Panos Vostanis

New approaches to interventions for refugee children.

The alarming global increase of persons forcibly displaced because of persecution, conflict, violence or human rights violation poses a number of challenges to health and other public sector services. Approximately 51.2 million individuals fall into this broad group, largely consisting of 33 million internally displaced, 17 million refugees and 1.2 million asylum seekers. Conflicts are no longer confined to regions, with the Syrian refugee crisis, for instance, spreading especially to Southern Europe, where Syrian refugees have already exceeded 1.5 million in Turkey alone, of whom 250,000 live in camps. Children under 18 years constitute around 50% of the refugee population, with a total of 25,000 unaccompanied minors applying for asylum annually across 80 countries. n nIn recent years, there has been increasing evidence on the prevalence of mental disorders in refugee children and the underpinning risk factors, but knowledge remains relatively limited about resilience building, treatment and service efficacy. Studies arise from post‐conflict areas or from Western countries with newly arrived (asylum seeking) or resettled (refugee) children and young people. The characteristics of these groups, societal contexts and service systems obviously differ, requiring a range of approaches. n nMost epidemiological studies have focused on post‐traumatic stress disorder, but when they have been extended to other conditions such as depression, the impact of both past trauma and current life adversities on child psychopathology has clearly emerged1. The mediating effect of parental mental illness and parenting capacity is prominent1, although surprisingly there has been less attention so far to the role of the quality of attachment relationships, including those with extended family members. Unaccompanied children have an elevated risk of psychopathology and lower service engagement compared to refugee children living with their parents2. n nThere has been less research on factors that promote mental health or that moderate stressors in this population, despite the acknowledgement of their direct relevance to planning interventions. Although not always theoretically driven, such studies have identified individual (spirituality, coping strategies, internal locus of control), family (financial circumstances, family acceptance and support) and community factors (neighbourhood safety, social support networks, school retention)3. These are important findings, but currently we lack a coherent model that connects them in order to inform the development of interventions and services. n nIn terms of childrens multiple needs, services often aspire to a socio‐ecological model, but this is not usually supported by research evidence, as most studies are still based on self‐reports, and programmes are rarely implemented at individual, family and community levels. Interventions usually draw on a variety of psychological frameworks, which are largely trauma‐focused, whether implemented individually or with groups, but without incorporating the family and community level4. They largely target re‐experiencing and reconstructing trauma‐related cognitions and emotions, and findings are not always exclusively based on refugee children, but rather on children exposed to war and political conflict, and living in a range of circumstances. The theoretical clarity and fidelity of interventions varies considerably, as well as their developmental perspective if adapted from adult programmes, or the demarcation between universal and targeted prevention5. n nOverall, the clinical and socio‐ecological fields are gradually converging. Therefore, we need to conceptualize intervention programmes and service development for refugee children in an integrated context. We should also take into consideration the vacuum or limitations of public services in most countries, where there is a huge mismatch between refugee numbers and resources, with this gap usually filled in part by non‐governmental organizations (NGOs) of varying philosophies, missions, structures and funding streams. The development of a comprehensive model should also be informed by organizational, in particular implementation theory. The framework proposed by Greenhalgh et al5 is useful, as it defines sequential stages, each with its own domains, i.e. innovation, adoption by individuals, assimilation by the system, diffusion, and dissemination. n nA service distinction should be made between displaced refugee children in low‐income countries and those resettled in high‐income health care systems, as well as between the acute and the resilience building phases. n nIn low‐income countries, the humanitarian crisis is usually tackled by the United Nations, governmental departments and international NGOs, and this period remains fluid in terms of acute needs and mobility. Group‐based, particularly school interventions where possible, are the most cost‐effective. A number of modalities have been used, and a small number of studies have employed experimental designs such as randomized controlled trials6. These have been based on play, creative‐expressive, cognitive‐behavioural, narrative exposure, interpersonal, and grief‐focused therapies, with a tendency to broaden their scope from only focusing on trauma7. This is a useful baseline, but it needs to be maximized through existing systems, predominantly communities and schools; non‐specialist health community workers or lay counsellors supporting parents as mediators; and local empowerment8. n nThe delivery of interventions in the absence of specialist professionals is another key challenge. In reality, the majority of interventions can only be delivered by suitably trained teachers, NGO staff and volunteers, or lay counsellors, who would thus integrate new skills to their “therapeutic key working role” to form the crucial links with the other eco‐levels9. This raises implications for consultancy, training and sustainability, e.g. through supervision, which will be the main focus of specialists in addition to using their sparse resources for acute and severe cases. Trauma‐focused interventions require a varying degree of skills and training, and this is a major practice issue in balancing treatment fidelity with a large‐scale impact on children. n nPractitioners and volunteers should be clear on the objectives at different stages of trauma exposure. A tiered model can be clinically and economically effective. Psychoeducation on symptom recognition and management (for example, nightmares) can be put in place relatively early through schools or community settings, preferably by involving parents, who may require additional input in their own right. For children who require a more active intervention, groups of relatively brief duration can be implemented by non‐specialist facilitators under clinical supervision, aiming at trauma re‐processing, and these should suffice for a substantial proportion of children. Those children who either do not respond or present with comorbid disorders that necessitate pharmacological treatment or more prolonged therapies, such as depression, should be the focus of the available specialist resources. n nWhen children are resettled in low‐ or middle‐income countries with limited specialist resources, similar approaches to those discussed previously can be adopted, particularly if they are placed in a relatively concentrated area. In high‐income countries, service models for a range of vulnerable children with complex needs should be applied, namely direct access, outreach work, and links with refugee charities and employment training10. The balance of interventions has gradually shifted from predominantly focusing on the pre‐flight trauma to more emphasis on resettlement factors, such as acquiring a new language and communication, socio‐cultural adjustment and identity, peer relationships (which can lead to bullying and further victimization), and school inclusion. n nSchools still provide an effective entry route into mental health services. Multi‐faceted case management can be provided in addition to the described therapeutic interventions, and this can include parenting input or liaison with adult mental health services. Unaccompanied minors require policies and systems equivalent to those for children in public care, e.g. appropriately trained residential staff and foster carers. Reliance on interpreters for a variety of languages makes their training and consistent relationship with services essential. n nFollowing recognition and referral to the appropriate service, a number of practice considerations should be made. Refugee children are likely to have different constructs of mental ill health, attributions that associate it with their asylum applications, and fears of stigma and deportation. Engaging them and alleviating such misconceptions is thus a major step towards a successful outcome. Their psychological mindedness will vary, as many refugee children first experience predominantly somatizing symptoms, and may require several attempts before accepting a trauma‐focused treatment. Involving their carers and initially setting goals of, for instance, risk management while developing a trusting relationship can lead to a therapeutic phase, while they also become more adjusted in their country of reception. n nIn conclusion, refugee children and young people pose a significant public health challenge across the world. Their complex needs require closer collaboration between mental health and non‐statutory services to maximize their respective skills and resources. A comprehensive multi‐modal service should include clear care pathways, case management, evidence‐based trauma‐focused interventions, consultancy, and training. n n n n nPanos Vostanis School of Psychology, University of Leicester, Leicester, UK

