Implementation and Evaluation of Teaching Recovery Techniques (TRT) Among Asylum-seeking and Refugee Children
Phase: NA
Conditions: Mental Health Disorder, Post-Traumatic Stress Disorder in Adolescence, Depression, Social Anxiety
Sponsor: Norwegian Institute of Public Health

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Promoting Asylum-seeking and Refugee Children's Coping With 
Trauma 
 
Protocol ID 16/54571 
November 1st, 2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Promoting Asylum-seeking and Refugee Children's Coping With 
Trauma 
Background and Status of Knowledge 
Mental health problems and disorders represent major risks for unsuccessful integration into 
societies’ productive institutions, and account for more than half of the health expenses [1]. 
Moreover, mental health problems increase the risk for social exclusion, peer rejection [2], 
and school drop-out [3] and is thereby a substantial barrier to social integration of refugees.  
Research among unaccompanied minor asylum-seekers1 awaiting a decision on their 
application for asylum has demonstrated prevalence of symptoms of post-traumatic stress 
disorder (PTSD)  from 54% to 76% [4, 5]. Furthermore, there is high stability of mental 
health problems and disorders among them after they receive residence [6, 7]. Improving the 
mental health of this vulnerable group of children may improve the life conditions and 
opportunities for the children themselves, and can thereby be economically beneficial to the 
receiving societies.  
There is general agreement in the literature that Trauma-Focused Cognitive Behavioral 
Therapy (TF-CBT) is the method of choice for treating PTSD in trauma-exposed children [8]. 
Nevertheless, health personnel and national health authorities have pointed to the existing 
challenges regarding both capacity and competence in mental health specialist services to 
meet the mental health needs of asylum-seekers and refugees [9-11]. In response to the 
resulting socio-cultural differences in mental health services, commissioned by three 
directorates, the Norwegian Institute of Public Health (NIPH) has recently implemented a 
low-threshold evidence based intervention (Teaching Recovery Techniques) to reduce 
trauma-related mental health problems and promote well-being among asylum-seeking and 
refugee minors. The overall aim of the proposed PhD project is to evaluate the effectiveness 
of the intervention, which was delivered by local environmental therapists, school personnel, 
and health nurses to UMA and URM. The PhD project is based on data that we collected in 
conjunction with the intervention; consequently, funding of the project will facilitate an 
immediate generation of new and important knowledge.   
Mental health, trauma and psychosocial stressors   
The World Health Organization (WHO) defines mental health as a state of well-being in 
which every individual realizes his or her own potential, can cope with the normal stresses of 
life, can work productively and fruitfully, and is able to make a contribution to her or his 
community [12]. In its most recent Strategy of good mental health [13], the Government 
describes mental health as including good mental health, quality of life, mental health 
problems and mental health disorders. Quality of life (QoL) involves a range of different 
positive experiences such as happiness, safety, affiliation, coping, and meaningfulness (p. 9), 
                                                          
1 Unaccompanied minor asylum-seekers (UMA) are children below 18 years of age, who travel without the 
company of an adult legal caretaker to seek asylum in a foreign country. We distinguish this group from 
unaccompanied refugee minors (URM), who are former UMAs that have been granted asylum and are resettled 
in municipalities. We refer to them as refugees even if protection was conceded for humanitarian or other 
reasons rather than to shield from persecution, imprisonment etc.  

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and is conceptualized in a variety of ways [14]. In the present study, QoL refers to perceived 
subjective wellbeing and self-efficacy. 
UMA and URM all have in common that they have experienced serious losses of or 
separation from parents and other family members. Additionally, a majority of them have 
been exposed to an accumulation of traumatic events before their arrival in the destination 
countries, when they feared for their own lives or for the lives of others [15, 16]. Many 
children demonstrate adaptive outcomes in spite of the amount of adversities they are exposed 
to [17, 18]. Nevertheless, war trauma increase the risk of symptoms of PTSD and other 
mental health problems among asylum-seeking and refugee children and youth [6, 19, 20]. 
Likewise, war-trauma may be associated with post-traumatic growth in some individuals [21], 
however, reduced QoL is frequently the outcome [22]. Furthermore, research with older 
refugees and war-affected populations  has shown that asylum-related and post-resettlement 
psychosocial stressors experienced after residence has been obtained, contribute to the 
maintenance and development of mental health problems [23-26] and decreased QoL [14, 22]. 
In Norway, as in Sweden, new and more restrictive immigration policies implemented in 
response to the unprecedented high numbers of asylum-seekers arriving in 2015 resulted in 
alarming increases in suicide attempts, self-harm, school-drop out, withdrawal, apathy, and 
flights among the UMA [27, 28]. However, we lack more specific information about the 
mental health reactions to the combined impact of traumatic events and asylum-stressors 
among UMA and URM. Such information may inform about the strengths and vulnerabilities 
of these children. Moreover, experiences of a substantial number of asylum-related and post-
resettlement psychosocial stressors provide a challenging context for the implementation of 
the intervention we are studying that may interfere with its effectiveness.   
 
