Trauma-focused treatment for traumatic stress symptoms in unaccompanied refugee minors: a multiple baseline case series.

Introduction: Unaccompanied refugee minors (URMs) are at increased risk of developing mental health problems, such as symptoms of posttraumatic stress disorder (PTSD) and depression. In addition, URMs face several barriers to mental health care. Few studies have evaluated trauma-focused interventions for URMs that target these issues. The current study evaluated a multimodal trauma-focused treatment approach for URMs. It aimed to provide an initial indication of the effectiveness of this treatment approach and to provide a qualitative evaluation assessing treatment satisfaction of the participating URMs. Methods: A mixed-methods study was conducted among ten URMs, combining quantitative data with qualitative data through triangulation. Quantitative data were collected using a non-concurrent multiple baseline design in which repeated, weekly assessments were carried out during a randomized baseline period, during treatment, and during a 4-week follow-up period. Questionnaires assessing PTSD (Children's Revised Impact of Event Scale) and symptoms of depression (The Patient Health Questionnaire-9, modified for adolescents) were used. In addition, treatment satisfaction was measured post-treatment using a semi-structured interview. Results: During the qualitative evaluation, all but one URM noted they found the trauma-focused treatment approach useful and felt the treatment had positively impacted their wellbeing. However, the results of the quantitative evaluation did not show clinically reliable symptom reductions at posttest or follow-up. Implications for clinical practice and research are discussed. Discussion: The current study presents our search in developing a treatment approach for URMs. It adds to the current knowledge about methodological considerations in evaluating treatments for URMs, the potential effects of trauma-focused treatments on URMs, and the implementation of treatments for URMs.Clinical trial registration: The study was registered in the Netherlands Trial Register (NL8519), 10 April 2020.

Overcoming barriers to mental health care: multimodal trauma-focused treatment approach for unaccompanied refugee minors.

BACKGROUND: This study evaluated the feasibility of a short-term, multimodal trauma-focused treatment approach adapted specifically for unaccompanied refugee minors (URMs) in the Netherlands. This approach aims to overcome barriers to mental health care and to reduce symptoms of posttraumatic stress disorder (PTSD) and depression. METHODS: An uncontrolled study was conducted, evaluating the main request for help, treatment integrity and feasibility, and the course of symptoms of PTSD (Children's Revised Impact of Event Scale-13) and depression (Patient Health Questionnaire modified for Adolescents). RESULTS: In total, 41 minors were included in the study. Most participants were male (n = 27), predominately from Eritrea (75.6%) with a mean age of 16.5 (SD = 1.5). Minors mostly reported psychological problems, such as problems sleeping, and psychosocial problems, including worries about family reunification. Deviations from the approach were made to meet the current needs of the minors. Factors limiting the feasibility of the approach were often related to continuous stressors, such as news concerning asylum status. CONCLUSIONS: The results provide a first indication that this approach partly overcomes barriers to mental health care and emphasize the added value of collaborating with intercultural mediators and offering outreach care. TRIAL REGISTRATION: The study was registered in the Netherlands Trial Register (NL8585), 10 April 2020, Retrospectively registered, https://www.trialregister.nl/trial/8585 .

Perceived treatment processes and effects of interactive motion-assisted exposure therapy for veterans with treatment-resistant posttraumatic stress disorder: a mixed methods study.

Background: A novel intervention, Multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), aims to reduce avoidance and improve engagement for patients with posttraumatic stress disorder (PTSD) who did not sufficiently respond to previous treatments. It has been found to effectively reduce PTSD symptoms for veterans with treatment-resistant PTSD. Symptomatic measures alone might not capture all treatment effects, and addition of qualitative outcomes may provide deeper understanding of treatment processes and treatment-induced changes. Objective: To study the perspectives of veterans with treatment-resistant PTSD on 3MDR treatment processes and effects and explore the relation of their experiences to PTSD symptom improvement. Method: A convergent parallel mixed methods design was applied. For the qualitative part, open-ended question interviews were conducted until data saturation was reached (N = 10). Thematic analysis, rooted in grounded theory, was performed. Quantitative data included pre- to posttreatment responder status based on a structured clinical interview for PTSD. Results: Treatment processes endorsed by the veterans were engaging, regulating distress, feeling supported, facing traumatic memories, allowing emotions, associating, and disengaging from trauma. In terms of effects, veterans reported positive changes following 3MDR, including openness, new learning, self-understanding, closure, and reintegration. High comparability across themes was observed for responders and non-responders, except for the themes closure and reintegration, which were reported more often or more in depth by responders. Conclusions: Veterans indicated 3MDR treatment processes that complied with its aims of breaking through avoidance and increasing engagement, thereby facilitating traumatic memory retrieval and processing. However, this did not necessarily translate into PTSD symptom improvement for all veterans. Walking towards trauma-related pictures was highlighted as unique component of 3MDR and connected to specific treatment processes and effects. Positive changes following 3MDR were experienced outside the domain of PTSD symptom improvement, implicating that 3MDR may beneficially impact veterans beyond symptom changes alone.

