Excerpt:
Introduction
Children, defined as any boy or girl under 18 years, make up almost half of the world’s refugee population (United Nations High Commissioner for Refugees, 2016) and are exposed to challenges, traumas and stressors at the individual, family, and community levels that increase their risk for mental health problems (Barenbaum et al., 2004; Betancourt & Khan, 2008; Reed et al., 2012). These may include forced migration, forced labor, witnessing of murder and mass killings, lack of food and shelter, rape, torture, loss and separation from family, recruitment and use by armed forces, physical abuse, and family and sexual violence (Lustig et al., 2004; Office of the Special Representative of the Secretary-General for Children & Armed Conflict et al., 2009). Overlaid on potentially traumatic events are the daily, chronic stressors caused by displacement and associated with living in the camp environment – lack of basic needs, crowded and unsafe living conditions, and interpersonal conflict, among others (Layne et al., 2010; Miller & Rasmussen, 2010).
Children affected by these types of traumas and stressors present with a wide range of mental health symptoms, including those associated with posttraumatic stress (PTS), depression, anxiety, conduct problems, risk behaviors (e.g., alcohol or drug use), and distress associated with grief reactions (Barenbaum et al., 2004; Lustig et al., 2004; Sagi-Schwartz, 2008; Attanayake et al., 2009; Okello et al., 2013[for review], Morgos et al., 2008; Fernando et al., 2010; Miller & Rasmussen, 2010; Reed et al., 2012; Meyer et al., 2013; Newnham et al., 2015). Prevalence is difficult to study in these contexts; however, most studies find higher rates of mental health problems among displaced children compared with non-displaced populations (Goldstein et al., 1997; Paardekooper et al., 1999; Tousignant et al., 1999; Morgos et al., 2008; Bronstein & Montgomery, 2011; Reed et al., 2012).
There remains limited evidence on the effectiveness of interventions to treat mental health problems of children in refugee settings in low- and middle-income countries (LMICs). Some studies suggest that cognitive–behavioral-based treatments can be effective for reducing mental health symptoms in refugee children (Bolton et al., 2007; Layne et al., 2010). Relatedly, some eclectic psychosocial programs have been tested with conflict-affected populations, and show an impact on outcomes such as self-esteem or hope, but not mental health (Tol et al., 2014). Studies have generally utilized focal disorder treatments – or treatments focused on one disorder or cluster of symptoms. For example, Layne and colleagues used a treatment developed for posttraumatic stress disorder (PTSD) and grief (Layne et al., unpublished treatment manual) and Bolton and team (2007) used a treatment developed for depression (Interpersonal Therapy for depression; IPT). In contrast to this focal disorder treatment model where everyone receives the same elements in the same order, in common elements approaches providers learn elements that can be combined in different ways (elements used, order, dose) to treat a range of common mental health symptoms, and how to handle comorbidity (e.g., depression, trauma, anxiety co-occurrence) (Chorpita et al., 2005; Weisz et al., 2011; Weisz et al., 2012; Murray et al., 2014a). This approach is potentially more efficient and sustainable in both high-income countries (Mansell et al., 2008; Weisz et al., 2011; Weisz et al., 2012) and in LMICs (Bolton et al., 2014; Murray et al., 2014a; Ventevogel, 2015; Weisz et al., 2015) because it does not require providers to learn multiple interventions. Additionally, in settings with high rates of disorder comorbidity, such as in refugee populations, a model that can address multiple disorders may also be more appropriate (Murray & Jordans, 2016).
Current project
This paper reports on: (1) an evaluation of a common elements treatment approach (CETA) (Bolton et al., 2007; Bolton et al., 2014; Murray et al., 2014a; Weisz et al., 2015) developed for comorbid presentations of depression, anxiety, post traumatic stress, and/or externalizing symptoms among children in three Somali refugee camps on the Ethiopian/Somali border; and (2) an evaluation of implementation factors including acceptability, applicability/fit, feasibility and treatment facilitators, and barriers from the perspective of staff of the implementing partner organization, lay providers, and families who engaged in…
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