Parenting in a post-conflict region: Associations between observed maternal parenting practices and maternal, child, and contextual factors in northern Uganda.

Studies show that war leads to an increase in harsh parenting and a decrease in parental warmth, which in turn has a devastating impact on children's development. However, there is insufficient research on the factors that affect parenting in post-conflict regions. In addition, most previous studies on the role of parenting in the context of war rely on self-reports, which are subject to a number of limitations. To complement existing research, the present cross-sectional study used behavioral observations of 101 mothers and their 6-12 year old children to assess parenting in post-conflict northern Uganda. The aim of the current study was to explore associations between observed maternal warmth and coercion and self-reported socioeconomic status (e.g., mother's educational level) as well as maternal (e.g., posttraumatic stress disorder), child (e.g., externalizing problems), and social contextual factors (e.g., family violence). Results show a link between observed parenting, child characteristics, and family violence. Higher levels of children's externalizing problems were associated with more severe maternal coercion. In addition, a negative association was found between family violence and maternal warmth. Findings are discussed in terms of their implications for prevention and intervention programs and the use of behavioral observations in post-conflict environments.

Continuous chains: childhood maltreatment and intimate partner violence victimization among displaced women in a war context.

BACKGROUND: Childhood victimization has been associated with long-term psychological effects and an increased risk of being victimized in later life. Previous research has primarily focused on sexual abuse during childhood, and a wide range of consequences have been identified. However, a significant gap remains in our understanding of the complex interaction between different forms of childhood abuse and violence in later life, particularly in the context of broader social stressors such as armed conflict and displacement. METHODS: This study examines the association between exposure to different types of childhood maltreatment in the context of family and intimate partner violence (IPV) among displaced women living in refugee camps in northern Iraq. Structured interviews were conducted by trained female psychologists with 332 women aged between 20 and 62 years. RESULTS: Results indicated that over one-third of the participating women reported experiencing at least one occurrence of IPV by their husbands within the past year. In addition, participants reported experiences of different types of maltreatment (physical, emotional, and sexual violence and physical and emotional neglect) perpetrated by family members in their childhood. While all forms of childhood maltreatment showed an association with IPV within the past year, only emotional childhood maltreatment was found to be a significant predictor of IPV in a multivariate analysis. CONCLUSION: The study highlights the ongoing impact of child maltreatment and its contribution to increased vulnerability to IPV victimization in later life. In addition, this study describes the specific cultural and contextual elements that contribute to IPV in refugee camps.

Complicated grief and posttraumatic stress after loss and separation under terror conditions.

The lives of people in conflict areas are often characterized by the experience of traumatic events frequently accompanied by loss and separation. These can equally trigger symptoms of posttraumatic stress disorder (PTSD) and complicated grief (CG). The aim of the present study was to investigate whether affected individuals could be assigned to distinct classes at symptom-cluster levels of these two disorders. Moreover, we aimed to identify event-related and sociodemographic predictors associated with membership in these pathological classes. Participants were Iraqi internally displaced persons (IDPs; N = 199) who fled their hometowns due to the ISIS conflict and reported having lost an important person within the past 5 years. Based on the PTSD Checklist for DSM-5 (PCL-5) and Inventory of Complicated Grief (ICG), a latent class analysis (LCA) was applied to examine different classes of symptom clusters. Multinomial logistic regression was used to determine which variables predicted assignment to these symptom classes. The impact of loss and separation among IDPs in Iraq manifested in CG symptoms in more than half of the affected population and was often accompanied by PTSD. LCA identified a low-symptoms class (17.6%), CG class (33.7%), PTSD class (12.1%), and comorbid PTSD+CG class (36.7%). The sudden or violent death of a loved one was identified as a distinguishing factor for PTSD. Furthermore, separation was associated with comorbidity. Aid agencies should take these specific factors into account to improve effective and economic aid delivery to IDPs continuously affected by terror.

Growing relevance of reports of adolescent cyberbullying victimization among adult outpatients.

