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- W2769723616 abstract "The mental health of refugee children and adolescents is a multifaceted phenomenon that needs to be understood and addressed across multiple sectors that influence all potential determinants of health, including housing, education, economic opportunities, and the larger policy and political context including immigration. The current state of interventions to address mental health problems in refugee children is limited and even more so for prevention programmes. This Review describes interventions of note that are delivered to individuals as well as parenting and school interventions, and broader socioeconomic and cultural interventions. Few studies aim to assess impact across multiple domains of the refugee experience. The multidimensional and collective character of challenges facing refugee children and families calls for comprehensive psychosocial interventions through which healing the psychological wounds of war is complemented by restoring and supporting the social and physical environment so that it is one in which children and their families can thrive. The mental health of refugee children and adolescents is a multifaceted phenomenon that needs to be understood and addressed across multiple sectors that influence all potential determinants of health, including housing, education, economic opportunities, and the larger policy and political context including immigration. The current state of interventions to address mental health problems in refugee children is limited and even more so for prevention programmes. This Review describes interventions of note that are delivered to individuals as well as parenting and school interventions, and broader socioeconomic and cultural interventions. Few studies aim to assess impact across multiple domains of the refugee experience. The multidimensional and collective character of challenges facing refugee children and families calls for comprehensive psychosocial interventions through which healing the psychological wounds of war is complemented by restoring and supporting the social and physical environment so that it is one in which children and their families can thrive. The pressures causing forced displacement show no signs of abating, with the global population of forcibly displaced people growing substantially over the past two decades from 34 million in 1997 to 66 million in 2016.1UNHCRGlobal Trends. Forced displacement in 2016. The UN Refugee Agency, Geneva, Switzerland2017Google Scholar In recent years, the Syrian conflict has forced the largest movement of a population since World War 2.1UNHCRGlobal Trends. Forced displacement in 2016. The UN Refugee Agency, Geneva, Switzerland2017Google Scholar Of those displaced, most remain either internally displaced in their countries of origin or stay in neighbouring countries, often in temporary settlements and camps. In 2016, of the 22·5 million who had crossed an internationally recognised border making them a refugee, half were younger than 18 years of age. Only 15% were hosted in high-income countries, many as asylum seekers awaiting formal refugee status. The mental health of forcibly displaced populations has been an important area of clinical work and research to understand how the interplay between biological, psychological, social, and cultural processes determines how individuals vary on a spectrum from successful integration and adjustment to chronic mental illness. The psychological impact on a child and their caregivers can be substantial—both positive and negative. Evidence suggests that two sets of factors are of key importance in understanding the risk and protective factors shaping the mental health of refugee children as well as being potential portals for interventions: exposure to past and ongoing traumatic events and the complexities of navigating the post-migration environment such as dealing with school, discrimination, and reconfigured family life. To leave an environment of extreme insecurity and arrive in a different country of relative safety enhances mental health and wellbeing for many; the focus of this Review, however, will be on interventions that have been developed to mitigate the varied mental health risks accompanying forced migration. This narrative review of preventive mental health interventions for refugee children arriving in high-income countries highlights the triple jeopardy that inhibits the roll-out of informed interventions for this population: limited mental health research in children, high mobility of refugee populations, and complex cultural differences. First, the study of preventive mental health interventions is a poorly researched and conceptualised area for all children at heightened risk of developing mental health problems, be they the child of a parent with mental illness, a child with learning and neurodevelopmental difficulties, or those living