ContextThe global refugee crisis requires that researchers, policymakers, and
clinicians comprehend the magnitude of the psychological consequences of forced
displacement and the factors that moderate them. To date, no empirical synthesis
of research on these issues has been undertaken.ObjectiveTo meta-analytically establish the extent of compromised mental health
among refugees (including internally displaced persons, asylum seekers, and
stateless persons) using a worldwide study sample. Potential moderators of
mental health outcomes were examined, including enduring contextual variables
(eg, postdisplacement accommodation and economic opportunity) and refugee
characteristics.Data SourcesPublished studies (1959-2002) were obtained using broad searches of
computerized databases (PsycINFO and PILOTS), manual searches of reference
lists, and interviews with prominent authors.Study SelectionStudies were selected if they investigated a refugee group and at least
1 nonrefugee comparison group and reported 1 or more quantitative group comparison
on measures of psychopathology. Fifty-six reports met inclusion criteria (4.4%
of identified reports), yielding 59 independent comparisons and including
67 294 participants (22 221 refugees and 45 073 nonrefugees).Data ExtractionData on study and report characteristics, study participant characteristics,
and statistical outcomes were extracted using a coding manual and subjected
to blind recoding, which indicated high reliability. Methodological quality
information was coded to assess potential sources of bias.Data SynthesisEffect size estimates for the refugee-nonrefugee comparisons were averaged
across psychopathology measures within studies and weighted by sample size.
The weighted mean effect size was 0.41 (SD, 0.02; range, −1.36 to 2.91
[SE, 0.01]), indicating that refugees had moderately poorer outcomes. Postdisplacement
conditions moderated mental health outcomes. Worse outcomes were observed
for refugees living in institutional accommodation, experiencing restricted
economic opportunity, displaced internally within their own country, repatriated
to a country they had previously fled, or whose initiating conflict was unresolved.
Refugees who were older, more educated, and female and who had higher predisplacement
socioeconomic status and rural residence also had worse outcomes. Methodological
differences between studies affected effect sizes.ConclusionsThe sociopolitical context of the refugee experience is associated with
refugee mental health. Humanitarian efforts that improve these conditions
are likely to have positive impacts.

Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis.

ContextRefugees experience multiple traumatic events and have significant associated
health problems, but data about refugee trauma and health status are often
conflicting and difficult to interpret.ObjectivesTo assess the characteristics of the literature on refugee trauma and
health, to identify and evaluate instruments used to measure refugee trauma
and health status, and to recommend improvements.Data SourcesMEDLINE, PsychInfo, Health and PsychoSocial Instruments, CINAHL, and
Cochrane Systematic Reviews (searched through OVID from the inception of each
database to October 2001), and the New Mexico Refugee Project database.Study SelectionKey terms and combination operators were applied to identify English-language
publications evaluating measurement of refugee trauma and/or health status.Data ExtractionInformation extracted for each article included author; year of publication;
primary focus; type (empirical, review, or descriptive); and type/name and
properties of instrument(s) included. Articles were excluded from further
analyses if they were review or descriptive, were not primarily about refugee
health status or trauma, or were only about infectious diseases. Instruments
were then evaluated according to 5 criteria (purpose, construct definition,
design, developmental process, reliability and validity) as described in the
published literature.Data SynthesisOf 394 publications identified, 183 were included for further analyses
of their characteristics; 91 (49.7%) included quantitative data but did not
evaluate measurement properties of instruments used in refugee research, 78
(42.6%) reported on statistical relationships between measures (presuming
validity), and 14 (7.7%) were only about statistical properties of instruments.
In these 183 publications, 125 different instruments were used; of these,
12 were developed in refugee research. None of these instruments fully met
all 5 evaluation criteria, 3 met 4 criteria, and 5 met only 1 of the criteria.
Another 8 standard instruments were designed and developed in nonrefugee populations
but adapted for use in refugee research; of these, 2 met all 5 criteria and
6 met 4 criteria.ConclusionsThe majority of articles about refugee trauma or health are either descriptive
or include quantitative data from instruments that have limited or untested
validity and reliability in refugees. Primary limitations to accurate measurement
in refugee research are the lack of theoretical bases to instruments and inattention
to using and reporting sound measurement principles.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=195170&pdfFileName=jrv20018.pdf

Measuring Trauma and Health Status in Refugees: A Critical Review

Background: Increasingly clinicians are being asked to assess and treat young refugees, who have experienced traumatic events due to war and organised violence. However, evidence-based guidance remains scarce.

