Promoting the Psych Well Being of Children Following War and Terrorism: Volume 4 NATO Security through Science Series: Human and Societal Dynamics ... Science, Human and Societal Dynamics)

PROMOTING THE PSYCHOSOCIAL WELL BEING OF CHILDREN FOLLOWING WAR AND TERRORISM

NATO Security through Science Series This Series presents the results of scientific meetings supported under the NATO Programme for Security through Science (STS). Meetings supported by the NATO STS Programme are in security-related priority areas of Defence Against Terrorism or Countering Other Threats to Security. The types of meeting supported are generally “Advanced Study Institutes” and “Advanced Research Workshops”. The NATO STS Series collects together the results of these meetings. The meetings are co-organized by scientists from NATO countries and scientists from NATO’s “Partner” or “Mediterranean Dialogue” countries. The observations and recommendations made at the meetings, as well as the contents of the volumes in the Series, reflect those of participants and contributors only; they should not necessarily be regarded as reflecting NATO views or policy. Advanced Study Institutes (ASI) are high-level tutorial courses to convey the latest developments in a subject to an advanced-level audience Advanced Research Workshops (ARW) are expert meetings where an intense but informal exchange of views at the frontiers of a subject aims at identifying directions for future action Following a transformation of the programme in 2004 the Series has been re-named and reorganised. Recent volumes on topics not related to security, which result from meetings supported under the programme earlier, may be found in the NATO Science Series. The Series is published by IOS Press, Amsterdam, and Springer Science and Business Media, Dordrecht, in conjunction with the NATO Public Diplomacy Division. Sub-Series A. B. C. D. E.

Chemistry and Biology Physics and Biophysics Environmental Security Information and Communication Security Human and Societal Dynamics

Springer Science and Business Media Springer Science and Business Media Springer Science and Business Media IOS Press IOS Press

http://www.nato.int/science http://www.springeronline.nl http://www.iospress.nl

Sub-Series E: Human and Societal Dynamics – Vol. 4

ISSN: 1574-5597

Promoting the Psychosocial Well Being of Children Following War and Terrorism

Edited by

Matthew J. Friedman National Center for Post-Traumatic Stress Disorder, US Department of Veterans Affairs and Professor of Psychiatry and Pharmacology, Dartmouth Medical School, Hanover, NH, USA

and

Anica Mikus-Kos Foundation TOGETHER – Regional Center for Psychosocial Well-being of Children, Ljubljana, Slovenia

Amsterdam • Berlin • Oxford • Tokyo • Washington, DC Published in cooperation with NATO Public Diplomacy Division

Proceedings of the NATO Advanced Research Workshop on The Importance of Psychosocial Wellbeing of Children in the Postwar Period for Social Reconstruction and Stability of Terrorist & War Affected Regions Ljubljana, Slovenia 7–9 June 2003

© 2005 IOS Press. All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without prior written permission from the publisher. ISBN 1-58603-558-4 Library of Congress Control Number: 2005932879 Publisher IOS Press Nieuwe Hemweg 6B 1013 BG Amsterdam Netherlands fax: +31 20 687 0019 e-mail: [email protected] Distributor in the UK and Ireland IOS Press/Lavis Marketing 73 Lime Walk Headington Oxford OX3 7AD England fax: +44 1865 750079

Distributor in the USA and Canada IOS Press, Inc. 4502 Rachael Manor Drive Fairfax, VA 22032 USA fax: +1 703 323 3668 e-mail: [email protected]

LEGAL NOTICE The publisher is not responsible for the use which might be made of the following information. PRINTED IN THE NETHERLANDS

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

v

Preface This book resulted from a NATO sponsored Advanced Research Workshop held in Ljubljana, Slovenia June 7–9, 2003. The conference was the inspiration of Anica Mikus-Kos, MD, a highly respected international expert on community-based interventions to promote the psychosocial well being of children following war and terrorism. Twenty-six experts from the former Yugoslavia, the former Soviet Union, Israel, Palestine, NATO countries and elsewhere met for a three-day conference that combined formal didactic presentations with focused discussions. Many participants were accomplished experts with extensive experience in providing community-based interventions for children during post-war reconstruction. Others had scientific experience conducting either research or program evaluation for such interventions. A third group of participants had experience in both the provision and evaluation of psychosocial services to children. These different perspectives are easy to identify from one chapter to the next and provide a creative tension regarding competing approaches to conceptualizing and implementing the most effective interventions. By the close of the conference, it was clear that such alternative views are complementary rather than contradictory. The purpose of this book, therefore, is to show how community-based psychosocial approaches can benefit from a thoughtful synthesis of both experiential and empirical strategies. The range of topics covered theoretical perspectives, practical issues and scientific questions concerning psychosocial interventions for children. The major focus, however, was on community-based interventions that link individual mental health/psychosocial well being with the health and stability of the community. There was much discussion about the best conceptual models within which to characterize the most effective community-based interventions and about whether it was possible to identify general principles for intervention that would be acceptable to all. In addition, three major domains of concern were identified as areas requiring further thought and development: implementation, program evaluation and research, and education and influence. The chapters in this book reflect the richness of the varying perspectives proposed on these issues. A number of conceptual models were presented that included specific case examples. Adjukovic provides a comprehensive theory of social reconstruction in post-war communities that remain torn by ethnic distrust based on a painful collective history. His model emphasizes: recovery from losses, violence and trauma; establishing social norms and tolerance; building community empowerment; promoting tolerance and ability to live together; establishing community trust and cooperation; promoting reconciliation; and achieving community stability and progress. Mikus-Kos provides a ringing challenge to the mental health community, urging it to broaden its focus to the suffering of children in post-conflict situations rather than concentrating on traditional diagnosis and treatment. She provides a vision of how mental health practitioners can achieve desired outcomes more successfully through community-based psychosocial initiatives. Drawing on her experience as director of the

vi

Together Foundation, she illustrates how to translate such a conceptual approach into feasible and effective interventions. Laor and colleagues, drawing on the Israeli experience with disasters and ongoing terrorist attacks, offer a systemic perspective that provides a common professional matrix for medical and social interventions; this approach focuses on disaster as a continuous social phenomenon and proposes models of community-based health and social service delivery. Metraux cautions against a unitary focus on post-traumatic reactions. He asserts that the key to social reconstruction is the working through of collective grief by acknowledging the irreversible loss of both the collective self and collective meanings. Strang and Ager define effective interventions as those that promote psychosocial change through culturally sensitive facilitation and rebuilding of the local infrastructure. They provide a conceptual framework with which to explore the assessment of the impact of events and issues of effective, appropriate and ethical interventions. Several chapters are devoted to detailed exploration of effective strategies for implementation of psychosocial interventions. Major barriers are also considered. Brymer and associates, describing their psychosocial program for children and adolescents in Kosovo, identify three distinct levels that had to be addressed: governmental (including UN divisions and NGOs), child-focused settings within the community (such as schools, children’s hospitals and juvenile detention centers), and training of professionals and paraprofessionals. Boothby and Halprin provide a superb case example in their longitudinal follow-up of Mozambican child soldiers reintegrated into their communities. Among the key psychosocial components that led to a surprisingly successful intervention were: family and community acceptance, traditional cleansing ceremonies, and attachments to adult caretakers and role models. Furthermore, practical participation within the community’s social fabric through marriage, acquisition and maintenance of a home and employment such as farming, all predicted successful reintegration for these severely traumatized former child soldiers. Many institutional barriers to successful implementation were considered. The list is quite extensive as noted in Agani’s chapter regarding the challenge of building child and adolescent mental health services in post-war Kosova. In addition, conference participants expressed great concern about institutional barriers to reconstruction efforts ranging from lack of receptivity by local schools, churches and community leaders to institutional turf wars between UNHCR, UNICEF, WHO, and international NGOs. With regard to program evaluation and research the most important methodological question discussed was the best way to evaluate community-based interventions. Such an assessment must address both qualitative and quantitative variables with scientific rigor in order to generate a valid empirical assessment of community based intervention. The greatest challenge in such an approach is to ensure that such evaluations have sufficient scope and sophistication to encompass the many complexities, contexts and interacting processes that are involved in community-based interventions. In addition, there are important ethical issues that must be taken into consideration when providing community interventions or when conducting an evaluation of such initiatives. All participants were in general agreement that rigorous evaluation is needed to develop evidence-based psychosocial interventions to guide future practice and policy for

vii

program directors, practitioners, donors, stakeholders and the scientific community. They expressed major concern, however, about which indices should be monitored during the reconstruction phase. This is because of a general consensus that traditional quantitative approaches cannot capture many of the most important psychological and functional outcomes at both the individual and community level. Among conference participants, opinion was divided about the best way to implement such an approach. Friedman’s chapter attempts to clarify the scope of the measurement challenge by identifying many of the distinct components that need to be included in any research or evaluation initiative such as: comprehensive assessment of community function, risk factors among affected children and clear strategies for promoting psychosocial well being. Balaban and associates provide a comprehensive review of the methodological challenges associated with rigorous assessment of persisting distress, functional impairment and behavioral/developmental disturbance exhibited by children and adolescents following war and terrorism. They also emphasize the importance of utilizing culturally sensitive instruments that will monitor the post-traumatic psychosocial environment since such factors may constitute independent risk factors for adverse psychological sequelae. This chapter contains a critical review and wealth of information on current empirical findings with assessment instruments utilized with children and adolescents following wars and disasters. Four domains are addressed: post-traumatic stress reactions/disorder, depression, anxiety and behavioral problems/disorders. Psychometric information is provided on all instruments that are cited. Finally, the authors provide a set of recommendations for future research to advance the assessment of children and adolescents after terrorism and disaster. Other chapters identify predictors of resilience and distress among children and adolescents. Baker’s chapter on Palestinian children exposed to the violent uncertainties of the Second Intifada illustrates that psychological, rather than geographic distance from aerial and land bombardment may be much more predictive of posttraumatic distress. Ispanovic-Radojkovic, drawing on her experience with Serbian children affected by war, identifies parental behavior, disruption of social support systems, polarizing ideological beliefs permeating post-war communities and the recreation of a new social memory that will promote psychosocial well-being as major challenges. The final domain addressed at this Advanced Scientific Workshop was education and influence. Given the usual lack of personnel qualified to provide psychosocial interventions, one of the practical challenges is to identify and train indigenous individuals to carry out such interventions. Van der Veer provides a thorough and practical primer for training counselors or psychosocial workers in areas of armed conflict. Such an undertaking requires a clear conceptual understanding about the relationship between theoretical knowledge, practical knowledge and counseling. Basic principles are discussed, and the training is described as an interactive process in which both the participants and the trainer develop their expertise. Conference participants identified many educational barriers: families and children need to be educated about the normalcy of post-traumatic distress in order to overcome the stigma that might interfere with intervention efforts. Community leaders need to be motivated to support and participate in psychosocial intervention efforts. Western mental health professionals require education on culturally sensitive approaches as well as methods for community empowerment. Education as a tool for influencing policy mak-

viii

ers and program directors was also considered at length. Finally, there was discussion about how best to educate and involve the media in this process so that its enormous power to reach the public can be utilized to promote resilience and foster recovery. Unfortunately, wars and terrorism continue to rage. The countless children who survive such violence require our assistance for psychosocial recovery. As we launch community-based interventions to promote individual well being during the reconstruction phase, it is essential that we do our best to provide interventions that work. Recognition of this goal prompted conference participants to propose that we put theory into practice by linking future psychosocial interventions with rigorous evaluation procedures. Given appropriate institutional support, this is clearly an achievable goal. There is a wealth of community, clinical and methodological experience on which to draw. Hopefully, this volume and the spirit of this NATO Advanced Scientific Workshop will promote future progress in this area. Matthew J. Friedman Anica Mikus-Kos

ix

Contents Preface Matthew J. Friedman and Anica Mikus-Kos

v

I. Conceptual Models Social (Re)construction of a Local Community After Massive Traumatization Dean Ajdukovic Activating Community Resources for the Well Being of Children and Stability Anica Mikuš Kos Disaster Intervention: An Integrative Systemic Perspective for Health and Social Service Professionals Nathaniel Laor, Leo Wolmer, Zeev Friedman, Smadar Spirman and Haim Y. Knobler

3

11

33

From Child Well-Being to Social Reconstruction? Jean-Claude Métraux

45

Psychosocial Interventions: Key Issues Facing Practitioners Alison B. Strang and Alastair Ager

61

II. Implementation Issues in the Development of Psychosocial Programs for Children, Adolescents, and Families in Kosovo Melissa J. Brymer, Rune Stuvland and Peter J. Medway Former Mozambican Child Soldier Life Outcome Study Neil Boothby and Jason Halprin Building Child and Adolescent Mental Health Services in a Post-War Kosova Ferid Agani

73

89

105

III. Program Evaluation and Research Post-War Communities Overcoming Traumas and Losses Matthew J. Friedman

113

x

Screening and Assessment for Children’s Psychosocial Needs Following War and Terrorism Victor F. Balaban, Alan M. Steinberg, Melissa J. Brymer, Christopher M. Layne, Russell T. Jones and John A. Fairbank Psychological Impact of Military Violence on Children as a Function of Distance from Traumatic Event: The Palestinian Case Ahmad M. Baker and Hana M. Kanan Growing Up in Communities Affected by War Veronika Ispanovic-Radojkovic

121

163

171

IV. Education and Influence Basic Principles in Training Trainers for Counsellors and Psychosocial Workers in Areas of Armed Conflict Guus van der Veer

181

Author Index

191

I. Conceptual Models

This page intentionally left blank

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

3

Social (Re)construction of a Local Community After Massive Traumatization Dean AJDUKOVIC University of Zagreb, Zagreb, Croatia The role of social contexts of both traumatization and healing from it needs to be considered as they have profound consequences for social reconstruction and reconciliation of communities that have been exposed to upheaval and organized violence. Erikson (1976) [1] used the term loss of communality to describe the consequences of the Buffalo Creek Dam disaster that destroyed many social, emotional and cultural supports systems necessary that otherwise facilitate recovery from trauma. Brom and Kleber (1989) [2] highlighted that the characteristics of a social situation are related to the intensity and content of the distress symptoms and the risks for developing the posttraumatic stress disorder (PTSD). Norris et al. (2002) [3] concluded that declines in social support and social embeddedness explained much of the mental health consequences of natural disasters. Ehrenreich (2002) [4] argued that the terms “social trauma”, “collective trauma” or “mass trauma” better capture the characteristics of repeated and prolonged violence. There is an increasing awareness that in full understanding of the consequences of mass trauma as well as of healing, it is necessary to move beyond the medical “dose-response” paradigm and to devote more study to the social factors that foster resilience or impede recovery. 1. Role of Social Context of Mass Traumatization The social contexts in which mass traumatization of thousands of people occur and in which their recovery should progress have qualities that distinguish them in important ways from individualized traumatization in which a person is a victim of an isolated violent attack, rape or a traffic accident. In the latter case, an individual is severely affected by the traumatic experience that can have implications for the rest of this person’s life. However, if the trauma victim has natural support systems available and if he or she needs professional assistance and has access to it, there is high likelihood of recovery and recapturing the mental health balance and social functioning. On the other had massive violence affects both individuals and the community. Such trauma is a part of the social processes and does not happen all of a sudden. It is typically intentional, meant to hurt and destroy, it is inflicted at selected individual, groups and communities in order to produce horror, suffering and subdue the local population. The consequences of both individual and mass traumatization are longlasting, but in the latter case the support mechanisms are also destroyed, making the recovery doubtful and frustratingly slow. In addition to suffered trauma, the affected people have to cope with a multitude of losses, such as family members and important others, a home, job and social status, the

4

D. Ajdukovic / Social (Re)construction of a Local Community After Massive Traumatization

loss of the home community as they knew it. The increase in family and public violence is a pattern that increases the likelihood of transgenerational transmission of violence. The people feel in such communities feel betrayed by the neighbors; they witness the shift in value systems and moral norms. It is no wonder that they feel disempowerment as individuals and as members of a community. It is extremely difficult for them to believe that the world can be a safe place again. The search for meaning of the past traumatic events and the meaning of the future becomes as important for such people as the reduction of the PTSD symptoms. Thus, understanding of the past that led to mass violence is essential for regaining the psychological balance of individuals and the community in the process of healing. The process of social breakdown described by Useem (1998) [5] helps better understand “what happened” in the societies and in a number of communities such as Srebrenica and Mostar in Bosnia Herzegovina or Vukovar and Kostajnica in Croatia during the period 1990–1995. We know from social psychology that functioning of any society is based on social norms – the accepted and expected behaviors in certain situations. The norms reflect the predominant society’s values, so that people know which behavior is right and desirable, and as such represents behavioral cornerstones. However, in times of upheaval social norms are violated, seemingly without consequences. When people confront previously unimaginable traumatizing events and suffering, the value structure which they have internalized may look inappropriate. Under such circumstances social institutions fail to provide stability and security to the people. In interpersonal relations minor interpersonal differences get blown out of proportion and people become confused, often frightened and feel uncertainty. Questions like: “Who are my neighbors? What is the future for my family and me?” become everyday concerns. The next stage is decreased trust in other people in the community and turning toward one’s own group – relatives, ethnic, religious, or any other group providing psychological safety. In difficult times our preference for contacts with people who belong to our group or that are similar to us grow stronger. Parallel to this, our relations to people who belong to outgroups decay and the negative attributes assigned to them as a group grow. If leaders support such behavior, emphasize the need for homogenization of the group and differences in relation to other groups, the community gradually becomes socially divided and different groups with conflicting interests start perceiving each other as enemies. The communities fall apart. In multiethnic societies, the differences between “ingroup” and “outgroup” that had no significance for social relations, under certain circumstances can suddenly become of paramount importance. According to the analysis of Michael Ignatieff (1999) [6], building on Freud’s old statement on “narcissism of minor differences”, when in a multiethnic country instability evolves, ethnic minorities start believing that the ethnic majority will use its advantage and turn the state institutions into instruments of ethnic dominance, so they start to feel insecure. It leads to the creation of what Ignatieff calls “a fiction of nationalism”. Individuals have the feeling that they cannot equally trust their friends and neighbors from a different ethnic group any longer. An illustration is the case of a woman from our study [7] who had been a very close friend with a married couple of another nationality for thirty years. As she puts it, “We were closer than sisters and brothers”. However, in the spring of 1991, she became alarmed by the fact that her friends preferred to exclusively watch the television program aimed at this ethnic group. She started to doubt the sincerity of their friendship and next started to interpret some of their statements as hostile toward her and her ethnic group.