Teaching Recovery Techniques: An Effective Short-term Intervention 
Teaching Recovery Techniques (TRT) is a manualized, short term, group based intervention, 
which specifically focuses on children’s symptoms of PTSD. TRT was developed by experts 
of the Children and War Foundation (C&W; www.childrenandwar.org) to heal children’s 
mental reactions to war and disaster-related trauma [29]. The aim of the intervention is to 
teach children self- help methods, by increasing perceptions of control and self-efficacy in 
relation to trauma symptoms, based on recommended and evidence based CBT- methods for 
trauma relief. The five sessions help students to understand the causes of trauma and 
recognize signs and symptoms. Adolescents are taught a range of coping skills to stop 
flashbacks and other intrusive images, sounds, or smells. Student hyperarousal is addressed 
through stabilization and relaxation techniques, and phobic avoidance behavior is gradually 
desensitized through use of relaxation with anxiety and anger hierarchies.  
The program is delivered to groups of 5 - 15 adolescents by local group-leaders in pairs that 
are trained by representatives from C&W.   
TRT has proven to be effective in reducing trauma-related mental health symptoms in 
contexts of war and disaster when delivered by non-clinicians and “lay” people [30-35]. 
However, TRT has rarely been implemented with UMA or URM in post-war contexts, who 
have a longer time span since the traumatic exposure than children in contexts of war, and 
who are experiencing additional psychosocial challenges. A small study conducted in the 

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U.K., showed more beneficial mental health effects among refugees than asylum-seekers, and 
the authors speculated if experiences of post-migration stressors might have reduced the 
effectiveness in the latter group [36]. A small pilot study in Sweden yielded positive effects of 
TRT among 48 UMA and URM.  
In spite of the focus of TRT to increase coping and self-efficacy, none of the above mentioned 
studies included any measures of QoL-related constructs. To enhance our knowledge of the 
effectiveness of TRT in post-war contexts, we expand on the designs of the referred studies 
by 1) including a wait-list control group; 2) examining longer term effects; 3) including QoL-
related outcomes (subjective wellbeing and self-efficacy) in addition to symptoms of  PTSD, 
and 4) taking the psychosocial context into consideration.  
Aims  
The overall aim is to evaluate the effectiveness on mental health of TRT among 
unaccompanied minor asylum-seekers and refugees. 
More specifically, we will: 
Examine the short and long-term effectiveness of TRT in reducing mental health symptoms 
and promote QoL 
 
 Primary hypothesis: The TRT intervention is expected to significantly improve the 
mental health status (i.e. alleviate symptoms of post-traumatic stress disorder, 
depression and anxiety and promote QoL) compared to the waiting-list control group.  
 Secondary hypotheses: 1) Asylum- related and post-resettlement psychosocial 
stressors predict mental health problems and QoL over and above pre-migration 
traumatic exposure. 2) Asylum-related and post-resettlement psychosocial stressors 
predict variation in the short and long term effects of the effect of the TRT.  
Method 
The study has been approved by the Regional Committees for Medical and Health Research 
Ethics (REK) ref 2016 / 355. 
Power   
Several power analyses have been performed to calculate the required sample size, given an 
α-level of 0.05 and power (1-β) of 0.80. The analyses show that a sample of n=150 will be 
sufficient to detect standardized regression effects of 0.20 or larger. For intervention effects 
there will be power to detect effect sizes of d=0.40 or larger. With use of linear mixed effect 
models and structural equation modelling, and the wait-list design, power will be even higher. 
Thus, we are confident that the planned sample size is sufficient to address the research 
questions posed.  
Sample  
The study involves about 170 UMA and URM > 8 years.  
Recruitment involved inviting reception centers and municipalities from all over Norway to 
participate as a first step. The children in the centers and municipalities that accepted to 
participate who spoke Pashto, Dari, Arabic, Somali or Tigrinya, were then invited to 

