1. 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

2. Children’s Hospital Center for Refugee Trauma A project under the Robert Wood Johnson Foundation’s Caring Across Communities program

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

4. Local Data: Somali Youth Mental Health Needs

5. Trauma exposure 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.

6. 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.

7. 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.

8. Goal Provide trauma informed care to Somali youth that is A) accessed B) effective

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

10. Revised Goal Adapt and evaluate a trauma intervention model for Somali adolescent refugees

11. Trauma Systems Therapy for Refugees

12. Social-Ecological Model School Peer Group Neighborhood Culture Family Individual Social environmental interventions Self-Regulation Interventions

13. 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.

14. Skill-based Psychotherapy Cultural leaders/ MAAs Legal advocacy Home-Based Service Elements Psychiatry

15. 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

16. Adaptation #1: Continuum of care Community education/ anti stigma School/teacher trainings School-based youth groups TST Prevention Early identification and intervention Intensive intervention

17. 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 systemSomali community

18. Process of Adapting Interventions for Refugees

19. Principles of Adaptation 1. True partnership with the community –Community Based Participatory Research Clinical team Leadership Team Family Advisory Board Religious leaders

20. Principles of Adaptation 2. Flexible approach, learn as we go

21. 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 Program Advisory Committee reviews and recommends adaptations as needed

22. Principles of Adaptation 3. Evaluate in stages –Accessed? –Accepted? –Effective?

23. 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

24. 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?

25. 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?

26. 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