New approaches to interventions for refugee children
Venue: World psychiatry official journal of the World Psychiatric Association

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. In 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. Most 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. There 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. In terms of children's 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. Overall, 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. A 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. In 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. The 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. Practitioners 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. When 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. Schools 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. Following 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. In 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. Panos Vostanis School of Psychology, University of Leicester, Leicester, UK