In the general population, prevalence rates of cyberbullying victimization have continuously increased over the past decades. However, the extent to which these increasing numbers affect clinical populations seeking treatment in outpatient services remains an open question. The present study sought to examine whether the increase of cyberbullying victimization is also reflected by increased reports of cyberbullying victimization in a clinical outpatient population. In addition, we assessed the incremental contribution of experiences of cyberbullying in the prediction of psychological symptoms when controlling for histories of childhood maltreatment and offline peer victimization. For this purpose, we analyzed routine data from N = 827 outpatients who had sought treatment at a University outpatient clinic for psychotherapy between 2012 and 2021 in a cross-sectional study design. Analyses showed that 8.3% of the patients born in the years 1980 to 2002 indicated the experience of cyberbullying victimization in their adolescence. The rate of reported cyberbullying victimization increased from 1 to 3% in patients born in the years 1980 to 1987 to 24% in patients born in the year 2000. A logistic regression revealed that patients born in the years 1995-2002 were up to nineteen times as likely to report cyberbullying victimization as patients born in the years 1980-1982. In addition, hierarchical multiple regression analyses indicated that cyberbullying victimization significantly accounted for an incremental proportion of variance (1%) in the prediction of psychological symptom distress after controlling for child maltreatment and offline peer victimization. In conclusion, this retrospective survey indicates an increase of the clinical relevance of cyberbullying victimization both in frequency of and potential contribution to etiology. Raising attention to cyberbullying in clinical care and research seems to be justified and warranted.

The role of psychotherapists' perceived barriers in providing psychotherapy to refugee patients.

Access to psychotherapy is critical to improving mental health, but only a small proportion of refugees receive treatment in the regular psychotherapeutic care system in high-income countries. In previous research, outpatient psychotherapists reported several barriers to more frequent treatment of refugee patients. However, it is unclear to what extent these perceived barriers contribute to the poor provision of services to refugees. In a survey of N = 2002 outpatient psychotherapists in Germany, we collected data on perceived treatment barriers and on the integration of refugees into regular psychotherapeutic practice. Half of the psychotherapists reported that they do not treat refugee patients. In addition, therapies provided for refugees were, on average, 20% shorter than for other patients. Regression analyses showed direct negative associations between psychotherapists' overall perception of barriers with the number of refugees treated and the number of sessions offered to refugee patients, even when controlling for sociodemographic and workload-related characteristics. Correlation analyses on the level of specific types of barriers further revealed that particularly language-related barriers and lack of contact with the refugee population are negatively correlated with the number of refugees treated and the number of sessions for refugees. Our findings indicate that the integration of refugees into regular psychotherapeutic care could be improved by measures to connect psychotherapists with refugee patients as well as professional interpreters and to ensure coverage of costs for therapy, interpreters and related administrative tasks.

Othering refugees: Psychotherapists' attitudes toward patients with and without a refugee background.

Objective: A large proportion of refugees present with psychological disorders that require psychotherapy as first-line treatment. However, even in countries with well-established psychotherapy system, refugees continue to face barriers to care. Psychotherapists' attitudes toward refugees may also impede access to psychotherapy, as it is evident that stereotypes of health professionals contribute to health care disparities. However, little is known about psychotherapists' attitudes toward refugees. Methods: In a cross-sectional online study of N = 2002 outpatient psychotherapists in Germany (Mage = 54.48 years, 73.1% female), a vignette experiment was applied to examine differences in therapists' attitudes toward refugee patients from the Middle East and non-refugee patients. Subsequently, associations between attitudes and psychotherapists' characteristics (e.g., provision of treatment for refugees) were analyzed. Results: Results showed significant differences between therapists' attitudes toward refugee and non-refugee patients (ηp2 = .23), with more therapy-hindering attitudes toward refugee patients. Higher therapy-hindering attitudes were significantly associated with less frequent provision of psychotherapy for refugees. Conclusion: Our findings provide initial evidence that psychotherapists perceive refugee patients as deviant from the norm and that these divergent attitudes may relate to disparities in mental health care. To avoid such a process of othering, training for psychotherapists should question stereotypes toward refugees.

Explaining the accumulation of victimization in vulnerable children: Interpersonal violence among children traumatized by war and disaster in a children's home in Sri Lanka.

