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      School and Community-Based Interventions for Refugee and Asylum Seeking Children: A Systematic Review

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          Abstract

          Background

          Research for effective psychological interventions for refugee and asylum-seeking children has intensified. The need for interventions in environments more easily accessed by children and families is especially relevant for newly arrived populations. This paper reviews the literature on school and community-based interventions aimed at reducing psychological disorders in refugee and asylum-seeking children.

          Methods and Findings

          Comprehensive searches were conducted in seven databases and further information was obtained through searching reference lists, grey literature, and contacting experts in the field. Studies were included if they reported on the efficacy of a school or community-based mental health intervention for refugee or asylum-seeking children. Two independent reviewers made the final study selection, extracted data, and reached consensus on study quality. Results were summarized descriptively. The marked heterogeneity of studies excluded conducting a meta-analysis but study effect-sizes were calculated where possible. Twenty one studies met inclusion criteria for the review reporting on interventions for approximately 1800 refugee children. Fourteen studies were carried out in high-income countries in either a school ( n = 11) or community ( n = 3) setting and seven studies were carried out in refugee camps. Interventions were either primarily focused on the verbal processing of past experiences ( n = 9), or on an array of creative art techniques ( n = 7) and others used a combination of these interventions ( n = 5). While both intervention types reported significant changes in symptomatology, effect sizes ranged from 0.31 to 0.93 and could mainly be calculated for interventions focusing on the verbal processing of past experiences.

          Conclusions

          Only a small number of studies fulfilled inclusion criteria and the majority of these were in the school setting. The findings suggest that interventions delivered within the school setting can be successful in helping children overcome difficulties associated with forced migration.

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          Most cited references24

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          Mental health of Cambodian refugees 2 decades after resettlement in the United States.

          Little is known about the long-term mental health of trauma-exposed refugees years after permanent resettlement in host countries. To assess the prevalence, comorbidity, and correlates of psychiatric disorders in the US Cambodian refugee community. A cross-sectional, face-to-face interview conducted in Khmer language on a random sample of households from the Cambodian community in Long Beach, Calif, the largest such community in the United States, between October 2003 and February 2005. A total of 586 adults aged 35 to 75 years who lived in Cambodia during the Khmer Rouge reign and immigrated to the United States prior to 1993 were selected. One eligible individual was randomly sampled from each household, with an overall response rate (eligibility screening and interview) of 87% (n = 490). Exposure to trauma and violence before and after immigration (using the Harvard Trauma Questionnaire and Survey of Exposure to Community Violence); weighted past-year prevalence rates of posttraumatic stress disorder (PTSD) and major depression (using the Composite International Diagnostic Interview version 2.1); and alcohol use disorder (by the Alcohol Use Disorders Identification Test). All participants had been exposed to trauma before immigration. Ninety-nine percent (n = 483) experienced near-death due to starvation and 90% (n = 437) had a family member or friend murdered. Seventy percent (n = 338) reported exposure to violence after settlement in the United States. High rates of PTSD (62%, weighted), major depression (51%, weighted), and low rates of alcohol use disorder were found (4%, weighted). PTSD and major depression were highly comorbid in this population (n = 209; 42%, weighted) and each showed a strong dose-response relationship with measures of traumatic exposure. In bivariate analyses, older age, having poor English-speaking proficiency, unemployment, being retired or disabled, and living in poverty were also associated with higher rates of PTSD and major depression. Following multivariate analyses, premigration trauma remained associated with PTSD (odds ratio [OR], 2.08; 95% CI, 1.37-3.16) and major depression (OR, 1.56; 95% CI, 1.24-1.97); postmigration trauma with PTSD (OR, 1.65; 95% CI, 1.21-2.26) and major depression (OR, 1.45; 95% CI, 1.12-1.86); and older age with PTSD (OR, 1.76; 95% CI, 1.46-2.13) and major depression (OR, 1.47; 95% CI, 1.15-1.89). More than 2 decades have passed since the end of the Cambodian civil war and the subsequent resettlement of refugees in the United States; however, this population continues to have high rates of psychiatric disorders associated with trauma.
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            Annual Research Review: Resilience and mental health in children and adolescents living in areas of armed conflict--a systematic review of findings in low- and middle-income countries.

