DirectorsInvestigators

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Community Dialogue and Needs Assessment for
Addressing Traumatic Stress among Resettled
African Refugee Youth in New Hampshire 

• Directors/Investigators
• Michelle V. Porche, EdD
• Wellesley Centers for Women, Wellesley College
• Lisa R. Fortuna, MD, MPH
• University of Massachusetts Medical School
• Stanley D. Rosenberg, PhD
• Dartmouth Medical School, PATT
• Funding Support and Partners
• New Hampshire Endowment for Health
• National Child Traumatic Stress Network
• Wellesley Centers for Women
• University of Massachusetts Medical Center
• New Hampshire Charitable Foundation

http//www.wcwonline.org/nhrefugee
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Traumatic Stress (Becker, et al., 2003)

• In traumatic stress we tend to focus on the event
  and not the individual response, but it is the
  nature of the response that is most important in
  understanding the effects of trauma on an
  individual's immediate and subsequent
  psychological functioning.
• Individuals and communities can experience severe
  and difficult events, it is the subjective
  psychological experience that is the crucial
  aspect of psychic trauma. In this sense, it could
  perhaps be said that trauma is in the eye of the
  beholder trauma exerts its effects through the
  prism of meaning. Environments and supports can
  be implemented to be responsive to psychic trauma
  and promote relief and even healing.

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Aims of this Needs Assessment

• Extension of New Hampshire Project for Adolescent
  Trauma Treatment (PATT), with primary focus on
  African resettled youth and families.
• Create trauma-informed and responsive systems
  within New Hampshire by
• strengthening awareness of treatment gaps for
  refugee youth
• understanding the intersection of immigration,
  culture and trauma in services needs
• identifying next steps for addressing traumatic
  stress among resettled refugee youth.

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General and Mental Health Care Concerns

• Limited period covered by health insurance
• 8 months
• Language Barriers increased access to
  interpretation services, greater variety of
  interpreters in order to maintain privacy of
  those needing mental health services
• Stigma and cultural differences in understanding
  emotional health and understanding trauma
• Competing demands basic needs need to be met
  first

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Trauma Specifics

• Need to define trauma in the context of refugee
  experiences
• Multiple traumacompounded with loss
• Intergenerationalshared and differing trauma
  between parents and youth
• Gender role stressaffecting men and women
  differently
• Stressors of acculturation, economic stability
  and adjustment following political violence and
  the refugee camp experience
• Is a community vs. an individual approach to
  intervention more helpful here?
• Alcohol abuse and addiction as co-morbid
  occurrences

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Sources of Resiliency

• Parents hopeful and invested in the prosperity of
  youth
• Youth often aspire to higher education and/or
  economic prosperity
• Religious practices and customs
• Family is a central source of support
• New Hampshire has dedicated ethnic leaders
• Traditions and the importance of respecting
  elders

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Provider Requests for InterventionsCultural
Competency Training

• Cultural competency training that includes
  increased understanding of
• differences related to countries of origin as
  well as tribal differences within specific
  countries
• religious practices and customs
• gender roles and expectations
• trauma in families and communities

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Cultural Competence in Interpreting Social Cues

• A classic example that you always hear from
  people in authority is, you know, when you talk
  with a kid or a young person, you want them to
  look you in the eye. And we read something into
  it if they dont look you in the eye. Well, in
  some cultures, as you know, you would never look
  an adult in the eye. Particularly if youre being
  reprimanded! So thats just one very concrete
  example in terms of why we have to do more in
  terms of cultural competency and cultural
  effectiveness training, so people can kind of
  understand the various dynamics.

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Suggested InterventionsTrauma Training

• Cultural and developmental understanding of
  trauma
• Increased understanding of the secondary effects
  of trauma on children whose parents experienced
  direct trauma
• Increased understanding of the effect of
  long-term stays in refugee camps
• Understanding what mental health means for the
  refugee community

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Secondary Effects of Trauma on Children

• There was a mother who seemed to be struggling
  with substance abuse issues, a single mom, and I
  believe she had four children. She spoke English,
  but she also wanted to make sure that she
  understood everything so she had an interpreter.
  But what ultimately happened in her case was that
  it sounded as if she became neglectful. She was
  starting to just go out and wander out and leave
  her children, sometimes leaving them with
  strangers. And then there was a question if she
  was struggling with her own mental illness
  issues. But what ultimately happened is DCYF came
  and removed the children.

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Cultural Understanding of Mental Health

• I was just talking to somebody actually last week
  from the World Health Organization in Geneva, who
  had just come back from Burundi. And he said,
  Theres two psychiatrists for fifteen million
  people. So theres really no mental health
  system there to speak of. And then culturally, a
  lot of people still believe in spirits and have
  different beliefs about why somebodys ill. And
  so bridging that sort of divide about our
  understanding clinically of mental health issues
  and trauma with somebodys cultural beliefs and
  faith is a challenge.