D. Ajdukovic / Social (Re)construction of a Local Community After Massive Traumatization

5

2. Role of Social Context in Trauma Healing There is strong tendency of people to return to the “normal” level of functioning in their everyday life as son as possible after disasters and social upheaval. After wars and conflicts the people in local communities inevitably meet former adversaries face to face. This is a very difficult experience for the traumatized people who have also suffered multiple losses and often feel betrayed by the important others. Many people also have to cope with the fact that they have missing family members, face unemployment, destroyed housing and community infrastructure, poor social services and schooling, loss of professional identity. Feeling lack of control over one’s life and lack of opportunity for planning one’s own life makes people feel disempowered and helpless, in addition to suffering from post-traumatic symptoms. The after-effects of organized violence extend far beyond the trauma symptoms, both in time and psychosocial implications. Under such conditions, creating the safe and stimulating environment in which the people and communities can heal is an almost impossible task given the priorities of meeting existential needs, rebuilding the infrastructure and lack of awareness for the mental health needs. Communities destroyed by violence need a community approach. The obstacles to putting it to work include the prevailing medical model in treating traumatized individuals regardless of the ethiology of trauma: be it a street rape, traffic accidents, sniper shooting at school children or a major surgery. Another obstacle is the focus almost exclusively on PTSD as a syndrome and treating the individual apart of the social milieu in which the recovery should progress. After organized violence one of the key issues is to reconstruct the meaningful environments. In doing this care-providers should appreciate the integrated, holistic helping approach that considers various levels of the ecology in which the traumatized individual is embedded. Similarly to a family, the community should be empowered to provide a holding context for its traumatized members and groups. However, the key question is: Do communities have such a capacity if they themselves are devastated and often divided across ethnic, religious or racial lines? The task of effective community-based interventions is to help facilitate psychosocial reconstruction of the communities, decrease social tensions among groups that have been involved in a conflict, provide treatment for the most traumatized individuals and work towards re-connecting community members. Therefore, we see the individual recovery from trauma and community social reconstruction as two parallel, interwoven and non-linear processes. While the individuals deal with disturbing posttraumatic symptoms, integrate their traumatic experiences and losses, the communities need to find ways to deal with a painful collective history, overcome conflicting narratives about who-did-what-to-whom among various community groups. The social context needs to be seen as safe enough to facilitate recovery. If the political leadership is determined to work on reinstating social norms and values that promote tolerance, equality and sense of belonging, the social context will be conductive to community and individual healing. If this is not the case, communities will remain divided, leading to very different inter-group perceptions and discriminatory behaviors [8]. We propose that recovery from trauma must be considered both with respect to the social context in which it was inflicted and with respect to the present context which may include strong ethnic or other lines of division, such as tensions among former refugees and the local population, between those that became enormously rich during the war and those who became poor at the same time. This is the context in which mas-

6

D. Ajdukovic / Social (Re)construction of a Local Community After Massive Traumatization

sive losses are grieved by the people whose self-esteem and self-awareness have been damaged, who feel bitter because they feel let down and betrayed by friends, neighbors and fellow citizens in key life moments. No wonder that many report having and altered world view and value system. For instance, in the Croatian city Vukovar whose population tremendously suffered in 1991 during the months-long attacks by the Yugoslav Army and the Serb paramilitaries, the residents agree that before 1999, the relations among ethnic groups used to be very close, and that ethnicity of neighbors, colleagues at work or friends was of no relevance. This social norm has drastically changed and the ethnic makeup became the key social marker in interpersonal relationships. The current practice of Serbian and Croatian children attending separate schools has never been seen before in the city. A high level of community division is evident in sports, arts, and culture. Distrust, feelings of personal insecurity, and almost exclusive involvement with one’s own ethnic group (except at work places and politics) is emphasized by the fact that most of the public places (coffee shops, restaurants) are seen as either “Croatian” or “Serbian”. Though some other countries have been living with similar divisions rooted in social, economic, racial, or religious differences for decades, including dysfunctional parts of major US cities, such experience has not been known in these communities. The key process that may be conducive to recovery from individual and collective traumatization and losses is community social reconstruction. It does not mean a renewal of the former social relationships and social institutions as the people knew it. Too much pain was inflicted among community members to aspire to rebuilding the same social environment as before. It is only possible to search for new forms of relationships, building different social structures and maintaining institutions that facilitate the normal social functioning in a different context that would be able to meet the needs of its members. Social reconstruction can be defined as a process within a community which brings the community’s damaged social functioning to a normal level of interpersonal and groups relations and renews the social fabric of the affected community [9]. We see three parallel and simultaneous processes that comprise community social reconstruction that can lead to favorable outcomes at different levels (Fig. 1). The starting assumption is that basic and existential needs are met to a certain degree, that the political leadership does not hinder the social reconstruction process and that there is the basic rule of law in the society. One of the processes in the model refers to recovery from losses and exposure to violence. It includes raising awareness about the consequences that exposure to mass violence and social transition have on the community, providing treatment to those who need it most. In the community recovery and healing, it is especially important to determine the destiny of missing community members and to enable dignified burial rituals for all members. A central and at the same time a very sensitive issue is the recognition of suffering and status of victims of collective violence. If you are traumatized, you have a valid reason not to believe other people. If your list of important others who betrayed you in a critical moment of your life is long, then you need someone to validate that you are not responsible for what happened to you. It is important that the victim gets such recognition from the community, and, if possible, from the perpetrator of the violence. Accepting the suffering of other people, and the possibility that someone from your own group may have caused it, requires compassion and trust that simply does not exist between former enemies who are overwhelmed by their own pain, victimization and suffering [10].

D. Ajdukovic / Social (Re)construction of a Local Community After Massive Traumatization

7

Figure 1. Model of facilitating community social reconstruction.

Another parallel process is based on activities that contribute to establishing new social norms and tolerance. The role of authorities is important because the messages they send have a strong impact on attitudes and on behavior of people. Messages about whether it is or it is not desirable to build bridges with members of other ethnic groups make people conform to what they think is the current behavioral norm, what is a “politically correct” behavior. Other prominent members of a community can have the same function in the formation of norms. Thus, in building norms, it is important that there is a simultaneous action “top down” as well as “bottom up” [11]. Half a century ago, social psychologist Gordon Allport (1954) [12] found that in order to improve relations between two conflicting groups, they need to maintain contact. Such contacts need to be on equal footing, frequent and supported by people of authority. And last but not least, both sides should share a common goal, while working towards it both sides should keep their independence.

8

D. Ajdukovic / Social (Re)construction of a Local Community After Massive Traumatization

The third parallel process is empowerment of different players of community change. This process should help individuals feel like dignified human beings and help them increase abilities to manage their own lives. At the same time, different systems of social support need to be strengthened, including professional and nonprofessional mental health care-providers. Increasing the feeling of self-esteem and self-efficiency is an important mechanism that improves quality of life of community members. This mechanism also contributes to raising the feeling of safety and community belonging. Over the course of time, through a spontaneous decline in tension, and conscious efforts, one can expect progress towards normalization of the community’s social functioning. At the same time this can let most of the suffering go unrecognized and trauma not worked through, thus making people susceptible to manipulation in the future. On the other hand, active promotion of social reconstruction can hopefully lead towards increased tolerance among the members of a community. The next phase cooperation and building mutual trust, is necessary for achieving overarching goals that are achievable. Social actions that involve members of different groups are a good vehicle towards this phase. It can be expected that trust will grow as a consequence of increased and more frequent contacts in more favorable environments. For social reconstruction to succeed it is important that the community reaches an interpretation of past conflicts that is reasonably acceptable to all parties involved. When there are significantly different narratives of events it is difficult to build relationships because they reflect very different sets of values. Experienced trauma and losses should be recognized and respected in the entire community, regardless of group membership. Sincere sympathy for other people’s losses and suffering is a very powerful bridge to another person. In our studies in Vukovar [8] we observed that a considerable number of Croats believe that the Serbs who remained living in Vukovar after the Croats were forced to flee, were either passive or active accomplices to their suffering. Therefore, they expect from the Serbs a gesture of apology and remorse and help in revealing the truth about their missing family members. On the other hand, the majority of the Serbs that we interviewed emphasize that they personally have not harmed anyone and cannot possible know the fate of the missing Croat neighbors. They do no see any reason to show remorse, recognize the Croats’ suffering and tell them that they too felt powerless in the face of the Serb paramilitaries. Intervention programs during which people from community groups in conflict jointly discuss events of collective violence, learn about the consequences of traumatization and mechanisms of recovery, and share personal experiences, lead to positive change [13]. Such change is a key for social reconstruction, because it may contribute to lowering of traumatic symptoms, increase cooperation with the other groups and mutual readiness to accept sympathy and apology if the other group expresses it. Our experience showed that good results in building connections among members of ethnic groups can be achieved through a program which included: understanding psychological processes related to loss and trauma, recognizing alternatives for constructive conflict resolution, sharing experiences about losses, and the planning social action [7]. In the next phase of social reconstruction, the issues of reconciliation will surface. The concept of reconciliation has a different meaning for different people. Nadler (2002) [10] posits that the key is socio-emotional reconciliation that is oriented toward overcoming conflict-induced feelings. He emphasizes that trust is a precondition for both offering and accepting apology. Namely, the perpetrator must have confidence that the victim will respond with forgiveness and readiness to open a new chapter in their relationship. The victim must have confidence that the perpetrator who asks for

D. Ajdukovic / Social (Re)construction of a Local Community After Massive Traumatization

9

forgiveness is sincere, and not manipulative. Such basic trust is more likely when the conflict ends with shared agreement on who is the victim and who is the perpetrator of violence. In such situations, continues Nadler, there is no need for proving who the victim is, and the perpetrator can expect that his confession of guilt will be returned with forgiveness. However, when there are different interpretations about the victim and perpetrator roles, reconciliation is in trouble. In order to reach key emotions – such as guilt and awareness of responsibility, gradual building of trust between the two sides is necessary. Under very difficult circumstances, when there is no possibility for socioemotional reconciliation, the process of instrumental reconciliation is the second best choice. Instrumental reconciliation, results from a series of steps in which one party needs to cooperate with the former enemy in order to accomplish a shared goal. In our opinion, the social reconstruction process described by our model, accounts for both forms of reconciliation, as conceptualized by Nadler (2002) [10]. Mechanisms for trauma recovery, healing from violence and losses, building social norms and tolerance, and strengthening community resources, can lead to more demanding levels of social reconstruction, including reconciliation. Those communities devastated by collective violence that invest in such a process will probably become more stable, with a greater amount of social capital, and will prosper. In such recovered communities, the victims of trauma will be able to turn to real survivors of trauma. References [1] Erikson, K.T. (1976) Disaster at Buffalo Creek. Loss of communality at Buffalo Creek, American Journal of Psychiatry, 133, 302–305. [2] Brom, D. & Kleber, R.J. (1989). Prevention of posttraumatic stress disorder. Journal of Traumatic Stress, 2, 335–351. [3] Norris, F.H., Byrne, C.B, Diaz, E. and Kaniasty, K. (2002) Psychosocial Resources in the Aftermath of Natural and Human-Caused Disasters: A Review of the Empirical Literature, with Implications for Intervention. White River Junction, VT: National Center for PTSD. [4] Ehrenreich, J. (2002) Caring for others, caring for yourself. New York: Mental Health Workers Without Borders. [5] Useem, B. (1998) Breakdown theories of collective action. Annual Review of Sociology, 24, 215–238. [6] Ignatieff, M. (1998) The warrior’s honor. Ethnic war and the modern concscience. New York: Henry Holt. [7] Ajdukovic, D., Ajdukovic, M. and Corkalo, D. (2002) Community social reconstruction, conflict management and community mental health – pilot project. Zagreb: Society for Psychological Assistance (unpublished). [8] Ajdukovi, D. and Corkalo, D. (in press) Trust and betrayal in war: close interpersonal processes and implications for social reconstruction. In: E. Stover and H. Weinstein (eds.) Rebuilding Communities: Justice in the Aftermath of Genocide and Ethnic Cleansing. Cambridge, MA: Cambridge University Press. [9] Ajduković, D. (2003) Socijalna rekonstrukcija zajednice /Community social reconstruction/. In: D. Ajdukovic (ed.) Socijalna rekonstrukcija zajednice: psihološki procesi, rješavanje sukoba i socijalna akcija /Community social reconstruction: psychological processes, conflict management and social action/. Zagreb: Society for Psychological Assistance, 11–39. [10] Nadler, A. (2002) Postresolution processes: Instrumental and socioemotional routes to reconciliation. In: G. Salomon and B. Nevo (eds.). Peace Education: The Concept, Principles, and Practices Around the World. New Jersey: Lawrence Erlbaum Associates, 127–141. [11] Corkalo, D. (2002) Croatia: For peace education in new democracies. In: G. Salomon and B. Nevo (eds.). Peace Education: The Concept, Principles, and Practices Around the World. New Jersey: Lawrence Erlbaum Associates, 177–186. [12] Allport, G. (1954) The nature of prejudice. Reading, MA: Addison-Wesley. [13] Staub, E. (2002) From healing past wounds to the development of inclusive caring: Contents and processes of peace education. In: G. Salomon and B. Nevo (eds.), Peace Education: The Concept, Principles, and Practices Around the World. New Jersey: Lawrence Erlbaum Associates, 73–86.

This page intentionally left blank

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

11

Activating Community Resources for the Well Being of Children and Stability Anica MIKUŠ KOS Foundation “TOGETHER” – Regional Center for Psychosocial Well being of Children WHO Collaborative Center for Child Mental Health, Counseling Center for Children, Adolescents and Parents, Ljubljana, Slovenia

Sadly, during armed conflicts and related events, children are exposed to the whole range of adversities, frightening events, losses, wounds, as the rest of the civilian population. So much has already been said and written about devastating traumatic experiences of children that there is no need to repeat it. Of importance is the question how children who can not be protected from exposure to adversities and atrocities can be assisted to cope with their experiences afterwards. Supporting and empowering children in this process is inseparably connected with building stability in their communities. Children who perceive the world and humanity as predominantly well-intended are less prone to become perpetrators of interethnic, religious and other conflicts. Providing war-affected children with positive experiences, which will counteract the experienced evil, will positively influence their views on humanity, attitudes, hope, trust and social behavior. The context, meaning and value attributed to traumatic events as well as the feelings caused by such experiences are important co-determinants of future coping capability. Although there is little research evidence, that scientifically confirms the previous statement, there is a great deal of literature on children affected by war that emphasizes the importance of the quality of post war life for their recovery. The quality of post war life is certainly not conditioned by professional therapeutic interventions. It is, instead, how adults, organizations and other important everyday factors in the life of children, provide care, necessities and enrichment. How many children suffer from long lasting psychosocial consequences of war? There is a tendency to exaggerate the number of children who will be chronically or permanently damaged psychologically by war related experiences. This tendency has a number of causes. Mental health professionals consciously or unconsciously tend to overemphasize the importance of their professional services and roles. Such an overemphasis may generate funds and other resources for mental health and psychosocial programs. Political reasons also can contribute to the tendency to exaggerate the long lasting impact of armed conflicts on the mental health of the general population and especially of children. Certainly there may be also other reasons. At the time I wrote this chapter, I found an article describing an interview with a psychologist, published in the leading Slovenian newspaper in 1993, on Bosnian children who came as refugees to Slovenia. Reading this article one gets the impression that aggression, criminal acts,

12

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

suicide attempts and other forms of severe psychosocial disorders will be commonly observed among Bosnian refugee children and youth. But research on the mental health of young Bosnian refugees [1] showed that in the 5th year of exile Bosnian children were doing well according to the following indicators: school achievement, school behavior, police records and adolescent pregnancies. In fact they were doing as well as Slovenian children with the exception of school achievement, which was quite understandable (because of new language, adaptation to new environment, traumatization, and low level of parental education). There are professionals who are very pessimistic and who predict that the majority of war-exposed children will experience long lasting or permanent psychosocial harm. Such statements are questionable. Indeed, there is no epidemiological proof that, in general, children exposed to war have more mental health problems in adulthood than non-exposed children. I am not aware of any epidemiological data showing that adults, who, as children, experienced bloody wars in East-European countries (Belorussia, Poland, Yugoslavia) or in heavily bombed German towns exhibit a higher rate of mental health disorders, as adults, than those who did not experience war. The prediction of the number of children, who will have long lasting psychological/ psychosocial consequences is based on: common sense conclusions, epidemiological studies, follow up studies, clinical observations, theoretical premises, experts’ estimation based on their professional experience and theories to which they adhere, as well as political and ideological attitudes and motives. In a simplified way the basic premises on prognosis at the population level can be presented as a continuum:

The identification of needs for psychological help (which usually means help provided by mental health professionals) is generally done by mental health professionals. According to professional criteria, there is an enormous number of persons who are in need of our help, and we – mental health professionals, are the potential saviors of individuals and consequently also saviors of communities. In reality the great majority of adults and children who experience wars, cope and recover successfully and develop socially healthy personalities. A recent paper, published on the web-side on the epidemiology of the mental health of refugee children. states that 25% of those children have psychosocial disorders (a). The publication on child mental health published on the occasion of the World Mental Health Day 2003 (2003) [2] states that up to 20% of children have mental health disorders. So, the difference between these two estimates is not very great. Warnings of permanent damage are unsubstantiated and should not be used even with the best intention to raise funds for psychosocial programs. UNICEF (2001) [3] states that the psychological consequences of armed conflict on children are so great that they can rarely be repaired. UNICEF indeed says that “time does not heal trauma”,

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

13

but there is no sound empirical basis for a generalization that risks stigmatizing whole populations of children affected by war as sick or permanently damaged. Even child survivors of Auschwitz did not turn out like this as a general rule, and there are no published studies of children from non-Western war zones to support such a conclusion [4]. Suffering Versus Disorders The opinion, that wars do not produce so many psychologically disabled children and adults in the future, does not diminish the huge impact of war related experiences on children’s suffering. But suffering should not be identified as a mental health disorder and impairment in psychosocial functioning. More significantly, war related events and the postwar situation have an important long lasting and deeply engraved influence on the child’s view of humanity, confidence in people and future, attitudes, beliefs and values; in short, they shape the child’s social construction of the world. Working with refugees from Bosnia and Herzegovina [5] and especially with children and adolescents, I have become more and more uncomfortable in using professional jargon or in translating their suffering into clinical diagnoses. Morally and emotionally I have had the feeling that there is something dishonest in reducing the totality of their experience to pathologic semantic categories. The categories of our classifications and our stereotyped professional vocabulary are not adequate to cover their suffering, humiliation, and deprivation on one side as well as their moral, emotional and social richness, and dignity and power to cope on the other side. Therefore I prefer to speak in a human language and not to use the professional vocabulary. In this perspective, I think that the vocabulary of suffering is in many cases more adequate than psychiatric terminology. Even if the therapeutic and “saving” role of mental health professional is much less important than usually presented, there are two major reasons for our moral obligation to protect and support children: preventing their suffering and preventing the development of negative attitudes, lack of confidence in fellow human beings, suspicion, hatred, and seeing the world as dangerous and evil. We, mental health professionals, have the reputation and consequent social authority to advocate for children and to influence the quality of their life. Community based psychosocial programs and those integrated in schools and other every day environments can facilitate the natural healing recovery processes and can counteract the bad experiences. Therefore besides being therapists, the moral obligation of mental health professionals is to become social activists and to transfer their knowledge to other persons of importance to children. Risk and Protective Factors The question is how to provide a restorative counter point to traumatic experiences and losses? Schematically, we can present the adverse impact of war related psychological processes (during the war and in the postwar period) and their outcome as follows:

14

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

From the presented explanatory model of mental health and psychosocial outcome of war related traumas and losses, a more specific question can be raised: What can professionals, international agencies, donors do to alleviate the suffering of children and to promote recovery and coping capacities of children. An especially important question is: How can mental health professionals use their social capital, knowledge, skills, and social power, for helping children in the regions affected by war and in post war circumstances? The presented model explaining the impact of war on children has important practical implications for choosing intervention strategies and for the allocation of money. Explanatory models are not just a pure theoretical and professional issue, they implicate social responsibility and professional ethics, they influence decision makers and they guide donors regarding the allocation of funds. In the presented concept special attention is paid to additional risk factors, which are not directly related to war, but are elements in the consequent chain of stresses and negative interactions. The presence of risk factors increases the probability of psychosocial disorders in a child. It is statistically linked with the psychosocial difficulties or

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

15

disorders among war-exposed children (compared with a randomly selected sample of the children of the same age who were not exposed to similar traumatic events, losses and other adversities). Exposure to multiple stressors, both chronic and acute, decreases the child’s ability to cope successfully. This is another reason why children should be protected from negative social processes in the post war period, such as poverty, injustice, family dysfunction, inadequate health care, poor education, etc. Protective factors and processes orient a child’s response to endangering influences into a positive direction. Those can be located in the child, in the family, in the school or in the broader environment. It is more appropriate to speak about protective processes in which protective factors are interrelated. There are huge individual differences in vulnerability, resiliency and coping. Recent research is uncovering the neuro-physiological basis of those differences. The protective function of the family in war related situation is often diminished as parents are themselves highly traumatized or depressed or not present in the child’s life. For the psychosocial programs aimed to assist all or most children, I have become especially interested in protective factors embedded within the school environment. The school as an institution is the most promising setting for psychosocial programs from which the majority population of children will benefit. The following protective factors were identified within the school environment framework: a safe, supportive and motivating psychosocial climate, teachers as psychosocial helpers providing special support to children in need, good relationships between children and teachers, good relationships with school mates, school achievement, successfulness in a specific subject, successfulness in a specific extracurricular school activity (sports, art, social activities) [6]. The role of the school on the impact of traumatic events and chronic adversities of refugee children. Protective factors in the broader environment are: the existence of a supportive social network, good quality of education, inclusion of children in organized activities, good relationships of children with adults beyond the family circle, good relationships with peers, a general atmosphere that fosters perspective and hope, maintaining the momentum of daily life, religion or other beliefs, etc. Even when family structures and parental capacities are weakened, children can often compensate for those deficiencies through good experiences, through links with other emotionally important persons and through positive experience in basic life systems such as school or church. Good experiences are the most important and the stronger the links, the more likely the child’s development will be influenced positively [7].

