Long-term efficacy of brief psychological treatments for common mental disorders in Myanmar refugees in Malaysia: 12-month follow-up of a randomized, active-controlled trial of integrative adapt therapy v. cognitive behavioral therapy.

BACKGROUND: Long-term efficacy of brief psychotherapies for refugees in low-resource settings is insufficiently understood. Integrative adapt therapy (IAT) is a scalable treatment addressing refugee-specific psychosocial challenges. METHODS: We report 12-month post-treatment data from a single-blind, active-controlled trial (October 2017-August 2019) where 327 Myanmar refugees in Malaysia were assigned to either six sessions of IAT (n = 164) or cognitive behavioral treatment (CBT) (n = 163). Primary outcomes were posttraumatic stress disorder (PTSD), depression, anxiety, and persistent complex bereavement disorder (PCBD) symptom scores at treatment end and 12-month post-treatment. Secondary outcome was functional impairment. RESULTS: 282 (86.2%) participants were retained at 12-month follow-up. For both groups, large treatment effects for common mental disorders (CMD) symptoms were maintained at 12-month post-treatment compared to baseline (d = 0.75-1.13). Although participants in IAT had greater symptom reductions and larger effect sizes than CBT participants for all CMDs at treatment end, there were no significant differences between treatment arms at 12-month post-treatment for PTSD [mean difference: -0.9, 95% CI (-2.5 to 0.6), p = 0.25], depression [mean difference: 0.1, 95% CI (-0.6 to 0.7), p = 0.89), anxiety [mean difference: -0.4, 95% CI (-1.4 to 0.6), p = 0.46], and PCBD [mean difference: -0.6, 95% CI (-3.1 to 1.9), p = 0.65]. CBT participants showed greater improvement in functioning than IAT participants at 12-month post-treatment [mean difference: -2.5, 95% CI (-4.7 to -0.3], p = 0.03]. No adverse effects were recorded for either therapy. CONCLUSIONS: Both IAT and CBT showed sustained treatment gains for CMD symptoms amongst refugees over the 12-month period.

Breaching the family walls: Modelling the impact of prolonged visa insecurity on asylum-seeking children.

OBJECTIVE: Children in asylum-seeking families are increasingly subject to deterrent host nation policies that undermine security in the post-migration context, however, little is known on the mental health consequences of such policy. This study examined the impact of prolonged visa insecurity on child mental health, by comparing two cohorts of refugee children entering Australia between 2010 and 2013, distinguished by visa security. METHODS: The insecure visa sample comprised children from Tamil asylum-seeking families, while the secure visa sample was drawn from refugee families participating in the multi-ethnic 'Building a New Life in Australia' cohort study. Children in each sample were assessed for current mental health problems and trauma exposure. Mothers were assessed for trauma exposure, post-migration family stressors and post-traumatic stress disorder (PTSD). The effects of prolonged visa insecurity on child mental health via family-and child-level variables were modelled using multi-level path analysis. RESULTS: Data comprised 361 children, aged 10-18, and 242 mothers across three levels of visa insecurity: permanent protection (n = 293), temporary protection (n = 40) and bridging visa (n = 28). Modelling showed that (1) visa insecurity was associated with poorer child mental health, (2) the association was mediated sequentially by post-migration family stressors and maternal PTSD and (3) the association was moderated by maternal PTSD. CONCLUSION: Our findings suggest that when government policy persistently undermines post-migration security, the capacity of families to protect children from accrued stressors is lowered, leaving a significantly higher proportion of children developing along trajectories of risk rather than resilience.

Preschool Behavioral Problems: Links with Maternal Oxytocin and Caregiving Sensitivity in the Postnatal Period, and Concurrent Maternal Psychopathology and Attachment State-of-Mind.

This study investigated maternal oxytocin, caregiving sensitivity and mother-to-infant bonding at 3-months postpartum as predictors of child behavior and psychological outcomes in the preschool years, when controlling for concurrent maternal negative emotional symptoms and adult attachment state-of-mind. Forty-five mother-child dyads were assessed at 3-months and 3.5 years postpartum using mix of questionnaires, observational, interview and biological methods. Results showed that lower levels of maternal baseline oxytocin at 3-months postpartum significantly predicted emotional reactivity in the child at 3.5 years. When maternal adult attachment state-of-mind and negative emotional symptoms were included, lower levels of maternal baseline oxytocin at 3-months postpartum significantly predicted withdrawn child behavior. In addition, unresolved adult attachment and maternal negative emotional symptoms were significantly associated child behavioral disturbance in a range of areas. Findings highlight maternal postnatal oxytocin as a potential indicator of children who may be more likely to show emotional reactivity and withdrawn behavior in the preschool years.