Antecedentes: Una nueva intervención, la reconsolidación y desensibilización de la memoria asistida por movimiento multimodular (3MDR), tiene como objetivo reducir la evitación y mejorar la adherencia de los pacientes con trastorno de estrés postraumático (TEPT) que no respondieron lo suficiente a tratamientos anteriores. Se ha descubierto que reduce eficazmente los síntomas de TEPT en los veteranos con TEPT resistente al tratamiento. Las medidas sintomáticas por sí solas pueden no capturar todos los efectos del tratamiento, y la adición de resultados cualitativos puede proporcionar una comprensión más profunda de los procesos de tratamiento y los cambios inducidos por el tratamiento.Objetivo: Estudiar las perspectivas de los veteranos con TEPT resistente al tratamiento sobre los procesos y efectos del tratamiento 3MDR y explorar la relación de sus experiencias con la mejoría de los síntomas de TEPT.Método: Se aplicó un diseño de métodos mixtos paralelos convergentes. Para la parte cualitativa, se realizaron entrevistas con preguntas abiertas hasta que se alcanzó la saturación de datos (N = 10). Se realizó un análisis temático, basado en la Teoría Fundamentada. Los datos cuantitativos incluyeron el estado del participante antes y después del tratamiento basado en una entrevista clínica estructurada para el TEPT.Resultados: Los procesos de tratamiento respaldados por los veteranos fueron los de involucramiento, regular la angustia, sentirse apoyados, enfrentar recuerdos traumáticos, permitir emociones, asociar, y desligarse del trauma. En términos de efectos, los veteranos informaron cambios positivos después de 3MDR, incluida la apertura, nuevo aprendizaje, la autocomprensión, el cierre y la reintegración. Se observó una alta comparabilidad entre los temas de los que respondieron y los que no respondieron, excepto para los temas cierre y reintegración, que fueron informados con más frecuencia o con mayor profundidad por los que respondieron.Conclusiones: Los veteranos indicaron que los procesos de tratamiento 3MDR cumplieron con sus objetivos de romper con la evitación y aumentar la adherencia, facilitando así la recuperación y el procesamiento de la memoria traumática. Sin embargo, esto no se tradujo necesariamente en una mejoría de los síntomas de TEPT para todos los veteranos. Caminar hacia imágenes relacionadas con el trauma se destacó como un componente único de 3MDR y conectado con procesos y efectos de tratamiento específicos. Los cambios positivos después de 3MDR se experimentaron fuera del dominio de la mejora de los síntomas del TEPT, lo que implica que 3MDR puede tener un impacto beneficioso en los veteranos más allá de los cambios en los síntomas por sí solos.

Prevalence of Potentially Traumatic Events, Other Life Events and Subsequent Reactions Indicative for Posttraumatic Stress Disorder in the Netherlands: A General Population Study Based on the Trauma Screening Questionnaire.