16

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

Assessment of Needs Usually the assessment of needs consists in counting children with symptoms. Much less effort is generally focused on the identification of additional adversities and traumatizing influences i.e. additional risk factors, reducing the child’s coping capacities, which could be prevented. The assessment of existing and potential resources and processes in communities and settings, which could protect children and promote their recovery is often neglected. Even the process of assessment can be damaging. The possible re-traumatizing impact of questionnaires on traumatic events is well known. Despite the warning that such questionnaires should only be used when psychological support to children af-

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

17

fected by memories is immediately available, the reality is much different. I have witnessed some trauma screenings, which were very questionable if not unethical. On the other hand, only counting children with symptoms does not say enough about the suffering of children. The difference between symptoms and suffering has already been emphasized in the paper. Unfortunately, when researchers find out the number of traumatized children, their findings do not greatly influence implementation of the programs and interventions. A negligible number among tens or hundreds of thousands of identified traumatized or otherwise psychologically affected children will receive professional mental health help. Community based and population oriented psychosocial programs will cover many more children, but still will be little more than a drop in the sea of the multitude of suffering children. Summerfield questions the conclusions of expansive assessments of needs for mental health interventions. For example, a report on the Balkan conflict stated that although there were 700,000 people in Bosnia-Herzegovina and Croatia with severe trauma needing urgent treatment, the local professionals could only provide services to less than 1% of them [8]. This suggests that an army of new mental health professionals would be needed to handle such a situation. During war, armed conflicts and terrorist attacks, when exposed children are psychologically affected, there is a need to do something or more correctly to do everything possible to help them. This is evident even without thorough estimates provided by costly assessments. Perhaps the previous paragraph reflects the frustration of a field worker who is too eager to initiate psychosocial activities that will diminish the suffering of children. But I speak from my twelve years of experience working with refugees in territories affected by armed conflicts, in which I have had some unpleasant experiences with assessments based on long questionnaires, asking about irrelevant issues. And most frustrating is the fact that all of the data stemming from these questionnaires has had very little impact on helping activities. Sometimes the obsession with assessment goes so far that some mental health professionals who are also policy makers for programs refuse to start psychosocial programs before the assessment is made. Days, months, energy and money are wasted. As UNICEF (2001) (3) stated assessment should focus on two main areas: • •

existing and potential psychosocial stress factors in the community; existing and potential community-based mechanisms for promoting psychosocial well-being and recovery.

Community Based Programs and Programs Imbedded in Existing Institutional Structures By community based programs we mean psychosocial activities that will benefit a considerable or critical number of the population for which the program is aimed. If we speak about psychosocial programs for children for instance, we have in mind programs, which will be available to reach a very great number of children, for instance, all children in primary schools. Another characteristic of community-based programs is that they are mostly embedded in existing structures and not within the framework of newly established autonomous or parallel activities.

18

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

Nowadays community based psychosocial programs reflect prevailing concepts and strategies of support for children affected by war. The main components are: • • • • • • •

activities improving the psychosocial quality of life of children in general non-specific psychosocial approaches integrated in existing social and organizational structures development and empowerment of social networks empowering existing structures of child care and protection linking with natural resource of coping such as local healers, religious organizations, activating and empowering natural resources children’s active participation in improvement of their own situation and the social situation in their community and closer environment providing security as much as possible.

Relief efforts can make matters worse if they reinforce a sense of powerlessness by treating those affected as helpless victims. Members of the affected community should be active partners in planning and carrying out relief efforts. Participation of the community has therapeutic benefits, helping to re-establish meaning and direction in people’s lives, enabling them to gain control over their situation, and raising selfesteem [3]. In all programs involvement of youth is very important. Young people themselves should be involved in community-based relief, recovery and reconstruction programs. One way to give adolescents a sense of meaning and purpose is to involve them in implementing programs for younger children [3]. Including children in pro social activities as volunteers helping for instance younger children in learning or the elderly in daily activities is a good way to involve youth. An excellent program of this kind started in Bosnia in 1996 and is still running. In the frame of the presented strategies the role and the moral obligation of mental health experts is to use their professional knowledge and experience and their social influence in order to develop, spread and promote those concepts and strategies. In chronic emergency situations as in territories affected by war and armed conflicts or in refugee camps, the mental health professional, who is only treating individual children and their parents, is not fulfilling his social obligations towards children and the community in general. The philosophy of community based programs is well presented by Metraux: When speaking about prevention and mental health promotion in the community and with the community, he states that mental health professionals should become multipliers who multiply their knowledge by working with promoters who are in direct contact with the community, such as, teachers, health workers, volunteers and other persons who interact with children in every day life circumstances. The other important characteristic of community based mental health promotion is the development and use of language, which is the language of the community and not the language of the professionals. Using diagnostic labels and esoteric, if not incomprehensible, professional language is not only counterproductive, but also the sign of professional arrogance. The philosophy supporting psychosocial interventions is basically the philosophy of the community, which is enriched with knowledge and know how stemming from the profession. The process of implementing professional interventions must be carefully considered with respect to various theories and approaches. The mental health multiplier should chose those which are acceptable and relevant for each specific psychosocial context.

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

19

Mobilizing creative forces in the community to find resources and strategies to overcome difficulties and to discover the realistic opportunities, which will empower the community and individuals is the most important healing process for individuals and for the community. Community based interventions have another important rationale i.e. that the majority of persons (children, parents) who find themselves in distress will not search for mental health help even when it is available. Why mental health professionals as therapists are not very important from an epidemiological perspective can be explained by quantitative and qualitative reasons: The quantitative aspect: • There are not enough mental health workers and services to help even a minority of psychologically affected persons • Very few people with traumatic experience will seek help from mental health professionals, even when professional help is available. The qualitative aspect: • The priorities of potential users are different, they do not expect the psychological help and are much more interested in practical help • Many people are embarrassed or ashamed to become “psy” clients. The profession is overestimating to a certain degree its “goods” provided to clients. Many ingredients of professional help are present in the interactions and communications between people facing catastrophes. Even without professional guidance, people are aware that symptoms of trauma are a normal reaction to the abnormal situation. The components of the process of debriefing is a part of everyday communication in informal groups of people. For instance: talking about difficulties, comparing symptoms, providing cognitive corrections of the perception of traumatic situation and mutually relieving feelings of guilt, exchanging practical advices, and recognizing the normality of difficulties. Pat Bracen also argued against narrow efforts to reduce mental health intervention to clinical solutions: “I believe that recovery from violence and other forms of war-time suffering depends to a great extent on the recovery (or development) of a “way of life”. In turn, this is always a social (not an individual) phenomenon.” Barmbaum et al. (2004) [9] divide intervention in: Nonspecific psychosocial interventions: • elimination of stresses • reconnection to tradition, culture • reestablishment of trust, self esteem, attachment and social network • regeneration of belief in the future • reestablishment psychosocial network • education Specific mental health intervention: • individual therapy • group therapy. The first groups of intervention are pillars of population oriented and community based intervention.

20

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

Specialized Services or Broad Psychosocial Programs The great majority of traumatized children are not helped by mental health professionals. Usually, the ones most in need do not receive help due to their family situation (very traumatized or depressed parents, etc.), to their living environment (distant villages, etc.). Many children can be helped/cope with “low intensity” interventions.

Community Models Versus Clinical Models

Philosophy

Strategy

Beneficiaries

COMMUNITY BASED MODELS Most for the most Mental health for all children Holistic, comprehensive Not only focused on trauma, focused on the whole range of suffering Improving quality of life Mobilizing resources in the community Supportive and healing atmosphere of the school Supportive environments and social network Low profile interventions All children in the population of children

CLINICAL MODELS Professionals should treat traumatized children

Psychological or psychiatric therapy Treatment of clients Individual therapy Group therapy Clinical methods Intense/high profile interventions Treating children who seek help Few children being clients of psychological services/ professionals

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

21

What can be sometimes observed is that mental health professionals are using the fashionable vocabulary of community work, but in reality their clinical concepts are still operating and reflected in conventionally established programs.

Mental Health Protection in the Post War Situation In many regions the post war situation is characterized by manifold social problems, depression, passivity, and deception. This scenario represents an additional threat to the mental health of the population and affects its coping capacities. The current transition from the socialist to the market economy in East European regions is linked to the deterioration or destruction of existing social systems. Thus, in post-socialist countries affected by war children exposed to traumatic events are also exposed to adversities linked with societal problems due to the transition processes. A huge number of families now face unemployment, poverty, social degradation and social exclusion. These circumstances are affecting children directly and through their families reactions. In addition, solidarity networks are falling to pieces and pre-war value systems are being replaced by values and aims of the market economy. Those processes certainly affect the recovery capacity of children and their mental health. The question is how can the mental health of children and youth be protected in such circumstances. The model of individual therapeutic interventions offered in specialized mental health services is of little value in the epidemiological sense. Community based and school based models of mental health protection and promotion and the public mental health approach are the only feasible ways of reaching an important part of the young population. Specialized mental health services and community based models should be integrated within an inter-sectorial and holistic system of activities. Mental health professionals should assume the social responsibility for mental health protection of all children in the region/ country and not only for those who are their clients. They will fulfill their social roles more successfully by spreading their precious knowledge and skills to the relevant child caring professions and to the community, advocacy and lobbing organizations. They should also strongly cooperate with systems in which children spend an important part of their life such as the schools. Another important strategy is to encourage youth to participate in pro-social voluntary activities. Those have multiple psychosocially positive impacts on involved youth such as developing social skills, self esteem, and providing a meaningful involvement which is highly socially gratifying. In addition, young volunteers assisting children with difficulties constitute a potent human resource of mental health support for those children. International agencies and other donors are prone to cut their support and resources for the protection of the psychosocial well-being and mental health of the population when the war is over. Since the postwar quality of life, psychosocial climate and prevailing morality are of crucial importance for recovery from war related traumas and losses, especially for children and adolescents, such reductions have additional ill effects.

Some New Views on Psychosocial Support and Assistance The main shift in the last years in the field of psychological protection and psychosocial support to children and parents, affected by war, is the shift from the clinical model

22

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

of treating trauma on an individual or small group basis to community based and population oriented programs, following the slogan “mental health for all children”. The basic findings and assumptions generating these changes are: • • • • • • • •

The majority of children in need of help and their parents do not utilize mental health services. Even those who come to ask for help are not necessarily the most traumatized or otherwise psychologically damaged. Children at high risk for psychosocial disorders can be helped directly by child focused interventions. People who themselves suffered from traumatic experiences can function as helpers. Psychosocial interventions for war affected children should include efforts to restore structures, safety and social supports for the entire populations of children. Mobilizing human resources in the community is the most important healing process for individuals and for the community. Children must be viewed as agents, acting on their own behalf. The quality of life in the post war period for the recovery of children is of crucial importance. The implementation of psychosocial approaches in normal every day life surroundings and in their normal surroundings guarantees their access to all children.

In order to provide some assistance to people in need, population oriented and outreaching models should be developed. This statement also applies to the protection of mental health and psychosocial well being of children in circumstances without war and in normal life situations. Under normal circumstances there is much too little effort devoted to attempt to reach the great number of children at risk or with psychosocial disorders who do not appear in mental health services. The most promising approaches of psychosocial protection of children affected by war and other disasters seem to be: • • • • • • • • • • • •

Acting according to the WHO slogan: Mental health for all children Focusing on coping Including a critical mass of involved persons/ institutions Focusing on local capacity building Linking to existing structures (schools, religious organizations, primary health care services, etc.) Giving priorities to community based and school based programs Building the pyramid of mental health protection starting from grass root activities and not from top services Enhancing children’s participation and involving children in meaningful and continuous participation in pro-social activities Including lay people and volunteers as helpers Taking into account the reality of acceptability and accessibility of psychosocial programs of mental health and related services in particular environments Holistic-tackling the total life situation of the child and family Basing interventions on local resources, mobilizing local resources

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

• • •

23

International programs performing in respectful partnership with local structures Broadening the definition of psychosocial interventions for war affected children to include efforts to restore structure, safety and social supports for entire populations of young people. Adapting programs of child protection to the social context, traditions and to the circumstances therefore the main player should be local and regional institutions, non-governmental organizations, professionals and other helpers.

As Yule stated [10] far more work is needed on family and community processes that foster resilience or impede recovery. We know much more about survivors’ problems than we do about how to solve them. We cannot focus solely on individual treatments because disasters affect whole families, whole communities. Moreover, disasters often occur in areas where few mental health professionals are available to provide such care. The most critical need may be to learn more about processes that halt, or even reverse, the erosion of disaster victims’ interpersonal and interpersonal resources that enable them to care for themselves and each other. An over inclusive clinical approach pushing hundreds of thousands of people into the position of psychologically harmed persons does not benefit them. The number of those who could be treated by therapists or are willing to be treated so is a negligible quantity. Then of course there is the question of efficiency of treatment. The number of children who are emotionally affected by war can be counted in tens of thousands or hundreds of thousands or millions. The number of children treated by therapists can be counted in tens or rarely in hundreds. In some villages in Kosovo in which in one day 40 or 60 persons were massacred during the war, no one child was treated by a mental health worker. Despite the influx of huge funds for psychosocial programs and activities of mental health workers, until now precious professional knowledge did not become available for those most in need. Interventions aimed to help children depend on the context in which children live. The situation is certainly different if you work as a therapist in a mental health center in Western Europe or if you work in Kosovo, in Bosnia, or in Chechen refugee camps in Ingushetia. The last three countries are those from which my experience stems. While a therapist in London is seeing children adolescents and parents with psychological disorders looking for therapeutic help and benefiting from it, I see a huge number of children in communities directly affected by war who cope well, who function well, who laugh, and who are emotionally giving persons. Of course, I also see a relatively small number of children who are emotionally harmed by war, but have not been treated and will not be treated by any psychotherapist simply because there are no experts or because parents have no energy, time, or money to take them to mental health service or because they are not familiar with services or because family priorities concerning emotional problems are not seen as important. In the described situation, individual help to children affected by war has a very small impact on the epidemiological situation and different models have to be developed. The Programs Developed by the Foundation “TOGETHER” The Foundation “TOGETHER” – Regional Centre for the Psychosocial Well-being of Children was initiated as an idea to protect and improve the psychosocial well-being of

24

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

children in South-Eastern Europe, specially of those affected by armed conflicts. It was founded in February 2002 by three parties, the NGO – Slovene Philanthropy, the City of Ljubljana and the Slovene Government. The aim of the Foundation “Together” is to mobilize Slovenia’s and international capacities for providing assistance to countries in the region to offer a better future to children as well as to contribute, through community based and child-focused activities, to the stability of the region. The Foundation has the following objectives: • • • •

To develop comprehensive inter-sectoral and inter-disciplinary models of psychosocial protection of children; To mobilize civil society resources on behalf of the well-being of children; To allow for exchange of experience and models of good practice; To develop cross-border networks and facilitate cooperation in the region.

The basic principle of the activities of the Foundation is to strengthen local structures, such as institutional child care organizations and NGO’s, as well as to develop models that can be sustained even after foreign assistance has been withdrawn. We implement programs for psychosocial assistance by developing models promoting children's mental health and quality of life. These models are community based. The most important activities include: •

• • • • • •

Psychosocial training for teachers aimed at strengthening their capacities to help children with special needs, such as traumatized children and otherwise emotionally affected children, and to improve the overall psychosocial climate of school; Training for medical workers helping them to provide psychological assistance to children and parents within the framework of primary health care services; Development of voluntary work as a means of community-based psychosocial help to children and adolescents in need; Development of voluntary work of children and youth as a means of their empowerment, development of social responsibility and prevention of psychosocial disorders; Development and support of child mental health institutions; Organization of conferences and seminars for the exchange of experiences between different countries and the presentation of different models of good practice and development of common projects; Publishing literature on psychosocial subjects.

The philosophy and practice of the Foundation “TOGETHER” stem from the Slovene experience of helping refugees from Bosnia and Herzegovina, who spent more than four years of exile in Slovenia. Lessons learned from this experience are: • • • •

Majority of persons who find themselves in distress will not search for mental health help even when it is available Those who come to ask for help are not necessarily the most traumatized The impact of psychotherapeutic interventions is very limited A sine que non is the adaptation of helping methods to the characteristic of the helped population and to the social context

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

• • •

25

Implementation of psychosocial programs for the whole population of children It is absolutely essential to prevent further traumatization during the life in asylum (e.g. school failure) The structured and predictable life environment (supporting school, good organization of every-day life) is among most important healing and protective factors.