Variations in prevalence and risk profiles for Common Mental Disorders amongst Rohingya, Chin and Kachin refugees from Myanmar.

BACKGROUND: Large variations in prevalence rates of common mental disorder (CMD) amongst refugees and forcibly displaced populations have raised questions about the accuracy and value of epidemiological surveys in these cross-cultural settings. We examined the associations of sociodemographic indices, premigration traumatic events (TEs), postmigration living difficulties (PMLDs), and psychosocial disruptions based on the Adaptive Stress Index (ASI) in relation to CMD prevalence amongst the Rohingya, Chin and Kachin refugees originating from Myanmar and relocated to Malaysia. METHODS: Parallel epidemiological studies were conducted in areas where the three groups were concentrated in and around Malaysia (response rates: 80-83%). RESULTS: TE exposure, PMLDs and ASI were significantly associated with CMD prevalence in each group but the Rohingya recorded the highest exposure to all three of these former indices relative to Chin and Kachin (TE: mean = 11.1 v. 8.2 v. 11; PMLD: mean = 13.5 v. 7.4 v. 8.7; ASI: mean = 128.9 v. 32.1 v. 35.5). Multiple logistic regression analyses based on the pooled sample (n = 2058) controlling for gender and age, found that ethnic group membership, premigration TEs (16 or more TEs: OR, 2.00; 95% CI, 1.39-2.88; p < 0.001), PMLDs (10-15 PMLDs: OR, 4.19; 95% CI, 3.17-5.54; 16 or more PMLDs: OR, 7.23; 95% CI, 5.24-9.98; p < 0.001) and ASI score (ASI score 100 or greater: OR, 2.19; 95% CI, 1.46-3.30; p < 0.001) contributed to CMD. CONCLUSIONS: Factors specific to each ethnic group and differences in the quantum of exposure to TEs, PMLDs and psychosocial disruptions appeared to account in large part for differences in prevalence rates of CMDs observed across these three groups.

Australian guidelines for the prevention and treatment of posttraumatic stress disorder: Updates in the third edition.

OBJECTIVE: This paper describes the development of the third edition of the National Health and Medical Research Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, posttraumatic stress disorder and Complex posttraumatic stress disorder, highlighting key changes in scope, methodology, format and treatment recommendations from the previous 2013 edition of the Guidelines. METHOD: Systematic review of the international research was undertaken, with GRADE methodology used to assess the certainty of the evidence, and evidence to decision frameworks used to generate recommendations. The Guidelines are presented in an online format using MAGICApp. RESULTS: Key changes since the publication of the 2013 Guidelines include a new conditional recommendation for Child and Family Traumatic Stress Intervention for children and adolescents with symptoms within the first 3 months of trauma, and a strong recommendation for trauma-focused cognitive behaviour therapy for the child alone or with a caregiver, for those with diagnosed posttraumatic stress disorder. For adults with posttraumatic stress disorder, strong recommendations are made for specific types of trauma-focused cognitive behaviour therapy and conditional recommendations are made for five additional psychological interventions. Where medication is indicated for adults with posttraumatic stress disorder, venlafaxine is now conditionally recommended alongside sertraline, paroxetine or fluoxetine. CONCLUSION: These Guidelines, based on systematic review of the international literature, are intended to guide decision making for practitioners, service planners, funders and those seeking treatment for trauma related mental health concerns. For an Australian Guideline, a critical limitation is the absence of research on the treatment of Australian Aboriginal and Torres Strait Islander peoples. The new online format of the Australian posttraumatic stress disorder Guidelines means that they can be updated as sufficient new evidence becomes available.

The contributions of maternal oxytocin and maternal sensitivity to infant attachment security.