Research in postconflict settings indicated that children's exposure to war and natural disaster is a significant predictor of experiencing violence within their families. However, it is unclear if this effect is driven by characteristics of traumatized children or their parents. To disentangle these different factors we conducted a survey in a children's home in Sri Lanka. A total of 146 institutionalized children (aged 8 to 17) were interviewed using standardized questionnaires administered by local senior counselors in order to assess children's exposure to mass trauma, family violence, and violence in the institution as well as their mental health. Linear regression analyses revealed that, controlling for potential confounds, previous exposure to civil war was a significant predictor of violence by guardians in the children's home. In addition, previous exposure to family violence was a significant predictor of violence by peers in the institutions. A mediation analysis showed that children's internalizing and externalizing behavior problems partly mediated the relationship between violence prior to the admission to the children's home and violence in the children's home. The findings of our study provide evidence for the assumption that the transmission of mass trauma into interpersonal violence can occur independently from parents through children's psychopathology.

Mental health problems moderate the association between teacher violence and children's social status in East Africa: A multi-informant study combining self- and peer-reports.

School victimization has been negatively associated with children's social status. However, previous studies have primarily focused on peer victimization, leaving a significant knowledge gap regarding violence by teachers. We hypothesized that, when almost all children experience violence by teachers, not only the experience of violence, but also other factors, for example, mental health problems, may influence children's social preference and centrality. We therefore examined potential moderation effects of children's internalizing and externalizing problems. We implemented a multistage cluster randomized sampling approach to randomly chose fifth- and sixth-grade students from primary schools throughout Tanzania. Using a multi-informant approach, data were collected from 643 children (51.0% girls, Mage = 12.79 years). Results showed inconsistent direct associations between teacher violence and social status, whereas mental health problems were consistently associated with lower social status. Significant interaction effects were found for internalizing problems; that is, teacher violence was associated with lower social status for increasing internalizing problems. However, no interaction effects were found for externalizing problems. The findings underline the burden of exposure to violence by teachers and the importance of mental health for children's social functioning. Knowledge about interrelations can be applied in interventions to effectively reduce violence by teachers toward students.

The mental health of forcibly displaced couples.

Most current research investigating traumatic stress is focused on its effects at the individual level, utilizing the implicit assumption that trauma-related disorders are mutually independent within families and communities. However, there is reason to assume that trauma-related symptoms within couples are influenced by each partner's risk factors and symptoms. Using the actor-partner interdependence model, this study aimed to test whether symptoms of posttraumatic stress disorder (PTSD) and depression were predicted by participants' partner's exposure to traumatic events over and above the influence of the participant's own experiences. For this purpose, we interviewed 687 heterosexual, married Iraqi and Syrian couples in Iraq's Kurdistan region who had been forcefully displaced. We assessed symptoms of PTSD and depression using locally validated scales. Nearly all participants (98.8%) reported exposure to at least one traumatic event, with husbands reporting exposure to a higher number of traumatic events than wives, d = 0.48, p < .001. More than half of the participants met the criteria for a probable PTSD (61.1%) or major depressive disorder diagnosis (60.4%). Within couples, significant actor effects of experienced trauma exposure on personal PTSD and depressive symptoms were observed for both husbands and wives. Further, there were significant partner effects of wives' traumatic experiences on husbands' PTSD and depressive symptoms as well as of husbands' traumatic experiences on wives' PTSD and depressive symptoms. The findings argue for the interdependence of trauma-related symptoms within dyads in a dual-trauma context, suggesting the presence of intracouple transmission of trauma-related symptoms.

"She finds you abhorrent" - The impact of emotional context information on the cortical processing of neutral faces in depression.

Depression is associated with abnormalities in patterns of information processing, particularly in the context of processing of interpersonal information. The present study was designed to investigate the differences in depressive individuals in cortical processing of facial stimuli when neutral faces were presented in a context that involved information about emotional valence as well as self-reference. In 21 depressive patients and 20 healthy controls, event-related potentials (ERPs) were recorded during the presentation of neutral facial expressions, which were accompanied by affective context information that was either self- or other-related. Across conditions, depressive patients showed larger mean P100 amplitudes than healthy controls. Furthermore, mean late positive potential (LPP) amplitudes of depressive patients were larger in response to faces in self-related than in other-related context. In addition, irrespective of self-reference, mean LPP responses of depressive patients to faces presented after socially threatening sentences were larger compared with faces presented after neutral sentences. Results regarding self-reference supported results of previous studies indicating larger mean amplitudes in self-related conditions. Findings suggest a general heightened initial responsiveness to emotional cues and a sustained emotion processing of socially threatening information in depressive patients.