5 
 
participate (see information below).  
A total of 18 TRT-groups have been conducted during the project period. To avoid cross-
contamination [37] of the intervention, the children were allocated to Intervention or Control 
groups on an institutional level. We endorsed half of the participating reception centers and 
resettlement municipalities to Intervention Groups, and the other half to wait-list Control 
Groups. We did this based on practical considerations related to the data collection, such as 
time frames of the commission, geographical location of the targeted centers and 
municipalities, and availability of bilingual research assistants. The Intervention Groups 
started the TRT soon after the information meeting, and the Control Groups started when they 
had completed the five weekly sessions and the W2 data collection. 
Overview of the recruitment process  
Invitation to participate in the study was sent to reception centers and resettlement 
municipalities, and health nurses of the local primary health care, based on contact 
information from the three commissioning directorates. Centers / municipalities that agreed to 
participate assigned a contact person that assisted the research team in the information and 
recruitment stages of the project. They typically approached the largest language groups in 
their respective institutions. The research team sent out brief, written information and sound 
tracks about the project in the respective languages to the children, with an invitation to attend 
an information meeting. We also invited their legal guardians (representatives), and the TRT-
group leaders to the information meeting, where we presented the intervention and the project, 
with the support of bilingual research assistants in the role as translators.  
Inclusion – exclusion criteria 
Inclusion criterion was based on the children fulfilling criteria indicative of PTSD on the 
Children’s Revised Impact of Event Scale (CRIES–8), that is, a score >17  on intrusion and 
avoidance subscales [38]. Thus, at the end of the information meeting, we asked the children 
who were interested in participating in the study to fill in the checklist, which we provided 
both in the five foreign languages and in Norwegian. The bilingual research assistants read the 
questions in the children’s mother tongue.  
The names of the children who qualified to receive the intervention were then given to the 
group leaders, who finalized the recruitment.  
Exclusion criteria involved known serious medical condition such as mental disabilities and 
psychotic disorder.  
All legal guardians of the invited unaccompanied minors < 16 years signed a consent form.  
Children > 16 years signed the consent form on their own behalf, but their legal guardians 
were informed about the project, and encouraged to discuss it with the child they represented. 
Procedures  
Treatment response was registered by self-report questionnaires administered before upstart 
of TRT (W1), two weeks after the completion of TRT (W2) and two months after completion 
of TRT (W3). The questionnaires were translated to the participants’ respective languages by 
standardized back-translation procedures. The children filled in the questionnaires in a group 
setting. The trained bilingual research assistants read the questions to the children, and 
assisted them with language issues.  

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Measures 
The included measures have demonstrated good psychometric properties in previous studies 
of mental health among children of war and disaster, including in TRT effect-studies. They 
have shown good psychometric properties in former studies in different cultures or involving 
multi-ethnic groups in Norway. 
Mental Health Outcomes  
Symptoms of PTSD: Children’s Revised Impact of Event Scale, CRIES-8 (31, 39) with eight 
items of intrusion and avoidance was used for screening purposes, and CRIES-13 (42) with 
additional five hyperarousal items was used at W1, W2 and W3 [30, 39].  
Qualitive of Life: 1)Subjective Well-being: Cantril Ladder [40]. The participants are 
presented with an illustration of a ladder with ten steps, and informed that the best possible 
life for them being on step10, and the worst possible life being a 0. 2) Perceived Self-
Efficacy: was measured by a short version of five items of The Generalized Self-Efficacy 
scale, GSE [41] that has previously been used with immigrant populations in Norway [42]. 
Predictors  
Traumatic events: 20 items developed in collaboration with the user groups.  
Asylyum-related stressors: 1)Length of asylum process + status of the asylum application, 
and 2) 13 stressors related to network problems and the psychosocial context in the centers 
that was developed in collaboration with the user group 
Post-resettlement stressors: short version of a daily hassles scale developed by the NIPH for 
studies of mental health in immigrant and refugee background youth populations [16].  
Child demographic background variables: age, gender, country of origin, length of stay in 
Norway. 
Statistical Analyses  
Treatment effects will be analyzed using ANCOVA and mixed regression models that may be 
flexibly adjusted according to the dependency structure in the repeated data.  
Relevance and Utility 
Developing evidence based interventions to promote the mental health of asylum-seeking and 
refugee children is highly relevant to major mental health policies and practices. According to 
an analysis of the health services’ psychosocial follow-up of asylum-seekers, [11], only 18% 
of the specialist mental health services report to have special competence with refugees. 
Moreover, a high proportion of the municipalities’ primary health care experience challenges 
in collaborating with the specialist services, related to lacking capacity and competence, 
declined referrals, or that the refugee group is not prioritized (Rambøll, 2016). Evidence 
based, low threshold selective interventions that can be implemented outside Child and 
Adolescent Mental Health services, are therefore highly needed. Implementing low-threshold 
interventions is in line with the Government’s strategy to improve the mental health of 
children and adolescents, which specifically mentions unaccompanied asylum-seeking and 
refugee minors [13] [12]. The Governments states that low-threshold interventions should be 
implemented early to avoid the development of serious mental disorders. Offering TRT to 
asylum-seeking children and young refugees in the early stages of the resettlement process (p. 
48), is in accordance with these claims. Immigrant health and evaluation of mental health 