This study investigated links between maternal postnatal oxytocin, maternal sensitivity, and infant attachment security. At 3-months postpartum, participants (n=88) took part in a structured parent-infant interaction. Maternal oxytocin levels were assessed via blood, before and after the interaction. At 12-months postpartum, mother-child dyads completed the Strange Situation Procedure. Neither baseline oxytocin, oxytocin response, or maternal sensitivity were identified as significant independent predictors of infant attachment security or organisation. However, an interaction effect was identified, with higher maternal sensitivity being associated with secure infant attachment for mothers who showed an increase in oxytocin during parent-child interaction. Results indicate that maternal sensitivity, when accompanied by an increase in maternal oxytocin during parent-child interaction, is associated with the establishment of a positive early parent-child attachment relationship. This adds to the growing body of evidence highlighting maternal oxytocin response as a key adaptive process in the postpartum period.

Psychological distress, resettlement stress, and lower school engagement among Arabic-speaking refugee parents in Sydney, Australia: A cross-sectional cohort study.

BACKGROUND: Schools play a key role in supporting the well-being and resettlement of refugee children, and parental engagement with the school may be a critical factor in the process. Many resettlement countries have policies in place to support refugee parents' engagement with their children's school. However, the impact of these programs lacks systematic evaluation. This study first aimed to validate self-report measures of parental school engagement developed specifically for the refugee context, and second, to identify parent characteristics associated with school engagement, so as to help tailor support to families most in need. METHODS AND FINDINGS: The report utilises 2016 baseline data of a cohort study of 233 Arabic-speaking parents (77% response rate) of 10- to 12-year-old schoolchildren from refugee backgrounds across 5 schools in Sydney, Australia. Most participants were born in Iraq (81%) or Syria (11%), and only 25% spoke English well to very well. Participants' mean age was 40 years old, and 83% were female. Confirmatory factor analyses were run on provisional item sets identified from a literature review and separate qualitative study. The findings informed the development of 4 self-report tools assessing parent engagement with the school and school community, school belonging, and quality of the relationship with the schools' bilingual cultural broker. Cronbach alpha and Pearson correlations with an established Teacher-Home Communication subscale demonstrated adequate reliability (α = 0.67 to 0.80) and construct and convergent validity of the measures (p < 0.01), respectively. Parent characteristics were entered into respective least absolute shrinkage and selection operator (LASSO) regression analyses. The degree of parents' psychological distress (as measured by the Kessler10 self-report instrument) and postmigration living difficulties (PLMDs) were each associated with lower school engagement and belonging, whereas less time lived in Australia, lower education levels, and an unemployed status were associated with higher ratings in relationship quality with the schools' cultural broker. Study limitations include the cross-sectional design and the modest amount of variance (8% to 22%) accounted for by the regression models. CONCLUSIONS: The study offers preliminary refugee-specific measures of parental school engagement. It is expected they will provide a resource for evaluating efforts to support the integration of refugee families into schools. The findings support the need for initiatives that identify and support parents with school-attending children from refugee backgrounds who are experiencing psychological distress or resettlement stressors. At the school level, the findings suggest that cultural brokers may be effective in targeting newly arrived families.

Prolonged grief in refugees, parenting behaviour and children's mental health.

BACKGROUND: Many refugees experience bereavement, and as a result they suffer elevated rates of prolonged grief disorder. Evidence also indicates that elevated rates of psychological disturbance in refugee children can be associated with parental mental health. This study examined the extent to which prolonged grief disorder in refugees is associated with their parenting behaviour and in turn with their children's mental health. METHODS: This study recruited participants from the Building a New Life in Australia prospective cohort study of refugees admitted to Australia between October 2013 and February 2014. The current data were collected in 2015-2016 and comprised 1799 adults, as well as 411 children of the adult respondents. Adult refugees were assessed for trauma history, post-migration difficulties, harsh and warm parenting, probable prolonged grief disorder and posttraumatic stress disorder. Children were administered the Strengths and Difficulties Questionnaire. The current analyses on bereaved refugees comprise 110 caregivers and 178 children. RESULTS: In this cohort, 37% of bereaved refugees reported probable prolonged grief disorder. Path analysis indicated that caregivers' grief was directly associated with children's emotional difficulties. Caregiver warmth was associated with reduced emotional problems in children of refugees with minimal grief but associated with more emotional problems in caregivers with more severe grief. More harsh parenting was associated with children's conduct problems, and this was more evident in those with less severe grief. CONCLUSION: Severity of prolonged grief disorder is directly linked to refugee children's mental health. The association between parenting style, grief severity and children's mental health highlights that managing grief reactions in refugees can benefit both refugees and their children.