Treating alcohol use disorder in the absence of specialized services - evaluation of the moving inpatient Treatment Camp approach in Uganda.

BACKGROUND: The gap between service need and service provision for alcohol-related disorders is highest in resource-poor countries. However, in some of these contexts, local initiatives have developed pragmatic interventions that can be carried out with limited specialized personnel. In an uncontrolled treatment study, we aimed to evaluate the feasibility, acceptability, safety, costs and potential effects of an innovative locally developed community-based program (the Treatment Camp) that is based on an inpatient clinic that moves from community to community. METHODS: Out of 32 treatment-seeking individuals 25 took part in the one-week Treatment Camp that included detoxification and counseling components. Re-assessments took place 5 and 12 months after their participation. We explored the course of a wide range of alcohol-related indicators, using the Alcohol Use Disorders Identification Test (AUDIT) as primary outcome complemented by a timeline follow-back approach and the Obsessive Compulsive Drinking Scale. Additionally, we assessed impaired functioning, alcohol-related stigmatization, symptoms of common mental health disorders and indicators of family functioning as reported by participants' wives and children. RESULTS: All alcohol-related measures decreased significantly after the Treatment Camp and remained stable up to the 12-month-assessment with high effect sizes ranging from 0.89 to 3.49 (Hedges's g). Although 92% of the participants had lapsed at least once during the follow-up period, 67% classified below the usually applied AUDIT cutoff for hazardous drinking (≥ 8) and no one qualified for the dependent range (≥ 20) one year after treatment. Most secondary outcomes including impaired functioning, alcohol-related stigmatization, symptoms of depression and indicators of family functioning followed the same trajectory. CONCLUSIONS: We found the Treatment Camp approach to be acceptable, feasible, safe and affordable (approx. 111 USD/patient) and we could obtain preliminary evidence of its efficacy. Due to its creative combination of inpatient treatment and monitoring by medical personnel with local mobility, the Treatment Camp appears to be more accessible and inclusive than other promising interventions for alcohol dependent individuals in resource-poor contexts. Effects of the approach seem to extend to interactions within families, including a reduction of dysfunctional and violent interactions.

Fuel to the fire: The escalating interplay of attachment and maltreatment in the transgenerational transmission of psychopathology in families living in refugee camps.

Maltreatment by parents can be conceptualized as pathogenic escalations of a disturbed parent-child relationship that have devastating consequences for children's development and mental health. Although parental psychopathology has been shown to be a risk factor both for maltreatment and insecure attachment representations, these factors` joint contribution to child psychopathology has not been investigated. In a sample of Burundian refugee families living in refugee camps in Western Tanzania, the associations between attachment representations, maltreatment, and psychopathology were examined by conducting structured interviews with 226 children aged 7 to 15 and both their parents. Structural equation modeling revealed that children's insecure attachment representations and maltreatment by mothers fully mediated the relation between maternal and child psychopathology [model fit: comparative fit index (CFI) = 0.96; root mean square error of approximation (RMSEA) = 0.05]. A direct association between paternal and child psychopathology was observed (model fit: CFI = 0.96; RMSEA = 0.05). The findings suggest a vicious cycle, wherein an insecure attachment to a mother suffering from psychopathology may be linked to children's risk to be maltreated, which may reinforce insecure representations and perpetuate the pathogenic relational experience. Interventions targeting the attachment relationship and parental mental health may prevent negative child outcomes.

Collaborative Assessment and Management of Suicidality (CAMS) compared to enhanced treatment as usual (E-TAU) for suicidal patients in an inpatient setting: study protocol for a randomized controlled trial.