The 12-month and lifetime prevalence of posttraumatic stress disorder (PTSD) in different country populations has been assessed while using clinical interviews. Because this methodology is relatively time-consuming and resource-intensive, disaster health researchers adopted instruments, like the Trauma Screening Questionnaire (TSQ). This study (1) used the TSQ to estimate the lifetime prevalence of potentially traumatic events and other life events (PTE/OLEs) and the one-week prevalence of subsequent reactions indicative for PTSD (based on DSM-IV PTSD criteria) in The Netherlands and (2) investigated risk and protective factors for the development of PTSD to overcome the lack of baseline comparison data on general populations and subgroups. The data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a representative study in the Dutch general population aged 18 to 64 years (N = 6646), using face-to-face interviews. Logistic regression modeling was used to assess PTSD correlates. The lifetime PTE/OLE prevalence was 71.1%. Among exposed subjects, one-week PTSD prevalence was estimated at 2.0%. The correlates of PTSD were female gender, Moroccan, or Turkish ethnicity, and exposure to sexual abuse and exposure time less than four years ago. The results are discussed in relation to earlier 12-month and lifetime general population prevalence of PTSD in the Netherlands and other countries, and TSQ-based disaster studies. General population replications can provide additional TSQ baseline data, and shed light on exposure and PTSD prevalence assessed with different instruments.

The moderating role of individual resilience in refugee and Dutch adolescents after trauma.

OBJECTIVE: Exposure to potentially traumatic events (PTEs) has been identified as a risk factor for various psychological problems in adolescents generally and in young refugees. The aim of this study was to examine whether individual resilience (assessed as a personality characteristic) can protect adolescents in diverse contexts from negative effects of trauma exposure. METHOD: A path model was used to assess whether individual resilience buffered the negative effects of exposure to PTEs in a cross-sectional study of adolescent refugees (aged 12-17 years; n = 117) and their Dutch peers (n = 148). Measurements included the Children's Revised Impact of Event Scale, Strengths and Difficulties Questionnaire, Satisfaction with Life Scale and the Resilience Scale. RESULTS: The moderating effects of individual resilience on the relationship between PTEs and mental health problems and life satisfaction were mixed: In the nonrefugee group, but not in the refugee group most moderation effects reached significance. CONCLUSION: Findings suggest that not all groups benefit similarly from individual-level resilience. Consequently, adolescents, who differ with regard to the risks to which they are exposed, may need different forms of support. This study points to the interplay of factors that contributes to demonstration of individual resilience. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Complex Posttraumatic Stress Disorder in Patients Exposed to Emotional Neglect and Traumatic Events: Latent Class Analysis.

The inclusion of a complex posttraumatic stress disorder (CPTSD) diagnosis in the 11th revision of the International Classification of Diseases reflects growing evidence that a subgroup of individuals with PTSD also suffer from disturbances in emotion regulation, interpersonal skills, and self-concept, which together are termed "disturbances in self-organization" (DSO). Although CPTSD is assumed to result from exposure to complex traumatic events, emotional neglect may be an important contributor. This study investigated the presence of CPTSD, defined by endorsement of PTSD and DSO symptoms in a clinical postwar generation sample. The sample consisted of 218 patients who had been exposed to emotional neglect in childhood, a subgroup of whom had also been exposed to potentially traumatic events. Using items from the Harvard Trauma Questionnaire and the Brief Symptom Inventory, a latent class analysis revealed two classes: high endorsement of almost all CPTSD symptoms (n = 83; 38.1%) and low endorsement of all CPTSD symptoms (n = 135; 61.9%). Contrary to our hypothesis, no DSO-only class was found. The R3step method showed gender and number of traumatic events to be significant predictors of class membership. Compared to the low endorsement class, individuals in the CPTSD class were more likely to be female, p = .013, and to report a higher number of traumatic experiences, p < .001. The potential intermediary role of emotional neglect in the development of DSO and CPTSD is discussed.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Tept complejo en pacientes expuestos a negligencia emocional y eventos traumáticos: un análisis de clases latentes TEPTC EN PACIENTES EXPUESTOS A NEGLIGENCIA: ACL El diagnóstico de trastorno de estrés postraumático complejo (TEPTC) propuesto en la 11' revisión de la Clasificación Internacional de Enfermedades refleja una evidencia creciente que un subgrupo de individuos con TEPT también sufre de problemas en la regulación emocional, habilidades interpersonales, y auto- concepto (conocido como "problemas en la auto-organización" [DSO], por sus siglas en inglés). Aunque se asume que el TEPTC es el resultado de la exposición a eventos traumáticos complejos, la negligencia emocional puede ser un contribuyente. Este estudio investigó la confirmación del TEPT y síntomas DSO (que juntos calificaban para TEPTC) en una muestra clínica de una generación post guerra. La muestra consistió en 218 pacientes que estuvieron expuestos a negligencia emocional en su infancia, un subgrupo que también había estado expuesto a potenciales eventos traumáticos. Usando los ítems del Cuestionario de Trauma de Harvard y el Inventario de Síntomas Abreviado, un análisis de clases latentes (ACL) reveló dos clases: alta confirmación de casi todos los síntomas de TEPTC (n=83; 38.1%) y baja confirmación de todos los síntomas de TEPTC (n=135; 61.9%). Contrario a nuestra hipótesis, no se encontró ninguna clase de sólo DSO. El método de pasos R3 mostró que el género y el número de eventos traumáticos son predictores significativos para la pertenencia a alguna clase. Comparado con la clase de baja probabilidad, los individuos de la clase TEPTC tenían más probabilidad de ser mujer, p = .013, y reportar un mayor número de experiencias traumáticas, p = .000. Se discute el rol intermediario potencial de la negligencia emocional en el desarrollo de DSO y TEPTC.

