Culturally sensitive stepped care for adolescent refugees: efficacy and cost–utility of a multicentric randomized controlled trial

Adolescent refugees and asylum seekers (ARAS) are highly vulnerable to mental health problems. Stepped care models (SCM) and culturally sensitive therapies offer promising treatment approaches to effectively provide necessary medical and psychological support. To our knowledge, we were the first to investigate whether a culturally sensitive SCM will reduce symptoms of depression and PTSD in ARAS more effectively and efficiently than treatment as usual (TAU). We conducted a multicentric, randomized, controlled and rater-blinded trial across Germany with ARAS between the ages of 14 to 21 years. Participants (N = 158) were stratified by their level of depressive symptom severity and then equally randomized to either SCM or TAU. Depending on their severity level, SCM participants were allocated to tailored interventions. Symptom changes were assessed for depression (PHQ) and PTSD (CATS) at four time points, with the primary end point at post-intervention after 12 weeks. Based on an intention-to-treat sample, we used a linear mixed model approach for the main statistical analyses. Further evaluations included cost–utility analyses, sensitivity analyses, follow-up-analyses, response and remission rates and subgroup analysis. We found a significant reduction of PHQ (d = 0.52) and CATS (d = 0.27) scores in both groups. However, there was no significant difference between SCM and TAU. Cost–utility analyses indicated that SCM generated greater cost–utility when measured as quality-adjusted life years compared to TAU. Subgroup analysis revealed different effects for the SCM interventions depending on the outcome measure. Although culturally sensitive, SCMs did not prove to be more effective in symptom change and represent a more cost-effective treatment alternative for mentally burdened ARAS. Our research contributes to the optimization of clinical productivity and the improvement of therapeutic care for ARAS. Disorder-specific interventions should be further investigated

Effectiveness and cost-effectiveness for the treatment of depressive symptoms in refugees and asylum seekers: a multi-centred randomized controlled trial

BACKGROUND: Current evidence points towards a high prevalence of psychological distress in refugee populations, contrasting with a scarcity of resources and amplified by linguistic, institutional, financial, and cultural barriers. The objective of the study is to investigate the overall effectiveness and cost-effectiveness of a Stepped Care and Collaborative Model (SCCM) at reducing depressive symptoms in refugees, compared with the overall routine care practices within Germany's mental healthcare system (treatment-as-usual, TAU). METHODS: A multicentre, clinician-blinded, randomised, controlled trial was conducted across seven university sites in Germany. Asylum seekers and refugees with relevant depressive symptoms with a Patient Health Questionnaires score of ≥ 5 and a Refugee Health Screener score of ≥ 12. Participants were randomly allocated to one of two treatment arms (SCCM or TAU) for an intervention period of three months between April 2018 and March 2020. In the SCCM, participants were allocated to interventions tailored to their symptom severity, including watchful waiting, peer-to-peer- or smartphone intervention, psychological group therapies or mental health expert treatment. The primary endpoint was defined as the change in depressive symptoms (Patient Health Questionnaire-9, PHQ-9) after 12 weeks. The secondary outcome was the change in Montgomery Åsberg Depression Rating Scale (MADRS) from baseline to post-intervention. FINDINGS: The intention-to-treat sample included 584 participants who were randomized to the SCCM (n= 294) or TAU (n=290). Using a mixed-effects general linear model with time, and the interaction of time by randomisation group as fixed effects and study site as random effect, we found significant effects for time (p < .001) and time by group interaction (p < .05) for intention-to-treat and per-protocol analysis. Estimated marginal means of the PHQ-9 scores after 12 weeks were significantly lower in SCCM than in TAU (for intention-to-treat: PHQ-9 mean difference at T(1) 1.30, 95% CI 1.12 to 1.48, p < .001; Cohen's d=.23; baseline-adjusted PHQ-9 mean difference at T(1) 0.57, 95% CI 0.40 to 0.74, p < .001). Cost-effectiveness and net monetary benefit analyses provided evidence of cost-effectiveness for the primary outcome and quality-adjusted life years. Robustness of results were confirmed by sensitivity analyses. INTERPRETATION: The SSCM resulted in a more effective and cost-effective reduction of depressive symptoms compared with TAU. Findings suggest a suitable model to provide mental health services in circumstances where resources are limited, particularly in the context of forced migration and pandemics. FUNDING: This project is funded by the Innovationsfond and German Ministry of Health [grant number 01VSF16061]. The present trial is registered under Clinical-Trials.gov under the registration number: NCT03109028. https://clinicaltrials.gov/ct2/show/NCT0310902

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 (Mage = 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

Impact of war and forced displacement on children's mental health-multilevel, needs-oriented, and trauma-informed approaches