The programs of the Foundation “TOGETHER” are respecting the following principles: • • • • • • • • • • • • • • • • • • •

“Health for all” Mental health for all children Population oriented Most for the most Holistic and inter sectorial Community based School based Critical mass of included persons/ institutions, which could have an impact on the community level Building the pyramid of mental health protection Structural approaches, linked with and integrated in existing structures (primary health care services, schools, kindergartens, volunteers running every day leisure time activities for children) Outreaching (mobile teams) Child oriented Based on local resources Involving volunteers and developing voluntary work of youth Collaboration/ partnership with local NGOs, institutions, local authorities Taking into account the reality of availability, accessibility and acceptability of mental health services Linking different regions of former Yugoslavia Continuous and sustainable Adapted to the social context, cultural traditions and to the circumstances

The following scheme is representing the process of building the pyramid of mental health protection, based from basic structures and networks. What can happen if the higher and more specialized service is created first is that it will not function as expected, because it is not rooted in the community and sufficiently imbedded in relevant basic structures. Simply, the work of the specialized mental health service can be limited by lack of clients (due to negative attitudes toward psychological and psychiatric institutions and professions), by lack of referral from schools, etc.

26

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

Mental health service

Health care

NGO’s Volunteers

Schools

Community structures Basic institutions Networks

In the Foundation “Together”, we have worked to empower and help the recovery of all children in the community and to enable normal social environments in which children live to provide additional and special help to children with particular emotional needs like traumatized children or children who lost their parents, which is a means of helping the recovery of the community and its development. The programs issued from the presented philosophy: Psychosocial programs for teachers in primary schools • •

• •

Primary schools embrace all children aged six to fifteen. The program includes a three day training for 10 local trainers (psychologists, psychiatrists, pedagogues, social pedagogues, social workers, etc.) and 4 three day course modules for teachers. Fifty to 100 teachers included in the 4 module training course are selected. The priority is given to schools from the most affected villages, municipalities and from schools with a very large number of IDP children or returnee children or children otherwise affected by armed conflicts. In between the courses teachers are expected to implement in their schools acquired knowledge, ideas and models of good practice, etc. The main pillar of the program is group work enabling teachers to exchange their own approaches of help to traumatized children and children with psychosocial problems and to discuss new approaches. The program is executed mostly by indigenous professionals (lecturers and trainers), which is an important way of building local capacities.

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

27

The main characteristics of the program are: •

• • • • • •

Development and enhancement of school based activities, aimed to educate and empower teachers for support and assistance to children with psychosocial difficulties and to enrich and improve the psychosocial climate of the school Linking the community with the school and developing methods for the mobilization of resources in the community, specially developing voluntary work Giving participants opportunities for exchange and for active involvement, including discussions on losses and traumas and post war stresses of teachers themselves Motivating and empowering teachers for psychosocial activities Strong emphasis on implementation Continuity Inter-sectorial cooperation – training run by multidisciplinary team.

The most important contents of the seminars were: • • • • • • • • • • • • •

The school system, the psychosocial climate of the schools The protective role of the school and teachers for children at risk and for children with psychosocial problems Traumas and losses Children with psychosocial difficulties and children with special needs Learning difficulties and learning disorders Relationships between peers and education for pro-social behaviour School violence and bullying Poverty – how can the school reduce the impact of poverty on children? Cooperation with parents Cooperation with the community and mobilising resources for the benefit of children and school Volunteers helping children with psychosocial and learning difficulties Children as volunteers The teacher – his work and his family, his professionals burdens and stresses, prevention of burn out.

International experts witnessed a high level of involvement of involved partner NGO’s, schools and participants. Those programs proved to be an efficient way of education and motivation of teachers for psychosocial activities in regions affected by war (Kosovo, Bosnia and Herzegovina, Ingushetia, Iraq) and a good way for capacity building and development of sustainable school based activities. Teachers in spite of their bad economic and otherwise uncertain social position were very enthusiastic in attending training and the level of implementation of acquired know how and new ideas was very high. International experts were again and again surprised by teachers’ good will, practical knowledge and diversity of models of good practice of help to children in distress. Developing voluntary work of children and youth The aim of these programs is to develop, through voluntary work, the sensitivity of children to social problems and to the problems of groups with special needs (handicapped, elderly, those with learning disabilities). Another goal is to provide a frame-

28

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

work within which to help volunteers develop social skills and to discover the sense that they can make a difference through their involvement and efforts. The program consists of the training of mentors who will monitor and supervise the work of young volunteers (primary, secondary and university students). Volunteers are involved continuously and work through the whole academic year, visiting their “client” once per week. An important component is the reflection of the social context in which volunteers work and an appreciation of their role, which represent civic education of youth. Courses for primary health care workers It includes physicians and nurses: The aim of the program is to improve the capacity of medical workers to recognize mental health problems and to develop their capacities to provide some basic help to clients within the framework of their everyday clinical activities. Counseling centers for children and parents The need for such centers stems from previously described basic psychosocial activities. With growing awareness of psychological and psychosocial problems of children and their families, it became apparent that a referral point was needed. The basic approach of the counseling centers is to promote outreach efforts to spread their activities throughout their assigned regions. “TOGETHER” has supported the development of two Counseling centers, one in Gračanica, Bosnia and the other in Ferizaj, Kosovo. The concept and logistic are presented in the following scheme.

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

29

Research and practice In general, the transfer, application and usefulness of research findings for practical work in protecting the mental health and psychosocial well-being of children affected by war are limited. It seems, thank God, that practice is developing much more quickly than evidence based and scientifically proved interventions. For instance the switch from a narrow focus on trauma to the whole range of psychological and psychosocial problems, caused by war and its consequences, from a clinical approach neglecting the social context to a holistic approach, from individual or group treatment of trauma in children affected by war to community wide programs, was and still is a process that is developing more or less independently from scientific evidence. The problem with the new approaches for which we are advocating is that there is a very great lack of scientific validation regarding the positive impact of those approaches. Among the most important statements of the conference Importance of Psychosocial Well being of Children in the Postwar Period for Social Reconstruction and Stability of terrorist and War Affected Regions, was the one about the lack of evaluation research, which is needed to provide evidence based arguments for financing and running community based psychosocial programs. Currently, the arguments favoring this approach are entirely pragmatic, based on social thinking and on common sense thinking. It is difficult to prove that psychosocial programs have an impact on mental health. There are so many more important influences than psychosocial programs: the whole social and political context, the quality of the social network and many others. There are also important methodological difficulties and obstacles to carrying out such research. For instance: it would not be ethical in war related circumstances to form a control group, deprived of help for the sake of research. In some psychosocial programs it also became evident that conducting an evaluation on the impact of the program would be more expensive than the interventional part of the program, itself. To be honest, in my fieldwork I have benefited very little from research. Being deeply immersed in providing assistance, I didn’t need assessment figures about numbers of traumatized children and their symptoms. Research was utilized only when it supported my concepts and proved “scientifically” that my practical solutions were effective. But I acknowledge the importance of research providing evidence that clinical work is important and should be given priority in the rang of helping activities. There is a tremendous need to bridge the gap between research and practice. This means first of all that field workers as users of research findings should define the hierarchy of research needs. Among those certainly is the analysis and evaluation of the impact of the various programs and interventions on the targeted population. To try to overcome this deficit in usable knowledge, a research consortium has been formed, bringing together United Nations agencies, humanitarian NGOs [11] and centers of research. The aim is to develop necessary indicators to assess problems of children affected by armed conflict in different settings, and to create instruments for more effective assessment of interventions. Of special interest will be efforts to develop improved means for assessing the efficacy of interventions. The project is foreseen as a contribution to bridging the gaps between scientific research, policymaking and practical psychosocial interventions.

30

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

About Difficulties, Obstacles and Mistakes in Psychosocial Programs Many mental health programs run and financed by international agencies have the following weakness or mistakes: • • • • • • • • • • • • • • • • • • • • • •

Help comes too late Help is cut when the war ceases/ refugees return Money is wasted for non appropriate programs Inadequately trained and prepared people are sent by international or humanitarian organizations Focusing on trauma and not on the complexity of adversities, being preoccupied by PTSD and ignoring other emotional consequences, psychosocial difficulties and “just” suffering Inadequate collaboration and links between programs Sending foreigners instead of using (enough) domestic professionals and lay helpers Not empowering domestic structures/ professionals, not supporting existing services, building parallel systems Not building (enough) the local capacities for psychosocial and psychological help Not aiming to develop sustainable, durable activities Lack of a developmental and capacity building perspective Assessing the needs according to one’s (foreign experts’) standards Funding programs which do not correspond to the most urgent needs Developing expensive programs for a very small number of children (not necessarily the most psychologically affected) Culturally/ contextually inappropriate programs Funding programs which are not attractive or acceptable to local people Being interested in research and not in helping children (territories affected by war are the promised land for researchers) Being culturally insensitive Not respecting the experience and wisdom and ideas of local people and not taking into consideration the needs expressed by local people Paternalistic or arrogant attitudes toward local people Training with content, which is not relevant for the situation and training without needed efforts for the implementation of the acquired knowledge and know-how Seducing the rare local professionals, buying them (invitation to foreign countries, etc) to adhere to PTSD and other western or fashionable concepts, creating a situation in which even many local professionals are no longer advocating for the real needs of their people.

Concerning difficulties and obstacles in the realization of the psychosocial programs, based on my experience in field work, I identified the following: Inadequate choice of mental health or related professionals •

People without adequate experience, people with clinical experiences, without experiences or preference for community work

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

• • •

31

People using language of the community based interventions, but acting as clinical interventionists People not knowing the context in which they work Arrogant people, lacking esteem and respect towards domestic professionals.

Our involvement in healing traumas can have also some negative motives: • • • • • •

To prove the importance of our profession. To find jobs for western mental health workers or for ourselves Opportunities to be heroic Conquest of geographically and professionally new fields of activities Looking for adventures Political reasons.

Inadequate approaches • • • • • • • • • • • • • •

Clinically oriented Focused on trauma, not taking into account the totality of adversities Not caring about the population of children, looking only for children with trauma or PTSD Failure to respect the social context Failure to utilize domestic resources Failure to not recognize the impact of the natural social network and community Failure to recognize the healing capacities of lay people Failure to not recognize the impact of the broader social context Fashionable programs (example: focused on conflict resolution techniques) “Parachute” programs without continuity Programs not linked or coordinated to other humanitarian activities Training, which is not useful for participants (in content, language, feasibility, etc.) Organizing a multitude of trainings without care for implementation Emergency programs not linked to future long lasting programs, not considering sustainability from the very beginning.

In Conclusion In conclusion to the presented reflections some questions can be raised. Are psychosocial programs for children affected by war needed at all and if so, why? Maybe the question sounds strange, but the fact is that humanity survived thousands of wars and numerous armed conflicts without psychological help, provided by professionals or psychosocial programs. But nowadays the general attitude of humanity towards children is changing. There is a moral obligation expressed in the Convention of Child’s Rights, according to which care givers and other adult persons have the obligation to protect the children and to care about their inner and outer quality of life. Psychosocial programs are a means of such care. So the answer to the posed question is yes.

32

A. Mikuš Kos / Activating Community Resources for the Well Being of Children and Stability

The allocation of money? Should the money be better invested in other ways of helping children than in psychosocial activities? For instance in food? It is difficult to answer this question. The amount of money spent for psychosocial programs is small. The existence of psychosocial programs has a larger meaning than helping relatively small populations of children covered by those programs. Psychosocial programs are in a sense messengers of care for children’s emotional well being. Without those programs the awareness of the obligation to improve the psychosocial quality of life of children would be probably much reduced. What kind of psychosocial assistance and the quality assistance? Much more important than the technical quality of help or chosen methods is the content and quality of human exchange between helpers and those who suffer losses, traumas and injustice, those whose image of the world and humanity was negatively affected by war. Help should be first of all understood as a positive counterpart for all their bad experiences. The role of mental health workers? Mental health workers have the important role of improving the psychosocial climate and activating resources in basic social structures important for children’s lives. Mental health professionals can empower and enhance the knowledge and skills of persons important for children’s wellbeing. In war related situations in which a huge number of children are suffering it is not enough for a mental health professional to perform high profile therapeutic work with a small number of children. His function and social obligations are much broader. In order to offer his knowledge, experience and social power for the benefit of the population and of the community he should become a social activist, educator, facilitator, and mediator.

References [1] Slodnjak V., (1997) Impact of War and Exile Life Conditions on Psychosocial Functioning of Refugee Adolescents. Follow up study. Center for psychosocial help to refugee, Slovene Philanthropy and Open Society Institute. [2] World Mental Health Day 2003: Emotional & Behavioural Disorders of Children & Adolescents. A Global Mental Health Education Program of the World Federation for Mental Health, 2003. [3] UNICEF, United Nations Children’s Fund: Psychosocial Working Group Meeting, Terms of Reference for Macedonia, 2001. [4] Weiss M.G., Saraceno B., Saxena S., Van Ommeren M. (2003): Mental Health in the Aftermath of Disasters: Consensus and Controversy. The Journal of Nervous and Mental Disease. Volume 191, Number 9, pp. 611–615. [5] Mikuš Kos, A., May be it could help somebody. Refugee Participation Network. Refugees Programe, Oxford, 1993, pp. 9–11. [6] Mikuš Kos, A., Protective Role of the School in the Psychosocial Development of the Child. In: Children in the Times of Social Crises. Institute for Educational Research UNESCO UNDP. Belgrade 1997. pp. 60–78. [7] Garbarino, J., (1982). Children and Families in the School Environment. New York: Aldine. [8] Summerfield, (1995). [9] Barenbaum J., Ruchkin V. and Schwab-Stone M. (Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA) (2004). The Psychosocial Aspects of Children Exposed to War: Practice and Policy Initiatives. Journal of Child Psychology and Psychiatry 45:1 pp. 41–62. [10] Yule, W., Bolton, D., Udwin, O., Boyle, S., O’Ryan, D., & Nurrish, J. (2000). The Long-term Psychological Effects of a Disaster Experienced in Adolescence:I: The incidence and course of PTSD. Journal of Child Psychology and Psychiatry and Allied Disciplines, 41. pp. 503–511. [11] Children and Armed Conflict: Data for Improving Intervention and Training: A Program of The Social Science Research Council in collaboration with the Office of the Special Representative of the Secretary-General of the United Nations for Children and Armed Conflict, May 2002.

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

33

Disaster Intervention: An Integrative Systemic Perspective for Health and Social Service Professionals Nathaniel LAOR a,b,c,∗, MD, PhD, Leo WOLMER a,b, MA Zeev FRIEDMAN d, MSW, Smadar SPIRMAN d, MA and Haim Y. KNOBLER e, MD a Tel-Aviv Community Mental Health Center and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel b The Cohen-Harris Center for Trauma and Disaster Intervention, The Association for Children at Risk, Israel c Yale Child Study Center, New Haven, CT d Emergency Treatment System, Population Headquarters, Social Services Administration, Tel Aviv – Jaffa Municipality e Mental Health Department, Medical Corps, Israel Defense Forces

Disasters are calamitous events that occur suddenly and unexpectedly and often involve destruction, physical loss and hardship. They extensively damage properties and lives, and exert a continuous disrupting impact on the matrix, livelihood and vital daily routines of communities and individuals. Disasters can be caused by human negligence, massive acts of violence, or by forces of nature. As demonstrated by the September 11th attack on the US and the March 11th attack on Spain, terrorism, including the threat of non-conventional warfare, may also be vast and far-reaching in its scope and consequences. Most societies are ill-prepared to face the challenge. It therefore behooves us to review our theory and practice in the area of disaster intervention. Higher mortality rates during disasters are associated with greater population density, extreme climate, poverty and poor industrial and economic development [1]. Because disasters occur on such a large scale [2], they disrupt not only individual daily activities but also the functioning of the entire social network. They affect the community’s infrastructure, resulting in a failure to provide for vital needs, widespread unemployment, and major health risks. Extensive destruction may lead to displacement of large populations. Coping is usually further hampered by limited community resources [1], and a poor level of preventive public education and community health services. The formal leadership may collapse, leading to social disarray, norm breaking and delinquent behavior, emergence of mythic ideologies, ascension of informal leadership, and social disintegration into primary affiliations. Even if the event itself is brief, its impact on individuals and society may persist for years. The psychosocial consequences of disaster are characterized by a variety of shortand long-term reactions in the area of mental health. Symptoms of posttrauma, grief and dissociation combine with different types of losses (e.g., family, friends, routines, ∗

Corresponding Author: Nathaniel Laor, MD, PhD, Tel-Aviv Community Mental Health Center, 9 Hatzvi St, Tel-Aviv, 67197. Email: [email protected].

34

N. Laor et al. / Disaster Intervention: An Integrative Systemic Perspective

belongings, neighborhood, homes, trust) in what we define as the “disaster syndrome” [3]. A systemic, social-oriented approach may enhance the effectiveness of health and social service professionals who are required to operate on such a broad scale [4]. Western health delivery systems have traditionally been centered around hospitals. In most Western societies where a system of public health is preserved, community health delivery services are specific and lack integration with community human services like education and welfare. The recent demands for accountability has added a focus on social and economic principles such as those related to privatization and cost containment, on the one hand, and on medical principles such as those related to evidencebased medicine, on the other. These principles may enhance accountability. However, without being complemented by a systemic public health approach they would be implemented at the expense of medical responsibility. It is customary to relegate the responsibility for disaster intervention to agencies dealing with social emergencies like the Army, the Police, or the Fire Department. These agencies themselves may need integration with one another as well as with the medical and mental health systems. They, too, may need a systemic social approach to the disaster phenomenon and the various interventions it requires. Lastly, some of these emergency-related agencies, like the Army or the Police, may be preoccupied with their own primary task while the community needs continuous and extensive professional attention. Unfortunately, most academic medical and health-related programs do not offer their students sufficient knowledge about, and tools for, disaster intervention. To treat the pathology caused by a disastrous event at the different levels affected, health and social service professionals need to formulate the problems at hand and work within the public system, while collaborating with professionals from a wide range of disciplines. They also need to cope with practical problems such as resource allocation, extended deployment, poor organization, information and communication, and be able to endure under continuous stress. This paper examines the role of the health and social service professionals intervening in the various phases of recovery after disaster, including large-scale terrorist attacks. We present a systemic perspective of disaster that allows medical and social interventions a common professional matrix: it focuses on disaster as a continuous social phenomenon and proposes models of community-based health and social service delivery.

The Role of Professional Leadership Leadership is the capacity to define a vision, communicate it effectively and facilitate a process by which a group develops trust and faith and moves in a particular direction. Leadership is about influence and inspiration, setting an example and making a difference. It is a dynamic and relational process involving interactions among leaders, followers and outside parties (individuals, institutions). It requires thoughtful and reflective self-assessment to identify and monitor strengths and weaknesses, both personal and systemic, in order to build effective plans of action [5]. Professional leadership in the areas of health and social service can be the difference between reacting to a disaster or massive trauma within a “neglectful system”, a “responsible system” or within a more advanced framework of “systemic preparedness”. To achieve the latter means transforming paradigms by introducing a shift in

N. Laor et al. / Disaster Intervention: An Integrative Systemic Perspective

35

perspective and focus from hospital based to public health based, from individuals to communities, from curative to preparatory and preventive, and from vulnerability to resilience. Professional leaders aiming at developing systemic preparedness must go beyond defining a vision. They must educate and empower professionals and their mediators (see below), and develop a process of inter-systemic reciprocal representation–that is, comprehensive collaboration bringing members of one system (e.g., community mental health) into key roles in another (e.g., municipal emergency system), and vice versa. This way community resilience is enhanced by the consolidation of an inter-systemic matrix that functions as an eco-niche to integrate and prepare the full range of urban disaster emergency services.