Associations between family-level adversity and society-level trauma with emotional and behavioural problems amongst children of West Papuan refugees.

Few studies have examined associations between family-level parental factors, society-level violence, and the emotional and behavioral status of children of refugee populations. Our study used cross-sectional epidemiological data to test a theoretical model of these key associations amongst a community sample of children (n = 162) of West Papuan refugees living in remote town in Papua New Guinea (PNG), a setting of endemic violence and poverty. Culturally adapted instruments were used to assess three types of intra-familial factors (adverse parenting, physical and/or sexual abuse and emotional abuse) and three types of society-level violence and stressors (exposure to systematic violence, peer violence, living difficulties). Emotional and behavioural problems were assessed using the Youth Self-Report Checklist. Path analysis was used to test theoretical associations. Key findings include direct associations between both family-level physical and/or sexual abuse (ß = .43; p < .001) and adverse parenting (ß = .40; p < .001) with emotional and behavioural problems amongst children. In the broader social domain, peer violence (ß = .29; p < .001) had a direct association with children's emotional and behavioural problems. Several indirect paths demonstrated a chain of relationships involving family- and society-level factors and emotional and behavioural problems in children. Only longitudinal data can provide further support for veridical causal pathways linking family and social factors with adverse emotional and behavioural outcomes in offspring of refugees, thereby supporting mechanisms leading to a transgenerational transmission of adverse mental health outcomes in refugee populations. Such data would give further support for a multisectoral approach to dealing with at risk families in refugee populations, in which attention should focus on supporting parents, and promoting the protection of children from abuse in the family and in the wider society.

An Integrative Adapt Therapy for common mental health symptoms and adaptive stress amongst Rohingya, Chin, and Kachin refugees living in Malaysia: A randomized controlled trial.

BACKGROUND: This randomised controlled trial (RCT) aims to compare 6-week posttreatment outcomes of an Integrative Adapt Therapy (IAT) to a Cognitive Behavioural Therapy (CBT) on common mental health symptoms and adaptive capacity amongst refugees from Myanmar. IAT is grounded on psychotherapeutic elements specific to the refugee experience. METHODS AND FINDINGS: We conducted a single-blind RCT (October 2017 -May 2019) with Chin (39.3%), Kachin (15.7%), and Rohingya (45%) refugees living in Kuala Lumpur, Malaysia. The trial included 170 participants receiving six 45-minute weekly sessions of IAT (97.6% retention, 4 lost to follow-up) and 161 receiving a multicomponent CBT also involving six 45-minute weekly sessions (96.8% retention, 5 lost to follow-up). Participants (mean age: 30.8 years, SD = 9.6) had experienced and/or witnessed an average 10.1 types (SD = 5.9, range = 1-27) of traumatic events. We applied a single-blind design in which independent assessors of pre- and posttreatment indices were masked in relation to participants' treatment allocation status. Primary outcomes were symptom scores of Post Traumatic Stress Disorder (PTSD), Complex PTSD (CPTSD), Major Depressive Disorder (MDD), the 5 scales of the Adaptive Stress Index (ASI), and a measure of resilience (the Connor-Davidson Resilience Scale [CDRS]). Compared to CBT, an intention-to-treat analysis (n = 331) at 6-week posttreatment follow-up demonstrated greater reductions in the IAT arm for all common mental disorder (CMD) symptoms and ASI domains except for ASI-3 (injustice), as well as increases in the resilience scores. Adjusted average treatment effects assessing the differences in posttreatment scores between IAT and CBT (with baseline scores as covariates) were -0.08 (95% CI: -0.14 to -0.02, p = 0.012) for PTSD, -0.07 (95% CI: -0.14 to -0.01) for CPTSD, -0.07 for MDD (95% CI: -0.13 to -0.01, p = 0.025), 0.16 for CDRS (95% CI: 0.06-0.026, p ≤ 0.001), -0.12 (95% CI: -0.20 to -0.03, p ≤ 0.001) for ASI-1 (safety/security), -0.10 for ASI-2 (traumatic losses; 95% CI: -0.18 to -0.02, p = 0.02), -0.03 for ASI-3 (injustice; (95% CI: -0.11 to 0.06, p = 0.513), -0.12 for ASI-4 (role/identity disruptions; 95% CI: -0.21 to -0.04, p ≤ 0.001), and -0.18 for ASI-5 (existential meaning; 95% CI: -0.19 to -0.05, p ≤ 0.001). Compared to CBT, the IAT group had larger effect sizes for all indices (except for resilience) including PTSD (IAT, d = 0.93 versus CBT, d = 0.87), CPTSD (d = 1.27 versus d = 1.02), MDD (d = 1.4 versus d = 1.11), ASI-1 (d = 1.1 versus d = 0.85), ASI-2 (d = 0.81 versus d = 0.66), ASI-3 (d = 0.49 versus d = 0.42), ASI-4 (d = 0.86 versus d = 0.67), and ASI-5 (d = 0.72 versus d = 0.53). No adverse events were recorded for either therapy. Limitations include a possible allegiance effect (the authors inadvertently conveying disproportionate enthusiasm for IAT in training and supervision), cross-over effects (counsellors applying elements of one therapy in delivering the other), and the brief period of follow-up. CONCLUSIONS: Compared to CBT, IAT showed superiority in improving mental health symptoms and adaptative stress from baseline to 6-week posttreatment. The differences in scores between IAT and CBT were modest and future studies conducted by independent research teams need to confirm the findings. TRIAL REGISTRATION: The study is registered under Australian New Zealand Clinical Trials Registry (ANZCTR) (http://www.anzctr.org.au/). The trial registration number is: ACTRN12617001452381.