The impact of childhood sexual abuse on the outcome of intensive trauma-focused treatment for PTSD.

Background: It is assumed that PTSD patients with a history of childhood sexual abuse benefit less from trauma-focused treatment than those without such a history. Objective: To test whether the presence of a history of childhood sexual abuse has a negative effect on the outcome of intensive trauma-focused PTSD treatment. Method: PTSD patients, 83% of whom suffered from severe PTSD, took part in a therapy programme consisting of 2 × 4 consecutive days of Prolonged Exposure (PE) and EMDR therapy (eight of each). In between sessions, patients participated in sport activities and psycho-education sessions. No prior stabilization phase was implemented. PTSD symptom scores of clinician-administered and self-administered measures were analysed using the data of 165 consecutive patients. Pre-post differences were compared between four trauma groups; patients with a history of childhood sexual abuse before age 12 (CSA), adolescent sexual abuse (ASA; i.e. sexual abuse between 12 and 18 years of age), sexual abuse (SA) at age 18 and over, or no history of sexual abuse (NSA). Results: Large effect sizes were achieved for PTSD symptom reduction for all trauma groups (Cohen's d = 1.52-2.09). For the Clinical Administered PTSD Scale (CAPS) and the Impact of Event Scale (IES), no differences in treatment outcome were found between the trauma (age) groups. For the PTSD Symptom Scale Self Report (PSS-SR), there were no differences except for one small effect between CSA and NSA. Conclusions: The results do not support the hypothesis that the presence of a history of childhood sexual abuse has a detrimental impact on the outcome of first-line (intensive) trauma-focused treatments for PTSD.

Planteamiento: Se asume que los pacientes con TEPT con una historia de abuso sexual infantil se benefician menos del tratamiento centrado en el trauma que aquellos sin dicha historia. Objetivo: Probar si la presencia de una historia de abuso sexual en la infancia tiene un efecto negativo en el resultado del tratamiento intensivo centrado en el trauma para el TEPT. Métodos: Pacientes con TEPT, 83% de los cuales sufrían de TEPT grave, participaron en un programa de terapia que consta de 2 × 4 días consecutivos de exposición prolongada (EP) y terapia EMDR (ocho de cada). Entre sesiones, los pacientes participaron en actividades deportivas y sesiones de psicoeducación. No se implementó una fase de estabilización previa. Las puntuaciones de síntomas de TEPT de las medidas administradas por el clínico y autoadministradas se analizaron usando los datos de 165 pacientes consecutivos. Las diferencias previas se compararon entre cuatro grupos de trauma: pacientes con antecedentes de abuso sexual infantil antes de los 12 años (ASI), abuso sexual adolescente (ASA, es decir, abuso sexual entre 12 y 18 años), abuso sexual (AS) a los 18 años o más, o sin antecedentes de abuso sexual abuso (NAS). Resultados: Se lograron grandes tamaños de efecto en la reducción de síntomas de TEPT para todos los grupos de trauma (ds de Cohen = 1,52­2,09). Para la Escala de TEPT Clínica Administrada por el Clínico (CAPS, por sus siglas en inglés) y la Escala de Impacto del Evento (IES, por sus siglas en inglés), no se encontraron diferencias en el resultado del tratamiento entre los grupos de trauma (edad). Para la Escala de autoinforme de síntomas de TEPT (PSS-SR, por sus siglas en inglés), no hubo diferencias, excepto por un pequeño efecto entre ASI y NAS. Conclusión: Los resultados no respaldan la hipótesis de que la presencia de un historial de abuso sexual infantil tenga un impacto perjudicial en el resultado de los tratamientos de primera línea (intensivos) centrados en el trauma para el TEPT.