Disaster as a Continuous Process To study the impact of disasters on individuals and communities, Laor and colleagues [3] divided disasters into four stages, each defined by specific characteristics. The pre-disaster stage is characterized by alerting signs of an impending event and may induce uncertainty and a sense of insecurity, particularly in previously traumatized individuals [6]. Not all disasters emit warning signs that allow for appropriate recruitment, however, and this stage is not always present. The first stage of a disaster, the event itself, includes the immediate response (e.g., rescue, evacuation, provision for medical and other vital needs) and is followed by, and sometimes indivisible from, the second stage, defined by massive structural and functional societal damage. The disruption of life routines may have severe deleterious effects on medical and psychological well being. The initial hope of survivors induced by the flood of incoming resources and widespread attention is soon replaced by a rude awakening: the devastation of existential supports and the cumbersome road toward recovery, complicated by insurmountable bureaucracy. The disillusionment brings about feelings of abandonment and injustice. The second stage may last around 18 to 36 months, during which time medical, mental health, and social interventions are offered so as to help the victims recover individual and social well-being. The third stage of disaster is characterized by a persistent strain on social systems (including medical) and general culture. The social systems are called upon to assimilate the experience so that they can provide a sense of security. In this stage, rapid social changes may present a threat to existing collective ideology and identity [7]. The specific culture of the medical system may also need to change and better align itself with goals prescribed by public health and community welfare [8]. If these issues remain unaddressed, their effects may surface months or years later, particularly when re-challenged by emergency. A word concerning terrorism is now in order. Terrorist activity is usually local and its physical effects relatively confined. It aims to erode those civic structures that ensure individual and communal safety, thereby creating a continuous loss of trust in one’s security. Individuals and communities under pervasive or large-scale terrorism may react to the arbitrary, unexpected and uncontrolled nature of the activity, resulting in secondary and tertiary disaster effects. The September 11 th terrorist attacks on the US are the first of their kind, engendering a massive primary disaster with global secondary and tertiary effects.

36

N. Laor et al. / Disaster Intervention: An Integrative Systemic Perspective

Endorsing the Systemic Perspective Disasters pose a tremendous challenge to health and social service professionals, who are confronted with a myriad of clinical disorders, both organic and psychological. In addressing the effects, a number of points must be kept in mind. First, it is important to conduct risk assessment early on and to reach as many people as possible. Screening tools need to be rapid and easy to use, reliable and sensitive, and assess risk factors (e.g., past functioning, disaster related events). This holds true in the area of medicine, in general, and mental health, in particular. One should bear in mind that most injured survivors will display concurrent psychological sequelae. Second, the physical injury usually presents to both the individual and the physician as more vital, and therefore the psychological effects may be ignored. However, conditions such as depression and stress syndromes may be detrimental to the recovery of survivors of disasters who suffer injury to, or the loss of, loved ones. Diagnosis and treatment of the physical and the psychological must go hand in hand. Planners of psychological aid to survivors may need to bear in mind that survivors are often reluctant to seek psychological professional help [9,10]. Moreover, survivors’ psychological profile may change: delayed and complicated responses could appear over time. Therefore, as an inherent part of the aftercare, systematic, broad-scale assessment and outreach programs should be implemented no later than one to three months after the disaster [11]. From a mental health perspective, the post-disaster community should be followed by clinical triage protocols to match risk groups with intervention programs [12,11,13]. Pynoos and colleagues (1998) (8) view the post-disaster role of mental health professionals as being to guide the adaptation of government and social institutions, school communities and intervention teams to suit the newly emerging needs. Data derived from population screening should guide the allocation of institutional responsibilities and resources. The same principles hold for the area of public health at large. It is well established that following a disaster there may be an increase incidence in stress related physical illness. Patients may present to family practitioners, pediatricians, and other medical specialists in the community as well as to the emergency room. For example, the community may show increased cardiac morbidity [14], diabetes [15], and sleep disorders [16]. The systemic intervention approach aims to show sensitivity to the structure of health systems and to the processes within them in response to disaster. It is grounded in the view that in the first stage of disaster (a) all are dealing with vital needs of individuals and (b) there is a great shortage of professionals to handle human suffering. Hence, the primary effects of a massive disaster may include, among others, role dedifferentiation—that is the loss of boundaries between traditionally differentiated roles: doctors may be caring for basic needs, and nurses and paramedics may be taking responsibility for medical procedures that under routine circumstances belong with physicians. For the more sophisticated professionals, the experience of role dedifferentiation may raise questions concerning the relevance of their involvement in the relief efforts. The primary regressive process needs to be counteracted by a process of planned role re-differentiation. This process takes into account the role that relevant community deployed agents (e.g., rescuers, fire brigade, public health workers and school nurses as well as primary care nurses and paramedics) may play as mediators of interventions. These agents are properly suited for the task as they already occupy positions in centers

N. Laor et al. / Disaster Intervention: An Integrative Systemic Perspective

37

of community care, which, during disasters, may be recruited into a program of Social Reactivation to implement large-scale medical and psycho-social interventions. The role of senior professionals is to oversee the whole process. Furthermore, the process should be implemented in a proactive and preventive manner in preparation for potential disasters, by integrating hospital and community, specialists and generalists, professionals and para-professionals, medical experts and service mediators. Five principles guide these activities [17]: Anticipate: Provide an integrated vision; foresee different scenarios and develop contingency plans; train professionals and paraprofessionals; allocate human and economic resources; create treatment protocols; develop local, national and international networks; facilitate collaboration among agencies (education, police, health, etc.); gain sponsorship and legitimacy. Re-differentiate: Identify extent of loss in terms of institutional and role dysfunction; plan role re-differentiation within and between systems; initiate interdisciplinary teams. Empower: Debrief, educate and empower service mediators in related fields who are in direct contact with survivors; help them to adapt and restore original roles; delegate therapeutic responsibilities to these agents. Supervise and assess: Define boundaries, provide knowledge, expertise and support to service mediators; assess program development and arising needs by feedback. Treat and follow-up: Focus on individual and family rehabilitation; consider delayed responses and deal with the tertiary effects of the disaster.

Social Systems and Disaster In times of disaster, health and mental health interventions, besides being wider in scope and more rapid and intense than under normal conditions, are subject to the social system within which they operate. Indeed, it is the preparedness and flexibility of the reacting system that sets the tone for the professional response. Social systems vary in structure, size, make-up, organization, and ideology, and all of these affect the way they respond to disasters. Social systems can be ranked according to their flexibility and adaptability. At one end are the disintegrated, disorganized and dysfunctional chaotic systems, whose response tends to be anarchic. Rigid or static systems are brittle and indifferent to the environment. In times of stress, these systems lack the capacity to adapt structures or functions and, therefore, tend to disintegrate. Learning systems are more flexible, but only in a reactive manner. They are sensitive to the environment, but their scope of adaptability is restricted to routine operations, based on past experience. At the other end of the scale are the meta-adaptive systems, which are both flexible and proactive. They are in effect learning systems that also incorporate facilities for prediction and long- and short-term planning in response to variable scenarios. During the first stage of disaster, rigid systems tend to remain encapsulated in normal routines, learning systems modify structures, create information centers and initiate outreach programs, and meta-adaptive systems, already partly prepared, may initiate the process of re-differentiation, interdisciplinary teaming-up and empowerment. In the second stage, rigid systems treat acute referrals in existing clinics; learning systems establish field stations and initiate self-training toward the formation of larger

38

N. Laor et al. / Disaster Intervention: An Integrative Systemic Perspective

trauma centers. Meta-adaptive systems concentrate on the rehabilitation of roles and institutions, and draw on prepared resources of national and international collaborations. In the third stage, rigid systems deal with (chronic) individuals referred to their clinics, whereas learning systems keep the operation of trauma centers. Both ignore the larger scope of the tertiary disaster: loss of ideology and identity. Learning systems may, however, internalize some of the learned lessons into the institutional response pattern. Meta-adaptive systems focus on the establishment of community-based disaster intervention centers that operate on both the sociocultural and the communal clinical levels to enhance regeneration and growth, and rehabilitate resilience and hardiness. After a disaster, systemic alienation may manifest itself in, and harm, various areas of the community that sustain social resilience and existential trust. It may impact control over the natural environment (reflected in displacement; artificial temporary villages); communal support (withdrawal to fragmented families); effective reliance on technology (refraining from the use of daily life technologies); cooperation with administration (alienation and passivity); pride in culture as a carrier of identity (disrupted cultural meaning and sense of historicity); and loyalty to nation and country as a source of security (feeling dismembered, shamed and betrayed).

Planning for Post-Disaster Interventions An integrated disaster recovery plan ought to focus on the medical system and its potential consumers as well as on the various dimensions of their environment. The consumers are individuals, families, neighborhoods and the entire communities. Individuals and their families may have suffered death or injuries, the loss of their home, and a disruption in their daily routine. Neighborhoods may have undergone physical and economic destruction, relocation, loss of routines, boundaries and safety, disintegration of informal networks, and restrictions on joyful leisure time activities. Finally, whole communities may suffer from poor leadership, insufficient resources, and the destruction of social and cultural institutions. To assist as many survivors as possible, professionals need to turn to already present authorities, and there must be mutual commitment on the parts of community leaders and local agencies. However, professionals should remember that the local mediators themselves have been traumatized and may need training in disaster-related techniques. It may first be necessary to repair the damage caused to the norms and functioning of the communal institutions themselves and to allow authorities (parents, doctors, nurses, etc.) to recover their original roles. Programs need to emphasize the transition from a freeze on past and disaster experiences to a creative future orientation; from a fixation on death and loss to an involvement with life and revitalization; from passive submission to grief, shame and anger to engagement of personal strengths; from withdrawal and alienation to involvement with nature, family, society and technology; and from a mythological world view to a revised sociocultural identity [17]. Interventions in the early, acute stage of disaster include psychological and medical triage in hospitals, schools and evacuation centers, either hands-on or via telephone hot lines. Professionals need to work with local authorities and the media to assess the level of damage and extent of support services. On this basis, they can then plan longer-term community and public health education programs. The mass media can

N. Laor et al. / Disaster Intervention: An Integrative Systemic Perspective

39

correct rumors and educate confused survivors about typical reactions to stress as normal responses and ways to cope with them. Parents can obtain helpful advice to deal with their children’s needs. In the area of mental health, psychological interventions are the first treatment choice. Professionals should be aware of well-intentioned efforts to donate medications and the urge to dispense them in an attempt to rapidly reach masses of individuals. Facilitation of proper support from family and friends, psycho-educative assistance, as well as recovering a “normal” routine may help prevent the development of serious sequelae. School reactivation programs conducted by educators have been found effective in improving the well-being of children and teachers as well as in facilitating the long-term adaptive functioning of the children [18,19]. A word concerning the mobilization of communal resources is now in order. Empowerment is the process by which individuals and communities replace their helpless stance by recovering their dignity and self-esteem, enhancing their critical selfawareness, control over resources and objectives, and sense of personal and collective responsibility [20]. Individuals identify specific needs and discover hidden leadership qualities, while communities gain a greater sense of interdependence, cohesion and cooperation. In dislocated population, empowerment allows communities to form and achieve greater control over their environment. These interventions facilitate the professional entry into the sphere of the long-term effects of the tertiary disaster, the sociocultural losses that threaten existing collective ideology and identity.

Taking Care of the Caretaker Due to the collapse of the sociocultural matrix, including its professional dimensions, team members extensively involved in helping people in stress experience basic rolerelated needs and may display a complex of emotional (disturbing affects); mental (cognition, self-efficacy); physical (fatigue, somatic reactions); behavioral (passivity, withdrawal) and spiritual (loss of meaning, position of caring) responses. In the literature, these are known as burnout, critical incident stress, countertransference, vicarious traumatization, or compassion fatigue [21,22]. The anxiety felt by physicians and nurses coping with the death of colleagues and with fear of their own deaths during the Severe Acute Respiratory Syndrome (SARS) epidemic in East Asia is an example. Post-disaster professional role containment and enhancement is essential to a good outcome. This may be achieved by defining a professional vision, creating an atmosphere of intellectual stimulation (supporting initiatives, delegating authority) and transmitting positive expectations concerning the professionals’ capacities and end results. Team members and those acting as mediators (e.g., paramedics, nurses), need to feel cared for and develop a sense of belonging and purpose. Professionals should be viewed as athletes running marathons, rather than shortdistance races. Awareness of each worker’s strengths, vulnerabilities, and individual losses helps regulate their exposure and prevents burnout. Program leaders need to help relief workers enhance individual coping mechanisms, tolerate the shock inherent in their work, and maintain the high levels of commitment and motivation needed to benefit from their increasing experience [12,23]. Leaders should facilitate adequate training, peer supervision, encourage mutual support, lead debriefing sessions, teach stress management skills and introduce appropriate pauses.

40

N. Laor et al. / Disaster Intervention: An Integrative Systemic Perspective

It is also the leader’s task to manage the work by setting priorities and clear assignments, transferring responsibility for routines, delegating authority, and encouraging the report of difficulties. Leaders and workers share the responsibility of ensuring a balanced life style, taking care of nutrition, sleep and routine, and regulating working hours, leisure and rest. Negative consequences as a result of continuous stress can be avoided by identifying approaching crises and recognizing burnout ahead of time, postponing assignments, avoiding over-identification, keeping professional and ethical boundaries, and ensuring functional flexibility [19,20].

Medical Responsibility and Public Preparedness Preparedness can significantly lessen the detrimental after-effects of a disaster. For example, as part of its Disaster Preparedness Program, the Tel Aviv-Jaffa Municipality has developed a Human Services Emergency Treatment System [24] that focuses on social and psychological welfare. This system is part of the Municipal Emergency Headquarters that includes other systems related to evacuation and absorption, health, and casualties. The Headquarters is activated, for example, in response to terrorist attacks, floods, and technological disasters. The ETS comprises eight multidisciplinary units that deal with on-site crises (triage and evacuation), family notification (of losses), hospital liaison, population behavior (information center), brief psychological support over the phone, emergency shelters (for evacuees), community resources (volunteers and donations), and the delivery of basic needs. The ETS headquarters coordinates the units and their cooperation with relevant institutions (e.g., police, army) as well as with the clinical trauma and disaster community centers, out of which the mental health professionals operate. In response to a crisis, emergency rescue teams are the first to arrive on the scene, followed by municipal multidisciplinary teams (psychologists, social workers, educators, physicians and nurses). The latter screen the vicinity and refer identified victims to Regional Trauma Centers. They also provide immediate assistance (physical and mental) at the disaster site and at evacuation centers. Multidisciplinary clinical teams (psychologists, psychiatrists and social workers) at the Regional Trauma Centers are responsible for the assessment and treatment of individuals, families and whole communities. The Liaison Unit follows-up hospitalized victims by visiting them at their homes upon discharge and referring them to Regional Trauma Centers when appropriate. The Family Notification Unit receives information about casualties from hospitals and from the Victim Identification Center, which is then transferred with sensitivity to the families. This unit also assists in every detail of funeral arrangements. At the Victim Identification Center a liaison representative from intervention teams works with families waiting for information, whereas special mental health teams work closely with the pathologist and the families during and after the identification process. After years during which interventions of the Welfare, Education and Community Mental Health systems have run in parallel without much integration, the Tel-Aviv Model has evolved the capacity to dynamically activate under a single emergency headquarters, a complex process of short- and long-term programs. These may be mobilized following local crises as well as in cases of national emergency, as described in the next two illustrations.

N. Laor et al. / Disaster Intervention: An Integrative Systemic Perspective

41

Following the bombing attack of the youth disco in 2001with dozens of dead and wounded adolescents, most of them from one high school, we established a joint incident command that took responsibility for immediate on-site intervention, and planned a multi-stage integrated program that included (1) school assessment and reactivation (four weeks), (2) school-based clinical interventions (three months), and (3) homebased and community family intervention and support as well as treatment programs (two years). The model was expanded in preparation for the 2003 war in Iraq due to warnings of non-conventional airborne attacks on Israel. Based on our experiences during the 1991 missile attacks in which about 3000 inhabitants were evacuated, we took the threat seriously and implemented a comprehensive program that included in a stepwise manner: • • • • • •

establishment of regional community trauma centers activation of whole neighborhoods by integrating the main institutions dealing with human services (e.g., primary care, schools, welfare, police, home front, medical emergency teams) with one another training and deployment of mobile teams covering cities in the greater Tel Aviv area emergency training of professionals and community leaders nationwide creation of an emergency human services integrated command for the greater Tel Aviv area (call center, communication, transportation and backup) collaboration with the Israeli army to manage the civilian-military interface (e.g., enhancing resilience of military bases, planning for mass evacuation and absorption, developing and implementing an intervention model for traumatized military units led jointly by civilian-military teams).

This model of an urban civilian-military emergency system was developed in collaboration with the Tel Aviv-Jaffa Municipality and the Department of Mental Health of the Israel Defense Forces. It was endorsed by the Surgeon General in 2002 as a model for the country and, with some modifications, is currently being emulated nationwide. However, when one approaches a nationwide model, one should not lose sight of its developmental history. Some areas in our own country and more so in countries that feel less concretely the threat of attack, are less prepared. Our model takes its lessons from the 1991 missile attacks during the Gulf War that caught the Israeli rear unprepared and misguided. Despite the concrete threat and the continuous blows dealt to the rear, the government of Israel was reluctant to declare the situation an emergency, thus avoiding the activation of economic and social structures allocated to deal with disaster. The lacuna left by governmental authorities is sometimes filled by communal agencies and local municipalities. However, these might still fail to attain (a) the formal integration of community health, social and education services with the municipal system, (b) legally prescribed standards for the allocation of resources for the community emergency system, and its activation (such as the acts that prescribed the foundation of the Federal Emergency Management Agency, FEMA, in the US), and (c) the integration of the rear, civil defense, and the emergency economic system, with existing community preparedness resources. In the absence of standards of responsible practice in the area of public health care delivery after disaster, one may easily avoid the issue of public negligence, as it is always defined in reference to the best existing information [25]. The systemic perspec-

42

N. Laor et al. / Disaster Intervention: An Integrative Systemic Perspective

tive on disaster allows us to formulate our partial failure following the Gulf War to develop a fully integrated and responsible community emergency system on the national level in Israel. Perhaps, due to persistent pressing needs and emergencies, we have been limited to intervening in the first and the second stages of disasters alone, leaving tertiary effects only partially attended. Counteracting continuous local and small-scale terrorist attacks may give a struggling community a sense of mastery. This should not come at the expense of ignoring the potential of such attacks to turn disastrous. Postponing the full scale implementation of the lessons of the past may have immediate and long-term consequences in terms of a communal sense of security, as well as real safety. To prevent such grave effects, medical professionals must take leadership and transform their system into a meta-adaptive one, calling into question existing ideologies, theory and practice of service delivery, and education programs, adapting them to face pressing community needs. The challenge to our community and our medical and social service system is common to most Western societies. In today’s global village, lessons can be more easily shared and collaboration generated, with the hope of lessening devastation and suffering.

