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

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

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

Trauma exposure

Trauma exposedNot exposed

94%

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

* 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.

PTSD

33%38%

29%

Full PTSDPartial PTSDNo 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 utilizationOf those with full PTSD, how many sought

services of any type?

92%

8%

No Services

Sought services

* 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.

Goal

• Provide trauma informed care to Somali youth that is A) accessed

B) effective

Challenge

• Few models of care for refugees

• Fewer with empirical support

• Fewer still adapted for Somali community/culture

Revised Goal

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

Trauma Systems Therapy for Refugees

Social-Ecological Model

School

Peer GroupNeighborhood

Culture

Family

Individual

Social environmental interventions Self-R

egula

tion I

nterv

entio

ns

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.

Skill-based

Psychotherapy

Cultural leaders/ MAAs

Legal advocac

y

Home-Based

Service Elements

Psychiatry

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

Community education/

anti stigma

School/teacher trainings

School-based youth groups

TST

Prevention

Early identification

and intervention

Intensive intervention

Adaptation #2: Continuum of cultural competence

Teachers and school staff educated in culture and trauma

Clinicians on SHIFA team gain expertise in Somali culture

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

Somali MAA staff gain knowledge of MH

Somali BUSSW graduates join MH profession

Raised awareness of School-based clinicians

Service system Somali community

Process of Adapting

Interventions for Refugees

Principles of Adaptation

1. True partnership with the community– Community Based Participatory Research

Clinical team

Leadership Team

Family Advisory BoardReligious leaders

Principles of Adaptation

2. Flexible approach, learn as we go

Process of Adaptation: Comprehensive Dynamic Trials- Continuous Quality Improvement

(CDT-QI; Rapkin & Trickett, 2005)

Intervention implemented and evaluated

TSTidentified for adaptation with Somali refugee group

Program Advisory Committee identified measures of fit and outcomes that are important to the community

“Lessons Learned” incorporated into intervention,adapted intervention implemented

Program Advisory Committee reviews and recommends adaptations as needed

Principles of Adaptation

3. Evaluate in stages– Accessed?– Accepted?– Effective?

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

• 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• 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?

• 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