screenings and psychological treatment for this high-risk population. Limitations include the convenient nature of the sample and the lack of a comparison group.

Improving mental health care for unaccompanied young refugees through a stepped-care approach versus usual care+: study protocol of a cluster randomized controlled hybrid effectiveness implementation trial.

BACKGROUND: More than half of the unaccompanied young refugees (UYRs) resettled in Europe report elevated levels of posttraumatic stress symptoms (PTSS) and comorbid symptoms. Earlier studies have highlighted the effectiveness of the trauma-focused preventive group intervention "Mein Weg" (English "My Way"), and the feasibility of trauma-focused cognitive behavioral therapy (TF-CBT) for UYRs. Both interventions are deemed to be empirically supported treatments (ESTs). However, UYRs seldom receive ESTs or, in fact, any treatment at all. In view of the high need and the limited treatment resources available, a stepped-care approach is indicated but has not been evaluated so far. The purpose of this trial is to compare the stepped-care approach BETTER CARE with usual care enhanced with screening and indication (usual care+). METHODS: In a cluster randomized controlled trial involving N = 540 UYRs living in up to N = 54 child and youth welfare service (CYWS) facilities, BETTER CARE will be compared with usual care+. We will randomize clusters comprising a CYWS facility with at least one eligible psychotherapist. BETTER CARE consists of step (1) screening and indication and either step (2) preventive trauma-focused group intervention "Mein Weg" delivered by trained CYWS staff or step (3) TF-CBT delivered by trained community therapists and supported by trained translators if necessary. Participants will be assessed 6 and 12 months after randomization. The primary outcome is the severity of PTSS after 12 months. Secondary outcomes are depressive and anxiety symptoms, quality of life, and proxy reported PTSS. Furthermore, drug use, health costs, benefits, and long-term effects on integration/acculturation will be assessed. DISCUSSION: The trial will directly integrate a stepped-care approach into existing structures of the German child welfare and (mental) health system. It could, therefore, serve as a blueprint for how to implement ESTs for UYRs. If successful, screening, prevention, and intervention will be sustainably implemented in CYWS in southern Germany. TRIAL REGISTRATION: German Clinical Trials Register DRKS00017453 . Registered on 11 December 2019.

The symptom representation of posttraumatic stress disorder in a sample of unaccompanied and accompanied refugee minors in Germany: a network analysis.

Background: Given the unprecedented number of traumatized refugee minors in Europe and the increased prevalence of mental disorders such as PTSD in this vulnerable population, new methodologies that help us to better understand their symptomatology are crucial. Network analysis might help clinicians to both understand which symptoms might trigger other symptoms, and to identify relevant targets for treatment. However, to date only two studies have applied the network analysis approach to an (adult) refugee population and only three studies examined this approach in children and adolescents. Objective: The aim of this study is to explore the network structure and centrality of DSM-5 PTSD symptoms in a cross-sectional sample of severely traumatized refugee minors. Method: A total of N = 419 (M age = 16.3; 90.7% male) unaccompanied (79.9%) and accompanied (20.1%) refugee minors were recruited in five studies in southern Germany. PTSD symptoms were assessed using the Child and Adolescent Trauma Screen (CATS). The network was estimated using state-of-the-art regularized partial correlation models using the R-package qgraph. Results: The most central symptoms were nightmares, physiological and psychological reactivity, and concentration problems. The strongest connections between symptoms were established for psychological and physiological reactivity, irritability/anger and self-destructive/reckless behaviour, intrusions and nightmares, nightmares and sleep disturbance, and between concentrations problems and sleep disturbance. Conclusion: This study furnishes information relevant to research and the clinical management of PTSD in refugee minors, and also in terms of comparisons with trauma-exposed children and adolescents without a migration background. Re-experiencing symptoms seem to be central in the refugee minor PTSD profile and thus merit special consideration in the diagnostic and treatment evaluation process. Investigating the PTSD network longitudinally and complementing between-subject analyses with within-subject ones might provide further insight into the symptomatology of refugee minors and how to treat them successfully.