in socioeconomically deprived environments. The barriers that inhibit research on representative samples of vulnerable child populations are manifold and range from ethical and consent issues to poor funding and limited attention. Second, refugee populations can be a highly mobile group often with immigration uncertainties, alongside linguistic, financial, and basic living needs to address. This situation makes it difficult to conduct and prioritise intervention studies when considering their many potential and immediate needs. Finally, refugees moving from low-income and middle-income to high-income contexts present an added level of cultural complexity with potentially different family, religious, and social values that shape the process of adjustment. These differences can contribute to isolation evinced by a lack of integration in local community structures, poor understanding of and access to mental health services, perceived discrimination and victimisation as well as limited previous exposure to research, thus making them a hard group to recruit for study. Key messages•Refugee children's needs must be assessed in the context of their broader family, school, and community environment•High quality research can be difficult to conduct because of factors affecting research for all vulnerable children but also because of cultural differences affecting notions of mental illness and the role of research•A focus on parents, including their own mental health needs, how stressors are managed in the family, and variance in assimilation for different family members, might improve mental health outcomes for children•School-based interventions hold promise as access to refugee children might be easier within the school and interventions to support peer relationships and a sense of belonging are important to consider•Broader contextual factors such as language barriers, poor living conditions, and being able to contribute to social and economic capital can potentially improve mental health outcomes•A continuum of care with multi-level and cross-sectoral intervention models to address the multitude of acculturative and resettlement stressors faced by resettled refugees is needed •Refugee children's needs must be assessed in the context of their broader family, school, and community environment•High quality research can be difficult to conduct because of factors affecting research for all vulnerable children but also because of cultural differences affecting notions of mental illness and the role of research•A focus on parents, including their own mental health needs, how stressors are managed in the family, and variance in assimilation for different family members, might improve mental health outcomes for children•School-based interventions hold promise as access to refugee children might be easier within the school and interventions to support peer relationships and a sense of belonging are important to consider•Broader contextual factors such as language barriers, poor living conditions, and being able to contribute to social and economic capital can potentially improve mental health outcomes•A continuum of care with multi-level and cross-sectoral intervention models to address the multitude of acculturative and resettlement stressors faced by resettled refugees is needed This Review includes forcibly displaced children who leave their native countries because of organised violence and arrive in a high-income country. The different terms used to describe this population are described in panel 1.2Institute of Migration. Glossary on Migration. International Migration Law Series No. 25 ed; 2011.Google Scholar The term refugee will be used throughout this Review to describe these populations, unless a study specifically focuses on one group. The findings will be presented according to: specific mental health interventions; parenting and family interventions; school and peer interventions; interventions addressing contextual factors; and finally, improving access to services. It is important to note the varied experiences of forced migrants, depending on their countries of origin, transit, and destination. Many might leave desecrated communities and then, especially for those arriving in high-income countries, travel through countries of transit, commonly including Mexico, Turkey, Greece, Libya, or Indonesia. Many transit and destination nations are experiencing different and evolving social pressures that might impact on mental health and these must be considered to ensure that any interventions developed can be implemented. For example, in Greece, which is both a transit and destination country, the interplay of mental disorder with the austerity experienced as a result of the global financial crisis can, for refugee children, interact with the risk afforded by exposure to organised violence.3Anagnostopoulos DC Giannakopoulos G Christodoulou NG A compounding mental health crisis: reflections from the Greek experience with Syrian refugees.Am J Psychiatry. 