Defining a combined constellation of complicated bereavement and PTSD and the psychosocial correlates associated with the pattern amongst refugees from West Papua.

BACKGROUND: Refugees are at risk of experiencing a combined constellation of complicated bereavement and posttraumatic stress disorder (PTSD) symptoms following exposure to complex traumas associated with personal threat and loss. Features of identity confusion are central to both complicated bereavement and PTSD and these characteristics may be particularly prominent amongst refugees from traditional cultures displaced from their homelands, families, and kinship groups. We investigate whether a combined pattern of complicated bereavement and PTSD can be identified amongst West Papuan refugees participating in an epidemiological survey (n = 486, response rate: 85.8%) in a remote town in Papua New Guinea. METHODS: Latent class analysis was applied to derive subpopulations of refugees based on symptoms of complicated bereavement and PTSD. Associations were examined between classes and traumatic loss events, post-migration living difficulties (PMLDs), and psychosocial support systems. RESULTS: The four classes identified comprised a complicated bereavement class (11%), a combined posttraumatic bereavement class (10%), a PTSD class (11%), and a low symptom class (67%). Symptoms of identity confusion were prominent in the posttraumatic bereavement class. Compared with the low symptom class, the combined posttraumatic bereavement class reported greater exposure to traumatic loss events (OR 2.43, 95% CI 1.11-5.34), PMLDs (OR 2.24, 95% CI 1.01-4.6), disruptions to interpersonal bonds and networks (OR 3.3, 95% CI 1.47-7.38), and erosion of roles and identities (OR 2.18, 95% CI 1.11-4.27). CONCLUSIONS: Refugees appear to manifest a combined pattern of complicated bereavement and PTSD symptoms in which identity confusion is a prominent feature. This response appears to reflect the combined impact of high levels of exposure to traumatic losses, PMLDs, and disruption of relevant psychosocial systems.

Longitudinal association between trust, psychological symptoms and community engagement in resettled refugees.

