Mediators of focused psychosocial support interventions for children in low-resource humanitarian settings: analysis from an Individual Participant Dataset with 3,143 participants.

BACKGROUND: Research on psychosocial interventions has been focused on the effectiveness of psychosocial interventions on mental health outcomes, without exploring how interventions achieve beneficial effects. Identifying the potential pathways through which interventions work would potentially allow further strengthening of interventions by emphasizing specific components connected with such pathways. METHODS: We conducted a preplanned mediation analysis using individual participant data from a dataset of 11 randomized controlled trials (RCTs) which compared focused psychosocial support interventions versus control conditions for children living in low- and middle-income countries (LMICs) affected by humanitarian crises. Based on an ecological resilience framework, we hypothesized that (a) coping, (b) hope, (c) social support, and (d) functional impairment mediate the relationship between intervention and outcome PTSD symptoms. A systematic search on the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed, PyscARTICLES, Web of Science, and the main local LMICs databases was conducted up to August 2018. The hypotheses were tested by using individual participant data obtained from study authors of all the studies included in the systematic review. RESULTS: We included 3,143 children from 11 studies (100% of data from included studies), of which 1,877 from six studies contributed to the mediation analysis. Functional impairment was the strongest mediator for focused psychosocial interventions on PTSD (mediation coefficient -0.087, standard error 0.040). The estimated proportion of effect mediated by functional impairment, and adjusted for confounders, was 31%. CONCLUSIONS: Findings did not support the proposed mediation hypotheses for coping, hope, and social support. The mediation through functional impairment may represent unmeasured proxy measures or point to a broader mechanism that impacts self-efficacy and agency.

Posttraumatic Stress Disorder and Childhood Traumatic Loss: A Secondary Analysis of Symptom Severity and Treatment Outcome.

Loss is a commonly experienced traumatic event among children. Although the experience of loss can potentially lead to posttraumatic stress symptoms (PTSS), little is known about PTSS levels after traumatic loss versus other traumatic events. We investigated data from a randomized controlled trial (RCT) on trauma-focused cognitive behavioral therapy (TF-CBT) versus a waitlist condition for children with PTSS. In a secondary analysis, we compared participants who reported traumatic loss as their index event (n = 23) to those who reported the two most frequently reported index events in the RCT: sexual abuse (SA; n = 59) and physical violence (PV; n = 55). The index event was rated according to the participants' most distressing traumatic event reported on the Clinician-Administered PTSD Scale for Children and Adolescents. Participants who experienced traumatic loss reported fewer PTSS and better general functioning than those who reported SA. A subgroup RCT (n = 19) revealed TF-CBT to be highly effective in reducing PTSS in cases of traumatic loss, d = 1.69. The effect sizes for PTSS indicated that all three trauma groups benefited from TF-CBT. In the waitlist group, PTSS symptoms improved for SA and PV, ds = 0.76 and 0.98, respectively, but not for traumatic loss, d = 0.23. These findings suggest that TF-CBT is a feasible and promising treatment for children who experience PTSS after traumatic loss. The results are limited by the post hoc quality of the analyses and lack of a measure of grief in the RCT.

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.

Trauma-focused cognitive behavioral therapy with unaccompanied refugee minors: a case series.

BACKGROUND: Unaccompanied refugee minors (URMs) are a group who are vulnerable to developing posttraumatic stress symptoms (PTSS). However, they rarely receive the treatment that is indicated and there are no treatment studies focusing exclusively on this group of adolescents. This case study evaluates the feasibility of trauma-focused cognitive behavioral therapy (TF-CBT) for URMs with PTSS. METHOD: A health care utilization sample of N = 6 was assessed prior to and after treatment with TF-CBT. Therapists were asked to report differences in treatment application and content in comparison to TF-CBT standard protocol. RESULTS: We found moderate to high levels of PTSS at baseline and a clinically significant decrease in symptoms at posttest. Some modifications to the TF-CBT protocol were made with regard to affective modulation which required more sessions than usual whereas fewer caregiver sessions were conducted. CONCLUSION: TF-CBT is feasible in reducing PTSS in severely traumatized URMs. Further research with controlled trials is necessary. TRIAL REGISTRATION: The trial registration: ClinicalTrials.gov Identifier NCT01516827. Registered 13 December 2011.

Stability of Treatment Effects and Caregiver-Reported Outcomes: A Meta-Analysis of Trauma-Focused Cognitive Behavioral Therapy for Children and Adolescents.