2016; 173: 1081-1082Crossref PubMed Scopus (2) Google Scholar The role of the international community is thus heightened, so as to ensure that the responsibility for forcibly displaced populations is shared across high-income nations and not solely an issue for countries along common migration routes.Panel 1DefinitionsMigrant: a person who has moved across an international border or within a state away from their habitual place of residence, regardless of their legal status; whether the movement is voluntary or involuntary; what the causes for the movement are; or what the length of the stay is.Refugee: a person who, owing to a well founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group, or political opinions, is outside the country of his nationality and unable or, owing to such fear, is unwilling to avail themselves of the protection of that country; often strictly defined according to the 1951 UN Refugee Convention.Asylum seeker: a person who seeks safety from persecution or serious harm in a country other than their own and awaits a decision on the application for refugee status under relevant international and national instruments.Stateless person: a person who is not considered as a national by any state under the operation of its law.Unaccompanied minor or separated child: a foreign national or stateless person younger than 18 years of age, who arrives on the territory of a state unaccompanied by a responsible adult.Trafficked: a person who has been recruited, transported, transferred, or harboured, by force or other forms of coercion, abduction, and deception, to achieve one person having control over another person, for the purpose of exploitation. Trafficking in people can take place within the borders of one state or might have a transnational character. Migrant: a person who has moved across an international border or within a state away from their habitual place of residence, regardless of their legal status; whether the movement is voluntary or involuntary; what the causes for the movement are; or what the length of the stay is. Refugee: a person who, owing to a well founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group, or political opinions, is outside the country of his nationality and unable or, owing to such fear, is unwilling to avail themselves of the protection of that country; often strictly defined according to the 1951 UN Refugee Convention. Asylum seeker: a person who seeks safety from persecution or serious harm in a country other than their own and awaits a decision on the application for refugee status under relevant international and national instruments. Stateless person: a person who is not considered as a national by any state under the operation of its law. Unaccompanied minor or separated child: a foreign national or stateless person younger than 18 years of age, who arrives on the territory of a state unaccompanied by a responsible adult. Trafficked: a person who has been recruited, transported, transferred, or harboured, by force or other forms of coercion, abduction, and deception, to achieve one person having control over another person, for the purpose of exploitation. Trafficking in people can take place within the borders of one state or might have a transnational character. Refugee children often manage to navigate a substantial number of changes and challenges, and many exhibit considerable resilience and strength; however, a proportion, because of previous experience, current family, school, and living circumstances as well as biological predisposition, can develop major mental health difficulties with associated implications for academic and social functioning (figure 1).4Mulligan CJ Clukay C Quinlan J et al.Genetics of risk and resilience in Syrian refugee youth.Am J Phys Anthropol. 2017; 162: 294-295Crossref Scopus (1) Google Scholar, 5Montgomery E Trauma, exile and mental health in young refugees.Acta Psychiatr Scand. 2011; 124: 1-46Crossref PubMed Scopus (34) Google Scholar For example, mental health problems might impede a refugee child's ability to adjust in the classroom and acquire a new language, with cascading consequences across several key facets of their resettlement such as establishing social support networks.6Iversen VC Sveaass N Morken G The role of trauma and psychological distress on motivation for foreign language acquisition among refugees.Int J Culture Mental Health. 2014; 7: 59-67Crossref Scopus (1) Google Scholar Depression, anxiety, or sleep disturbance, often in combination, are more common in refugee children than in the general population.5Montgomery E Trauma, exile and mental health in young refugees.Acta Psychiatr Scand. 2011; 124: 1-46Crossref PubMed Scopus (34) Google Scholar, 7Jakobsen M Demott MA Heir T Prevalence of psychiatric disorders among unaccompanied asylum-seeking adolescents in Norway.Clin Practice Epidemiol Mental Health. 