Posttraumatic world assumptions among treatment-seeking refugees.

The clinical relevance of negative changes in cognitions about oneself, others, and the world is reflected in the diagnostic criteria for posttraumatic stress disorder (PTSD) in the DSM-5 and complex posttraumatic stress disorder in the ICD-11. Although such changes in cognition have been posited to be especially relevant for traumatised refugees, few studies have examined this in refugee populations. The present study used a cross-sectional design to compare negative cognitions among 213 adult treatment-seeking refugees with those in previously published samples from the general population, veterans with combat-related PTSD, and whiplash victims. Measures included the World Assumptions Scale (WAS) and the Events and DSM-IV PTSD subscales of the Harvard Trauma Questionnaire (HTQ). Path models examined the relation of the WAS subscales to five demographic and trauma-related variables. Results showed that world assumptions were especially negative with regard to Benevolence of World, Benevolence of People, and Luck subscales, on which refugees scored lower than all reference samples. Differences between the refugee sample and the reference samples were smallest with regard to self-worth and self-controllability. World assumptions were associated with gender and PTSD symptom severity but not with age, length of residence in the Netherlands, and number of traumatic event types. The DSM-5 criterion of negative changes in belief about oneself, others, and the world appears more applicable to refugees than the more narrowly formulated ICD-11 criterion of diminished and defeated sense of self. Prevention and treatment efforts with refugees may need to be especially aimed at preventing a further decline of trust as well as restoration of trust in others and the world.

Lives on hold: A qualitative study of young refugees' resilience strategies.

Although the literature on positive adjustment following traumatic events is growing, only a few studies have examined this phenomenon in young refugees. Using the social-ecological framework, the aim of this study was to identify factors and processes that according to young refugees promote their resilience. A total of 16 treatment-seeking refugees aged 13-21 years, living in the Netherlands, were interviewed. Data analysis revealed four resilience strategies: (1) acting autonomously, (2) performing at school, (3) perceiving support from peers and parents, and (4) participating in the new society. These strategies interacted with one another and demonstrated the interrelatedness between individuals and their social context. Having to wait long for a residence permit and being older appeared to negatively influence participants' resilience strategies. These findings suggest that resilience refers to a dynamic process that is context and time specific.

Growing from experience: an exploratory study of posttraumatic growth in adolescent refugees.

OBJECTIVE: The aim of this study was to explore perceived posttraumatic growth (PTG) and its associations with potentially traumatic events (PTEs), dispositional optimism, perceived social support, posttraumatic stress disorder (PTSD) symptoms, and satisfaction with life (SWL) among adolescent refugees and asylum seekers. METHOD: A cross-sectional design was employed including 111 refugees, aged 12-17, that were recruited from asylum seeker centres throughout the Netherlands. Measurements included the revised Posttraumatic Growth Inventory for Children, Children's Impact of Event Scale, Multidimensional Scale of Perceived Social Support, The Life Orientation Test, and the Satisfaction with Life Scale. RESULTS: Participants reported mean PTG scores (20.2) indicating an average response of some perceived change, while reporting high levels of PTSD symptoms (30.6). PTG and PTSD symptoms were not related with each other (r=0.07, p=0.50). PTG was positively associated with dispositional optimism (r=0.41, p<0.01) and social support (r=0.43, p<0.01). A hierarchical regression analysis demonstrated that dispositional optimism (ß=0.33; p<0.05) and social support (ß=0.27; p<0.05) positively predicted PTG, explaining 22% of the PTG variance above demographic variables and PTEs. PTG was also positively related with SWL (r=0.37, p<0.01). CONCLUSIONS: Perceived PTG and PTSD symptoms appear to be independent constructs, which co-occur in adolescent refugees and asylum seekers. The relationship between PTG and mental health remains inconclusive; PTG was positively related to SWL and not associated with PTSD symptoms. Longitudinal research is required to determine causality between PTG and mental health in this refugee population confronted with many traumatic experiences and challenging migration tasks.