The efficacy of trauma-focused treatments for children and adolescents is well researched. However, less is known about the long-term and caregiver-reported effects. Searched databases were PsychInfo, MEDLINE, Cochrane Library, PTSDPubs, PubMed, Web of Science, and OpenGrey. Treatment effects of trauma-focused cognitive behavioral therapy (TF-CBT) were computed at 12-month follow-up with posttraumatic stress symptoms (PTSS) as primary outcome and symptoms of depression, anxiety, and grief as secondary outcomes. Concordance between participant and caregiver ratings were investigated. TF-CBT showed large improvements across all outcomes from pre-treatment to 12-month follow-up (PTSS: g = 1.71, CI 1.27-2.15) and favorable results compared to active treatments and treatment as usual at 12-month follow-up (PTSS: g = .35, CI .13-.56). More pronounced effects were found in group settings. No significant differences were detected between participant and caregiver ratings with high reliability across almost all outcomes and assessment points. TF-CBT is a reliable treatment for pediatric PTSS and secondary symptoms with stable results at 12-month follow-up.

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.

"Same Same or Adapted?" Therapists' Feedback on the Implementation of Trauma-Focused Cognitive Behavioral Therapy With Unaccompanied Young Refugees.

Background: Rates of trauma exposure and posttraumatic stress disorder (PTSD) are high among refugee youth. Although there is a vast evidence base on effective trauma-focused interventions for children and adolescents, there is only limited understanding of how to adapt these interventions for oftentimes severely traumatized young refugees. This study aims to investigate adaptations undertaken during trauma-focused cognitive behavioral therapy (TF-CBT) in a pilot study with unaccompanied refugee minors (URMs). Method: Written answers on five questions given by N = 9 therapists on N = 16 TF-CBT cases were analysed qualitatively using Mayring's content analysis. The questions were on (1) additional techniques used in the sessions, (2) obstacles to TF-CBT treatment, (3) cultural factors considered and most helpful components for (4) patient and (5) therapist. The categories were built inductively and analysed descriptively. Results: In addition to the regular TF-CBT components, added content mostly concerned the so-called "crisis of the week", meaning a more lengthy discussion of struggles and concerns in their daily lives. Few obstacles in treatment were reported, and little cultural factors had to be considered. The implementation of a trauma narrative and the agenda provided by the manual were frequently reported as helpful. Conclusion: The results of this study indicate that the manualized evidence-based treatment TF-CBT can be used in the culturally heterogeneous population of URMs with minor adaptations. These findings can contribute to future research as well as clinical practice with URMs.

The German Translation of the Stress and Anxiety to Viral Epidemics-9 (SAVE-9) Scale: Results from Healthcare Workers during the Second Wave of COVID-19.

Healthcare workers (HCW) are among those most directly affected by the COVID-19 pandemic. Most research with this group has used ad hoc measures, which limits comparability across samples. The Stress and Anxiety to Viral Epidemics-9 scale (SAVE-9) is a nine-item scale first developed in Korea, and has since been translated into several languages. We report on data collected from 484 German HCW between November 2020 and March 2021, during the "second wave" of coronavirus infections. We conducted item analysis, confirmatory factor analysis on the previously found factor solutions of the SAVE-9, examined correlations with established measures of depression, generalized anxiety, and insomnia, and compared scores between different groups of HCW. The psychometric properties of the German SAVE-9 were satisfactory and comparable to previous findings from Korea and Russia. Correlations with mental health measures were positive, as expected. We found some significant differences between groups of HCW on the SAVE-9 which were consistent with the literature but did not appear on the other mental health measures. This suggests that the SAVE-9 taps into specifically work-related stress, which may make it a helpful instrument in this research area.

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.

What was helpful in today's session? Responses of clients in two different psychotherapies for posttraumatic stress disorder.

The aim of this study was to qualitatively analyze and compare the written responses clients in treatment for posttraumatic stress disorder (PTSD) gave when asked about helpful and negative aspects of the previous session. Data were collected during a randomized quantitative study comparing dialogical exposure therapy (DET, a gestalt-based integrative therapy, n = 58) and cognitive processing therapy (CPT, a cognitive-behavioral therapy, n = 52). We developed a coding manual using Mayring's (2015) qualitative content analysis approach and were able to code responses reliably. Five main categories emerged, unspecified and specific therapy elements, therapeutic relationship, client process, and general positive experience, with the first three containing subcategories. Each therapy had its own codes for specific therapy elements, while the other codes were identical for both treatments. The results for specific therapy elements were in accordance with the theories behind the two treatments, with CPT clients naming cognitive factors most frequently, whereas in DET, emotions were the most frequently mentioned. Results for therapeutic relationship were surprisingly similar given that DET therapists consider the therapeutic relationship to be an active ingredient, while CPT therapists consider it as the basis for the intervention rather than a working mechanism in itself. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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.