2014; 10: 53-58Crossref PubMed Google Scholar, 8Bean T Derluyn I Eurelings-Bontekoe E Broekaert E Spinhoven P Comparing psychological distress, traumatic stress reactions, and experiences of unaccompanied refugee minors with experiences of adolescents accompanied by parents.J Nerv Ment Disease. 2007; 195: 288-297Crossref PubMed Scopus (0) Google Scholar Rates of post-traumatic stress disorder (PTSD) are particularly high relative to population norms, especially in unaccompanied minors.7Jakobsen M Demott MA Heir T Prevalence of psychiatric disorders among unaccompanied asylum-seeking adolescents in Norway.Clin Practice Epidemiol Mental Health. 2014; 10: 53-58Crossref PubMed Google Scholar Emerging evidence shows how previous exposure to potentially traumatic experiences interacts with the post-migration environment to either exacerbate or attenuate the risk of having PTSD, as shown in longitudinal studies of unaccompanied minor children resettled in the Netherlands and Belgium, an 8 year longitudinal study of refugee children in Denmark, and a study of Somali adolescents resettled in the USA.5Montgomery E Trauma, exile and mental health in young refugees.Acta Psychiatr Scand. 2011; 124: 1-46Crossref PubMed Scopus (34) Google Scholar, 9Ellis B MacDonald HZ Lincoln AK Cabral HJ Mental health of Somali adolescent refugees: the role of trauma, stress, and perceived discrimination.J Consult Clin Psychol. 2008; 76: 184-193Crossref PubMed Scopus (0) Google Scholar, 10Bean T Eurelings-Bontekoe E Spinhoven P Course and predictors of mental health of unaccompanied refugee minors in the Netherlands: one year follow-up.Soc Sci Med. 2007; 64: 1204-1215Crossref PubMed Scopus (0) Google Scholar, 11Vervliet M Lammertyn J Broekaert E Derluyn I Longitudinal follow-up of the mental health of unaccompanied refugee minors.Eur Child Adolesc Psychiatry. 2014; 23: 337-346Crossref PubMed Scopus (26) Google Scholar Longitudinal studies of both child and adult refugees confirm the prolonged negative effect that exposure to pre-migration traumatic events and post-migration stressors can have a decade or more after migration.12Tam SY Houlihan S Melendez-Torres G A systematic review of longitudinal risk and protective factors and correlates for posttraumatic stress and its natural history in forcibly displaced children.Trauma Violence Abuse. 2017; 18: 377-395Crossref Scopus (0) Google Scholar, 13Bogic M Ajdukovic D Bremner S et al.Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK.Br J Psychiatry. 2012; 200: 216-223Crossref PubMed Scopus (49) Google Scholar, 14Silove D Steel Z Bauman A Chey T McFarlane A Trauma, PTSD and the longer-term mental health burden amongst Vietnamese refugees.Soc Psychiatry Psychiatr Epidemiol. 2007; 42: 467-476Crossref PubMed Scopus (53) Google Scholar, 15Beiser M Resettling refugees and safeguarding their mental health: lessons learned from the Canadian refugee resettlement project.Transcult Psychiatry. 2009; 46: 539-583Crossref PubMed Scopus (0) Google Scholar, 16Carlsson JM Olsen DR Mortensen EL Kastrup M Mental health and health-related quality of life: a 10-year follow-up of tortured refugees.J Nerv Ment Dis. 2006; 194: 725-731Crossref PubMed Scopus (0) Google Scholar Furthermore, studies done 60 years after World War 2 showed that the psychological effects of conflict could be lifelong, with human rights violations a risk factor for PTSD, and deprivation and threat to life, risk factors for depressive symptoms.17Strauss K Dapp U Anders J von Renteln-Kruse W Schmidt S Range and specificity of war-related trauma to posttraumatic stress; depression and general health perception: displaced former World War II children in late life.J Affecti Dissord. 2011; 128: 267-276Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar PTSD has also been shown to cluster in families18Sack WH Clarke GN Seeley J Posttraumatic stress disorder across two generations of Cambodian refugees.J Am Acad Child Adolesc Psychiatry. 1995; 34: 1160-1166Summary Full Text PDF PubMed Google Scholar with negative effects on attachment and parenting.19van Ee E Kleber RJ Jongmans MJ Mooren TT Out D Parental PTSD, adverse parenting and child attachment in a refugee sample.Attach Human Dev. 2016; 18: 273-291Crossref PubMed Scopus (1) Google Scholar There is also some diverging evidence in certain refugee groups, with higher levels of conduct disorder and substance misuse20Ezard N Substance use among populations displaced by conflict: a literature review.Disasters. 2012; 36: 533-557Crossref PubMed Scopus (0) Google Scholar in some studies but not others,21Giuliani KKW Mire O Ehrlich LC Stigler MH Dubois DK Characteristics and prevalence of tobacco use among Somali youth in minnesota.Am J Prevent Med. 2010; 39: S48-S55Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar as well as increased physical health needs.6Iversen VC Sveaass N Morken G The role of trauma and psychological distress on motivation for foreign language acquisition among refugees.Int J Culture Mental Health. 