BACKGROUND: The mental health and social functioning of millions of forcibly displaced individuals worldwide represents a key public health priority for host governments. This is the first longitudinal study with a representative sample to examine the impact of interpersonal trust and psychological symptoms on community engagement in refugees. METHODS: Participants were 1894 resettled refugees, assessed within 6 months of receiving a permanent visa in Australia, and again 2-3 years later. Variables measured included post-traumatic stress disorder symptoms, depression/anxiety symptoms, interpersonal trust and engagement with refugees' own and other communities. RESULTS: A multilevel path analysis was conducted, with the final model evidencing good fit (Comparative Fit Index = 0.97, Tucker-Lewis Index = 0.89, Root Mean Square Error of Approximation = 0.05, Standardized Root-Mean-Square-Residual = 0.05). Findings revealed that high levels of depression symptoms were associated with lower subsequent engagement with refugees' own communities. In contrast, low levels of interpersonal trust were associated with lower engagement with the host community over the same timeframe. CONCLUSIONS: Findings point to differential pathways to social engagement in the medium-term post-resettlement. Results indicate that depression symptoms are linked to reduced engagement with one's own community, while interpersonal trust is implicated in engagement with the broader community in the host country. These findings have potentially important implications for policy and clinical practice, suggesting that clinical and support services should target psychological symptoms and interpersonal processes when fostering positive adaptation in resettled refugees.

Identifying distinctive psychological symptom profiles among a nationally representative sample of refugees resettled in Australia.

OBJECTIVE: The number of refugees worldwide is unprecedented in recent history. Little is known, however, about profiles of psychological symptoms following persecution and displacement. METHODS: This study reports on a latent class analysis that identified profiles of posttraumatic stress disorder (PTSD), depression and anxiety symptoms in a nationally representative sample of 1625 refugees in Australia. The association between specific symptom profiles, exposure to potentially traumatic events and post-migration stressors, and overall health and help-seeking was examined. RESULTS: Latent class analysis yielded an optimal five-class solution. These classes comprised the Pervasive Symptom class (19.2%), the High PTSD Symptom class (17.1%), the High Depression/Anxiety Symptom class (16.4%), the Moderate PTSD Symptom class (16.2%) and the Low Symptom class (31.1%). Participants in the symptomatic classes were more likely to be female, older and report greater post-migration stressors than those in the Low Symptom class. In addition, individuals in classes characterized by PTSD symptoms had been exposed to more types of potentially traumatic events. Membership in symptomatic classes was associated with poorer overall heath and greater help-seeking. CONCLUSION: Qualitatively distinct symptom profiles were observed in a nationally representative sample of refugees. In addition to a group of people who reported high symptoms across psychological disorders and may warrant clinical intervention, we identified two subclinical classes who may be missed by existing diagnostic classification systems. Post-migration stressors play an important role in influencing refugee symptom profiles over and above exposure to potentially traumatic events. Clinicians should consider specific symptom profiles and contextual factors when planning interventions with refugees.

The impact of post-traumatic stress disorder symptomatology on quality of life: The sentinel experience of anger, hypervigilance and restricted affect.

BACKGROUND: It is unclear which specific symptoms of post-traumatic stress disorder are related to poor perceived quality of life. OBJECTIVE: To investigate the influence of post-traumatic stress disorder symptomatology on quality of life in traumatic injury survivors. METHOD: Traumatic injury survivors completed questionnaires on post-traumatic stress disorder symptomatology and quality of life at 3 months ( n = 987), 12 months ( n = 862), 24 months ( n = 830) and 6 years ( n = 613) post trauma. RESULTS: Low quality of life was reported by 14.5% of injury survivors at 3 months and 8% at 6 years post event. The post-traumatic stress disorder symptom clusters that contributed most to poor perceived quality of life were numbing and arousal, the individual symptoms that contributed most were anger, hypervigilance and restricted affect. CONCLUSIONS: There was variability in the quality of life of traumatic injury survivors in the 6 years following trauma and a consistent proportion reported low quality of life. Early intervention to reduce anger, hypervigilance and restricted affect symptoms may provide a means to improving the quality of life of traumatic injury survivors.

The HTQ-5: revision of the Harvard Trauma Questionnaire for measuring torture, trauma and DSM-5 PTSD symptoms in refugee populations.