Providing manualized individual trauma-focused CBT to unaccompanied refugee minors with uncertain residence status: a pilot study.

BACKGROUND: Unaccompanied refugee minors (URMs) seeking asylum show high rates of posttraumatic stress disorder (PTSD), depression and anxiety. In addition, they experience post-migration stressors like an uncertain residence status. Therefore, psychotherapeutic interventions for URMs are urgently needed but have scarcely been investigated up to now. This study aimed to examine manualized individual trauma-focused cognitive behavioural therapy (TF-CBT) for URMs with PTSD involving their professional caregivers (i.e. social workers in child and adolescent welfare facilities). METHODS: We conducted an uncontrolled pilot study with three follow-up assessments (post-intervention, 6 weeks, and 6 months). Participants who met the PTSD diagnostic criteria were treated in a university psychotherapeutic outpatient clinic in Germany with a mean of 15 sessions of TF-CBT. All participants (n = 26) were male UM (Mage = 17.1, SD = 1.0), predominately from Afghanistan (n = 19, 73.1%) and did not have a residence permit. The sample was severely traumatized according to the number of traumatic event types reported (M = 11.3, SD = 2.8). The primary outcome was PTSD measured with the Child and Adolescent Trauma Screen (CATS) and the Diagnostic Interview for Mental Disorders in Childhood and Adolescence (Kinder-DIPS). Secondary outcomes were depression, behavioural and somatic symptoms. All but the somatic symptoms were assessed in both self-report and proxy report. RESULTS: At post-intervention the completer sample (n = 19) showed significantly decreased PTSD symptoms, F(1, 18) = 11.41, p = .003, with a large effect size (d = 1.08). Improvements remained stable after 6 weeks and 6 months. In addition to PTSD symptoms, their caregivers reported significantly decreased depressive and behavioural symptoms in participants. According to the clinical interview, 84% of PTSD cases recovered after TF-CBT treatment. After 6 months, youths whose asylum request had been rejected showed increased PTSD symptoms according to individual trajectories in the Kinder-DIPS. The effect was, however, non-significant. CONCLUSIONS: Intervention studies are feasible with URMs. This pilot study presents preliminary evidence for the efficacy of an evidence-based intervention like TF-CBT in reducing PTSD symptoms in URMs. Stressors related to asylum proceedings after the end of therapy have the potential to negatively influence psychotherapy outcomes.

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.

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.

Focused psychosocial interventions for children in low-resource humanitarian settings: a systematic review and individual participant data meta-analysis.

BACKGROUND: Results from studies evaluating the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in humanitarian settings in low-income and middle-income countries have been inconsistent, showing varying results by setting and subgroup (eg, age or gender). We aimed to assess the effectiveness of these interventions, and to explore which children are likely to benefit most. METHODS: We did a systematic review and meta-analysis of individual participant data (IPD) from 3143 children recruited to 11 randomised controlled trials of focused psychosocial support interventions versus waiting list. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, PsycArticles, Web of Science, and the main local low-income and middle-income countries (LMICs) databases according to the list of databases relevant to LMIC developed collaboratively by Cochrane and WHO Library, up to November, 2016. We included randomised controlled trials that assessed the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in LMICs, compared with waiting lists (eg, inactive controls). We excluded quasi-randomised trials, studies that did not focus on psychosocial support interventions, and studies that compared two active interventions without control conditions. We requested anonymised data from each trial for each of the prespecified variables for each child who was randomly assigned. The main outcomes considered were continuous scores in post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, and anxiety symptoms assessed with rating scales administered immediately (0-4 weeks) after the intervention. We harmonised all individual items from rating scales using item response theory methods. This study is registered with PROSPERO, number CRD42013006960. FINDINGS: We identified a beneficial effect of focused psychosocial support interventions on PTSD symptoms (standardised mean difference [SMD] -0·33, 95% CI -0·52 to -0·14) that was maintained at follow-up (-0·21, -0·42 to -0·01). We also identified benefits at the endpoint for functional impairment (-0·29, -0·43 to -0·15) and for strengths: coping (-0·22, -0·43 to -0·02), hope (-0·29, -0·48 to -0·09), and social support (-0·27, -0·52 to -0·02). In IPD meta-analyses focused on age, gender, displacement status, region, and household size we found a stronger improvement in PTSD symptoms in children aged 15-18 years (-0·43, -0·63 to -0·23), in non-displaced children (-0·40, -0·52 to -0·27), and in children living in smaller households (<6 members; -0·27, -0·42 to -0·11). INTERPRETATION: Overall, focused psychosocial interventions are effective in reducing PTSD and functional impairment, and in increasing hope, coping, and social support. Future studies should focus on strengthening interventions for younger children, displaced children, and children living in larger households. FUNDING: European Commission FP7th Framework Programme for Research (Marie Curie International Outgoing Fellowship) and the National Institute on Aging.