Antecedentes: Dado el número sin precedentes de menores traumatizados refugiados en Europa y la prevalencia aumentada de trastornos mentales tales como el TEPT en esta población vulnerable, nuevas metodologías que nos ayuden a una mejor comprensión de su sintomatologiía son cruciales. El análisis de redes podría ayudar a los clínicos, tanto para comprender qué síntomas podrían gatillar otros síntomas y para identificar blancos relevantes para el tratamiento. Sin embargo, a la fecha sólo dos estudios han aplicado la aproximación de análisis de redes a una población de refugiados (adultos) y sólo tres estudios examinaron esta aproximación en niños y adolescentes.Objetivo: El objetivo de este estudio es explorar la estructura de redes y centralidad de los síntomas de TEPT del DSM-5 en una muestra transversal de menores refugiados severamente traumatizados.Método: Fueron recrutados un total de N= 419 (edad M= 16.3; 90,7% masculino) menores refugiados en cinco estudios en el sur de Alemania, no acompañados (79,9%) y acompañados (20,1%). Los síntomas de TEPT fueron evaluados usando el Tamizaje de Trauma para niños y adolescentes (CATS por sus siglas en inglés). La red se estimó utilizando modelos de correlación parcial regularizados de última generación utilizando el gráfico de paquete R.Resultados: Los síntomas más centrales fueron las pesadillas, la reactividad fisiológica y psicológica y los problemas de concentración. Las conexiones más potentes entre síntomas estuvieron establecidas por la reactividad psicológica y fisiológica, la irritabilidad/rabia y conducta autodestructiva/impulsiva, intrusiones y pesadillas, pesadillas y alteraciones del sueño, y entre problemas de concentración y alteraciones del sueño.Conclusión: Este estudio proporciona información relevante para la investigación y el manejo clínico del TEPT en menores refugiados, y también en términos de comparaciones con niños y adolescentes expuestos a trauma sin antecedentes de migración. Los síntomas de re-experimentación parecen ser centrales en el perfil de TEPT en los menores refugiados y por lo tanto merece una consideración especial en el proceso de evaluación diagnóstica y el tratamiento. La investigación longitudinal de la red del TEPT y la complementación de los análisis entre sujetos con los de otro sujeto podrían proporcionar una mayor comprensión de la sintomatología de los menores refugiados y cómo tratarlos en forma exitosa.

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

BACKGROUND: Asylum-seeking children and adolescents (ASCs) who have resettled in Western countries show elevated rates of psychological distress, including Posttraumatic Stress Symptoms (PTSS), depression, and anxiety. Most longitudinal data suggest a relatively stable course of symptoms during the first years in exile. However, no longitudinal examination of the mental health of ASCs, who resettled in Europe in the wake of the 2015-17 European migrant crisis, has been conducted so far. METHODS: A prospective cohort study looked at 98 ASCs who resettled in southern Germany throughout 2015-17. They mainly came from Afghanistan, Syria, Eritrea, and Iraq. Baseline assessments were undertaken 22 months, on average, after resettlement, and follow-up assessments 1 year thereafter. Seventy-two ASCs could be secured for the follow-up. The measures included self-report questionnaires screening for PTSS, depression, anxiety, externalizing behavior, and post-migration factors that were administered in an interview-like setting. Results were analyzed using hierarchical multiple regression analysis. RESULTS: Participating ASCs reported on average eight potentially traumatic experiences and high levels of psychological distress at baseline that had significantly declined at follow-up. At follow-up, rates of clinically significant symptoms ranged from 9.7% (externalizing behavior) to 37.5% (PTSS). There was considerable individual variation in symptom change resulting in multiple mental health trajectories. ASCs whose asylum applications had been rejected presented significantly more symptoms than ASCs whose asylum applications had been accepted between assessments. Baseline psychopathology and asylum status predicted follow-up symptom severity. CONCLUSIONS: In contrast to earlier studies, the symptom severity in this sample of ASCs in Germany ameliorated between assessments. Decisions on the asylum applications of ASCs are thought to contribute to the course of symptoms. Since levels of psychological distress were still high, dissemination and implementation of appropriate treatments for ASCs is crucial.

Mental health and associated stress factors in accompanied and unaccompanied refugee minors resettled in Germany: a cross-sectional study.

BACKGROUND: Studies throughout Europe have shown that asylum-seeking children and adolescents (ASC) are at risk of developing mental disorders. The most common mental-health problems in ASC include posttraumatic stress symptoms (PTSS), internalizing symptoms such as depression and anxiety, and externalizing behaviour. Being an unaccompanied refugee minor (URM) was found to be highly predictive for higher levels of psychological distress within ASC. Nevertheless, and even though Germany is Europe's biggest host country for ASC, studies that reliably examine the mental health of both URM and accompanied refugee minors (ARM) in Germany with psychometrically tested measures are still lacking. METHODS: A cross-sectional survey in 19 facilities for minor refugees in Bavaria, Germany, screening for PTSS, depression, anxiety, externalizing behaviour, and post-migration factors was conducted. Participants were 98 ASC (URM, n = 68; ARM, n = 30) primarily from Afghanistan, Syria, and Eritrea. In 35.7% of interviews, interpreters were involved. RESULTS: Both URM and ARM reported high levels of psychological distress and large numbers of potentially traumatic events, with 64.7% of URM and 36.7% of ARM scoring above the clinical cut-off for PTSS, 42.6% of URM and 30% of ARM for depression, and 38.2% of URM and 23.3% of ARM for anxiety. The total number of traumatic experiences was found to be the most robust predictor for PTSS, depression, and anxiety. Lower levels of individual resources, lower levels of social support in the host country, and poorer German language proficiency were associated with higher levels of psychological distress within both groups. URM reported significantly more traumatic events than ARM. CONCLUSIONS: ASC in Germany are severely distressed and burdened by the experiences of various types of potentially traumatic events. The levels of distress found in the current study correspond with rates that have been reported in previous studies with ASC throughout Europe. Limitations of the present study include the convenience sample and the cross-sectional nature of findings.