BACKGROUND: The Harvard Trauma Questionnaire (HTQ) was developed 25 years ago as a cross-cultural screening instrument to document trauma exposure, head trauma and trauma-related symptoms in refugees. This article aims to: (i) outline the process of revision of Part IV of the HTQ to (a) include the new DSM-5 diagnostic criteria for PTSD, and (b) separate out and more fully develop the refugee-specific functioning items; and (ii) promote a consistent approach to the validation of the HTQ-5 when adapted for use in other cultures and language groups. METHODS: Our process involved item mapping; expert consultations; generating items according to the new DSM-5 criteria; and drafting, refinement and finalization of the revised measure focusing closely on issues of meaning, future translation into multiple languages and comprehension amongst groups with low literacy and little or no exposure to Western trauma concepts. Validity and reliability testing of the new HTQ-5 is underway. RESULTS: The HTQ symptom checklist was modified consistent with current DSM-5 diagnostic criteria to identify those refugees at risk for mental health and other symptoms associated with traumatic life events, disability and dysfunction. CONCLUSIONS: Accurate screening of post-traumatic distress and dysfunction enables those working with refugees to triage them more effectively to scarce health and mental health resources. When developing screening measures to inform public health policy and practice, it is vital that these measures can bridge the gap between western (etic) nosologies and indigenous (emic) understandings of traumatic stress.

The structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua.

PURPOSE: Refugees may be at risk of experiencing a complicated form of bereavement. As yet, however, the nosological status of this putative category across cultures remains in question. We apply qualitative and quantitative methods to investigate the manifestations, prevalence, factorial structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua, a population with no past exposure to western concepts of grief or to formal mental health services. METHODS: Qualitative methods (focus groups and informant interviews) were used to identify cultural expressions of complicated bereavement derived from international classification systems, that is, DSM 5 persistent complex bereavement disorder (PCBD) and ICD-11 prolonged grief disorder (PGD) in developing a structured interview applied by trained field workers. Participants were adult West Papuan refugees and their offspring recruited from households (n = 486, response 85.8%) across nine villages in a remote town in Papua New Guinea. RESULTS: The qualitative data obtained from focus groups (n = 20) and informant interviews (n = 4) with local psychiatrists supported the cultural validity of complicated bereavement. 16% (n = 78) of the sample met criteria for PCBD based on DSM-5 criteria and 103 (21%) met criteria for PGD based on ICD-11 criteria. Confirmatory factor analysis yielded a six-factor model of complicated bereavement with a moderately good fit to the data. The model included dimensions of anger/negative appraisal (AN), avoidance/giving up, estrangement from others, and confusion and diminished identity. In contrast, the DSM-5 three-factor model and the ICD-11 two-factor model each yielded a poor fit. Cumulative traumatic losses (ß = 0.16, P = 0.03), duration since displacement [(ß = 0.10, P = 0.02)] and postmigration living difficulties (ß = 0.20, P = 0.01) were associated with an aggregated index of complicated bereavement, supporting the concurrent validity of the structure identified. CONCLUSIONS: Culture and exposure to persecution and displacement may contribute to the content and configuration of the complicated bereavement reaction, an issue that requires recognition in international classification systems and clinical practice.

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

BACKGROUND: High-income countries like Australia play a vital role in resettling refugees from around the world, half of whom are children and adolescents. Informed by an ecological framework, this study examined the post-migration adjustment of refugee children and adolescents 2-3 years after arrival to Australia. We aimed to estimate the overall rate of adjustment among young refugees and explore associations with adjustment and factors across individual, family, school, and community domains, using a large and broadly representative sample. METHODS: Data were drawn from Wave 3 of the Building a New Life in Australia (BNLA) study, a nationally representative, longitudinal study of settlement among humanitarian migrants in Australia. Caregivers of refugee children aged 5-17 (N = 694 children and adolescents) were interviewed about their children's physical health and activity, school absenteeism and achievement, family structure and parenting style, and community and neighbourhood environment. Parent and child forms of the Strengths and Difficulties Questionnaire (SDQ) were completed by caregivers and older children to assess social and emotional adjustment. RESULTS: Sound adjustment according to the SDQ was observed regularly among young refugees, with 76-94% (across gender and age) falling within normative ranges. Comparison with community data for young people showed that young refugees had comparable or higher adjustment levels than generally seen in the community. However, young refugees as a group did report greater peer difficulties. Bivariate and multivariate linear regression analyses showed that better reported physical health and school achievement were associated with higher adjustment. Furthermore, higher school absenteeism and endorsement of a hostile parenting style were associated with lower adjustment. CONCLUSIONS: This is the first study to report on child psychosocial outcomes from the large, representative longitudinal BNLA study. Our findings indicate sound adjustment for the majority of young refugees resettled in Australia. Further research should examine the nature of associations between variables identified in this study. Overall, treating mental health problems early remains a priority in resettlement. Initiatives to enhance parental capability, physical health, school achievement and participation could assist to improve settlement outcomes for young refugees.