BACKGROUND: The Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic framework that has been shown to reduce suicidal ideation and overall symptom distress. CAMS has not been previously evaluated in a standard acute inpatient mental health care setting with only short treatment times for suicidal patients. In this randomized controlled trial (RCT) we are investigating whether CAMS is more effective than Enhanced-Treatment as Usual (E-TAU) in reducing suicidal thoughts as primary outcome variable. We are also investigating depressive symptoms, general symptom relief, and the quality of the therapeutic alliance as secondary outcomes. METHODS/DESIGN: This RCT is designed as a single-center, two-armed, parallel group observer-blinded clinical effectiveness investigation. We are recruiting and randomizing 60 participants with different diagnoses, who are admitted as inpatients because of acute suicidal thoughts or behaviors into the Clinic for Psychiatry and Psychotherapy, Ev. Hospital Bethel in Bielefeld, Germany. The duration of treatment will vary depending on patients' needs and clinical assessments ranging between 10 and 40 days. Patients are assessed four times, at admission, discharge, 1 month, and 5 months post-discharge. The primary outcome measure is the Beck Scale for Suicide Ideation. Other outcome measures are administered as assessment timepoints including severity of psychiatric symptoms, depression, reasons for living, and therapeutic relationship. DISCUSSION: This effectiveness study is being conducted on an acute ward in a psychiatric clinic where patients have multiple problems and diagnoses. Treatment is somewhat limited, and therapists have a large caseloads. The results of this study can thus be generalizable to a typical inpatient psychiatric hospital settings. TRIAL REGISTRATION: This clinical trial has been retrospectively registered with the German Clinical Trials Register; registration code/ DRKS-ID: DRKS00013727 (on January 12, 2018). In addition, the study was also registered with the International Clinical Trials Registry Platform of the World Health Organization (identical registration code). Registry Name: "Evaluation von CAMS versus TAU bei suizidalen Patienten - Ein stationärer RCT".

Child maltreatment, peer victimization, and social anxiety in adulthood: a cross-sectional study in a treatment-seeking sample.

BACKGROUND: Childhood adversities, especially emotional abuse, emotional neglect, and peer victimization are considered to be crucial risk factors for social anxiety disorder (SAD). We investigated whether particular forms of retrospectively recalled childhood adversities are specifically associated with SAD in adulthood or whether we find similar links in other anxiety or depressive disorders. METHODS: Prevalences of adversities assessed with the Childhood Trauma Questionnaire (CTQ) and a questionnaire of stressful social experiences (FBS) were determined in N = 1091 outpatients. Adversity severities among patients with SAD only (n = 25), specific phobia only (n = 18), and generalized anxiety disorder only (n = 19) were compared. Differences between patients with anxiety disorders only (n = 62) and depressive disorders only (n = 239) as well as between SAD with comorbid depressive disorders (n = 143) and SAD only were tested. RESULTS: None of the adversity types were found to be specifically associated with SAD and severities did not differ among anxiety disorders but patients with depressive disorders reported more severe emotional abuse, physical abuse, and sexual abuse than patients with anxiety disorders. SAD patients with a comorbid depressive disorder also reported more severe adversities across all types compared to SAD only. CONCLUSION: Findings indicate that particular forms of recalled childhood adversities are not specifically associated with SAD in adulthood. Previously established links with SAD may be better explained by comorbid depressive symptoms.

Effectiveness of inpatient versus outpatient complex treatment programs in depressive disorders: a quasi-experimental study under naturalistic conditions.

