YOURTREAT is a randomized controlled rater-blinded two-arm multi-center superiority trial with a 1:1 allocation ratio to two parallel groups. Individuals who are screened eligible for the trial will participate in a comprehensive diagnostic interview (t1). Amongst other information (detailed below), this structured interview will assess the diagnosis of PTSD according to DSM-5. We expect that we will have to interview approximately N = 220 children and adolescents (N = 55 per site) in order to identify 80 participants (N = 20 per site) who fulfill the diagnostic criteria of PTSD. These PTSD patients will be immediately randomized to one of the two arms of the trial; KIDNET or TAU. For individuals included in the KIDNET group, the treatment starts within one month after the diagnostic interview and should be terminated the latest five months after randomization. For the beginning and ending of the NET, a tolerance window of one week is considered acceptable. Deviations from this time window will be reported. Individuals assigned to TAU will be informed about treatment and counseling options within the local general health care system immediately after the diagnostic interview.
Six months after the diagnostic interview and the randomized group allocation, the first follow-up interview will take place (t2). This time point was selected in order to assure a minimum time interval of one month between the end of KIDNET and the first follow-up interview. In this way, the diagnostic interview which measures PTSD symptoms in the past month, will not be biased by the experience of symptoms during exposure therapy. The second follow-up interview (t3) is scheduled for 12 months after randomization. For the appointments of the follow-up interviews, a tolerance window of +/- 2 weeks is considered acceptable. Deviations from this time window will be reported. See Fig. 1 for a schematic overview of the participant flow through the trial. The study protocol was written following the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) Statement 2013 . See Additional File 1 for the SPIRIT checklist. The trial was registered at the German Clinical Trials Registry (Deutsches Register Klinischer Studien; DRKS) on 15 May 2019 (ID: DRKS00017222).
Outcomes of the Trial
The primary outcome of the trial will be the change in PTSD symptom severity from the diagnostic interview before treatment initiation (t1) to the follow-up assignments (t2 and t3). PTSD symptoms will be measured at each assessment by a structured clinical interview using the Clinician-Administered PTSD Scale for DSM-5 – Child/Adolescent Version [CAPS-CA-5; 33]. The CAPS represents the gold standard for the assessment of PTSD and will be administered by trained psychologists with the help of ITAs who can interpret, if required. In order to standardize the translation of the ITAs, we will translate the CAPS-CA-5 into the most common languages spoken by the patients, e.g. Arabic, Kurdish, Dari and Farsi. Treatment response will be defined as the results of a mixed linear model with the CAPS-CA-5 total symptom score as outcome variable and time and intervention group as well as their interaction as fixed factors. Furthermore, group means (KIDNET vs TAU) will be compared and the between-group effect sizes (Cohen’s d) will be calculated at each follow-up assessment.
In addition, the following continuous secondary outcomes will be assessed before treatment (t1) and at each follow-up assessment (t2 and t3). The change of these secondary outcomes will be also evaluated by mixed linear models (see section on statistics for more details).
- Depressive symptoms as well as internalizing and externalizing behavior will be assessed by the Hopkins symptom checklist-37 for refugee adolescents [HSCL-37; 34] The HSCL-37A has been widely used in refugee populations and has shown excellent internal consistency (Cronbach’s alpha = .90) as well as adequate convergent validity with the Strength and Difficulties Questionnaire [SDQ; 35] of r=.65 .
- Suicidal ideation will be assessed by the Columbia Suicide Severity Rating Scale (C-SSRS) which has a high internal consistency (α = .93 - .94) and allows for a detailed risk assessment .
- Stress caused by discrimination will be assessed by the Adolescent Discrimination Distress Index (ADDI) which exhibited adequate internal consistency for the subscales regarding institutional, educational, and peer discrimination (α = .60 - .72) .
- Physical health will be assessed by 17 items selected from the Screening for Somatoform Symptoms 7 (SOMS-7) based on their frequency and sensitivity to change .
