Validity of the Cantril Ladder as a Measure of Well-being and Life Satisfaction in Refugee Youth Experiencing Post-Traumatic Stress Symptoms

Asylum-seeking and refugee children and youth have elevated risk for mental health problems, including substantially higher prevalence of PTSD, depression, and anxiety than general populations. Given the need to scale community-based interventions like Teaching Recovery Techniques (TRT) and ensure participant safety, simple session-by-session measures are used to monitor well-being. In Sweden, the Cantril Ladder is used within a safety protocol to flag youth with low life satisfaction for further suicide risk screening (C-SSRS). However, concerns exist about the validity of single-item life satisfaction measures in specific populations such as refugee youth who face ongoing stressors. The study aimed to examine whether the Cantril Ladder validly reflects well-being/life satisfaction among refugee youth experiencing post-traumatic stress symptoms by testing whether depression (PHQ-9) and self-efficacy (GSE) scores explain variance in Cantril Ladder scores. The hypothesis was that life satisfaction would be negatively associated with depression and positively associated with self-efficacy, such that PHQ-9 and GSE would significantly account for variance in Cantril Ladder scores.

Prior research indicates refugee youth resettled in high-income countries are vulnerable to mental disorders, with markedly higher prevalence of PTSD and depression compared with general populations. The Cantril Ladder is widely used with adolescents and deemed reliable and valid in general youth samples, yet the validity of single-item life satisfaction measures can vary and may be narrower in scope than multi-item scales. Therefore, validation in specific populations is warranted, especially among refugees who experience unique ongoing stressors. Life satisfaction is strongly and inversely related to depression, social stress, and suicidality, and low life satisfaction can predict later mental health problems. Conversely, higher depression can lead to subsequent decreases in life satisfaction. Self-efficacy is positively associated with life satisfaction; those with higher self-efficacy cope better with stress, which supports higher life satisfaction, whereas low self-efficacy relates to greater stress and lower life satisfaction. These literatures support expectations of negative correlations between life satisfaction and depression, and positive correlations with self-efficacy among refugee adolescents.

Design: Cross-sectional self-report analysis using pre-intervention data from ongoing randomized trials of the community-based TRT program in Sweden. Setting: Recruitment from schools and healthcare clinics in Linköping, Uppsala, Östersund, Västerås, and Gävle (April 2019–March 2020). Participants: N=51 refugee youth (41 male, 10 female), ages 12–20 (M=17.5, SD=2.06). Inclusion criteria: screened positive for PTSD symptoms (CRIES-8 total ≥17), ≤5 years in Sweden, interested in TRT, and not in ongoing treatment where therapists advised against participation. Surveys completed in Swedish (n=19), Tigrinya (n=11), Dari (n=10), Arabic (n=6), Somali (n=4), and English (n=1). Measures: CRIES-8 (PTSD risk screening; total 0–40; cut-off 17). Cantril Ladder (0–10; higher indicates greater life satisfaction; low 0–4, average 5–7, high 8–10). PHQ-9 (depression severity; 0–27; standard severity cut-points; good reliability and validity). GSE (10 items; total 10–40; higher self-efficacy; cross-cultural reliability). Data collection: Secure online platform (Qualtrics); data exported to SPSS; de-identified and stored on Uppsala University servers. Ethics: Approved by Uppsala Regional Ethics Committee (Dnr. 2018/382). Informed consent procedures described; participants could withdraw; incentives provided. Analysis: Descriptive statistics for sample and measures. Hierarchical multiple linear regression predicting Cantril Ladder scores. PHQ-9 entered first; demographic covariates (age, gender, language) examined initially and excluded from final models due to non-significance/collinearity. GSE added in a subsequent step to assess incremental variance explained. Assumptions (normality, linearity, homoscedasticity, multicollinearity) were checked (residual diagnostics, scatterplots, Kolmogorov–Smirnov tests). Model fit indices reported (F, R, R2/Adjusted R2), along with unstandardized coefficients and 95% CIs.

Sample characteristics: Mean age=17.5 (SD=2.06). Mean Cantril Ladder life satisfaction=5.33 (SD=2.77). Mean PHQ-9=12.08 (SD=6.50) indicating moderate depressive symptoms. Mean GSE=27.31 (SD=6.59). Internal consistency was good for all measures (α>0.70). No associations with gender; age was excluded in regression due to collinearity. Regression results: PHQ-9 alone significantly predicted Cantril Ladder scores (R=0.398; R2=0.159; F(1,49)=9.232; p=0.004), accounting for 15.9% of variance. Adding GSE increased explained variance; the two predictors together explained approximately 19.3% of variance in life satisfaction (Adjusted R2=0.193; F(1,48)=6.997; p=0.002). In the combined model, PHQ-9 was negatively associated with life satisfaction (B=-0.162; 95% CI: -0.272, -0.053), and GSE was positively associated (B=0.109; 95% CI: 0.002, 0.217). GSE explained approximately 6.7% of the variability in life satisfaction in the presence of PHQ-9. The influence of PHQ-9 was dominant (ΔR2≈0.159; p=0.004). Comparative context: The mean life satisfaction (5.33) among refugee youth in this study was lower than the 2010 HBSC survey mean in 31 high-income countries (7.58±1.89), underscoring reduced well-being in this group.

Findings supported the hypothesized relationships: life satisfaction (Cantril Ladder) was negatively associated with depressive symptoms (PHQ-9) and positively associated with self-efficacy (GSE). Although the variance explained was modest, the model was statistically significant and consistent with prior literature on adolescents. The lower mean life satisfaction relative to general adolescent populations emphasizes the vulnerability of refugee youth with post-traumatic stress symptoms and underscores the need for robust safety procedures in community interventions like TRT. The results provide evidence that the Cantril Ladder has moderate concurrent validity in this population and can function as a quick, feasible tool to track well-being in session-by-session safety protocols, with low scores prompting more detailed assessments (e.g., suicide risk screening and mental health referral).

The Cantril Ladder demonstrated moderate concurrent validity with depression and self-efficacy among refugee youth experiencing post-traumatic stress symptoms. It appears to be a practical component of safety protocols within community-based interventions to monitor well-being and flag youth needing further support. Future research should confirm these findings in larger samples, expand psychometric evaluation (including face validity and broader construct validity), and consider qualitative approaches to better understand how refugee youth interpret and use the Cantril Ladder.

- Cross-sectional design precludes causal inference. - Reliance on self-report measures and subjective outcomes may introduce measurement bias. - Limited demographic detail captured, restricting analysis of potential confounders/moderators related to life satisfaction. - Modest sample size (N=51), which may limit statistical power and generalizability. - Explanatory power of models was relatively low, though statistically significant, suggesting additional factors influence life satisfaction not captured here.