Factor structures of Complex Posttraumatic Stress Disorder and PTSD in a community sample of refugees from West Papua.

OBJECTIVES: The intention to include a category of Complex Posttraumatic Stress Disorder (CPTSD) in ICD-11 has renewed interest in this construct. Although growing evidence from high income countries supports the construct validity of CPTSD, little parallel research has been undertaken across cultures. We tested theoretically supported CPTSD structures (a one-factor, six-factor, one-factor higher-order, and two-factor higher order structure) in a community sample of West Papuan refugees living in a remote town, Kiunga, in Papua New Guinea (PNG). PROCEDURES: A community-wide survey was conducted (2016-2017; response rate 85.5%) amongst 486 West Papuans. Culturally adapted measures were applied to assess cumulative traumatic exposure, postmigration living difficulties (PMLDs), CPTSD symptoms, and functional impairment. FINDINGS: A six factor structure for CPTSD provided the best fit to the data, consistent with our past study amongst West Papuans. CONCLUSIONS: The cross-cultural validity of our findings is supported by the isolation of West Papuan participants from services treating traumatic stress. To further support the universal applicability of CPTSD, our findings need to be confirmed amongst other refugee groups from diverse cultural backgrounds.

The Range and Impact of Postmigration Stressors During Treatment of Trauma-Affected Refugees.

Trauma-affected refugees commonly experience postmigration stressors, which can compound conflict-related emotional distress. Our study aimed to assess clinician-rated frequency and types of postmigration stressors deemed to be interfering with the treatment of refugees attending a service for trauma-related mental distress. A total of 116 patients completed 6 months of multidisciplinary treatment. Clinician-rated postmigration stressors were registered at each session. Outcome measures were Harvard Trauma Questionnaire and Global Assessment of Functioning, function (GAF-F) and symptom. Postmigration stressors were deemed to impact on 39.1% of treatment sessions with medical personnel. Issues related to work, finances, and family were the most frequently identified stressors. Postmigration stressors interfering with treatment were more common among male refugees, those living alone, those from Middle Eastern origin, and persons with low baseline GAF-F. Explicitly identifying and, where possible, dealing with postmigration stressors may assist in averting their interference with the treatment of distress in refugees.

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

OBJECTIVE: To evaluate the relative efficacies of trauma-focused cognitive behavior therapy and problem-solving therapy in treating post-traumatic stress disorder in children affected by civil conflict in Aceh, Indonesia. METHOD: A controlled trial of children with post-traumatic stress disorder ( N = 64) randomized children to either five individual weekly sessions of trauma-focused cognitive behavior therapy or problem-solving therapy provided by lay-counselors who were provided with brief training. Children were assessed by blind independent assessors at pretreatment, posttreatment and 3-month follow-up on post-traumatic stress disorder, depression and anger, as well as caregiver ratings of the child's post-traumatic stress disorder levels. RESULTS: Intent-to-treat analyses indicated no significant linear time × treatment condition interaction effects for post-traumatic stress disorder at follow-up ( t(129.05) = -0.55, p = 0.58), indicating the two conditions did not differ. Across both conditions, there were significant reductions in post-traumatic stress disorder on self-reported ( t(131.26) = -9.26, p < 0.001) and caregiver-reported ( t(170.65) = 3.53, p = 0.001) measures and anger ( t(127.66) = -7.14, p < 0.001). Across both conditions, there was a large effect size for self-reported post-traumatic stress disorder (cognitive behavior therapy: 3.73, 95% confidence interval = [2.75, 3.97]; problem-solving: 2.68, 95% confidence interval = [2.07, 3.29]). CONCLUSIONS: These findings suggest that trauma-focused cognitive behavior therapy and problem-solving approaches are comparably successful in reducing post-traumatic stress disorder and anger in treating mental health in children in a post-conflict setting. This pattern may reflect the benefits of non-specific therapy effects or gains associated with trauma-focused or problem-solving approaches.