Finally, the rate of participants who still meet the diagnostic criteria of PTSD according to the CAPS-CA-5, as well as the PTSD response rate will be assessed at each follow-up assessment (t2 and t3). The PTSD response rate will be defined as the rate of participants who show clinical significant symptom improvement on the CAPS-CA-5, according to the reliable change index (RCI). In the absence of an established value of clinical significance for the DSM-5 and for populations of children and youth, the RCI will be calculated from the study data following the suggestion of Jacobson and Truax . These dichotomous variables will be analyzed by Fisher’s exact Tests.
Originally, we also aimed at assessing the secondary outcome acculturation (by the Frankfurt Acculturation Scale for Youth [FRACC-Y; 40]) as an additional parameter of integration. However, during the first diagnostic interviews for the trial, it became evident that the questions were extremely difficult to answer for participants with a high symptom burden and significantly prolonged the duration of the interview. We therefore decided to omit this secondary outcome in order to enhance the quality and validity of the entire interview.
Demographic information (including age, gender, information regarding the flight to Germany, religion, education, and the current living situation) will be assessed. Furthermore, a short medical anamnesis including addiction will take place at each diagnostic interview.
Adverse and potentially traumatic experiences including family and intimate partner violence as well as war exposure will be assessed by checklists. In more detail, an adapted version of the War and Adversity Exposure Checklist [WAEC; 41] will be employed to assess war-related and general traumatic life events, the short version of the Family Violence Checklist  will be used to measure violent experiences within the family, while an unpublished checklist created by our work group will be employed to measure intimate partner violence. Post-migration living conditions for young refugees will be assessed by a brief questionnaire developed by the Neuner work group. Furthermore, for accompanied young refugees whose parents agree to participate, parental psychopathology will be assessed by the refugee health screener [RHS-15; 43] and the Primary Care PTSD Screen for DSM-5 [PC-PTSD-5; 44] and parental behavior by the Parent Behavior Inventory . The RHS has been repeatedly used in refugee populations and shows a high internal consistency (α = .95), and good convergent validity (r = .88-.91) with diagnostic proxy instruments for anxiety, depression and PTSD . The PC-PTSD offers a more detailed risk assessment for the diagnosis of PTSD and exhibits a high consistency with a clinical diagnosis of PTSD according to the DSM-5 criteria (diagnostic accuracy of .86 with a cut-off of 3 ).
These variables are included in the diagnostic interview as they might impact children’s mental health and treatment success.
In order to generate hypotheses for forthcoming studies, the following exploratory outcomes will be assessed:
- Economic status and economic behavior, assessed by an adaption of the consumption and asset checklist from Haushofer (46), which was previously employed in low-income countries
- Non-suicidal self-injury, measured by four items of the German version of the self-injurious thoughts and behaviors interview [SITBI-G; 47]
- Diagnosis of complex PTSD, assessed by thirteen items following the definition of the proposed ICD-11 criteria 
YOURTREAT is a multi-center study with four participating centers. Frank Neuner (Bielefeld University) is the principal investigator of the trial. Treatments will take place at the refugee outpatient clinic for children and adolescents at the Medical Center Hamburg Eppendorf (supervised by Areej Zindler), the outpatient clinic for psychotherapy of the University of Konstanz (supervised by Michael Odenwald and Anselm Crombach), the outpatient clinic of the Catholic University Eichstätt-Ingolstadt (supervised by Rita Rosner) and the outpatient clinic of Bielefeld University (supervised by Frank Neuner). The four study centers have extensive experience with the treatment of children and adolescents, including young refugees. Furthermore, all study centers have established recruitment procedures and referral pathways which can be employed for the purpose of the current trial. Only two of the centers (Bielefeld and Konstanz) had experience with KIDNET before the trial, Eichstätt-Ingolstatt had tried tf-CBT with refugee children before, and Hamburg has applied various approches to treat young refugees.