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Follow Through with Services

• We found that often times a family would be
  referred for care for a child, but the family
  didnt follow up on it. And when the health
  agency followed up with the family, they said,
  Hm, my kids okay now. They might have come
  into either a sick-care visit or a well-child
  visit saying, Theyre not sleeping. Theyre
  angry. They seem, you know, withdrawn. But when
  it actually came time to make that next step,
  even with a facilitated referral they said, You
  know what? Theyre okay. And thats something we
  havent quite gotten our hands around, going
  whats happening in between that time?

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Suggested InterventionsSchool Programs

• Accommodation strategies for working with
  students who have behavioral problems related to
  trauma
• Information for teachers regarding strategies for
  working with traumatized students, help them to
  understand boundaries of involvement with clear
  directions for referrals
• Funding that would allow mental health to partner
  with schools consultation around how to set up a
  classroom, appreciation of culture, training
  about trauma and its meaning for youth,
  psychotherapy sessions or a group in the school.
• Cultural liaison person within the schools
• Family orientation nights at the childrens
  schools, with interpreter assistance

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Strengths and Barriers to Learning

• We discovered a need for some of our children
  that have had in their early years no educational
  experience and extended periods in a camp and a
  lot of war trauma and their families experiencing
  that stress a long time. A strength of all the
  families is that theyre very motivated to learn.
  Education is highly valued. But they just have so
  many barriers to overcome in terms of not having
  skills that can be used readily in a new culture.

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Adjustment to School

• Parents are trying to learn English, get some
  job-training skills, find a secure place to live,
  pay their bills, take care of their children, and
  then begin the process of settling and
  acclimating into the community. So the children
  have to come to school. But its their first
  educational experience. And a lot of them enjoy
  learning but maybe exhibit some behaviors that
  are difficult in school -- a very difficult time
  sitting and attending for long periods of time,
  which is very natural.

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Culturally Defined Expectations of Parent
Involvement

• And my role is to support and encourage families
  that might not otherwise come. So we look for
  barriers like transportation or understanding. In
  Africa, when you turn your children over to the
  school, then they become the parent. And so you
  only go to school if theres a severe problem.
  And something that we had to learn to understand,
  because it was scary for parents to come, and it
  didnt make sense to them. Theyre very
  respectful of educators. Which is a very positive
  thing in many ways, but also can be a problem if
  they might have concerns and worries, because
  they dont know that they can be a partner in
  their childs education.

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Educators Need for Trauma Training

• Educators are hungry for information. There are
  sort of different levels. I think that just
  understanding cultures is a really important
  piece of the training. God Grew Tired Of Us,
  about the Sudanese boys, was presented and a lot
  of our staff went to that. But to understand that
  its a truly different experience for kids. You
  know, we all feel at a loss with some of the
  behaviors. So we do a lot of trial and error. So
  it would be nice if someone thats had some good
  success with trauma could train us. Tell us about
  good research showing how to teach kids whove
  experienced trauma.

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Suggested Interventions Adaptation of
Evidence-Based Treatment

• Adaptation of interventions so that they are
  responsive to trauma but focused on communities
  rather than individual families.
• Group work rather than individual therapy
• Training of community leaders to be mental health
  workers
• School-Based groups/narrative therapy/CBT groups
• Parental empowerment and outreach by culturally
  competent liaison
• A medical home integrated mental health, medical
  and social services from providers skilled at
  working with the refugee and immigrant
  population, and with adolescents and people in
  poverty
• Home visits by providers to see families where
  they are most comfortable

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Suggested InterventionsPost-Resettlement
Programs

• Short-term resettlement support and educational
  workshops that might start once the honeymoon
  period is over, so that individuals know what to
  expect and better understand feelings of
  distress, rather than feeling isolated
• Women-centered groups and educational advancement
  of girls and women
• Literacy projects for parents
• ESL classes that fit work schedule better
• Train the trainer model of ESL so that
  individuals learn English from African community
  leaders who share the same ethnic background
• Medical and mental health literacy for parents
• Employment training and opportunity
• Culturally competent interventions to respond to
  domestic violence

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Suggested InterventionsCultural Brokers and
Mentors

• Newcomer groups providing access to information
  about nuts and bolts of daily living in NH,
  school systems, social service agencies, local
  and US culture
• Reverse mainstreaming in schools, where the
  other youth can come in and work together with
  refugee/resettled youth, so that they develop
  peer relationships

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Next Steps

• Recruitment of an advisory group to guide the
  development of community selected pilot
  interventions including seeking appropriate
  funding
• Inform the development of trainings responsive to
  the need of mental health providers, schools,
  communities, ethnic leaders and families
• Cultural competence
• Refugee and cross-cultural mental health
• Child and adolescent trauma intervention/treatment
  
• Dissemination of results across community
  sectors, for policy makers and the greater mental
  health field