BACKGROUND: Due to long waiting periods for outpatient psychotherapy and the high resource requirements of inpatient treatment, there is a need for alternative treatment programs for patients with depressive disorders. Thus, we investigated the effectiveness of the "Bielefeld Outpatient Intensive Treatment Program of Depression" (BID) in comparison with a typical inpatient treatment program by using a prospective quasi-experimental observational study. We assumed (i) that both complex programs are effective in pre-post analyses after 6 weeks and (ii) that inpatient treatment is more effective compared with the outpatient program. METHODS: Four hundred patients with depressive psychopathology - a majority with depressive episodes (ICD-10 F3X) - took part in the BID and 193 in the inpatient program. Different self- (i.e., BDI) and expert measures (i.e., MADRS) of psychopathology at baseline (t1) and 6 weeks later (t2) were applied to examine treatment effects. RESULTS: Treatment effects were high in separate analyses of both groups with Cohen's d ranging from 1.10 to 1.76., while ANOVA comparative analyses did not reveal any significant differences between both treatment settings nor did a set of independent covariates analyzed here. Response rates of BDI (p = .002) and MADRS (p = .001) were higher in the outpatient group. Results indicate BID not to be inferior compared to an inpatient program, although diverging pathways to treatment, higher rates of clinical recurrent depressive disorders and severe episodes as well as lower rates of employment and partnership in the inpatient treatment group have to be considered. CONCLUSION: Outpatient intensive treatment programs may represent a solution for patients needing more than a treatment session once per week but less than a complex inpatient or day clinic program.

Trauma and perceived social rejection among Yazidi women and girls who survived enslavement and genocide.

BACKGROUND: In August 2014, the Islamic State of Iraq and Syria (ISIS), a terrorist organization, attacked the Yazidi's ancestral homeland in northwestern Iraq. Among other atrocities, they abducted thousands of women and girls and traded many of them into sexual slavery. The aim of this study is to determine the mental health of women and girl survivors of these events in relation to enslavement and experiences with genocide-related events, as well as perceived social rejection in their community. METHODS: Between February and July 2017, trained local assessors interviewed a sample of 416 Yazidi women and girls (65 of whom had survived sexual enslavement), aged between 17 and 75 years, and living in internally displaced person camps in the Kurdistan Region of Iraq. Post-traumatic stress disorder (PTSD) and depression symptoms were assessed using validated Kurdish versions of standard instruments. Scales for trauma exposure and perceived rejection were developed for the purpose of this study. RESULTS: Participants reported a high number of traumatic events. More than 80% of girls and women, and almost all participants who were formerly enslaved, met criteria for a probable DSM-5 PTSD diagnosis. Trauma exposure and enslavement predicted poor mental health. In addition, among formerly enslaved girls and women, perceived social rejection in their community mediated the relationship between traumatic enslavement events and depression symptoms. CONCLUSIONS: In a context of maximum adversity, enslavement and war-related events contribute to high levels of PTSD and depression. Perceived social rejection seems to play a role in the relationship between trauma exposure and mental health among abducted genocide survivors. Providing psychosocial support and treatment for Yazidi people is essential and urgently required.

Postepileptic seizure PTSD: A very rare psychiatric condition in patients with epilepsy.

PURPOSE: It has been shown that relatives of patients with epilepsy could experience a seizure as a traumatic event followed by a posttraumatic stress disorder (PTSD). In one questionnaire study, 51% of the patients with epilepsy were reported to have a PTSD caused by a traumatic seizure, termed postepileptic seizure PTSD by the authors. However, it remained unclear whether these patients had further psychiatric comorbidities and if certain seizure features may foster the development of the proposed epilepsy-specific PTSD. METHODS: We conducted a structured clinical interview assessing psychiatric disorders in 120 patients with difficult-to-treat epilepsies. We also used a modified version of the Posttraumatic Stress Diagnostic Scale conducted as an interview to assess the number of patients who fulfilled the criteria for a PTSD caused by an epileptic seizure. We additionally compared certain features of traumatic versus nontraumatic seizures. RESULTS: Fifty of the 120 patients identified a seizure that fulfilled the criteria for a traumatic event, whereas 28 patients identified a worst seizure not meeting the trauma definition. Six patients fulfilled all PTSD criteria caused by a traumatic seizure. However, three of these patients also had a regular PTSD, and in two further patients, the results of the clinical interview suggested that the PTSD-like symptoms could be better explained by an adjustment disorder. We could not identify seizure characteristics differentiating traumatic from nontraumatic seizures. CONCLUSION: Our results showed that it is recommendable to conceptualize an epileptic seizure as being potentially traumatic in nature when assessing PTSD in patients with epilepsy, although we could not identify specific characteristics that could differentiate between traumatic and nontraumatic seizures. However, while using interview-based psychiatric assessment, we found a very low rate of a postepileptic seizure PTSD. It is worth conducting a comprehensive psychiatric diagnostic interview to differentiate PTSD-like symptoms from other comorbidities, such as epilepsy-related adjustment disorder.