Subject Inclusion and Exclusion Criteria
Young refugees who fulfill the diagnosis of PTSD according to DSM-5 may take part in the study. In more detail, the inclusion criteria are:
- being a refugee allocated to a community close to one of the participating centers but not necessarily with a permanent permit to stay
- PTSD diagnosis according to CAPS-CA-5
- Age 10-18 years
- Informed consent obtained from participant (if participant is ≥16) or participant and caregiver/legal guardian (if participant is <16)
For pragmatic reasons (availability of a sufficient number of ITAs in each language), YOURTREAT will mainly recruit young refugees from Syria, Iraq, and Afghanistan, the countries, where the majority of refugees who were seeking asylum in Germany in 2015 originate from.
The following exclusion criteria will be implemented in the trial:
- Acute risk of harm of self or others requiring inpatient treatment
- Clinical signs of acute psychotic disorder
- Clinical signs of mental retardation which would prevent effective psychotherapy
- Concurrent psychotherapeutic treatment
- Anxiolytic treatment with benzodiazepines as this medication is known to interfere with exposure-based psychotherapy (other medication is allowed and will be monitored).
- High alcohol or drug consumption (≥ 2-3 days of consumption per week) represents an exclusion criterion if participants cannot assure their preparedness and confidence to control their consumption in favor of the treatment they would receive in the framework of the trial
Recruitment and Eligibility Screening
All participating centers have extensive experience with the recruitment and treatment of children and adolescents, including young refugees. Participants will be recruited using established recruitment pathways of the specialized outpatient clinics of the centers.
In addition to these conventional recruitment procedures, the trial aims to introduce an innovative entryway for young refugees to psychotherapeutic treatment. In more detail, we plan to train Intercultural Therapy Assistants (ITAs) from the refugee and migrant community in each of the four participating centers who cover the most common languages among the current refugee communities. The tasks of the ITAs will be to interpret the diagnostic interviews and therapy sessions for all participants who do not speak German fluently in all study centers. Furthermore, the ITAs can additionally support the therapeutic process as well as the access to psychotherapy by accomplishing the following tasks
- Accompany young refugees to and from the therapeutic sessions
- Reduce prejudices against mental health problems and psychotherapy by awareness-raising in the refugee community and de-stigmatization of mental health conditions
- Support the recruitment procedure by approaching young refugees (e.g. in schools), by providing basic information about health and mental health, by offering a screening for mental health symptoms including PTSD using the Refugee Health Screener (RHS-15; ) and the Primary Care PTSD Screen for DSM-5 [PC-PTSD-5; 44], and by making qualified referrals of PTSD cases to the trial or to other specialists in the health care system.
The involvement of ITAs in recruitment and psychotherapy will be documented in detail throughout the trial.
Diagnostic interviews will be conducted by clinicians with at least a Bachelor’s degree with the help of ITAs who interpret the interview. The first diagnostic interview (t1) will comprise the assessment of demographic information, a short medical anamnesis including addiction, traumatic and adverse event exposure by means of checklists for war and adversity exposure as well as family and intimate partner violence, and post-migration living conditions. Furthermore, the diagnosis and symptom severity of PTSD will be determined by administering the CAPS-CA-5 . Since our population of young refugees has experienced multiple traumatic experiences, the CAPS symptoms can be answered in relation to several traumatic stressors (and not only to one index trauma). The CAPS will be amended by additional items assessing complex PTSD in the same response format. In order to be eligible for the trial, subjects will have to meet the diagnostic criteria of PTSD according to DSM-5 . This structured interview will be succeeded by questionnaires assessing depressive symptoms and internalizing and externalizing symptoms [HSCL-37A; 34], suicidality [C-SSRS; 36], non-suicidal self-injury [four items from SITBI-G; 47], economic status and behavior (adapted from 46), discrimination [ADDI; 37] and physical health (excerpts from SOMS-7; Rief & Hiller, 2003). The follow-up interviews will employ the same questionnaires as detailed above. All diagnostic data will be recorded directly on Case Report Forms and are considered to be source data.