An interpretative phenomenological analysis of the experience of self-harm repetition and recovery in young adults.

Six young adults (aged 19–21u2009years) with repeat self-harm for over 5u2009years were interviewed about their self-harm, why they continued and what factors might help them to stop. Interpretative phenomenological analysis identified six themes: keeping self-harm private and hidden; self-harm as self-punishment; self-harm provides relief and comfort; habituation and escalation of self-harm; emotional gains and practical costs of cutting, and not believing they will stop completely. Young adults presented self-harm as an ingrained and purposeful behaviour which they could not stop, despite the costs and risks in early adulthood. Support strategies focused on coping skills, not just eradicating self-harm, are required.

Longitudinal pathways between mental health difficulties and academic performance during middle childhood and early adolescence

There is a growing appreciation that child functioning in different domains, levels, or systems are interrelated over time. Here, we investigate links between internalizing symptoms, externalizing problems, and academic attainment during middle childhood and early adolescence, drawing on two large data sets (child: mean age 8.7 at enrolment, nxa0=xa05,878; adolescent: mean age 11.7, nxa0=xa06,388). Using a 2-year cross-lag design, we test three hypotheses - adjustment erosion, academic incompetence, and shared risk - while also examining the moderating influence of gender. Multilevel structural equationxa0models provided consistent evidence of the deleterious effect of externalizing problems on later academic achievement in both cohorts, supporting the adjustment-erosion hypothesis. Evidence supporting the academic-incompetence hypothesis was restricted to the middle childhood cohort, revealing links between early academic failure and later internalizing symptoms. In both cohorts, inclusion of shared-risk variables improved model fit and rendered some previously established cross-lag pathways non-significant. Implications of these findings are discussed, and study strengths and limitations noted. Statement of contribution What is already known on this subject? Longitudinal research and in particular developmental cascades literature make the case for weaker associations between internalizing symptoms and academic performance than between externalizing problems and academic performance. Findings vary in terms of the magnitude and inferred direction of effects. Inconsistencies may be explained by different age ranges, prevalence of small-to-modest sample sizes, and large time lags between measurement points. Gender differences remain underexamined. What does this study add? The present study used cross-lagged models to examine longitudinal associations in age groups (middle child and adolescence) in a large-scale British sample. The large sample size not only allows for improvements on previous measurement models (e.g., allowing the analysis to account for nesting, and estimation of latent variables) but also allows for examination of gender differences. The findings clarify the role of shared-risk factors in accounting for associations between internalizing, externalizing, and academic performance, by demonstrating that shared-risk factors do not fully account for relationships between internalizing, externalizing, and academic achievement. Specifically, some pathways between mental health and academic attainment consistently remain, even after shared-risk variables have been accounted for. Findings also present consistent support for the potential impact of behavioural problems on childrens academic attainment. The negative relationship between low academic attainment and subsequent internalizing symptoms for younger children is also noteworthy.