2014; 7: 59-67Crossref Scopus (1) Google Scholar Several studies have shown the high rates of social care alongside mental health needs among unaccompanied minors.8Bean T Derluyn I Eurelings-Bontekoe E Broekaert E Spinhoven P Comparing psychological distress, traumatic stress reactions, and experiences of unaccompanied refugee minors with experiences of adolescents accompanied by parents.J Nerv Ment Disease. 2007; 195: 288-297Crossref PubMed Scopus (0) Google Scholar, 22Jensen TK Fjermestad KW Granly L Wilhelmsen NH Stressful life experiences and mental health problems among unaccompanied asylum-seeking children.Clin Child Psychol Psychiatry. 2015; 20: 106-116Crossref PubMed Scopus (7) Google Scholar A 1 year study of more than 300 male Sudanese adolescents in the USA highlights several important resettlement factors that can contribute to improved outcomes, including cultural and living needs. Many had outcomes indicating a high level of functioning, therefore ensuring that new arrivals feel safe and supported in the post-migration environment is important for good physical and mental health.23Geltman PL Grant-Knight W Ellis H Landgraf JM The “Lost Boys” of Sudan: use of health services and functional health outcomes of unaccompanied refugee minors resettled in the U.S.J Immigr Minor Health. 2008; 10: 389-396Crossref PubMed Scopus (0) Google Scholar Resilience is a dynamic process driven by time-dependent and context-dependent variables—it is more complex than just a balance between risk factors and protective factors.24Sleijpen M Boeije HR Kleber RJ Mooren T Between power and powerlessness: a meta-ethnography of sources of resilience in young refugees.Ethnicity Health. 2016; 21: 158-180Crossref PubMed Scopus (9) Google Scholar, 25Song SJ Evidence base of resilience in war-affected youth: Syrian refugee adolescents.J Am Acad Child Adolesc Psychiatry. 2016; 55: S6Summary Full Text Full Text PDF Google Scholar Studies of resilience in refugee children, including a systematic review from ethnographic data, shows that although there are some universal resilience processes, resilience in young refugees has substantial variability.18Sack WH Clarke GN Seeley J Posttraumatic stress disorder across two generations of Cambodian refugees.J Am Acad Child Adolesc Psychiatry. 1995; 34: 1160-1166Summary Full Text PDF PubMed Google Scholar Commonly identified resilience domains include individual characteristics, family strengths, cultural influences, education, and community supports.26Pieloch KA McCullough MB Marks AK Resilience of children with refugee statuses: a research review.Can Psychol. 2016; 57: 330-339Crossref Scopus (1) Google Scholar Other factors identified to promote resilience among refugee children include social support (from friends and community), a sense of belonging, valuing education, having a positive outlook, family connectedness, and allegiances to one's original culture.26Pieloch KA McCullough MB Marks AK Resilience of children with refugee statuses: a research review.Can Psychol. 2016; 57: 330-339Crossref Scopus (1) Google Scholar A review of resilience identified eight protective factors to promote psychosocial wellbeing in adolescent refugees.27Weine SM Ware N Hakizimana L et al.Fostering resilience: protective agents, resources, and mechanisms for adolescent refugees' psychosocial well-being.Adolesc Psychiatry. 2014; 4: 164-176Crossref Google Scholar These included finances to provide for necessities; host language proficiency; social support networks; engaged parenting; family cohesion; maintaining cultural links; educational support; and faith or religious involvement. Potential targets identified for preventive work included: friends and peers; parents; extended family members; school staff; faith community networks; and resettlement agency caseworkers and health-care providers.27Weine SM Ware N Hakizimana L et al.Fostering resilience: protective agents, resources, and mechanisms for adolescent refugees' psychosocial well-being.Adolesc Psychiatry. 2014; 4: 164-176Crossref Google Scholar The interventions that do have an evidence base are often from relatively small, unreplicated studies, therefore the overall dearth of evidence lends difficulty to the entire exercise of identifying appropriate preventive interventions from which to draw conclusions. Rather than limit this narrative review to an endless list of research that needs to be conducted, relevant perspectives and evidence from studies of migrant children and adult refugees in high-income countries, as well as refugee children in low-income and middle-income countries (LMICs) contexts, are incorporated where relevant, to inform the review with the best available conclusions drawn from the field. No one framework to conceptualise the domains of prevention of mental illness in refugee children is used in this review however, Bronfenbrenner's bioecological model of development alongside models including those of the intergenerational transmission of trauma, post-conflict cycle of violence, family stress, migration and daily stressors, peer interactions, and community relationships have been used to inform the findings (figure 2).28Reed RV Fazel M Jones L Panter-Brick C Stein A Mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors.Lancet. 