Prevalences of mental distress and its associated factors in unaccompanied refugee minors in Germany

Prevalences for mental disorders within minor refugees are comparatively high and heterogeneous. To reduce heterogeneity and identify high-risk subgroups, we compared unaccompanied refugee minors (URM) to accompanied refugee minors (ARM) regarding depressive symptoms and mental distress. Furthermore, we examined associative factors of mental distress in URM on a broad scale. We conducted a survey with a cross-sectional design in four German University hospitals. The sample consisted of n = 172 URM and n = 52 ARM aged 14–21. Depressive symptoms were assessed via the Patient Health Questionnaire (PHQ-9). Mental distress was assessed by the Refugee Health Screener (RHS-15). Mann–Whitney test was used to examine differences between URM and ARM. Associated factors of mental distress were evaluated via a stepwise multiple regression analysis. URM showed significantly higher mean scores for PHQ-9 (p < .001) and RHS-15 (p < .001) compared to ARM indicating medium effect sizes. Furthermore, URM were significantly more likely to surpass the cut-off for depression (61.6% vs. 30.8%) and overall mental distress (81.4% vs. 53.8%) compared to ARM. The factors Number of stressful life events (SLE), Female gender, and Fear of deportation were found to be associated with an increased mental distress in URM, whereas Weekly contact to a family member, School attendance, and German language skills were accompanied with lower distress scores. All six factors accounted for 32% of the variance of mental distress in URM (p < .001). Within minor refugees, URM are a highly vulnerable subgroup, which should receive particular attention and more targeted measures by health authorities. Our results indicate that these measures should comprise a rapid promotion of family contact, school attendance, language acquisition, and the fast processing of asylum applications. However, the cross-sectional design limits the interpretability of the results.

START adolescents: study protocol of a randomised controlled trial to investigate the efficacy of a low-threshold group treatment programme in traumatised adolescent refugees

IntroductionNo evaluated therapeutic approaches, that can efficiently be established in routine mental healthcare, are currently available for traumatised adolescent refugees in Germany. This study evaluates the efficacy of the Stress-Traumasymptoms-Arousal-Regulation-Treatment (START) programme to reduce trauma-related symptoms and psychological distress in traumatised adolescent refugees based in Germany.Methods and analysisThis randomised, waiting-list-controlled, multicentre trial with a 12-week follow-up will include 174 refugee minors with partial or full post-traumatic stress disorder who are fluent in either Arabic, Dari, English, German or Somali. Eligible refugee minors will be randomised to the START or waiting-list control groups. The manualised 8-week START programme is based on techniques of dialectical behaviour therapy (DBT), fosters adaptive coping with emotional distress and traumatic symptoms and comprises eight therapy modules and a booster session. Study assessments are planned at baseline, post-treatment (ie, after programme participation or waiting time), booster session at week 12 or 12-week waiting time, and at the 12-week follow-up. Primary and coprimary outcomes are changes in psychological distress and traumatic symptoms at post-treatment and will be analysed as response variables in linear mixed regression models. Secondary outcomes are changes in further trauma-related and other psychopathological symptoms, emotion regulation and intermediate effects of the programme at follow-up. We will also assess effects of the programme with ecological momentary assessments and on neuroendocrine stress parameters using hair cortisol.Ethics and disseminationThis study has been approved by the lead ethics committee of Rhineland-Palatinate and the ethics committees of participating sites. The study results will be disseminated through peer-reviewed publications and scientific conferences.Trial registration numberDRKS00020771.

How effective is group intervention in the treatment for unaccompanied and accompanied refugee minors with mental health difficulties: A systematic review

Background: Unaccompanied refugee minors (URM) are at significantly higher risk of trauma exposure and mental illness. Research examining the most effective treatments for this population is limited. Aims: To study the available research evidence on outcomes from various group interventions in this population. The objective is to investigate if these can be used clinically in future interventions. Methods: Systematic review was carried out for patient outcomes where group therapy was used as treatment in URM. Studies with ARM (Accompanied refugee minors) were included because of similarities between these groups and because many studies were mixed population. Results: Seventeen papers met eligibility criteria with a total of N = 1,119 participants. About 80% studies with a quantitative component reported improvements, and 69% of the studies that carried out statistical analyses reported statistically significant improvements in mental health symptoms. Every qualitative measure reported positive outcome for the participants. Studies with URM tended to show improved outcomes more often than studies exclusively with ARM. Conclusions: The evidence demonstrates the efficacy of group therapy in improving mental health outcomes, although the number of studies with robust methodology is small. Group intervention has potential to improve engagement and outcomes of URM with mental illness. Future direction for research is discussed.