Development of a framework for prospective payment for child mental health services

Objectives There is a need to develop a payment system for services for children with mental health problems that allows more targeted commissioning based on fairness and need. This is currently constrained by lack of clinical consensus on the best way forward, wide variation in practice, and lack of data about activity and outcomes. In the context of a national initiative in England our aim was to develop a basis for an improved payment system. Methods Three inter-related studies: a qualitative consultation with child and adolescent mental health services (CAMHS) stakeholders on what the key principles for establishing a payment system should be, via online survey (nu2009=u2009180) and two participatory workshops (nu2009=u200991); review of relevant national clinical guidelines (nu2009=u200915); and a quantitative study of the relationship between disorders and resource use (nu2009=u20091774 children from 23 teams). Results CAMHS stakeholders stressed the need for a broader definition of need than only diagnosis, including the measurement of indirect service activities and appropriate outcome measurement. National clinical guidance suggested key aspects of best practice for care packages but did not include consideration of contextual factors such as complexity. Modelling data on cases found that problem type and degree of impairment independently predicted resource use, alongside evidence for substantial service variation in the allocation of resources for similar problems. Conclusions A framework for an episode-based payment system for CAMHS should include consideration of: complexity and indirect service activities; evidence-based care packages; different needs in terms of impairment and symptoms; and outcome measurement as a core component.

Transitioning care‐leavers with mental health needs: ‘they set you up to fail!’

BACKGROUNDnChildren in the UK care system often face multiple disadvantages in terms of health, education and future employment. This is especially true of mental health where they present with greater mental health needs than other children. Although transition from care - the process of leaving the local authority as a child-in-care to independence - is a key juncture for young people, it is often experienced negatively with inconsistency in care and exacerbation of existing mental illness. Those receiving support from child and adolescent mental health services (CAMHS), often experience an additional, concurrent transfer to adult services (AMHS), which are guided by different service models which can create a care gap between services.nnnMETHODnThis qualitative study explored care-leavers experiences of mental illness, and transition in social care and mental health services. Twelve care-leavers with mental health needs were interviewed and data analysed using framework analysis.nnnRESULTSnSixteen individual themes were grouped into four superordinate themes: overarching attitudes towards the care journey, experience of social care, experience of mental health services and recommendations.nnnCONCLUSIONSnExisting social care and mental health teams can improve the care of care-leavers navigating multiple personal, practical and service transitions. Recommendations include effective Pathway Planning, multiagency coordination, and stating who is responsible for mental health care and its coordination. Participants asked that youth mental health services span the social care transition; and provide continuity of mental health provision when care-leavers are at risk of feeling abandoned and isolated, suffering deteriorating mental health and struggling to establish new relationships with professionals. Young people say that the key to successful transition and achieving independence is maintaining trust and support from services.

A sequence analysis of patterns in self-harm in young people with and without experience of being looked after in care

OBJECTIVESnYoung people in the public care system (looked-after young people) have high levels of self-harm.nnnDESIGNnThis paper reports the first detailed study of factors leading to self-harm over time in looked-after young people in England, using sequence analyses of the Card Sort Task for Self-harm (CaTS).nnnMETHODSnYoung people in care (looked-after group: nxa0=xa024; 14-21xa0years) and young people who had never been in care (contrast group: nxa0=xa021; 13-21xa0years) completed the CaTS, describing sequences of factors leading to their first and most recent episodes of self-harm. Lag sequential analysis determined patterns of significant transitions between factors (thoughts, feelings, behaviours, events) leading to self-harm across 6xa0months.nnnRESULTSnYoung people in care reported feeling better immediately following their first episode of self-harm. However, fearlessness of death, impulsivity, and access to means were reported most proximal to recent self-harm. Although difficult negative emotions were salient to self-harm sequences in both groups, young people with no experience of being in care reported a greater range of negative emotions and transitions between them. For the contrast group, feelings of depression and sadness were a significant starting point of the self-harm sequence 6xa0months prior to most recent self-harm.nnnCONCLUSIONSnSequences of factors leading to self-harm can change and evolve over time, so regular monitoring and assessment of each self-harm episode are needed. Support around easing and dealing with emotional distress is required. Restricting access to means to carry out potentially fatal self-harm attempts, particularly for the young persons with experience of being in care, is recommended.nnnPRACTITIONER POINTSnSelf-harm (and factors associated with self-harm) can change and evolve over time; assessments need to reflect this. Looked-after young people reported feeling better after first self-harm; fearlessness of death, access to means, and impulsivity were reported as key in recent self-harm. Underlying emotional distress, particularly depression and self-hatred were important in both first and most recent self-harm. Looked-after young people should undergo regular monitoring and assessment of each self-harm episode and access to potentially fatal means should be restricted. The CaTS would have clinical utility as an assessment tool Recruiting participants can be a significant challenge in studies with looked-after children and young people. Future research with larger clinical samples would be valuable.