2012; 379: 250-265Summary Full Text Full Text PDF PubMed Scopus (92) Google Scholar, 29Miller KE Rasmussen A War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks.Soc Sci Med. 2010; 70: 7-16Crossref PubMed Scopus (318) Google Scholar, 30Silove D The ADAPT model: a conceptual framework for mental health and psychosocial programming in post conflict settings.Intervention. 2013; 11: 237-248Crossref Google Scholar, 31Fazel M A moment of change: facilitating refugee children's mental health in UK schools.Int J Educ Dev. 2015; 41: 255-261Crossref Scopus (2) Google Scholar, 32Danieli Y Norris FH Engdahl B Multigenerational legacies of trauma: modeling the what and how of transmission.Am J Orthopsychiatry. 2016; 86: 639Crossref PubMed Scopus (1) Google Scholar, 33Conger RD Ge X Elder GH Lorenz FO Simons RL Economic stress, coercive family process, and developmental problems of adolescents.Child Dev. 1994; 65: 541-561Crossref PubMed Google Scholar, 34Rees S Thorpe R Tol W Fonseca M Silove D Testing a cycle of family violence model in conflict-affected, low-income countries: a qualitative study from Timor-Leste.Soc Sci Med. 2015; 130: 284-291Crossref PubMed Scopus (9) Google Scholar As for interventions, there will always need to be cultural adaptations and nuances to reflect local and refugee contexts but given the substantial numbers involved, the evidence base needs to be appropriately and practically expanded. A small evidence base for interventions for refugee children in high-income countries (HIC) exists, limiting the conclusions that can be drawn. Several systematic reviews on mental health mechanisms and interventions have been published over the past few years on refugee children and unaccompanied minors as well as adults and other forcibly displaced populations from which we can try to inform our understanding of possible preventive interventions.35Anders M Christiansen H Unaccompanied refugee minors: a systematic review of psychological interventions.Kindheit Entwicklung: Z Klin Kinderpsychologie. 2016; 25: 216-230Crossref Scopus (5) Google Scholar, 36Brown R Witt A Fegert J Keller F Rassenhofer M Plener P Psychosocial interventions for children and adolescents after man-made and natural disasters: a meta-analysis and systematic review.Psychol Med. 2017; 47: 1893-1905Crossref PubMed Scopus (1) Google Scholar, 37Colucci E Szwarc J Minas H Paxton G Guerra C The utilisation of mental health services by children and young people from a refugee background: a systematic literature review.Int J Culture Mental Health. 2014; 7: 86-108Crossref Scopus (9) Google Scholar, 38Dalgaard NT Montgomery E Disclosure and silencing: a systematic review of the literature on patterns of trauma communication in refugee families.Transcult Psychiatry. 2015; 52: 579-593Crossref PubMed Scopus (0) Google Scholar, 39Fazel M Reed RV Panter-Brick C Stein A Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors.Lancet. 2012; 379: 266-282Summary Full Text Full Text PDF PubMed Scopus (179) Google Scholar, 40Graham HR Minhas RS Paxton G Learning problems in children of refugee background: a systematic review.Pediatrics. 2016; 137: e20153994Crossref PubMed Scopus (0) Google Scholar, 41Hassan G Ventevogel P Jefee-Bahloul H Barkil-Oteo A Kirmayer LJ Mental health and psychosocial wellbeing of Syrians affected by armed conflict.Epidemiol Psychiatr Sci. 2016; 25: 129-141Crossref PubMed Google Scholar, 42LeBrun A Hassan G Boivin M Fraser SL Dufour S Lavergne C Review of child maltreatment in immigrant and refugee families.Can J Public Health. 2016; 106: eS45-eS56Crossref PubMed Google Scholar, 43Nose M Ballette F Bighelli I et al.Psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in high-income countries: systematic review and meta-Analysis.PLoS One. 2017; 12: e0171030Crossref PubMed Scopus (0) Google Scholar, 44Peltonen K Punamaki R-L Preventive interventions among children exposed to trauma of armed conflict: a literature review.Aggress Behav. 2010; 36: 95-116Crossref PubMed Scopus (0) Google Scholar, 45Slobodin O de Jong JT Family interventions in traumatized immigrants and refugees: a systematic review.Transcult Psychiatry. 2015; 52: 723-742Crossref PubMed Scopus (3) Google Scholar, 46Sullivan AL Simonson GR A systematic r" @default.
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- W2769723616 title "Preventive mental health interventions for refugee children and adolescents in high-income settings" @default.
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