Between power and powerlessness: a meta-ethnography of sources of resilience in young refugees.

OBJECTIVE: This article reviews available qualitative studies that report young refugees' ways of dealing with adversity to address their sources of resilience. DESIGN: We searched five electronic databases. Twenty-six empirical studies were included in the review. A meta-ethnography approach was used to synthesize these qualitative studies. RESULTS: Six sources of resilience emerged: (1) social support, (2) acculturation strategies, (3) education, (4) religion, (5) avoidance, and (6) hope. These sources indicated social as well as personal factors that confer resilience in young refugees, but most of them also had counterproductive aspects. CONCLUSION: The results, from an ecological developmental perspective, stressed the interplay between protective and risk processes in the mental health of young refugees who had resettled in Western countries, and they emphasized the variability as well as the universality of resilience-promoting processes. Further research is needed to explore the cultural shape of resilience and the long-term consequences of war and migration on young refugees.

Trauma exposure and refugee status as predictors of mental health outcomes in treatment-seeking refugees.

Aims and method This study aimed to identify predictors of symptom severity for post-traumatic stress disorder (PTSD) and depression in asylum seekers and refugees referred to a specialised mental health centre. Trauma exposure (number and domain of event), refugee status and severity of PTSD and depression were assessed in 688 refugees. Results Symptom severity of PTSD and depression was significantly associated with lack of refugee status and accumulation of traumatic events. Four domains of traumatic events (human rights abuse, lack of necessities, traumatic loss, and separation from others) were not uniquely associated with symptom severity. All factors taken together explained 11% of variance in PTSD and depression. Clinical implications To account for multiple predictors of symptom severity including multiple traumatic events, treatment for traumatised refugees may need to be multimodal and enable the processing of multiple traumatic memories within a reasonable time-frame.

Father-involvement in a refugee sample: relations between posttraumatic stress and caregiving.

Despite increased attention to the role of fathers within families, there is still a dearth of studies on the impact of trauma on father-involvement. This study investigates the quantity of father-involvement and the influence of posttraumatic stress on the quality of involvement in a refugee and asylum seeker population. Eighty refugees and asylum seekers and their young children (aged 18-42 months) were recruited. Measures included assessment of parental trauma (Harvard Trauma Questionnaire), quantity and quality of involvement (quantity of caregiving and Emotional Availability Scales), and perception of the father-child relationship (interview). The results show that fathers were less involved in caregiving tasks and play activities than mothers. No parental gender differences were found on each of the Emotional Availability Scales. Traumatic stress symptoms negatively affected the perception and the actual quality of parent-child interaction (sensitivity, structuring, nonhostility). Nevertheless, almost all fathers described their relationship with their child as good and their child as very important to them. As the quality of father-involvement is of importance to the development of the child, traumatized fathers are as much in need of clinical intervention as mothers. Despite the impact of posttraumatic stress, refugee fathers clearly are involved in the lives of their children. Mechanisms such as a deliberate withdrawal when stressed and compensation might enable affected fathers to step into the interaction when needed, raise the quality of involvement with their child, and diminish the negative impact of stress resulting from trauma and migration.

Bouncing forward of young refugees: a perspective on resilience research directions.

While studies on the consequences of trauma and forced migration on young refugees have focused mainly on their pathology, a focus on resilience in young refugees is needed to adequately represent their response to adversity and to help understand their needs. The aim of this article is to present a proposed study of resilience in young refugees which has been informed by an overview of achievements and challenges in the field of resilience. IN ORDER TO ADVANCE THE FIELD OF RESILIENCE, SEVERAL TOPICS NEED CLARIFICATION: definition and assessment of resilience, the relation of resilience to other constructs and the underlying biological and external factors influencing resilience. With respect to young refugees, the cross-cultural applicability of resilience has to be examined. Qualitative research, mixed method designs, comparative studies, and longitudinal studies seem especially promising in furthering this goal. The proposed study compares refugee adolescents with Dutch adolescents. Data from qualitative evidence synthesis, interviews, questionnaires, experiments, and DNA analysis will be combined to provide a multifaceted picture of factors contributing to resilience, resulting in a better understanding and efficient use of "resilience" to meet the needs of traumatised youth.