For young refugees who are accompanied by either one parent, both parents, or a legal guardian (who is not an institutional guardian), we aim at assessing mental health symptoms of guardians using the RHS and the PC-PTSD-5. If parents/ guardians give their informed consent to participate, they will be screened for mental health symptoms by means of the RHS during each diagnostic interview of the child. Additionally, demographic data of the parents/ guardians will be assessed, too. Furthermore, we will assess the Parent Behavior Inventory  in order to investigate interrelations between parent/ guardian mental health, child mental health, and parental behavior.
See Fig. 2 for an overview of the procedures of the clinical trial YOURTREAT including enrolment, diagnostic assessments, and interventions.
Narrative Exposure Therapy for Children and Adolescents (KIDNET)
In the trial, eleven sessions of KIDNET will be provided according to the manual . During the treatment, the child, with the assistance of the therapist, constructs a chronological narrative of her or his whole life with a focus on the re-construction of the memory of the traumatic events. While the sessions dedicated to the narration of the client’s live are individual sessions with the client, parents or caregivers are invited to participate together with their children in three sessions which concern psychoeducation, current problems, and future perspectives.
In the first session (100 minutes), the parent/ caregiver should be present. For the trial, caregivers will be defined as the primary attachment figure. In case of unaccompanied refugee minors, this will be the caregiver the child trusts the most. If the child or adolescent is unable to identify a single significant caretaker or reports that he or she does not want a caretaker to participate, this session takes place in individual format with the patient. The first session serves the goal to provide psychoeducation about PTSD and KIDNET, to motivate the caregiver for the continuous support of the treatment, to educate about the internalizing and externalizing stress reactions of the child and about adaptive responses, as well as to provide a continuous monitoring of the safety and well-being of the child throughout the trial. In the second session of KIDNET (100 minutes), which is conducted with the client alone, the lifeline exercise is performed in order to obtain a first overview of the survivor’s life story. A rope symbolizes the course of life, flowers symbolize positive emotionally arousing events, while stones symbolize negative experiences, including traumatic events. The therapist guides the patient to name the most important life experiences without going into detail. This is succeeded by the development of the narration of the patient’s life from birth to present which may start already in the lifeline session and is continued in the subsequent therapy sessions. While all significant events which were brought up in the lifeline exercise are mentioned in the narration, the most severe traumatic experiences are treated in detail by means of exposure therapy in the following sessions (100 minutes for each exposure therapy session). However, in contrast to other exposure-based treatments for PTSD which involve repeated exposure to one index trauma, a main focus of KIDNET is the chronological reconstruction of autobiographical memory. Furthermore, KIDNET does not contain a variety of therapeutic components such as relaxation training or cognitive coping but mainly focuses on the narrative elements. Next to the sessions dedicated to the narration of the client’s life, KIDNET will comprise an additional session of 50 minutes together with the caregiver that can be scheduled during the course of exposure therapy according to the needs of the patient. It should give the caregiver the opportunity to ask questions regarding the general therapeutic process and to discuss implications of the therapy for the daily live. Furthermore, options of how the caregiver can further support the therapeutic process can be discussed. If children or adolescents prefer to discuss everyday problems without the presence of the caregiver, this session will be scheduled with the patient alone. The process of the narration of the client’s life will be finalized by a reflection of the narration of the life story in the 10th session (100 minutes).
Finally, the last session of the therapy (50 minutes) will again include the caregiver and serve to celebrate the completion of the treatment as well as to discuss ways of how to cope with residual symptoms and how to further support the client. If desired by the client, the last session can also take place without the caregiver.
Treatment as Usual (TAU)
Children and adolescents allocated to the TAU group will be referred to the local regular health care system for treatment. Immediately after the communication of group allocation, they will receive detailed information on how to find psychotherapeutic support in their community. For children under the age of 16, the psychoeducation on how to find psychotherapeutic support in the community will take place in the presence of the parent or guardian. The interventions provided to the TAU group will be assessed after each follow-up diagnostic assessment.