Exploring the challenges of meeting child mental health needs through community engagement in Kenya

BACKGROUNDnDespite growing evidence on the extent of child mental health problems in low-middle-income countries, the gap between need and provision remains high. Previous research in high income countries has demonstrated that evidence-based interventions can be scaled-up through community consultation, particularly by engaging key stakeholders.nnnAIMSnThis study aimed to explore community stakeholders views on childrens mental health needs and culturally acceptable interventions in Kenya, to ascertain how to integrate global service standards with culturally-specific expectations.nnnMETHODSnFocus groups were conducted with community stakeholders (seven young people 14-17xa0years, seven parents, nine teachers and 11 other professionals). These participants were recruited from an urban community of internally displaced and disadvantaged families in Nakuru.nnnRESULTSnResults indicated that Kenya faced similar challenges in meeting mental health needs as in other countries, including economic constraints, limited knowledge, stigma and systemic issues, but that these were manifested in culturally specific ways that were linked to societal and professionals attitudes and local context.nnnCONCLUSIONSnStakeholders views are important in informing the planning, delivery and evaluation of interventions. However, for such interventions to be sustained, a clear therapeutic framework, evidence-base and sociocultural adaptation are likely to be important factors.

Mental health problems of Syrian refugee children: the role of parental factors

War-torn children are particularly vulnerable through direct trauma exposure as well through their parents’ responses. This study thus investigated the association between trauma exposure and children’s mental health, and the contribution of parent-related factors in this association. A cross-sectional study with 263 Syrian refugee children-parent dyads was conducted in Turkey. The Stressful Life Events Questionnaire (SLE), General Health Questionnaire, Parenting Stress Inventory (PSI-SF), Impact of Events Scale for Children (CRIES-8), and Strengths and Difficulties Questionnaire were used to measure trauma exposure, parental psychopathology, parenting-related stress, children’s post-traumatic stress symptoms (PTSS), and mental health problems, respectively. Trauma exposure significantly accounted for unique variance in children’s PTSS scores. Parental psychopathology significantly contributed in predicting children’s general mental health, as well as emotional and conduct problems, after controlling for trauma variables. Interventions need to be tailored to refugee families’ mental health needs. Trauma-focused interventions should be applied with children with PTSD; whilst family-based approaches targeting parents’ mental health and parenting-related stress should be used in conjunction with individual interventions to improve children’s comorbid emotional and behavioural problems.

An interpretative phenomenological analysis of young people's self-harm in the context of interpersonal stressors and supports: Parents, peers, and clinical services

RATIONALEnSelf-harm in young people is of significant clinical concern. Multiple psychological, social and clinical factors contribute to self-harm, but it remains a poorly understood phenomenon with limited effective treatment options.nnnOBJECTIVEnTo explore young womens experience of self-harm in the context of interpersonal stressors and supports.nnnMETHODnFourteen adolescent females (13-18 years) who had self-harmed in the last six months completed semi-structured interviews about self-harm and supports. Interpretative phenomenological analysis was undertaken.nnnRESULTSnThemes identified were: 1) Arguments and worries about family breakdown; 2) Unhelpful parental response when self-harm discovered and impact on seeking support; 3) Ongoing parental support; 4) Long-term peer victimization/bullying as a backdrop to self-harm; 5) Mutual support and reactive support from friends (and instances of a lack of support); 6) Emotions shaped by others (shame, regret and feeling stupid to self-harm); and 7) Empty promises - feeling personally let down by clinical services. These themes were organised under two broad meta-themes (psychosocial stressors, psychosocial supports). Two additional interconnected meta-themes were identified: Difficulties talking about self-harm and distress; and Impact on help-seeking.nnnCONCLUSIONnParents and peers play a key role in both precipitating self-harm and in supporting young people who self-harm. The identified themes, and the apparent inter-relationships between them, illustrate the complexity of self-harm experienced in the context of interpersonal difficulties, supports, and emotions. These results have implications for improving support from both informal and clinical sources.