Method:  Published studies on the mental health difficulties of refugee children and adolescents, associated risk and protective factors, as well as effective interventions, particularly those designed to reduce war-related post-traumatic stress disorder (PTSD) symptoms, were identified and reviewed. The findings are summarised.

Results:  Young refugees are frequently subjected to multiple traumatic events and severe losses, as well as ongoing stressors within the host country. Although young refugees are often resilient, many experience mental health difficulties, including PTSD, depression, anxiety and grief. An awareness of relevant risk and protective factors is important. A phased model of intervention is often useful and the need for a holistic approach crucial. Promising treatments for alleviating symptoms of war-related PTSD include cognitive behavioural treatment (CBT), testimonial psychotherapy, narrative exposure therapy (NET) and eye movement desensitisation and reprocessing (EMDR). Knowledge of the particular needs of unaccompanied asylum-seeking children (UASC), working with interpreters, cross-cultural differences, medico-legal report writing and the importance of clinician self-care is also necessary.

Conclusion:  More research is required in order to expand our limited knowledge base.

Practitioner review: assessment and treatment of refugee children and adolescents who have experienced war-related trauma.

Trajectories of resilience and dysfunction following potential trauma: A review and statistical evaluation.

The Children's Revised Impact of Event Scale (CRIES) is a brief child-friendly measure designed to screen children at risk for Posttraumatic Stress Disorder (PTSD). It has good face and construct validity, a stable factor structure, correlates well with other indices of distress, and has been used to screen very large samples of at-risk-children following a wide range of traumatic events. However, few studies have examined the scale's validity against a structured diagnostic interview based on the DSM-IV criteria for PTSD. In the present study, the CRIES and the PTSD section of the Anxiety Disorders Interview Schedule-Child and Parent Version (ADIS-CP) were administered to a sample of children and adolescents (n=63) recruited from hospital accident and emergency rooms and the validity of the CRIES as a screening tool evaluated. Cutoff scores were chosen from this sample with a low base-rate of PTSD (11.1%) to maximize sensitivity and minimize the likelihood that children with a diagnosis of PTSD would fail to be identified. Cutoff scores were then cross-validated in a sample of 52 clinically referred children who had a high base-rate of PTSD (67.3%). A cutoff score of 30 on the CRIES-13 and a cutoff score of 17 on the CRIES-8 maximized sensitivity and specificity, minimized the rate of false negatives, and correctly classified 75-83% of the children in the two samples. The CRIES-8 (which lacks any arousal items) worked as efficiently as the CRIES-13 (which includes arousal items) in correctly classifying children with and without PTSD. Results are discussed in light of the current literature and of the need for further development of effective screens for children at-risk of developing PTSD.

/pdf/the-children-s-revised-impact-of-event-scale-cries-validity-26m0g7r18k.pdf

The Children’s Revised Impact of Event Scale (CRIES): Validity as a screening instrument for PTSD.

To evaluate the psychometric properties of the Impact of Event Scale (IES scale) in children a study was conducted on 1787 children exposed to the warfare in Croatia, Bosnia and Herzegovina. The study group comprised 877 girls and 910 boys ranging in age from 6 to 15 years attending 28 arbitrary selected schools in Zagreb. High levels of posttraumatic reactions were found in the group of children. The pattern of endorsement and the factor structure of the IES scale were similar to that found in other samples. This supports the use of the IES in the assessment of posttraumatic stress reactions in children. Two factors emerged from a Principal Component Analysis, labeled intrusion (9 items), and avoidance (4 items). As in other studies, this study documented problems with several items (items 2, 12 and 15), items that should be considered omitted from the IES. Girls reported significantly more distress on 13 out of the 15 items. Both the overall IES score as well as the intrusion and avoidance score were significantly higher in girls than boys. The factor structure for boys and girls were very similar, and the reliability of the scale was adequate across different age groups and for subgroups of displaced and refugee children.

Factor analysis of the impact of event scale with children in war

To assess the amount of stress exposure and reactions among children following a war situation, two comparative groups of non-displaced (N = 64) and displaced children (N = 70) from Croatia were administered a modified version of the War Trauma Questionnaire as well as the Impact of Event Scale (IES). The results showed that a majority of the children had been exposed to armed combat, with displaced children significantly more exposed to destruction of home and school as well as to acts of violence, and loss of family members, than the non-displaced children. Regarding the IES scores, displaced children had significantly higher scores for the total score and for the intrusion and avoidance subscales. For girls the total score and intrusion score were significantly higher than for boys. Different exposure factors were significantly related to the IES scores, especially for the intrusion subscale of the IES.

Gordana Kuterovac

Papers

Factor analysis of the impact of event scale with children in war

Children in war: A silent majority under stress