Choice of comparator
The aim of this trial is to test the efficacy of KIDNET for traumatized refugee children and adolescents in specialized outpatient clinics with the help of trained intercultural therapy assistants (ITAs). For this purpose, it is necessary to compare KIDNET as provided in the specialized outpatient clinics with the efficacy of the treatment that would be available without this module, i.e. a TAU condition. So far, no data exists regarding the efficacy of TAU in this understudied population. Policy makers often point at the limited evidence regarding the efficacy of trauma treatment for refugees in industrialized countries to justify the limited efforts to invest in the improvement of mental health care for refugees. By comparing a short-term, trauma-focused intervention with TAU for young refugees in Germany, the results of this trial can therefore inform major public-health related decisions in Germany, for example, regarding the usefulness of complementary treatment structures for refugees and the necessity to pay costs for interpreters for treatment.
Measures against bias
Subjects will be randomly allocated to the two arms of the trial using block-permuted randomization stratified by center based on computer-generated lists that will be provided by the independent statistician. Participants who fulfill the inclusion criteria, including a diagnosis of PTSD, will be immediately assigned to the interventions. Diagnosticians for the baseline diagnostic interview will receive a sequentially numbered, sealed, opaque envelope which will reveal group allocation in case the subject meets the diagnostic criteria for PTSD. The random sequence that determines treatment allocation is kept in a sequence of enumerated sealed envelopes that are provided to the centers. The envelopes will remain sealed to ensure concealment of the sequence of treatment allocations from the research team, assessors and the therapists. At the moment a patient is assigned to the trial he single corresponding envelope is opened to reveal the allocation of the therapist. Block sizes vary randomly and will not be disclosed in order to assure concealment.
Due to the behavioral nature of the intervention, neither participants nor therapists and ITAs who interpret the therapy can be blinded. However, the group allocation of the subjects will be concealed from the independent outcome assessors who will conduct the follow-up interviews. At the beginning of the follow-up interviews, participants will be instructed not to reveal any information related to the group they have been assigned to or regarding the therapeutic process. After the completion of all diagnostic instruments of the follow-up interview, the independent assessors will complete a questionnaire asking whether any information regarding group allocation was revealed in the diagnostic interview. Cases of premature unblinding will be documented and reported.
Measures taken to prevent bias in assessment
The diagnostic interviews will be conducted by specially trained assessors. As the CAPS-CA-5  serves as the primary outcome of the study, assessors are extensively trained in this instrument. During the trial, all interviews will be videotaped and a random selection of 10% per site will be checked and rated by an independent evaluator to assess interrater-reliability of the CAPS-CA-5.
Treatments with KIDNET will be conducted by expert clinicians (minimum Bachelor’s degree) specialized in the field of psychotraumatology. All study therapists receive a training in KIDNET which includes a two days basic training including the theoretical background of the treatment, the practical implementation of KIDNET, case demonstrations, practical exercise and role-plays in small groups under supervision of experienced KIDNET therapists. This initial training is followed by an advanced training which includes the discussion and review of test cases. Furthermore, treatment fidelity during the trial will be assured by external NET case consultation with experienced NET therapists of at least every fourth therapy session as well as regular supervision and intervision meetings at the study centers. The frequency of supervision and intervision meetings at the sites will be recorded throughout the study. In addition, all sessions will be videotaped and a random selection of 10% per site will be checked by independent raters for consistency with the treatment manual. Finally, 10% of the therapy session sheets (which assess the date, duration, main topics covered in the session, as well as difficulties in the KIDNET process) of all centers will be reviewed. Observed inconsistencies with the treatment manual will be documented, but do not constitute an exclusion criterion for the trial.