            Researchers focused on mental health of conflict-affected children are increasingly interested in the concept of resilience. Knowledge on resilience may assist in developing interventions aimed at improving positive outcomes or reducing negative outcomes, termed promotive or protective interventions. We performed a systematic review of peer-reviewed qualitative and quantitative studies focused on resilience and mental health in children and adolescents affected by armed conflict in low- and middle-income countries. Altogether 53 studies were identified: 15 qualitative and mixed methods studies and 38 quantitative, mostly cross-sectional studies focused on school-aged children and adolescents. Qualitative studies identified variation across socio-cultural settings of relevant resilience outcomes, and report contextually unique processes contributing to such outcomes. Quantitative studies focused on promotive and protective factors at different socio-ecological levels (individual, family-, peer-, school-, and community-levels). Generally, promotive and protective factors showed gender-, symptom-, and phase of conflict-specific effects on mental health outcomes. Although limited by its predominantly cross-sectional nature and focus on protective outcomes, this body of knowledge supports a perspective of resilience as a complex dynamic process driven by time- and context-dependent variables, rather than the balance between risk- and protective factors with known impacts on mental health. Given the complexity of findings in this population, we conclude that resilience-focused interventions will need to be highly tailored to specific contexts, rather than the application of a universal model that may be expected to have similar effects on mental health across contexts. © 2013 The Authors. Journal of Child Psychology and Psychiatry © 2013 Association for Child and Adolescent Mental Health.
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              A critical review of psychological treatments of posttraumatic stress disorder in refugees.

              Despite much research evidence that refugees suffer from elevated rates of posttraumatic stress disorder (PTSD), relatively few studies have examined the effectiveness of psychological treatments for PTSD in refugees. The field of refugee mental health intervention is dominated by two contrasting approaches, namely trauma-focused therapy and multimodal interventions. This article firstly defines these two approaches, then provides a critical review of 19 research studies that have been undertaken to investigate the efficacy of these treatments. Preliminary research evidence suggests that trauma-focused approaches may have some efficacy in treating PTSD in refugees, but limitations in the methodologies of studies caution against drawing definitive inferences. It is clear that research assessing the treatment of PTSD in refugees is lagging behind that available for other traumatized populations. The review examines important considerations in the treatment of refugees. A theoretical framework is offered that outlines contextual issues, maintaining factors, change mechanisms and the distinctive challenges to traditional trauma-focused treatments posed by the needs of refugees with PTSD. Copyright © 2010 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2014
                24 February 2014
                : 9
                : 2
                : e89359
                Affiliations
                [1]Oxford University Department of Psychiatry, Warneford Hospital, Oxford, United Kingdom
                University of California, San Francisco, United States of America
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: MF. Performed the experiments: RT. Analyzed the data: RT MF. Contributed reagents/materials/analysis tools: RT MF. Wrote the paper: RT MF.

                Article
                PONE-D-13-31784
                10.1371/journal.pone.0089359
                3933416
                24586715
                00ff45a3-6f9a-4980-b733-42ac5734f3e9
                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 3 August 2013
                : 21 January 2014
                Page count
                Pages: 10
                Funding
                This study was funded by a NIHR Post-Doctoral Fellowship for MF (PDF-2010-03-10). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine
                Clinical research design
                Systematic reviews
                Mental health
                Psychology
                Behavior
                Adjustment (psychology)
                Attention (behavior)
                Emotions
                Developmental psychology
                Human relations
                Personality
                Psychological defense mechanisms
                Psychological stress
                Therapies
                Non-clinical medicine
                Environmental health
                Health care providers
                Health care quality
                Health services research
                Public health
                Behavioral and social aspects of health
                Child health

                Uncategorized
                Uncategorized

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