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promoting interventions that may contribute to better health services for refugees and other  
traumatized children and youth are important targets in the NIPH strategy [43]. 
User Groups  
At the upstart of the evaluation study, we established a user group of 3 unaccompanied minor 
asylum-seekers that we have met with 3 times, with one last meeting scheduled in May 2018.  
In the first meeting we informed about the project and discussed the role of the user group. 
We also discussed the stressors that asylum-seeking minors experience during their stay in 
reception centers. Based on this, we developed a checklist of asylum-stressors that we 
presented to the user group to get their feedback in the second meeting. They also gave input 
and advice to the content and structure of information we were to use in  recruiting of asylum-
seeking and refugee participants to the project. In the third meeting we discussed what 
traumatic events that are relevant and typical to unaccompanied minors, as a basis for the 
development of a revised checklist of traumatic experiences. The plan for the upcoming final 
meeting, is to get the users’ perspectives on what they consider important topics for future  
grant proposals. 
For the purpose of the proposed PhD study, we will establish a new user group, comprising 3 
– 4 unaccompanied minors that has received residence in Norway. We will meet once or 
twice annually to discuss study questions and interpret the results of the analyses.   
Progress Plan 
Project period: 20.06.2017- 31.12.2021  
2017 – 2018 activities: Recruitment, intervention, data collection. Completed 
2019 – 2021 activities: establish and meet with user group. PhD courses. Analyze data and 
write 5 articles   
Project Management, Organization and Cooperation  
The proposed study is anchored in the NIPH, Division of Mental and Physical Health. Senior 
researcher B. Oppedal is the Principal Investigator (PI). Implementation and data collection 
were funded by The directorate of immigration, The directorate of diversity and integration, 
and The directorate of children, youth, and family affairs. The scientific dissemination is 
funded by the Council of Mental Health and The Norwegian Institute of Public Health. In 
addition to the PI, the research team includes a PhD student, and four scholars with 
comprehensive, long term experience and state of the art expertise in methodological 
approaches of intervention research, clinical work and research related to asylum-seeking and 
refugee children: 
Anne Kristine Solhaug, Cand. Psychol, is currently a research coordinator on the NIPH 
evaluation project. Her empirical master thesis focused on URM, and she has been engaged in 
voluntary work with refugees from a variety of perspectives over the years. 
E. Roysamb, Professor, Department of Psychology, University of Oslo, and NIPH. Co-
supervisor. Prof. Roysamb is one of Norway’s leading researchers within the field of mental 
health, in particular within the field of positive mental health. Based on this and his high-level 
expertise with statistics, he contributes valuable resources to the research team.  
R. Calam, Professor Emerita, Division of Psychology and Mental Health, the University of 

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Manchester, UK. Prof. Calam has years of experience in implementing and evaluating TRT 
among refugee families in Turkey and Lebanon. Her research group has particularly focused 
on the role of parents in enhancing the effect of TRT on their offspring. She will contribute 
her expertise in planning and conducting the evaluation of the effects of the TRT, and giving 
feedback to the manuscript writing.   
A. Sarkadi, Professor, Department  of Public Health and Caring Sciences, Uppsala 
University, Sweden. Prof. Sarkadi has recently pilot tested TRT among unaccompanied minor 
asylum-seekers in Sweden. She is currently the PI of a recently launched RCT assessing 
effectiveness of TRT among asylum-seeking and refugee minors in Sweden. A collaboration 
between the two ongoing Nordic studies of TRT provides a number of opportunities to learn 
from each other, share data and discuss analytic choices.  
Implementation of Research Findings 
The main target groups for popular scientific dissemination of results are policy-makers and 
immigrant-refugee non-governmental organizations, asylum-seeking or refugee children and 
youth. The NIPH Department of Communication will be involved in planning strategies for 
communication with these groups through our traditional channels. We will collaborate with 
the C&W in producing popular scientific reports and fact sheets that can be easily available 
on various websites. Moreover, we will collaborate with the directorates that commissioned 
the evaluation study in organizing conferences and seminars to communicate research 
findings both to the local agents in charge of the care and support of refugee and asylum-
seeking minors, and to local primary mental health care service providers.    
Ethical Aspects 
The proposed PhD study is part of a more comprehensive study to implement and evaluate 
TRT that has been approved by REK (2016/355). The study protocol that was approved 
addressed main issues related to doing research in vulnerable asylum-seeking and refugee 
child populations.   
Collaboration with the Council of Mental Health (CMH) 
The proposed study is well within the Strategic Plans of the CMH, what regards the focus on 
promoting the mental health of children and youth, information about refugee population’s 
mental health, and the focus on low threshold intervention. Project coordinator C. Elvedal, 
CMH, has provided us with valuable input regarding important issues to include in the 
proposal. She has read a draft of and given feedback to the study protocol. We have discussed 
a potential collaboration in relation to the progress of the study, the dissemination of 
important research findings should the study be granted, and how the specific competence of 
the study team can be made available to the CMH if needed. 

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