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Adapting Interventions for Refugee Youth: Trauma Systems Therapy for Somali Adolescent Refugees. B. Heidi Ellis Alisa Miller Saida Abdi

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Adapting Interventions for Refugee Youth: Trauma Systems Therapy for Somali Adolescent Refugees

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Adapting interventions for refugee youth trauma systems therapy for somali adolescent refugees

Adapting Interventions for Refugee Youth: Trauma Systems Therapy for Somali Adolescent Refugees

B. Heidi Ellis

Alisa Miller

Saida Abdi

And the Project SHIFA team: Naima Agalab, Abdi Yusuf, Colleen Hayden, Molly Benson, Lee Staples, Ellen Devoe, Deb Socia, Hassan Warfa, Yolanda Coentro, Imani Seularine, Amy Spindel, Glenn Saxe, Lisa Baron, Bob Kilkenny


Children s hospital center for refugee trauma

Children’s Hospital Center for Refugee Trauma

A project under the Robert Wood Johnson Foundation’s Caring Across Communities program


Overview

Overview

  • Need

  • Overview of Trauma Systems Therapy

  • Process and principles of adapting treatment for refugees

  • Questions for the field


Local data somali youth mental health needs

Local Data: Somali Youth Mental Health Needs


Adapting interventions for refugee youth trauma systems therapy for somali adolescent refugees

Trauma exposure

  • Youth reported having experienced on average 7 traumatic events (range 0-22)*

94%

* Ellis, et al. (2008). Mental health of Somali adolescent refugees: The role of trauma, stress, and perceived discrimination. Journal of Consulting and Clinical Psychology, 76, 184-193.


Adapting interventions for refugee youth trauma systems therapy for somali adolescent refugees

PTSD

  • Nearly 2/3 of youth reported significant PTSD symptoms, and 1/3 screened positive for Full PTSD*

* Ellis, et al. (2008). Mental health of Somali adolescent refugees: The role of trauma, stress, and perceived discrimination. Journal of Consulting and Clinical Psychology, 76, 184-193.


Service utilization

Service utilization

Of those with full PTSD, how many sought services of any type?

* Ellis, et al. (2008). Mental health of Somali adolescent refugees: The role of trauma, stress, and perceived discrimination. Journal of Consulting and Clinical Psychology, 76, 184-193.


Adapting interventions for refugee youth trauma systems therapy for somali adolescent refugees

Goal

  • Provide trauma informed care to Somali youth that is

    A) accessed

    B) effective


Challenge

Challenge

  • Few models of care for refugees

  • Fewer with empirical support

  • Fewer still adapted for Somali community/culture


Revised goal

Revised Goal

  • Adapt and evaluate a trauma intervention model for Somali adolescent refugees


Trauma systems therapy for refugees

Trauma Systems Therapy for Refugees


Adapting interventions for refugee youth trauma systems therapy for somali adolescent refugees

Social-Ecological Model

Culture

Neighborhood

Peer Group

School

Social environmental interventions

Family

Self-Regulation Interventions

Individual


Adapting interventions for refugee youth trauma systems therapy for somali adolescent refugees

Trauma Systems Therapy (TST)

. . . Is about a traumatized child who has trouble regulating emotions, a social environment that cannot help contain or even triggers this dysregulation, and the interface between emotion regulation and the social environment.


Service elements

Service Elements

Cultural leaders/ MAAs

Psychiatry

Skill-based

Psychotherapy

Home-Based

Legal advocacy


Tst fit with refugees

TST: Fit with refugees

  • Emphasis on social environment and acknowledging core role of environmental stress in child’s symptoms

  • Inclusion of advocacy

  • Integration of systems

  • Strong community-based components

  • Fidelity is measured flexibly, via principles


Adaptation 1 continuum of care

Adaptation #1:Continuum of care

Prevention

Community education/

anti stigma

School/teacher trainings

Early identification and intervention

School-based youth groups

TST

Intensive intervention


Adaptation 2 continuum of cultural competence

Adaptation #2: Continuum of cultural competence

Religious and Parent leaders educated about mental health, support youth access to care

Service system

Somali community

Teachers and school staff educated in culture and trauma

Somali MAA staff gain knowledge of MH

Raised awareness of School-based clinicians

Clinicians on SHIFA team gain expertise in Somali culture

Somali BUSSW graduates join MH profession


Process of adapting interventions for refugees

Process of Adapting Interventions for Refugees


Principles of adaptation

Principles of Adaptation

1. True partnership with the community

  • Community Based Participatory Research

Religious leaders

Family Advisory Board

Leadership Team

Clinical team


Principles of adaptation1

Principles of Adaptation

2. Flexible approach, learn as we go


Adapting interventions for refugee youth trauma systems therapy for somali adolescent refugees

Process of Adaptation: Comprehensive Dynamic Trials- Continuous Quality Improvement (CDT-QI; Rapkin & Trickett, 2005)

Intervention implemented and evaluated

Program Advisory Committee reviews and recommends adaptations as needed


Principles of adaptation2

Principles of Adaptation

3. Evaluate in stages

  • Accessed?

  • Accepted?

  • Effective?


Access

Access

  • 100% of those referred for services enrolled in treatment (n=40)

    • 100% of those who have enrolled in treatment have remained in treatment (duration of treatment range 0-7 months)

    • 80% of those in individual treatment were referred from group

    • 8 parents have contacted program asking for additional services for sibling

    • 4 parents approached independently asking for services for their children


Adapting interventions for refugees questions for the field

Adapting interventions for Refugees:Questions for the field

  • What constitutes an adaptation?

    • Change in language or content of the intervention?

    • The infrastructure you build around the core intervention that allows access?

    • The process of community outreach that accompanies the successful implementation of an intervention with a new group?

  • Is the goal to be culture-specific, or to find adaptations that generalize among refugees?


Evaluating interventions for refugees questions for the field

Evaluating interventions for Refugees:Questions for the field

  • What constitutes a successful intervention for refugees?

    • Is a change in symptoms among treated individuals meaningful if most refugees are not engaging in services?

    • Do we document, manualize, and ‘count’ collateral work outside the core intervention? Is this work actually an essential ingredient of the intervention?


Do we need alternatives to the rct

Do we need alternatives to the RCT?

  • Limitations to RCT in Community Based Research (Rapkin & Trickett, 2005)

    • Random assignment

      • Ethics of other conditions: what if there are no viable alternatives for this linguistic/cultural group? How does community perceive ‘denying’ a child a certain service?

    • Independence

      • community involvement leads to change across the whole group from which participants are drawn

      • Adjustment of one youth may affect adjustment of others

    • Adherence to strict fidelity and no systematic way to capture or further incorporate “lessons learned”

      • Particularly important when working with groups for whom there is little evidence base to draw from


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