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
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
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Childrens Hospital Center for Refugee Trauma
A project under the Robert Wood Johnson
Foundations Caring Across Communities program
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Overview

• Need
• Overview of Trauma Systems Therapy
• Process and principles of adapting treatment for
  refugees
• Questions for the field

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Local Data Somali Youth Mental Health Needs
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Trauma exposure

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

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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.
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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.
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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.
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Goal

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

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Challenge

• Few models of care for refugees
• Fewer with empirical support
• Fewer still adapted for Somali community/culture

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Revised Goal

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

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Trauma Systems Therapy for Refugees
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Social-Ecological Model
Culture
Neighborhood
Peer Group
School
Family
Social environmental interventions
Self-Regulation Interventions
Individual
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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.
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Service Elements
Cultural leaders/ MAAs
Psychiatry
Skill-based Psychotherapy
Home-Based
Legal advocacy
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TST Fit with refugees

• Emphasis on social environment and acknowledging
  core role of environmental stress in childs
  symptoms
• Inclusion of advocacy
• Integration of systems
• Strong community-based components
• Fidelity is measured flexibly, via principles

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Adaptation 1Continuum of care
Prevention
Community education/ anti stigma School/teacher
trainings
Early identification and intervention
School-based youth groups
TST
Intensive intervention
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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
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Process of Adapting Interventions for Refugees
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Principles of Adaptation

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

Religious leaders
Family Advisory Board
Leadership Team
Clinical team
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Principles of Adaptation

• 2. Flexible approach, learn as we go

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Process of Adaptation Comprehensive Dynamic
Trials- Continuous Quality Improvement (CDT-QI
Rapkin Trickett, 2005)
Intervention implemented and evaluated
TST identified 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
TST identified 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
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Principles of Adaptation

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

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Access

• 100 of those referred for services enrolled in
  treatment (n40)
• 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

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Adapting interventions for RefugeesQuestions
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?

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Evaluating interventions for RefugeesQuestions
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?

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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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