Measures taken to avoid attrition bias
In order to avoid systematic drop-out of the study, participants will receive a compensation of 20 € in form of a voucher for each follow-up interview. Furthermore, the inclusion of the caregivers and ITAs in the therapeutic process is intended to increase the cultural acceptance of the intervention as well as the reliability of the children and adolescents to show up for the sessions and diagnostic interviews. Finally, we will analyze all trial participants as randomized (intention-to-treat analyses).
Data will be collected at the study centers according to the General Data Protection Regulation (GDPR). The PI will appoint and supervise a data management team (DMT) responsible for all aspects related to data storage, data integrity, and data monitoring during the project period. Data storage and transfer will be conducted exclusively in an encrypted manner.
The centers will transfer the pseudonymized encrypted data to a secured server accessible by the DMT. The DMT will create a merged pseudonymized dataset only accessible by themselves which will be stored for the project duration. Checks for completeness as well as range checks will be conducted to ensure data integrity. Furthermore, the DMT will perform at least one site-monitoring per year at each participating center where access will be granted to source documents in order to check for completion of informed consent sheets and consistency with the entered data.
Statistical analyses will be conducted by the independent certified biostatistician Theodor May, who will also supervise the DMT in accordance with the General Data Protection Regulation (GDPR). For long-term storage, the anonymized data set (after deletion of the code-list and database lock) will be stored in the Bielefeld university data repository and provided to external scientists upon request for further analysis.
Power Analysis and Sample Size Calculation
The Ruf et al. pilot study  achieved a treatment effect size of 1.9 for NET and 0.3 for the waiting-list control group. However, we expect that the contrast will be smaller for this study, as we will have an active control condition and will provide detailed information to children and adolescents from the TAU condition on how to seek treatment in the regular health care system. Therefore, we base the effect size calculation at a conservative estimation of a between-group effect size of d = 0.6. To test the hypothesis that a treatment with KIDNET is more effective than TAU, with a one-sided alpha level set at 0.05 and a power level of 0.8, we need to enroll N = 72 subjects (N = 36 per group) into the present study. Once randomized, loss to follow-up was small (generally lower than 5%) in the Ruf et al. study  as well as in other NET studies . Most importantly, as the main analysis of the primary outcome measure will be calculated using a mixed-effects model, all randomized cases can be included in the statistical analyses. Therefore, the intended sample size of N = 80 will be sound to answer the research questions of the trial.
The confirmatory analysis of this study will be calculated as a mixed-effects model with the CAPS-CA-5 score as the outcome variable. Mixed models are especially suited for longitudinal studies as they can account for serial correlation within participants, are relatively robust to randomly missing data, and can incorporate certain nonrandom missing data without biasing model estimates. In detail, participants will be modeled as a random factor (including random intercepts or random intercepts and slopes), while time and intervention (KIDNET vs. TAU) as well their interaction will be modeled as fixed factors. The hypothesis that KIDNET is superior to TAU in the treatment of PTSD will be evaluated by the significance test of the interaction effect time × intervention.
In case of a significant interaction effect, two planned general linear hypotheses will be calculated as post-hoc tests for linear mixed effect models in order to test between-group differences at t2 and t3. One-sided p-values will be adjusted for multiple comparisons following the Holm procedure.
We will perform an intention-to-treat analysis, that is, all trial participants will be analyzed as randomized, even if they discontinue treatment or are unavailable for one or both of the follow-up interviews. The between-group effect size (Cohen’s d) will be calculated at each follow-up assessment (t2 and t3). The intention-to-treat analysis will be supplemented by a modified intention-to-treat analysis which will include only those participants who participated in at least one post-randomization diagnostic interview. Furthermore, participants who were randomized to KIDNET will be included only if they participated in at least one KIDNET therapy session.