The effectiveness of psychosocial interventions in war-traumatized refugee and internally displaced minors: systematic review and meta-analysis.

Background: The United Nations reported that in 2016 over 65 million people worldwide have forcibly left home. Over 50% are children and adolescents; a substantial number has been traumatized and displaced by war. Objective: To provide an overview of the effectiveness of psychosocial interventions in this group we conducted a narrative review and a meta-analysis of intervention studies providing data on posttraumatic stress symptoms (PTSS), depression, anxiety, grief, and general distress. Method: We searched PILOTS, MEDLINE, WoS, Embase, CENTRAL, LILACS, PsycINFO, ASSIA, CSA, and SA for studies on treatment outcomes for war-traumatized displaced children and adolescents. Between-group effect sizes (ES) and pre-post ES were reconstructed for each trial. Overall pre-post ES were calculated using a random effects model. Results: The narrative review covers 23 studies with a variety of treatments. Out of the 35 calculated between-group ES, only six were significant, all compared to untreated controls. Two of them indicated significant adverse effects on symptoms of general distress or depression. When calculating pre-post effect sizes, the positive between-group results of cognitive behavioural therapy (CBT) and interpersonal therapy (IPT) were reproduced and singular other treatments showed significant positive effects. However, the mean pre-post effects for PTSS and depression could not be interpreted due to the high heterogeneity of the included studies (PTSS: ES = 0.78; I2 = 88.6%; depression: ES = 0.35; I2 = 93.1%). Only the mean pre-post effect for seven active CBT treatment groups for depression (ES = 0.30, 95% CI [0.18, 0.43]) was interpretable (Q = 3.3, df = 6, p = .77). Conclusion: Given the large number of children and adolescents displaced by war there were regrettably few treatment studies available, and many of them were of low methodological quality. The effect sizes lagged behind the effects observed in traumatized minors in general, and often were small or non-significant. However, CBT and IPT showed promising results that need further replication.

Planteamiento: Las Naciones Unidas informaron de que en 2016 más de 65 millones de personas en todo el mundo han tenido que abandonar a la fuerza sus hogares. Más del 50% son niños y adolescentes. Muchos de ellos han sido traumatizados y desplazados por la guerra. Objetivo: Con el fin de proporcionar una visión general de la eficacia de las intervenciones psicosociales en este grupo, se realizó una revisión narrativa y un metanálisis de los estudios de intervención que proporcionaban datos sobre síntomas de estrés postraumático (SEPT), depresión, ansiedad, duelo y malestar general. Método: Buscamos en PILOTS, MEDLINE, WoS, Embase, CENTRAL, LILACS, PsycINFO, ASSIA, CSA y SA estudios sobre resultados de tratamiento para niños y adolescentes traumatizados y desplazados por la guerra. Se reconstruyeron los tamaños del efecto (TE) entre los grupos y los TE pre-post para cada ensayo. Los TE generales pre-post fueron calculados usando un modelo de efectos aleatorios. Resultados: La revisión narrativa consta de 23 estudios con una amplia variedad de tratamientos. De los 35 TE entre grupos calculados, sólo 6 fueron significativos, todos en comparación con controles no tratados. Dos de ellos indicaban efectos adversos significativos en los síntomas de malestar general o en los síntomas de depresión. Al calcular los TE pre-post, se reprodujeron los TE entre grupos positivos de la terapia cognitivo-conductual (TCC) y la terapia interpersonal (TIP) y otros tratamientos singulares mostraron efectos positivos significativos. Sin embargo, los efectos promedio pre-post para SEPT y depresión no pudieron interpretarse debido a la alta heterogeneidad de los estudios incluidos (SEPT: TE = 0.78, I2 = 88.6%, depresión: TE = 0.35; I2 = 93.1%). Sólo se pudo interpretar el efecto promedio pre-post para 7 grupos activos de tratamiento con TCC para la depresión, TE = 0.30, IC del 95% [0.18, 0.43] (Q = 3.3, df = 6, p = 0.77). Conclusión: Dado el gran número de niños y adolescentes desplazados por la guerra, lamentablemente existen pocos estudios de tratamiento disponibles y muchos de ellos de baja calidad metodológica. Los tamaños del efecto se quedaron a la zaga de los efectos observados en los menores traumatizados en general, y a menudo eran pequeños o no significativos. Sin embargo, la TCC y la TIP mostraron resultados prometedores que necesitan replicarse más.