References [1] Ursano, R.J., Fullerton, C.S. and McCaughey, B.G. (1994), Trauma and disaster, in Ursano, R.J., McCaughey, B.G. and Fullerton, C.S. (Eds.), Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos, Cambridge University Press, Cambridge, pp. 3–27. [2] World Health Organization. (1991), Psychosocial Guidelines for Preparedness and Intervention in Disaster. WHO, Geneva: MNH/PSF/91.3. [3] Laor, N., Wolmer, L., Spirman, S. and Wiener, Z. (2003), “Facing war, terrorism, and disaster: Toward a child-oriented comprehensive emergency care system”. Child and Adolescent Psychiatric Clinics of North America, Vol. 12, pp. 343–361. [4] Henretig, F. (2001), “Biological and chemical terrorism defense: A view from the “front lines” of public health”, American Journal of Public Health, Vol. 91, pp. 718–720. [5] Bass B.M. and Avolio B.J. (1994), Improving organizational effectiveness through transformational leadership. Thousand Oaks, CA: Sage Publications. [6] Toren, P., Wolmer, L., Weizman, R., Magal-Vardi, O. and Laor, N. (2002), “Retraumatization of Israeli civilians during a reactivation of the Gulf War threat”, Journal of Nervous and Mental Disease, Vol. 190, pp. 43–45. [7] Danieli, Y. (1998), Conclusions and future directions, in Danieli, Y. (Ed.), International Handbook of Multigenerational Legacies of Trauma. Plenum Press, NY, pp. 669–689. [8] Pynoos, R.S., Goenjian, A.K. and Steinberg, A.M. (1998), “A public mental health approach to the postdisaster treatment of children and adolescents”, Child and Adolescent Psychiatry Clinics of North America, Vol. 7, pp. 195–210. [9] Norwood, A.E., Ursano, R.J. and Fullerton, C.S. (2000), “Disaster psychiatry: Principles and practice”, Psychiatry Quarterly, Vol. 71, pp. 207–266. [10] Schwarz, E.D. and Kowalski, J.M. (1992), “Malignant memories. Reluctance to utilize mental health services after a disaster”, Journal of Nervous and Mental Disease, Vol. 180, pp. 767–772. [11] Lindy, J.D., Grace, M.C. and Green, B.L. (1981), “Survivors: Outreach to a reluctant population”, American Journal of Orthopsychiatry, Vol. 51, pp. 468–478. [12] Austin, L.S. and Godleski, L.S. (1999), “Therapeutic approaches for survivors of disaster”, Psychiatric Clinics of North America, Vol. 22, pp. 897-910. [13] Pfefferbaum, B., Nixon, S.J., Tucker, P.M., Tivis, R.D., Moore, V.L., Gurwitch, R.H., Pynoos, R.S. and Geis, H.K. (1999), “Posttraumatic stress responses in bereaved children after the Oklahoma City bombing”, Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 38, pp. 1372–1379. [14] Meisel, S.R., Kutz, I., Dayan, K.I., Pauzner, H., Chetboun, I., Arbel, Y. and David, D. (1991), “Effect of Iraqui missile attack on incidence of acute myocardial infarction and sudden death in Israeli civilians”, Lancet, Vol. 338, pp. 66–661.

N. Laor et al. / Disaster Intervention: An Integrative Systemic Perspective

43

[15] Rubinstein, A., Koffler, M., Villa, Y. and Graff, E. (1993), “The Gulf War and diabetes mellitus”. Diabetic Medicine, Vol. 10, pp. 774–776. [16] Mellman, T.A., David, D., Kulick-Bell, R., Hebding, J. and Nolan, B. (1995), “Sleep disturbance and its relationship to psychiatric morbidity after Hurricane Andrew”, American Journal of Psychiatry, Vol. 152, pp. 1659–1663. [17] Laor, N. and Wolmer, L. (2002), “Children exposed to disaster: The role of the mental health professional”, in Lewis, M. (Ed.), Textbook of Child and Adolescent Psychiatry, 3rd ed. Williams and Wilkins, Baltimore, pp. 925–937. [18] Wolmer, L., Laor, N., and Yazgan, Y. (2003), Implementing relief programs in schools after disasters: The teacher as clinical resource. Child and Adolescent Psychiatry Clinics of North America, 12(2), 343–361. [19] Wolmer, L., Laor, N. Dedeoglu, C., Siev, J., and Yazgan, Y. (submitted) Teacher-mediated intervention after disaster: A controlled three-year follow-up of children’s functioning. [20] Rappaport, J. (1987), “Terms of empowerment/exemplars of prevention. Toward a theory for community psychology”, American Journal of Community Psychology, Vol. 15, pp. 121–145. [21] Young, M.A. (1998), The Community Crisis Response Team Training Manual, 2nd edition. National Organization for Victim Assistance, Washington D.C. Retrieved April 20, 2004 from http://www.ojp. usdoj.gov/ovc/publications/infores/crt/. [22] Young, B.H., Ford, J.D., Ruzek, J.I., Friedman, M.J., and Gusman, F.D. (1998). Disaster mental health services: A guidebook for clinicians and administrators. Department of Veterans Affairs. The National Center for Post-Traumatic Stress Disorder. Retrieved April 20, 2004 from http://www.ncptsd.org. [23] Cohen, R.E. (1987), “The Armero tragedy: Lessons for mental health professionals”, Hospital and Community Psychiatry, Vol. 38, pp. 1316–1321. [24] Spirman, S., Friedman, Z. and Buchner, N. (2001), Mass Emergency Treatment System. Tel Aviv-Jaffa Municipality, Tel-Aviv. [25] Laor, N. and Agassi, J. (1990), Diagnosis: Philosophical and Medical Perspectives, Kluwer Academic Press, Dordrecht, The Netherlands.

This page intentionally left blank

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

45

From Child Well-Being to Social Reconstruction? Jean-Claude MÉTRAUX 1

To what extent, in post-war periods, does child well being have an impact on social reconstruction? I will try to answer this question with the aim of improving psychosocial interventions in present or former areas of conflict. As the theme of the international conference held in Ljubljana in June 2003,2 links individual and society, present and future, I will base my argument on the research I conducted during the past two years entitled “Peace and social creation: study of the paradoxical dynamics between individual and collective grief ”.3 Grief is both an individual and collective process. It links past losses with the creation of the future. I have already suggested that individual well being and social reconstruction are not very clear concepts. We often use these kinds of words or expressions without explaining the meaning we give them. Does well-being imply the obliteration of suffering? And, if not, what does it mean? Does social reconstruction necessarily mean the expansion of a western “democratic model” which emphasises individual “liberty”? And, if not, which model does it suggest? Which kind of well-being and social reconstruction do we aim to promote? The perpetrators of crimes against humanity, war crimes and genocides, responsible for the disruption of entire communities, were once children. They often lived, during their childhood or youth, in a post-war period – after World War II or in exYugoslavia. At that time, some of them may have had feelings of relative well-being: nothing could actually prove the contrary. What then were the seeds of war in their young minds? This is of course a difficult, perhaps impossible, question to answer. But let us keep it in mind, in order to avoid being blinded by an apparent well-being, an apparent resilience, which on a long-term basis might produce the brains of future perpetrators of armed conflicts.

Trauma and Grief: An Irreducible Contrast During wars, children and adults experience different kinds of trauma and losses. Such post-traumatic reactions and grief should help us consider the dynamics between childhood well-being and social reconstruction in post-war periods. Although these processes have already received much attention from specialists, some characteristics are 1

Childpsychiatrist, Lausanne, Suisse. E-mail: [email protected]. Workshop “The importance of psychosocial wellbeing of children in the postwar period for social reconstruction ans stability of terrorism and war affected regions”, Ljubljana, June 7th–9th, 2003. 3 This research will constitue the subject of a book « Deuils collectifs et création sociale » which will be published in March 2003 (Paris, Editions La Dispute). 2

46

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

often omitted or misunderstood. Among others, many authors still consider loss as a trauma. But ttrauma and losses, or post-traumatic reactions and grief should be distinguished, and even understood as opposites. First at a phenomenological level: trauma consists of an excess of sensations, which saturate the canals of perception and leave no place for other perceptions; as new and unknown sensations such as post-traumatic feelings. Trauma also becomes a new frame of reference for future perceptions, whatever they are. 4 In contrast, loss implies that a former source of sensations, and perceptions have completely vanished. This first dichotomy is neither the only one, nor the most important for our present discussion. Trauma always has a destructive impact. It destroys past meanings, even threatening the human ability of giving meaning: a major aspect of the highly valued concept of resilience. If many persons who survive after traumatic experiences, “adapt themselves” to unspeakable events, such coping does not imply absence of impact, as the word “adaptation” might suggest. Described as a prototype of resilience by Boris Cyrulnik,5 Stanislas Tomkiewicz, a psychiatrist who lived his adolescence in Warsaw ghetto and his youth in concentration camps, said himself that his successful coping did not help him to recover his lost adolescence.6 Furthermore, the coping mechanisms may cease to be effective at any time.7 As adaptive processes, they may break down when the context changes and requires a new adaptation. Losses, on the contrary, are creative tragedies. Grief processes sow the seeds for creating meanings. Early child development is already directed by an original grief, consecutive to the initial separation from the mother:8 obliged to relinquish its omnipotence, the baby cannot continue to think, “he is the world”. Archaeology has also discovered that the first cultural objects left by all past societies are linked with funerals, such as graves. Thus, grief seems to constitute the matrix of individuals and societies. Trauma and grief have very different impacts on memories. To remember something, either for an individual or a community, means first that the experienced event vanished, is now absent, and secondly that we created an image which is now present in our minds.9 And the disappearance of a past reality associated with the creation of an image constitutes the exact definition of a grief process,10 with the understanding that this image of lost reality never stops transforming itself, during and after the working through process. In order to understand how grief is the creator of memories, of all memories, a short review of individual grief processes is useful. According to John Bowlby 11 and Michel Hanus,12 they involve three main stages: The “state of shock” (Hanus), “blazing wish of again finding the lost one” (Bowlby), is characterised by the negation of the irreversibility of death which alternates with attempts to either rediscover the deceased or to forget his death;

4

Jean-Luc Ferry, Les puissances de l’expérience, I, Paris, Editions du Cerf, 1991. Author, among other titles, of « Un merveilleux malheur » (Paris, Odile Jacob, 1999) where he defends the concept of resilience. 6 Stanislas Tomkiewicz, L’adolescence volée, Paris, Calmann-Levy, 1999. 7 Serge Tisseron, Le Monde Diplomatique, August 2003, p. 32. 8 Donald W. Winnicott, Jeu et réalité, Paris, Gallimard, 1975. 9 Paul Ricoeur, La mémoire, l’histoire, l’oubli, Paris, Seuil, 2000. 10 Jean-Claude Métraux, Approche systémique des familles en deuil. Neuropsy, 6, 4, pp. 193–202, 1991. 11 John Bowlby, Attachment and Loss III, Loss: Sadness and Depression, London, Penguin Books, 1980. 12 Michel Hanus, Les deuils dans la vie, Paris, Maloine, 2001. 5

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

47

The stage of “disorganisation” (Hanus), “despair and depression” (Bowlby), which requires a clear acknowledgement of the irreversibility of loss, the definitive absence of past reality; The stage of reorganisation (Hanus) or restoration (Bowlby). It is reached when the memory, previously focused on the loss itself, the gap excavated by this loss, turns towards shared experiences – with or through the lost person – which might feed one’s own future. Such a new image articulates past experienced events in a single narrative, and then re-creates the narrative identity.13 I personally prefer to name these three stages respectively: closing stage or denial stage, opening stage or depressive stage memory stage. Many griefs follow this process without too many difficulties. Others indefinitely fossilise at one of its two first stages:14 the creative potential of grief is then inhibited. Trauma, on the other hand, produces both impossible memories of unspeakable facts and repetitive resurgence of traumatic events, known as flashbacks. Survivors express the understandable wish of forgetting these unforgettable pains that invade them day and night. The present, stuck to the past, becomes an endless repetition. There is no feeling of absence, no transformation of experienced reality into genuine images, no possibility of changing, colouring or enriching the narration of the past of evolution or change of the images. In other words, trauma prevents true memories. Thus, trauma and loss lead to radically different conceptions of time. Trauma congeals time and amputates one’s narrative identity.15 Victims cannot yet link past history, prior to traumatic events, and actual life. Thus memories of previous experiences become inaccessible. Meanwhile the working through of grief allows time to breathe. By the creation of memories, grief links past to present, allows the use of past experiences as bricks for the construction of tomorrow – what undoubtedly is essential during periods of social reconstruction. Further, by integrating all significant life events into a unique and coherent narration, this process of linking times reconstructs the narrative identity after any crucial event. Grief, therefore, is the best medicine to cure identities broken by trauma.16

From Individual to Collective Grief Processes If theoreticians, despite careful observations, have often missed the contrast between trauma and loss, as well as the creative potential of grief, they have also omitted other essential elements. They have not understood that collective grief over lost meanings goes through the same stages as for individuals. They have also paid little attention to 13

Paul Ricoeur, op. cit. Jean-Claude Métraux, Broken bridges – community grief processes as a key factor for the development of individual, family and community ressources. In van Willigen L. (Ed.), Health hazards of organised violence in children (II), Pharos, Utrecht, pp. 93–110, 2000. 15 Jean-Claude Métraux, Au temps du silence, la nosographie reste muette. Les syndromes posttraumatiques en question. In Maqueda F. (Ed.), Traumatismes de guerre. Actualités cliniques et humanitaires, Hommes et perspectives, Paris, pp. 41–66, 1999. 16 Jean-Claude Métraux, De la victime à l’acteur. Adolescence, 19, 2, pp. 579–607, 2001. 14

48

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

collective grief, except in the specific cases of family grief and with regard to extreme situations such as genocides.17 But, even in such context, they have failed to give a clear definition of “collective grief” or to distinguish it from collective trauma. Finally, most theoreticians never understood that in situations of extreme poverty, wars and even post-war periods, when persons in mourning must struggle every day for their own survival, grief processes usually freeze before they can begin.18 For the man or woman who only hopes he or she will survive until nightfall, the working through of losses represents a very dangerous risk: the depressive stage weakens the constant vigilance necessary to detect and face threats. This explains why depressive symptoms are some kind of luxury that seldom occur during wars and early post-war periods.19 Frozen grief is characterised by a fixation on the present time, or hypervigilance, and by a priority accorded to physical survival and to the survival of personal identity. Fixated on their present fate, people are unable to imagine any future: refugees, asylum seekers and displaced persons cannot think either of a return20 home or of a long-term stay in the host region or country. Community, on the other hand, receives more attention than individuals. Homogeneity is required to rescue a collective identity and later transmit it to survivors’ children. Individuals are tied by this collective imperative: they may hardly choose freely their own personal way, or even work through their individual grief before the whole community begins such a process. In communities where missing persons are numerous, where no corpse documents a husband’s, father’s or brother’s death, the postponed acknowledgement of this irreversible loss adversely affects any focus on identity survival. Then, in damned communities condemned to survival, individual and collective grief processes cannot be separated. This suggests that every stage of individual grief has a translation on the collective level. And we are led to study the destiny of collective grief, in dreadful contexts as well as in more secure environments. We need first to specify the definition of collective losses and grief. The total sum of individual losses, even simultaneous and similar, is insufficient: every one, in such a case, works through his or her personal grief related to the loss of a different object, person or meaning. Even though the emotions might be more or less similar among all group members, it does not necessarily imply a collective process. There must be the loss of a common “object”. In an organization of widows or mothers in which every member lost a husband, son or daughter and every member works through a personal grief: the collective loss concerns the absence of remains, of corpses, which is shared by all these women and even is the meaning of their organization. It means that only a community, defined by the presence of a collective self and shared meanings, may experience a collective loss. I will illustrate this definition and the difficulties it implies by the tragic case of Srebrenica, in East Bosnia. Whom does the expression “Srebrenica community” designate today? The previous inhabitants, who have mostly been killed or dispersed all over world? The numerous people who fled to Bratunac and nearby villages before enduring 17

Michel Hanus et coll., Morts et deuils collectifs, Revue de la Société de Thanatologie, No 123, 2003. Jean-Claude Métraux, Aux temps de la survie, le droit au silence. Bulletin trimestriel de la Fondation Auschwitz, No 69, pp. 43–50, 2000. (Reproduction of Revue Médicale de la Suisse Romande, 117, No 5, pp. 419–424, 1997). 19 Milton J. Friedman, Post-war communities overcoming traumas and losses, Conference held in Ljubljana, Workshop “The importance of psychosocial wellbeing of children in the postwar period for social reconstruction ans stability of terrorist and war affected regions”, June 7th, 2003. 20 In the case of Srebrenica, the politics of Republika Srpska which does all to prevent returnees to come back, strengthens this tendency, but does not explain the whole phenomenon. 18

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

49

the siege in the martyred city? The actual population, mainly Serbs who occupied the empty houses after the slaughters? The difficulty of specification shows that the original collective self was completely disrupted. Split into an infinity of microcommunities, haunted by the ghosts of so many missing persons, the survivors can only think of their community as a dream or a nightmare. Furthermore, past shared collective meanings also disappeared, to the point that it is today nearly impossible to discover what they were. We may only identify the new meanings, which substituted for them. Among these new meanings, there are some, probably most of them, that are specific to each micro-community: refugees in so many countries, asylum seekers, displaced persons, returnees, old women, young orphans and so on. Other new meanings, such as searching with despair for the lost collective identity or building a return myth – “all former inhabitants will once go back”, try to restore the fiction of a unique community: they offer an identity of substitution, a shared collective meaning by default. Consequently, there are two main categories of collective losses and grief: 21 the loss of collective self and the loss of collective meanings. And as the present community is never the mere copy of past and future ones, as meanings die, change and flourish, as each community has a memory of its past meanings articulated by collective narratives, we may deduce that collective losses and grief are frequent in any community, even when its history has not been an endless succession of tragedy.

Grief of the Collective Self The community is not the same as it was before. The “we” is not the same “we”, has not the same borders, does not include the same persons. In the case of Srebrenica, the death of so many men and the violation of so many women seriously compromised even the possibility of a collective self in future generations. The loss of missing persons’ remains, when corpses are not discovered and identified, as well as the dispersion of survivors all over the world, disrupted real and symbolic links so that the community nowadays seems spectral or mythic. And by the disappearance of its former structure, from a common earth to a common landscape, the collective self also lost its physical anchoring. Collective grief follows a similar process as individual grief. The stages are the same and both kinds of grief may fossilise during the closing or opening stages. But, because of the different characteristics of psychological and social organisations, because also of the permanent interaction between individual and collective grief, their dynamics differ. In frozen grief – or “zero” stage – we have already observed that it is nearly impossible to distinguish the individual and collective dimensions of grief. In the closing – or denial – stage, the community fabricates an artificial self, which maintains the illusion of permanence. For example, families in mourning who 21 There are three kinds of individual losses (Jean-Claude Métraux, Deuils collectifs et création sociale, Paris, Editions La Dispute, 2003): a) loss of external objects or persons, in other words the loss of another; their grief leads to the construction or reconstruction of self. b) loss of self; their grief leads to the construction or reconstruction of meanings. c) loss of meanings; their grief leads to the creations of personal Values.