Overcoming barriers to mental health care: multimodal trauma-focused treatment approach for unaccompanied refugee minors

Background This study evaluated the feasibility of a short-term, multimodal trauma-focused treatment approach adapted specifically for unaccompanied refugee minors (URMs) in the Netherlands. This approach aims to overcome barriers to mental health care and to reduce symptoms of posttraumatic stress disorder (PTSD) and depression. Methods An uncontrolled study was conducted, evaluating the main request for help, treatment integrity and feasibility, and the course of symptoms of PTSD (Children's Revised Impact of Event Scale-13) and depression (Patient Health Questionnaire modified for Adolescents). Results In total, 41 minors were included in the study. Most participants were male (n = 27), predominately from Eritrea (75.6%) with a mean age of 16.5 (SD = 1.5). Minors mostly reported psychological problems, such as problems sleeping, and psychosocial problems, including worries about family reunification. Deviations from the approach were made to meet the current needs of the minors. Factors limiting the feasibility of the approach were often related to continuous stressors, such as news concerning asylum status. Conclusions The results provide a first indication that this approach partly overcomes barriers to mental health care and emphasize the added value of collaborating with intercultural mediators and offering outreach care. Trial registration: The study was registered in the Netherlands Trial Register (NL8585), 10 April 2020, Retrospectively registered, https://www.trialregister.nl/trial/8585.

Potential traumatic events and symptoms of post-traumatic stress in unaccompanied refugee minors—a comparison with youth in foster care

Building knowledge on how child welfare services (CWS) should tailor services for unaccompanied refugee minors (URMs) is important. URMs and youth in foster care are high-risk groups taken care of by the CWS in Norway. Little is known on whether knowledge gained from youth in foster care can inform services for URMs, and if these groups are comparable in terms of experiences of potential traumatic events (PTEs) and post-traumatic stress disorder (PTSD) symptom load. Eighty-one URMs reported PTEs and PTSD-symptoms using an adapted version of the Child and Adolescent Trauma Screen (CATS). Responses were described and compared with a sample of 303 youth in foster care in linear regression models. We present relative risks (RR) and standardized mean differences (SMD) for the PTEs and the PTSD subscale and total score between the groups in forest plots. URMs had experienced a mean (standard deviation) of 6.4 (3.4) PTEs and 43.9% reported to have PTSD-symptoms at or above the clinical cut off. Compared to the foster youth, URMs reported more exposures of interpersonal violence outside of the family (RRs ranging from 66.4 [95%CI 18.1; 243.5) to 1.3 (1.0, 1.5)], and more PTSD-symptoms in the re-experiencing subscale [SMD = 0.3 (95% CI 0.1, 0.6)]. The frequency and types of PTEs and the PTSD-symptom load and profile among URMs and youth in foster care differed. Findings underscore the importance of qualified and targeted care for URMs, and that this care should differ to that of other high-risk groups in the CWS.

The Challenges of Quantitative Surveys Among Hard-to-Survey Populations – A Case for Mixed-Methods Designs Based on a Survey With Unaccompanied Refugee Minors

Surveys of specific target groups that are hard to survey are prone to errors and biases. In this paper, we use the Total Survey Error (TSE) framework and a study on unaccompanied refugee minors (URM) in Germany to discuss how a mixed-methods quantitative-dominant research design can address challenges of quantitative-only surveys of such groups. We show that unit nonresponse and measurement are two main levels of bias that can be partly supplemented by qualitative research. In addition, taking ethical considerations into account when researching URMs affects the quality of quantitative surveys. This effect cannot be avoided, but it should be classified by researchers. We conclude that surveying hard-to-survey populations benefits from a combination of quantitative surveys and semi-structured interviews.

Mental Health Outcomes of Unaccompanied Refugee Minors: a Rapid Review of Recent Research

Purpose To examine mental health outcomes of unaccompanied refugee minors during global policy shift. Additionally, to consider mental health service delivery and placement type for this group. Methods A rapid systematic search of research published since 2018 which related to mental health outcomes of unaccompanied refugee minors. Data extracted, risk of bias assessed and outcomes reviewed qualitatively. Research Findings We found 181 papers, of which 14 met inclusion criteria. This review found consistently high levels of PTSD and PTSS among URMs in various contexts. Exposure to trauma, being unaccompanied (compared to accompanied), being female and being older are associated with poor outcomes. Depression and anxiety were consistently high among URMs and associated with discrimination, limited language attainment and daily hassles. Summary High rates of mental illness and symptoms among unaccompanied refugee minors were consistent across national and settlement contexts but the quality of the evidence is variable with significant heterogeneity of assessment. We relate persistence of poor mental health outcomes with problems accessing mental health services and discuss the role of key post-migration factors influencing outcomes—in particular placement type and the use of detention centres.