The infliction of war and military aggression upon children must be considered a violation of their basic human rights and can have a persistent impact on their physical and mental health and well-being, with long-term consequences for their development. Given the recent events in Ukraine with millions on the flight, this scoping policy editorial aims to help guide mental health support for young victims of war through an overview of the direct and indirect burden of war on child mental health. We highlight multilevel, need-oriented, and trauma-informed approaches to regaining and sustaining outer and inner security after exposure to the trauma of war. The impact of war on children is tremendous and pervasive, with multiple implications, including immediate stress-responses, increased risk for specific mental disorders, distress from forced separation from parents, and fear for personal and family's safety. Thus, the experiences that children have to endure during and as consequence of war are in harsh contrast to their developmental needs and their right to grow up in a physically and emotionally safe and predictable environment. Mental health and psychosocial interventions for war-affected children should be multileveled, specifically targeted towards the child's needs, trauma-informed, and strength-and resilience-oriented. Immediate supportive interventions should focus on providing basic physical and emotional resources and care to children to help them regain both external safety and inner security. Screening and assessment of the child's mental health burden and resources are indicated to inform targeted interventions. A growing body of research demonstrates the efficacy and effectiveness of evidence-based interventions, from lower-threshold and short-term group-based interventions to individualized evidence-based psychotherapy. Obviously, supporting children also entails enabling and supporting parents in the care for their children, as well as providing post-migration infrastructures and social environments that foster mental health. Health systems in Europe should undertake a concerted effort to meet the increased mental health needs of refugee children directly exposed and traumatized by the recent war in Ukraine as well as to those indirectly affected by these events. The current crisis necessitates political action and collective engagement, together with guidelines by mental health professionals on how to reduce harm in children either directly or indirectly exposed to war and its consequences

Survival states as indicators of learning performance and biological stress in refugee children: a cross-sectional study with a comparison group

Background: Our goal was to accurately detect young children at risk for long-term psychiatric disturbances after potentially traumatic experiences in the course of relocation. In addition to detailed assessment of parent-rated parent and child symptomatology, we focused on disruptive behaviors in the education environment summarized as survival states, as these frequently lead to clinical referral. Methods: We screened 52 refugee children aged 3-7 (M = 5.14 years, SD = 1.17) for symptoms of Posttraumatic Stress Disorder (PTSD) with the Child and Adolescent Trauma Screening (CATS) in parent rating. The parents' mental health was assessed using the Refugee Health Screener (RHS-15). Furthermore, the child's educators were asked to evaluate the pathological survival states of the child and we made a general assessment of the children's symptoms with the Strengths and Difficulties Questionnaire (SDQ) rated by parents and educators. Children in the refugee sample completed a working memory learning task (Subtest Atlantis from the Kaufmann Assessment Battery for Children, KABC-II) and delivered saliva samples for testing of the cortisol level. Results: The parental rating of their child's PTSD symptoms was significantly related to their own mental well-being (r = .50, p &amp;lt; .001). Children with survival states in educator ratings exhibited weaker learning performance (F = 3.49, p &amp;lt; .05) and higher evening cortisol levels (U = 113, z = ? 1.7, p &amp;lt; .05, one-tailed). Conclusions: Survival states are promising indicators for children's learning performance and distress level complementary to parent rating of child PTSD, which is highly intercorrelated with the parents' own symptom load. Trial registration number: DRKS00021150 on DRKS Date of registration: 04.08.2020 retrospectively registere

Non-verbal cognitive development, learning, and symptoms of PTSD in 3- to 6-year-old refugee children

As IQ tests are commonly used as key assessment method, we address the question whether our commonly used standardized IQ tests are appropriate for children from families of diverse cultures and different educational levels in a refugee population. We examined 109 refugee children aged 3-7 years (M = 5.10 years, SD = 1.25) with the 'Kaufman Assessment Battery for Children ' (KABC-II; Kaufmann &amp;amp; Kaufmann, 2015) on a language-free scale (Scale of Intellectual Functioning, SIF) and learning performance (subtest Atlantis). With a non-verbal IQ of 81.5 (SD = 18.01), the population mean of the refugee children is more than one standard deviation lower than the mean of the German norm population. Standardized scores follow the normal distribution and are not correlated to any of the assessed markers of adversity (flight duration, time spent in Germany, child PTSD in parent rating, parental symptom load, and parental education level).Conclusion: The interpretation of IQ test results for refugee children should be done cautiously as results may underestimate their cognitive capacity. Environmental factors, such as high illiteracy among parents in this study, the lack of institutional education of children and high lifetime stress, may explain our findings.Trial registration: DRKS00021150. What is Known: • There is a high pervasiveness for the use of standardized IQ tests in the German health and education system to determine eligibility for special education and social services. What is New: • Refugee children score significantly lower than German children in a language-free IQ test. As results are normally distributed and not correlated to any of the assessed markers of adversity, the low scores in the refugee group might be due to missing formal education