50

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

“fabricate” a substitute child to replace a dead one,22 by giving him the same first name exemplify a typical case of fossilisation. In broader collective grief, there are different kinds of “fabrication”. First, the re-writing of genealogies in order to assert a consanguinity with mythic ancestors: this approach has been utilized from ancient Greek genealogists to imperial Japan in the 5th century,23 from Indonesian Bugi-Masar in 17th century24 to contemporaneous nationalist and fundamentalist movements all over the world. Secondly, the construction of monuments dedicated to the memory of dead and disappeared people, such as the recently inaugurated monument in Potocari, a few kilometres from Srebrenica, or the Yad Vashem, erected half a century ago, as the memorial of the victims of the Shoah in Jerusalem. If such a “fabrication” helps the community and its members to acknowledge the loss, to later enter into the depressive stage, it sometimes happens that the collective grief nevertheless remains paralysed at that phase: “abuses of memory”25 then become a real threat. (In order to reduce this risk, some artists proposed memorials in movement, progressively disappearing or perpetually re-constructed, even re-created, by the contemporaries.26) Thirdly, the constitution of Truth and Reconciliation commissions, reports and actions. Once again these initiatives attest to an awareness, an intent of overstepping the denial. Now and then, as in South Africa, it succeeds, provided that once the commission’s formal agenda is achieved, it allows for the possibility of entering into a new stage. This condition implies the necessity of accepting, even with pain, that a perfect truth is never reached, that any reconciliation is by definition a creative and unpredictable process. But, if Truth and Reconciliation aspires to some kind of mythical ideals, a forever unending aim to which the community dedicates indefinitely all its endeavours, these ethical imperatives transform themselves into figures of denial. This is because the word “Re-conciliation” creates the illusion of being able to restore lost collective self. Meanwhile the idea of a unique Truth, linked with a gone past, fossilises the collective narrative identity, excluding most events of the more recent past – nearly sixty years in the Israeli case. The long-term search of a “true Truth”, when a traumatic “past does not go past”,27 creates the fantasy of being able to master a past that is impossible to master. In that case, another kind of denial, linked with another fossilised grief of meaning, will then impregnate the society. Let us also mention many organizations of missing persons’ families: their members dedicate their entire energy to find all lost remains and to demand from authorities the restitution of all corpses. Even if this objective is politically understandable, even if the identification of skeletons helps family members’ individual grief, it is impossible to forget that the restitution of corpses will never happen for all missing persons. And, as in Argentina, grief concerning remains continues to be stuck in the first stage for twenty-five years or more. The danger: the 22 E.O. Poznansky, The “replacement child”: A saga of unresolved parental grief, J. Pediat. 81(6), 1190– 1193, 1972. 23 François Macé, La double écriture des traditions dans le Japon du VIIIème siècle. Fondation et refondation, histoire et recommencements. In M. Détienne et coll., Transcrire les mythologies, Paris, Albin Michel, 1994, pp. 77–102. 24 Gilbert Hamonic, L’histoire comme éclatée… Deux ordres de conservation du passé en pays bugismakassar (Célèbes-Sud, Indonésie). In M. Détienne et coll., Transcrire les mythologies, Paris, Albin Michel, 1994, pp. 114–128. 25 Paul Ricoeur, La mémoire, l’histoire, l’oubli, Paris, Seuil, 2000. 26 Régine Robin, La mémoire saturée, Paris, Stock, 2003, pp. 372–373. 27 An expression from the historian Henri Rousso about what he named “the grief of Vichy” after the World War II in France (Le deuil de Vichy de 1944 à nos jours, Paris, Seuil, 1987).

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

51

artificial collective self which is “fabricated” includes the missing persons and their family members but tends to exclude the other survivors, the persons who could bury their killed loved ones or did not lose anybody. New breaches tear the social fabric. Of course, the usual authorities’ efforts to promote collective amnesia strengthens their tendency to hyperamnesia which are both symptoms of collective denial. We observe thus that “fabrication” constitutes a necessary step in any collective grief process: usefulness of cemeteries, monuments, Truth and Reconciliation commissions, in order to allow communities to acknowledge their irreversible losses and later to begin the transition towards the depressive stage. But, at the same time, if the grief fossilises at this denial stage, the fabrication becomes a goal in itself and the risks are numerous for any society. In the opening – or depressive – stage, that is after the acknowledgement of an irreversibly lost collective self, new configurations and representations of collective self emerge in a community whose members are submerged by emotions, sadness and culpability among others. But, for community survival, to let all members simultaneously begin their own depressive stages would be too risky: some must remain vigilant while others’ defences are weakened. It leads to a differentiation between members. Cohesion lessens. Solidarity may even vanish. Sometimes, in true conspiracies of culpability, 28 some members form a coalition and accuse others of expressing too little or too much sadness. Internal conflicts and splits, may emerge. In our former example, if all women members of the organization simultaneously acknowledge the impossibility of finding remains of all missing persons, and then enter together into a depressive stage, vigilance in the face of government’s passivity, amnesia or hypocrisy would lessen. The risk of losing their ethical fight would increase dangerously. Then, it is useful for the survival of their organization and struggle, even for the whole society, that some people remain at the denial stage while others become aware of the irreversibility of their loss: some remains will be lost forever and the community will have once to deal with the missing of its former self. But this awareness, at least if publicly expressed, will hurt other members, still fixed in the denial stage. They might even foment a conspiracy of culpability against the iconoclasts who dared “to accept the unacceptable” (emergence of new representations), and even exclude them (emergence of a new configuration). The organization might then quickly split in two or more factions. The depressive stage explains the dissatisfactions in South Africa about the Truth and Reconciliation process: the dissatisfactions do not mean that Truth and Reconciliation Commission did not perform its work well; it means that the Commission finished its work and that the society entered into a new stage. But it also shows that this depressive stage is the most dangerous period for any community: many societies “prefer” never to cross the threshold. During the memory stage, the community creates new collective meanings adjusted to its new self. Lost remains of missing persons give birth to memories of remains, to symbolic substitutes of real remains and funerals that will sow the future. As empty stretchers, more than two thousand and four hundred years ago… in the wellknown Pericles’ funeral oration,29 most beautiful hymn to a democracy that does not usurp its name. (Actual psychologists and psychiatrists should be a little bit more modest!) As testimonies of irreversibility, such substitutive rituals already further the indi28 Analogy with a figure observed at the family level. Cf. K. Tooley, The choice of a survival sibling as “scapegoat” in some cases of maternal bereavement – a case report. J. Child Psychol. Psychiat. 16, 331–339, 1975. 29 Thucydide, La Guerre du Péloponnèse, Paris, Gallimard, coll. Folio, 2000.

52

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

vidual working through in individual grief of missing loved ones. They also allow the identification of other kinds of remains: the breath of the agora, the whisper of a mistreated dignity or other muzzled voices. The demands for corpses and their identification take then a new meaning: the re-creation of a collective memory drawn in the bogs of history. And this new meaning may be shared by all survivors, even by those who still did not work through their individual grief over missing remains. Since the dawn of humanity collective grief has been the melting-pot in which collective meanings originated, the springs of cultures and founts of identities. Therefore, every stage of collective grief produces innovations, whose type – artificial self, representations, new collective meanings – and process – fabrication, emergence or creation – differ.

Grief of Collective Meanings As communities are always the unique creators of their shared meanings, only they can decree their death: when some people call on others to grieve over their past ideals, it reveals an abuse of power, that is also impossible to fulfil. Any added meaning, after any successful grieving for a past self, means the loss of a previous bundle of meanings. It then leads to a collective grief process. Reciprocally, human beings are semantic creatures who cannot live without meanings: the Hungarian writer Imre Kertèsz showed that it was even true after the hell of Auschwitz. 30 Therefore, a new bundle of meanings, bearing the imprint of grief, immediately substitutes for the lost one: it implies that any meaning involves a matrix that reveals which stage was achieved in the prior grieving process. I name these matrices Collective Values31 – analogous to imaginary significations in Castoriadis’ language.32 They articulate past and present meanings and interpret the change of meanings through history. What does it concretely mean? When grief over meanings remains frozen – mainly in a context of daily survival –, communities dedicate their strengths to the preservation of their collective identity. Actual meanings, supposedly eternal, are considered identical to those of ancestors. The illusion of permanence remains although meanings change. Survival, as a Collective Value, may be recognised in nearly all “archaic” and “traditional” communities, from their structure of parenthood to their origin myth. During the closing – or denial – stage, communities do not acknowledge the loss of meaning which they instigated themselves. For example, past militants of lost revolutions whose new discourse, embedded within current globalisation, reveals the unceasing postponed mourning of their past ideals. Communities endeavour to simultaneously resuscitate them and bury their shadow from collective memory. In order to fulfil these paradoxical requirements, they fabricate an hallucinatory world or an hallucinatory self according to their unreasonable hopes: they interpret the history of their collective meanings, the articulation between present and past ones, as a linear and uninterrupted progression towards their hallucinatory conceptions of world and self. Mastering – of nature, time and anything else – becomes then the Collective Value, among others, to master both history and the future. Communities consider present as an im30

Imre Kertèsz, Kaddish pour l’enfant qui ne naîtra pas, Arles, Actes Sud, 1995. I put a capital letter to Values in order to designate this specific kind of values. 32 Cornelius Castoriadis, L’institution imaginaire de la société, Paris, Seuil, 1975. 31

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

53

provement over past and future as the predicted improvement of the present: values “sold” by modernity have thus interpreted the history of social meanings as a constant progression since the birth of humanity. These linear scales of progress, towards an hallucinatory future imply an increasing differentiation inside the communities. Faster or slower, stronger or weaker, right or wrong, modern or traditional, dominator or dominated people perform their task of mastering better or worse. Others cannot simply rise above their own Weltanschauung. And individuals’ optical illusions, seem then to prevail on communities. A comparison between Survival and Mastering shows that the apparent emphasis put by a society on individual or on community – individualism versus holism according to the vocabulary of Louis Dumont33 – is determined by security feelings, versus insecurity ones, that the environment propitiates in the mere perspective of community survival: unpretentiousness is once again required from western societies. All the more if we consider the now revealed origin of individualism: collective grief fossilised at the initial stage, thus remains in its baby diapers! Despite their radical differences, combinations between Survival and Mastering do exist. When, for good or bad reasons, a society governed by Mastering fears for the survival of its nuclear Value, a syncretic figure appears: as in Germany between the two World Wars, constrained to survival by the Versailles treaty, Survival of Mastering offers a ground to totalitarianism. And when communities formerly founded on Mastering convert themselves to Survival, after recent new losses of meanings, they may use their old techniques of denial in order to impose their present goal – survival of a threatened identity – to members and neighbours: such a Mastering of Survival may be observed in many fundamentalist, nationalist, racist and extreme right-wing movements. At the time of the opening – or depressive – stage, communities painfully feel the empty space left by lost meanings. As in our contemporaneous western societies, they then tend then to idealise past delight, feel nostalgia as well as culpability for having lost it. Some communities believe that God, Gods or their substitutes – such as Reason – abandoned them: they interpret Gods’ flight as a punishment for not having worshipped them enough. Others lose any trust in the possibility of interpreting the world. Thus, the transition between past and new meanings seems nearly impossible to fully understand. The hand of Destiny must somehow move human puppets. Accident and Chance are then supposed to govern the future. Balanced unbalance or Unbalanced balance could be appellations for such a Value: the unbalanced community searches for a new balance; any precarious balance is continuously threatened by unbalance. Since the eighties, this conception spread in western societies: unlimited globalisation coupled with undifferentiated meanings, caused such growth. Despite discourses, neither communities, nor individuals as subjects, are really valued. Others are included in the globalisation process or marginalized by society. After reaching the memory stage, communities will manage to articulate prior and actual meanings in the same collective narratives. They know now that memories of old meanings feed the new ones, without reducing actual meanings to former ones. Creation is then the central Value. Past is a seed planted in the present to allow a new future to flourish. Community and individual are both highly valued. Others are considered as full members of the same humanity: their differences are recognised as a testimony of creative imaginary present in any society. Unfortunately, this Value is 33

Louis Dumont, Homo hierarchicus, Paris, Gallimard, 1966.

54

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

nearly never found in societies: except perhaps in Athens in the fifth century before JC34 – but many others, women and slaves, were excluded from the agora –, perhaps also the zapatist movement in Chiapas during last decade. In the case of Bosnia, the main actors of war were ethnic fundamentalists impregnated by Survival. Encouraged by the death of communism, occidental societies – such as Germany which so quickly recognised the independence of Croatia and Slovenia – were then inhabited by Mastering. And now, when social reconstruction is despairingly aimed, the world context becomes dominated by panegyrics to globalisation that Unbalanced Balance inspires. Would the course of history be the mere translation of collective grief processes? This analysis reminds us, above all, the “untold dimension” of social reconstruction: which kind of reconstruction do we want? A reconstruction in terms of Survival: do we wish to rebuild the society as it was before the war? A reconstruction in terms of Mastering: would we like to build societies, houses and bridges stronger than before, more adapted to the actual world – including its wars, terrorism and counterterrorism –, with the illusion of being able to master the future? A reconstruction in terms of Balanced unbalance: would we stake our economy on games of national and international capital? Or a reconstruction in terms of Creation: would we dare to try a (re)creation inspired by experiences accumulated for centuries, respecting the right to a true otherness, focusing on both communities and individuals?

Paradoxical Dynamics Between Individual and Collective Grief Working through the collective grief of meanings is then the key for social reconstruction. But we are struck by the difficulty and the slowness of this process. The Value of Creation, this testimony of collective working through, has been so rare through history! Nuclear Values so seldom change! If we look at concrete examples, this extreme slowness strikes us even more. In Athens, 403 before JC, the polis locked itself in a long denial after the loss of meanings that accompanied the fall of the Democracy one year before;35 and during the next century, the Philosopher Platon sowed the seeds of Mastering which overwhelmed the Occident until the past century.36 In France, after the second World War, it took more than fifty years to work through the grief of common republican meanings buried in Vichy.37 (Is now this grief really achieved? The polemics of Islamic veils, in French schools, show us that it is still not the case). In exYugoslavia, collective meanings torn apart at the same time, during bloody battles between Partisans, Ustashis and Tshetniks, also sank in a denial which awaited the fratricidal fights of the last decade to be tragically reinstated: even torture camps such in Omarska, among the worse Serb crimes of the last war, happened at the exact place where their elders were once slaughtered by Ustashis. But, as happens too often, human beings did not learn lessons of history. The societies of ex-Yugoslavia fell then into another denial, of the loss of past socialist meanings, proven by the determination to forget and silence them: public mention of Tito’s reign was hardly evident two or three years ago. 34

Cornelius Castoriadis, op. cit. Nicole Loraux, La cité divisée , Paris, Payot, 1997. 36 Cornelius Castoriadis, Sur Le Politique de Platon, Paris, Seuil, 1999. 37 Henri Rousso, Le syndrome de Vichy de 1944 à nos jours, Paris, Seuil, 1987. 35

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

55

This extreme slowness of collective grief processes outlines, in post-war periods, the necessity of planning very long-term actions. Reciprocally it stresses the irrelevancy of short-term or middle-term psychosocial programs. And strongly questions most of the emergency actions performed by NGO’s running avec armes et bagages38 from one conflict area to another. The paradoxical dynamics between individual and collective grief may explain this extreme slowness. Indeed grief is firstly a remarkable competency of the psyche: this jewel of humanity has its first residence in our brains. And this is thanks to these individual jewels that raise the possibility for societies to work through collective grief, to create collective meanings and Values. But, reciprocally, frozen or fossilised collective grief inhibits or slackens the individual grief processes. As frozen grief homogenise communities, a member who would work through his or her own loss represents a danger for the collective. And when a collective grief is set at its denial stage, individuals who personally acknowledge the irreversible loss strongly threaten the society’s belief in its hallucinatory world: the community will often banish such adventurers. But, despite this sword of Damocles’, some individuals always begin their personal grief process, even when frozen collective grief encloses the community in an ice-vice. In and near Srebrenica, some grandmothers came back and planted splendid flowers around houses without electricity and water, even having pleasure taking a bath in the Drina river. Among the very few young people who returned, some of them, in June 2003, organised the Days of Srebrenica. They invited popular youth music bands, although organizations of widows felt it was an insult to collective Memory. Contrary to grief, history never freezes! Let us work through our own grief! The central role of collective grief of meanings has troublesome consequences for our theories and practices: our claimed and hidden priorities as mental health professionals, as well as the priorities of NGO’s, governmental and international agencies, find also their grounds in collective Values39 which reveal a grief process of meanings and the stage where it got bogged down! Our blindness which prevents us from seeing the radical differences which contrast post-traumatic reactions and grief, our focus on trauma which often leads us to consider losses as a simple category of traumatic events, our restricted focus on losses of persons, property or objects and our corollary forgetting of meanings – this nightmare of post-war periods –, our usual inability to identify the creative potential of grief, our insistence on human beings’ resilience and adaptability to hell, our stress on individuals, and limited interest on collective processes, all these trends confirm our difficulties with our own collective grief of meanings. The expression “to master trauma” badly distorts our denial of uncontrollable realities, our poor appraisal of human radical imagination.40 This vocabulary, as well as our emphasis on individuals, suggests that Mastering too often remains our Central Value. It means that our own grief of meanings is frequently stuck at their denial stage! Even a declared faith in human creativity or community psychology does not change the diagnosis. East and West, South and North, many governmental institutions, NGO’s and civil associations publicly plead in favour of beneficiaries’ empowerment – but here the root “power” already unmasks the mystification –, acknowledgement of 38

En français dans le texte. Elsewhere, I named Qualities these collective Values. Cf. Deuils collectifs et création sociale, op. cit. 40 A Castoriadis’ concept. Cf. L’institution imaginaire de la société, op. cit. 39

56

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

the social dimension, attention to collective memories and inherited culture, respect of others’ human rights and reciprocity, all these theoretical barometers of Values and grief. Even with some organizations at the time of their establishment, their claimed meanings seemed in harmony with the wishes of the communities within which they work. Nevertheless the environment quickly changes: objectives, projects and meanings need to be constantly adjusted to the evolution of the social context. Let us think about organizations whose first goal would be psychosocial attention to adolescents affected by war. As time passes in post-war years, youths’ main problem often ceases to be war-linked losses and becomes socio-economic, severe difficulties to find a job among others. The organizations’ adaptation to this new situation requires a collective grief of meaning. But, in such circumstances, some organizations “feel” that the external changes threaten their existence: then they develop then survival mechanisms. As with any community, they begin to focus on themselves, on their internal functioning, and attempt an internal homogenisation. Others sink into denial: they carry their point to the supposed beneficiaries, breaking their oath about autonomy and reciprocity. If the “users” resist, they are quickly considered ungrateful. And as denial cannot be equal in all members, as voices which remind about painful losses threaten the collective negation, organizations frequently disown their democratic principles, give more attention to power than to participation, reform their structure to suppress undesirable memories. Thus the world-wide focus on management instead of meaning, on dysfunction instead of loss, might be interpreted as symptoms of a denial stage in the collective grief of meanings. But a further working through implies other serious perils: the related change of initial meanings may disappoint the donors, international NGO’s or governmental organisations, who then face their own grief of meanings! These obstacles may lead to a denial of local realities, with the temptation of cutting off subsidies or imposing from above orientation and structural changes. Once again, despite claims to the contrary, reciprocity draws back and collective memory suffocates. Consequence: all organizations involved in humanitarian or development programs, including those outside the psychosocial domain, should give a priority to their own grief of meanings, if only to comply with their declared intentions! This is the first, and difficult major step towards social reconstruction in post-war regions. We should agree to be the first clients of our programs! Which programs to design. But which meanings did we lose? Which specific grief of meaning do we have to undertake? As a lost meaning is always substituted by another which obscures the loss, the question is not so easy to answer, all the more as times of denial bury the memory of lost meanings. When they briefly emerge to consciousness, they are received by instantaneous judgements of equivocation, devaluation, blindness or youth’s mistake. Then, to begin our inquiry, we can only rely upon modest tokens. Among others, the transformation of our vocabulary reflects suspicious signs, such as the growing use, in our professional discussions, of expressions such as post-traumatic stress disorder or resilience. Or more recently in western societies, the invasion, for any purpose, of words such as terrorism, violence, democracy, on occasions when we used to employ different terminology. If we discover past words or concepts that have been replaced, we will identify the contour of our lost meanings, or at least their shadows. And if we identify them, we will already have progressed greatly in our working through to move beyond the denial stage by entering into the depressive stage.