The validity of Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) as screening instrument with Kurdish and Arab displaced populations living in the Kurdistan region of Iraq.

BACKGROUND: The Posttraumatic Stress Disorder Checklist (PCL) is a valid and reliable self-report measure for the assessment of Posttraumatic Stress Disorder (PTSD). Recently the PCL was updated according to the DSM-5 criteria for PTSD. So far only a few studies have examined the psychometric properties of the PCL-5, and all of these are restricted to populations living in industrialized countries. The aim of this study was to determine the psychometric properties and diagnostic utility of the PCL-5 as a screening instrument for war-affected displaced Kurdish and Arab populations. The specific goal was to determine a contextually valid cut-off score for a probable diagnosis of PTSD. METHODS: The PCL-5 was translated into Arabic and two Kurdish dialects. Trained interviewers administered these translations as assisted self-reports to 206 adults living in camps for displaced people in Iraq, together with depression and war-exposure instruments. Two weeks later, 98 randomly chosen subjects were reassessed by expert clinical psychologists. In the absence of a gold-standard instrument with proven validity in this context, the expert interviewers applied the PCL-5 items in the form of a clinical interview and used a DSM-5-algorithm to determine a diagnosis of PTSD. Receiver operator characteristics (ROC) were performed to determine a valid cutoff-score. RESULTS: The internal consistency of the PCL-5 was high (alpha = .85) and the instrument showed an adequate convergent validity. Using the cut-off score of 23, the PCL-5 achieved the optimal balance of sensitivity and specificity (area under the curve = .82, p < .001; sensitivity = .82, specificity = .70). CONCLUSIONS: Given that the comparison of the two assessments included both a re-test interval and validation by different interviewers, our results indicate that the PCL-5 can be recommended as an assessment and screening instrument for Kurdish and Arab populations.

Preparing the Field for Feasibility Testing of a Parenting Intervention for War-Affected Mothers in Northern Uganda.

In this article, we discuss the successful implementation of an adapted evidence-based parenting intervention for families affected by two decades of war in Northern Uganda. The adaptation and adoption of such interventions to support mental health and family functioning is widely endorsed by prevention scientists and considered a priority in global mental health. The preparation and early adoption phases of engaging with a highly vulnerable community affected by war trauma are documented in this paper along with a discussion of the steps taken to adapt a parenting intervention for cultural and contextual fit. This study is a component of an overall program of research aimed at reducing the long-term negative effects of war on parenting practices and childhood outcomes, which have considerable implications for preventing mental, neurological, and substance-use disorders. The processes described here cover a 4-year period culminating in the implementation of the nine-session Enhancing Family Connection intervention piloted with a group of 14 mothers. The lessons in cultural adaptation have been valuable and the feasibility results promising for further testing the intervention.

CRITICAL ANALYSIS OF THE CURRENT TREATMENT GUIDELINES FOR COMPLEX PTSD IN ADULTS.

According to current treatment guidelines for Complex PTSD (cPTSD), psychotherapy for adults with cPTSD should start with a "stabilization phase." This phase, focusing on teaching self-regulation strategies, was designed to ensure that an individual would be better able to tolerate trauma-focused treatment. The purpose of this paper is to critically evaluate the research underlying these treatment guidelines for cPTSD, and to specifically address the question as to whether a phase-based approach is needed. As reviewed in this paper, the research supporting the need for phase-based treatment for individuals with cPTSD is methodologically limited. Further, there is no rigorous research to support the views that: (1) a phase-based approach is necessary for positive treatment outcomes for adults with cPTSD, (2) front-line trauma-focused treatments have unacceptable risks or that adults with cPTSD do not respond to them, and (3) adults with cPTSD profit significantly more from trauma-focused treatments when preceded by a stabilization phase. The current treatment guidelines for cPTSD may therefore be too conservative, risking that patients are denied or delayed in receiving conventional evidence-based treatments from which they might profit.