Continuous secondary outcome measures are analyzed in the same way. In absence of a valid cut-off score for clinically significant change or treatment response of the CAPS-CA-5, the rate of subjects with clinically significant improvement as well as worsening based on the reliable change index (RCI) will be compared between groups using Fisher’s exact tests at the follow-up assessments t2 and t3, separately. For this purpose, the RCI will be calculated based on the pre-treatment scores of the study sample following the suggestion of Jacobson and Truax . Missing values due to premature withdraw will be considered as treatment failure (classified as no response).
In addition, in case of significant treatment effects, center effects regarding the primary efficacy endpoint are investigated. For this purpose, the change in CAPS-CA-5 at t3 (compared to baseline t1) are analyzed exploratively using a mixed-effects model that includes participants as a random factor and center, intervention and center × intervention as fixed factors. The significance level will be set at 0.05 for all analyses.
Safety and Ethical Aspects of the Trial
The trial procedures follow the Declaration of Helsinki and the ICH Guidelines for Good Clinical Practice [ICH-GCP; 51]. The ethics committee of the German Psychological Association (Deutsche Gesellschaft für Psychologie, DGPs) approved the study procedures (approval date: 06 May 2019).
So far, no trial has ever reported serious adverse events (SAEs) caused by psychotherapy of trauma-related disorders in children and adolescents [cf. 52, 53]. Since the planned treatment study can be therefore considered as safe, we refrain from installing an external safety monitoring committee for pragmatic reasons. Instead, we have appointed a SAE management committee constituted of the lead investigators at the sites (Areej Zindler, Rita Rosner, Anselm Crombach, Michael Odenwald), the PI (Frank Neuner), the independent biostatistician, and the external advisory board of the trial who will supervise the safety of the study.
The following dangerous occurrences will be defined as SAEs in accordance to the ICH-GCP and will be closely monitored during treatment, and at the follow-up assessments:
- Attempted suicide
- Event which results in death (suicide or other)
- Life-threatening event
- Event which results in significant disability
All such dangerous events and other safety aspects will be forwarded to the SAE management committee. In addition, the independent biostatistician will conduct interim analyses after 30% and 50% of the completed 6-months follow-ups in order to monitor the symptom development as well as the occurrence of potential SAEs. If an SAE is identified, the SAE management committee will investigate whether there is a causal link between the trial and the SAE. If the SAE management committee decides that further trial participation would be a safety concern for the patient, the patient will be withdrawn from the study. In the case of serious safety concerns, the trial will be stopped.
Informed Consent Procedure
Trained psychologists or medical doctors (minimum Bachelor’s degree) will introduce the study procedures to the participants. Our study population of young refugees is particularly vulnerable, as their age as well as their limited knowledge of the German health system might impair their ability to understand the aims and procedures of the study. In order to assure the comprehension of the information of the informed consent, and to standardize the informed consent between the centers, we have decided to supplement the written informed consent for the trial by a video which reads out the exact wording of the informed consent. Furthermore, the informed consent is written in easy language. The written informed consent will be available in the languages of the participants. They will detail the study procedures including diagnostic interviews, randomization, treatment options, potential temporary distress after interviews or therapeutic sessions, the possibility of terminating study participation without any disadvantage, and data management. Trained psychologists or medical doctors (minimum Bachelor’s degree) will answer questions arising, and will subsequently obtain written informed consent from subjects who decide to participate in the trial.
Coping with distress
Similar to the re-experiencing symptoms that PTSD patients experience in everyday life, patients might also experience high and distressing levels of anxiety or other unpleasant emotional reactions during assessments or sessions of exposure-based psychotherapy. However, in contrast to their everyday experience, where they usually have to deal with these symptoms on their own, the assessor/ therapist can help them to cope with these reactions, e.g. by reinforcing reality or by providing psychoeducation.
Individuals assigned to the TAU condition who still suffer from PTSD will be offered a treatment with KIDNET or an equally effective therapy within the participating outpatient clinics. Furthermore, participants who do not benefit from KIDNET (i.e. still suffer from PTSD at the last follow-up) will be offered additional treatments at the participating centers or will be referred to appropriate in- or out-patient treatments.