Case report: manualized trauma-focused cognitive behavioral therapy with an unaccompanied refugee minor girl.

BACKGROUND: There is uncertainty whether young traumatized refugees should be treated with culturally adapted psychotherapy or with an evidence-based western approach. As yet, empirical studies on culturally adapted treatments for unaccompanied young refugees in industrialized host countries are not available. Studies do, however, suggest that trauma-focused treatment is promising for this group. OBJECTIVE: We describe the treatment of an unaccompanied refugee minor girl with posttraumatic stress disorder (PTSD) who underwent manualized trauma-focused cognitive behavioral therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006). METHODS: A 17-year-old girl from East Africa, who came to Germany without a caregiver, was treated for PTSD resulting from several traumatic experiences and losses in her home country and while fleeing. She lived in a group home for adolescents. Baseline, post, and follow-up data are reported. RESULTS: The girl participated in 12 sessions of manualized TF-CBT. Her caregiver from the youth services received another 12 sessions in line with the treatment manual. Symptoms decreased in a clinically significant manner; at the end of the treatment, the girl was deemed to have recovered from PTSD. Treatment success remained stable over 6 months. CONCLUSIONS: Manualized TF-CBT is feasible for young refugees without significant cultural adaptations. It can, however, be seen as culturally sensitive.

Lessons from writing sessions: a school-based randomized trial with adolescent orphans in Rwanda.

BACKGROUND: Treatments for adolescents affected by long-term loss in low- and middle-income countries are lacking. As school-based interventions are cost-efficient and easy to disseminate, an evaluation of this treatment setting for adolescents is worthwhile. OBJECTIVE: Examining the effect of a school-based unstructured emotional writing intervention (sensu Pennebaker, group 1) about the loss of a parent to reduce adaptation problems to loss, compared to writing about a hobby (group 2), and non-writing (group 3). METHOD: We randomly assigned 14-18-year-old Rwandan orphans to one of the three conditions (n=23 per condition). Before and after the intervention, subjects completed the Prolonged Grief Questionnaire for Adolescents and the Mini International Neuropsychiatric Interview for Children and Adolescents, Part A, on depression as self-report measures of long-term effects of early parental loss. RESULTS: Repeated measures analyses of variance showed no differential effect for any of the three conditions but revealed a significant effect of time at posttest regarding grief severity. Reduction of grief symptoms was significantly higher in subjects with elevated grief. Depressive symptoms showed no significant change from pre- to posttest in the emotional writing condition, whereas they significantly decreased in the control condition. CONCLUSIONS: RESULTS imply that unstructured, brief emotional writing might not be indicated in adolescents affected by early parental loss who show severe and long-term distress; a more structured approach seems recommendable.

Is traumatic stress research global? A bibliometric analysis.

BACKGROUND: The representation of low- and middle-income countries (LMIC) in traumatic stress research is important to establish a global evidence base, build research capacity, and reduce the burden of unmet mental health needs around the world. Reviews of the traumatic stress literature up to 2002 showed trends toward globalization although LMIC were only marginally represented compared to high-income countries (HIC). OBJECTIVE: To examine the global nature of current traumatic stress research. In particular, we were interested in the extent to which traumatic stress research is: (1) conducted in LMIC, (2) conducted by LMIC researchers, and (3) accessible to them. METHOD: Using the databases PubMed, PsychInfo, and PILOTS, we systematically searched for peer-reviewed articles on traumatic stress published in any language in the year 2012. Out of the 3,123 unique papers identified, we coded a random sample (N=1,000) for study, author, article, and journal characteristics. RESULTS: Although our sample involved research in 56 different countries, most papers (87%) involved research in HIC, with 51% of all papers describing studies in the United States. In 88% of the papers, the author team was affiliated with HIC only. Less than 5% of all author teams involved collaborations between HIC and LMIC researchers. Moreover, 45% of the articles on LMIC studies published by a HIC corresponding author did not involve any LMIC co-authors. LMIC researchers appeared to publish empirical studies in lower impact journals. Of the 1,000 articles in our sample, 32% were open access and 10% were made available via different means; over half of the papers were not accessible without subscription. CONCLUSIONS: Traumatic stress research is increasingly global but still strongly dominated by HIC. Important opportunities to build capacity in LMIC appear to be missed. Implications toward more international traumatic stress research are discussed.