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

57

Our first question, about the impact of childhood well-being on social reconstruction, has no clear answer. This is because the adults who appraise this well-being are entangled in their own unachieved grief of meanings which distort their criteria for evaluation. For example, common sense too frequently links well-being with absence or decrease of suffering. But, during the grief processes, sadness and anxiety are unavoidable, especially in the advanced stage of despair: some suffering, paradoxically, becomes then a condition for creative social reconstruction. In this perspective, the child’s major necessity lays in escaping adults’ socialization through their denial or frozen grief in order to be protected against germs of Survival and Mastering, the seeds of future wars. Dean Ajdukovic41 showed us this danger: Serbian and Croatian pupils from Vukovar are nowadays even more reluctant than their parents to be gathered in the same classrooms. The Values of Survival and Mastering, present in parents’ language since the cradle, at least influence children. But it is possible to avoid their total socialization. First by the mentioned work in our professional communities: if a few drops of the Creation Value could soak up psychologists, psychiatrists, teachers and social workers’ discourses, some cause for hope would be appropriate. We should then consider our professional communities as laboratories for social reconstruction: especially with regard to the difference between war and post-war societies who still fight for their survival – remember Srebrenica – that may determine the likelihood of favourable outcomes. Furthermore, as constant threats perpetuate freezing mechanisms, we must try to create micro-environments of security at schools or elsewhere, with programs such as those designed by Anica Mikus Kos in ex-republics of ex-Yugoslavia.42 During World War II, Anna Freud and Dorothy Burlingham already observed the positive influence of a stable daily context:43 children may then occasionally give up their survival mechanisms, which are major factors for transmission of frozen grief over generations. For the children are not only the recipients of parents’ words, meanings and Values. They may also recreate adults’ collective narratives before transmitting them to their future sons and daughters. They benefit by having freedom in a space in which they may collectively “write” their own narratives, inspired by adults’ who give them freedom in this space. It means, as Ferid Agani44 asserts through his experience in Kosovo, that we have to emphasise the work with – among – parents and teachers. Helping them to work through their collective grief of meanings through this matrix of narratives, memories and Values. By good or bad luck, the paradoxical dynamic between individual and collective grief offers a complementary path. Because the community is never so homogeneous as it would like to be and there are always some courageous people who have passed beyond the denial stage, they remember meanings that history killed, even with some nostalgia – this marks depressive stages. (Look at the so-called “yugo-nostalgia” observed in some people through all republics of ex-Yugoslavia). 41 Dean Ajdukovic, Social (re)construction of a local community after massive traumatization, Conference held in Ljubljana, Workshop “The importance of psychosocial wellbeing of children in the postwar period for social reconstruction ans stability of terrorist and war affected regions”, June 8th, 2003. 42 Anica Mikus Kos, Activating community resources for individual and common well-being and stability, Conference held in Ljubljana, Workshop “The importance of psychosocial wellbeing of children in the postwar period for social reconstruction ans stability of terrorist and war affected regions”, June 7th, 2003. 43 Anna Freud & Dorothy Burlingham, War and children, New York, Ernst Willard, 1943. 44 Ferid Agani, Building of the Mental Health Services for Children in a Post-war Kosovo, Conference held in Ljubljana, Workshop “The importance of psychosocial wellbeing of children in the postwar period for social reconstruction ans stability of terrorist and war affected regions”, June 8th, 2003.

58

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

In any community, despite social pressures, some individuals pursue their individual grief of meaning. Despite risks of not being listened to, being blamed and even excluded, they do not restrain their creativity but use it to express their thoughts through enigmatic metaphors – “between the lines”45 –, incomprehensible by persons still stuck in Survival or Mastering. And they may manage to diffuse the Value of Creation in small or larger collectives, even within whole communities or societies. If this had never happened, the landscape of humanity would have been much more boring: without Athens, Chiapas and other islands of hope. Sometimes, the working through of individual grief of meaning slowly contaminates the whole community and stimulates the collective grief process. We must then study these spontaneous examples and learn from them. In order to design methodologies that can spread iconoclasts’ grief of meanings throughout any collectivity, community or society. Beginning by symbolically burying dead meanings and dedicating their graves. The methodologies used in some community projects in Nicaragua,46 Switzerland47 and ex-Yugoslavia,48 although they still need to be improved, already demonstrate large possibilities. Rituals of purification in Mozambique, with the purpose of reintegrating children soldiers – guilty of blood crimes in their own villages – constitute another source of inspiration. They consist in a re-creation of ancestral rituals, traditionally carried out when minds were supposedly invaded by “bad spirits”, among others, spirits of deceased persons who were not honoured as the customs ordain. Such programs could promote a social reconstruction based on the Value of Creation. A never-ending reconstruction: as meanings always die and spring up, collective grief processes are undertaken again and again.

Grief and politics Nevertheless, such actions might be still insufficient. Look at history textbooks: how is this matter is usually taught in schools? So frequently governed by denial and survival mechanisms, they probably constitute the main context of a child’s socialization, the main obstacle to social reconstruction. And school programs are designed by Ministries of Education that is finally by politicians. Remember also the collective grief of meanings I previously mentioned. Despite huge differences in space and time, political organisations always played an important role in the propagation and perpetuation of denial. In 403, the party of Democrats forbade Athenian citizens to remind themselves about the civil war.49 In France, de Gaulle wanted to re-establish a sham unity so quickly that he promoted the amnesia of the discord between Petain’s supporters and members of the Resistance movements during the Vichy years.50 In ex-Yugoslavia, Tito adopted in 1945 the discourse of the New 45

Cf. Léo Strauss, Persecution and the Art of Writing, Chicago, Macmillan Publishing Co, 1952. Jean-Claude Métraux, Formation à la prévention auprès de familles en situation de crise, familiale ou sociale. Sauvegarde de l'Enfance, 48, 3, pp. 220–241, 1993. 47 Jean-Claude Métraux, François Fleury, Creators of their Future. Group Work with Traumatized Communities. In Perren-Klingler G. (Ed.), Trauma, From individual Helplessness to Group Resources, pp. 141–162, Bern, Haupt, 1995. 48 Anica Mikus Kos, op. cit. 49 Nicole Loraux, op. cit. 50 Henri Rousso, op. cit. 46

J.-C. Métraux / From Child Well-Being to Social Reconstruction?

59

Man, placing the recent past in the burial vault of history: if the Partisans’ victories against Germans were constantly commemorated, the horrors committed between Yugoslavians remained usually silenced. And nearly fifty years later, the memory of communism was hushed up by recently-born political parties: when, in August 2003, the Croatian prime-minister Racan was photographed near a Tito’s portrait, tumultuous discussions began in his own party. Thus, Values defended by major political actors are themselves inhabited by frozen or fossilised grief of meanings. It is the case, at least in post-war periods, of nearly all political organisations. They raise the common denial to an official level: American and British leaders’ discourses after the Iraq war prove it one more time. As they write so many pages of history, politicians are among the main spreaders of denial to the next generations. Exceptions earn our respect. Such as, once again, the Truth and Reconciliation promoted by the South African government itself. But they occur too infrequently. Most organizations throughout the world, which call for such Commissions, are “merely” civil organisations. As in Peru, these initiatives must often wrestle with the inertia of their government, despite public claims to the contrary. Our support for such laudable declarations therefore needs to be made with caution. We should then invent ways of helping politicians’ communities, from parties to parliaments, to work through their own collective grief of meanings. But this task exceeds the limits of the present paper.

This page intentionally left blank

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

61

Psychosocial Interventions: Key Issues Facing Practitioners Alison B. STRANG and Alastair AGER

Abstract. The ever-growing range of approaches to psychosocial intervention in areas of armed conflict reflects a wide diversity in underlying perspective. Practitioners are faced with questions of effectiveness and appropriateness of interventions. The author presents a conceptual framework formulated by the Psychosocial Working Group that offers a way of understanding psychosocial well being that embraces the breadth of the field. This framework is used to explore the assessment of the impact of events, and issues of effective, appropriate and ethical interventions. Keywords. Psychosocial interventions, conceptual frameworks, psychosocial best practice, ethics

Practitioners have now been gaining experience of psychosocial interventions in complex emergencies for a number of decades. There is a growing body of expertise, and – as the title of this book itself reflects – a variety approaches are subsumed under this umbrella term. For example the directory of psychosocial projects in BosniaHerzegovina and Croatia complied by Inger Agger (1994) [1] includes a vast array, including: psycho-education through radio and television broadcasts; summer art and music camps; support groups for trauma survivors; medical care for women; psychiatric services; legal counselling; knitting and handicrafts for income generation; educational and play activities for pre-school children; education on alcohol related problems and recreational and cultural activities. These approaches all represent a shared recognition that the effects of armed conflict are not just physical, but also psychological and social. However, such diversity, whilst enriching the field, reflects fundamentally different theoretical perspectives on the nature of psychosocial issues and the causes of problems. These theoretical perspectives have been discussed elsewhere [2,3]. Whilst there is an increasing range of guidelines becoming available [4] they too reflect different theoretical perspectives The practitioner is thus faced with different approaches that are seen to be valid and effective according to different sets of value judgements and different contexts.

How Can Psychosocial Needs Be Assessed? As a result of this very richness and breadth, practitioners are faced with difficulties at the most fundamental level of how appropriate interventions can be developed. Firstly the question arises as to how to appraise the impact of the crisis. It is widely acknowledged that people can be exposed to the same events and yet be affected by them differently, but there is no clear agreement on how those differences may be manifested.

62

A.B. Strang and A. Ager / Psychosocial Interventions: Key Issues Facing Practitioners

Secondly, there is disagreement about how activities should be focused. Where needs are clear, there is a lack of consensus in the field as to the most appropriate response to needs.

How Can Cultural Sensitivity Be Ensured? There has been much debate around the importance of cultural sensitivity in programming. Derek Summerfield has led the way in arguing of the dangers of imposing western concepts on non-western cultures [6]. However, it is not necessarily clear what this might mean in practice. Questions still remain: are efforts to use appropriate language to describe psychological phenomena enough? For example, is it appropriate to major on counselling provision amongst a community who need to be taught both the word and the concept? Is the employment and training of local staff sufficient to ensure cultural appropriateness? If not, how can culturally appropriate solutions best be discovered? If local traditional practices are to be incorporated, how can an external agency determine which are appropriate? For example, where is the evidence base for endorsing local healing or cleansing rituals?

What Is the Ethical Basis for Psychosocial Intervention? When a group of psychosocial practitioners get together, it is not long before the question of ethics is addressed. What is the ethical basis for interfering in a society of which you are not part? Is there a danger of imposing external cultures and values and undermining traditional ways of life? Surely we must stand up for basic human rights? We should avoid patching up societies and thus enabling basic inequities and oppression to continue.

What Is the Role of Psychosocial Intervention in Transforming Societies? This paper will present a framework developed by a consortium of humanitarian agencies and academic institutions known as the Psychosocial Working Groupi. The framework aspires to describe the scope of psychosocial intervention and to provide a way of understanding psychosocial well-being. It is hoped that this way of understanding will contribute constructively to these debates enabling those closest to the work to throw some more light on the issues facing the field, suggest ways of answering some of the key questions and perhaps anticipate others that might arise.

A Framework Humanitarian psychosocial programmes in areas of armed conflict are by definition concerned to promote psychosocial well-being. This term, though much used, is not easy to define. Most fundamentally it emphasises the close connection between psychological aspects of our experience (our thoughts, emotions and behaviour), and our wider social experience (our relationships, traditions and our culture). Therefore the proposed framework begins with the assumption that it is generally appropriate to con-

A.B. Strang and A. Ager / Psychosocial Interventions: Key Issues Facing Practitioners

63

Figure 1. Factors Influencing Psychosocial Well-being.

sider the needs of individuals within the social context of a family or household which, in turn, is located within an ‘affected community’ [7]. However the use of the word ‘community’ is contentious, particularly in the context of areas affected by conflict. For example, in a refugee camp people may have come from many different places. They may not know one another; families will be separated; there will be unaccompanied children. In what sense does such a gathering constitute a community? Similarly, even where people are returning to their home area after conflict, some former residents will be returning and some will not, social relationships may be massively disrupted by experiences of the conflict. People may be deeply divided by for example eethnicity or religion or politics. Perhaps, at best, it is appropriate to talk of a ‘potential’ community. Jean-Claude Metraux suggests a minimal definition: ‘a group of persons who share a similarity which is relevant for all of them’ [8]. This definition allows the identification of those who belong to a group, inviting exploration of the factors that they share without making unjustified assumptions about homogeneity. The framework concerns a community that has been affected by some ‘event’ or ‘events’, such as conflict, mass displacement, natural disaster etc. The nature of these events is very diverse; they can be catastrophic or cumulative. They often contribute to broader conditions or circumstances that continue to impact people over many years. The challenge for psychosocial programming is to understand exactly how a community and its members have been affected by events, and thus how they might be best supported. If a community is seen is terms of resources (Hobfoll, 1998 (9)), then it can be argued that the common feature of such events and conditions is that they challenge the community and its members by disrupting or diminishing the resources of that community in some manner. This framework suggests that there are three key resource areas that are most valuable in understanding the impact of conflict on psychosocial well-being. ‘Human capacity’ refers to the health (physical and mental) and knowledge and skills of an individual. Human capacity may be reduced when people become depressed, withdraw from social life or become physically disabled. The deaths of people

64

A.B. Strang and A. Ager / Psychosocial Interventions: Key Issues Facing Practitioners

usually lead to a loss of skilled labor in household and communities. Even the feeling of having less control over events and circumstances may contribute to people feeling less able to meet the challenges they face. In these terms, improving physical and mental health, or education and training in support of increased knowledge, enhances human capacity and thus psychosocial well-being. It is the ‘social ecology’ or pattern of social networks in a group of people that enable them to function as a community. Through these networks and relationships individual capacities can be released as resources that support the well being of the group as a whole [10]. Furthermore, there is strong empirical evidence linking individual mental health to the presence of effective social engagement [11]. Armed conflict often leads to a disruption of the social ecology of a community, where relations between families and peers change, or where religious and civic organizations cease to function. It is necessary to address damage to social ecology in order to promote psychosocial well-being. Finally, conflict may also disrupt the culture and values of communities when common values are challenged and human rights are violated. It may become more difficult for people to follow cultural traditions that have previously provided a sense of unity and identity to communities. ‘Culture’ has been defined by Geertz as, ‘..systems of meaning which provide a cosmology, a world view, and are manifested in behavior and beliefs’ [12]. Where these shared meanings are disrupted, reference points are lost, a sense of right and wrong is undermined, and behavior loses its purpose. The framework identifies ‘culture and values’ as the final key resource area crucial in understanding psychosocial well-being. The framework identifies these three areas as providing the key to understanding psychosocial well-being itself. They cannot be separated out as distinct phenomena; rather they provide different lenses to describe the same phenomena. Thus each domain pervades the others. Human resources are essentially invested in people, and so are social relationships. Similarly social relationships reflect the culture and values of a community. Human resources themselves cannot be specified in isolation from culture and values (the knowledge of soothsaying practices, or even the ability to weave carpets, take on very different significance according to cultural context). Although these issues are seen as definitive in understanding psychosocial well-being, they are not seen as the only factors that impact on well-being in complex emergencies. It is recognized that the loss of material and economic resources of households, the disruption of infrastructure on communal and regional levels, and the degradation of the environment all have an important impact on psychological well-being. Such issues form part of the broader context within which individuals, families and communities begin to engage with the events that have affected their lives.

Affected Communities as ‘Actors’ These domains suggest a way of mapping the human, social and cultural capital available to people responding to the challenges of prevailing events and conditions. The picture is essentially a dynamic one recognizing that individuals, families, groups and communities actively deploy the resources available to them in order to shape their world. This engagement involves interaction between the various resource areas highlighted. For example, if possible, when a parent is sick or missing, family networks (social ecology) will be drawn on to provide alternative childcare (human resource). If

A.B. Strang and A. Ager / Psychosocial Interventions: Key Issues Facing Practitioners

65

a child is lost (breakdown of social networks), people will spend time and energy (human resource) to look for that child. Neighbors and families will get together to celebrate festivals and reinforce cultural identity. In turn, cultural and religious explanations will provide comfort in a crisis, and strategies for action. The effectiveness of this engagement and the utilization of resources within the community may be seen to be a measure of the ‘resilience’ of that community. It follows that communities and individuals affected by armed conflict are not passive victims. They are – like the rest of humanity – actors engaged in responding to the challenges and opportunities of their lives. Like the rest of humanity, their responses may by effective, ineffective, or dysfunctional, and will probably be a mixture of all three. However, the impact of war is colossal. It can reduce the resources available drastically, and because of the close interaction between resources, the effect of disruption is not just cumulative but multiplied. For many it can become impossible to maintain very much effective engagement. It is in recognition of this circumstance that humanitarian agencies step in.

Assessing the Impact of Events It is much easier to measure risk factors than effects. Catalogues of exposure to traumatic events [13] have been used effectively to make the case for psychosocial assistance. However, it is generally acknowledged that, individuals and communities are differentially affected by the same events. There is not a direct relationship between exposure and levels of psychosocial well-being. In order to know how to help, it is necessary to look more closely at the impact of those events. Psychometric instruments such as the Harvard Trauma Questionnaire [14], or the Impact of Events Scale [15] offer a way forward that focuses on the individual response to events. De Jong used the Impact of Events Scale in Sierra Leone, where results showed 99% of the population having levels of disturbance indicative of severe post-traumatic stress disorder (PTSD) [13]. The PTSD diagnosis implies that some form of mental health treatment would be appropriate. But with those sorts of numbers, in an emergency situation, mental health treatment on a western model is impractical even if it were agreed that it would be advisable. The resource-based framework potentially provides a structure for mapping the way communities, as well as individuals are impacted by events – a way of understanding risk and protective factors. The model broadens the focus, directing attention to appraising disruption in all three key resource areas; human resources (which includes mental health); social ecology; and the otherwise neglected area of culture and values. The appraisal of human capacity would include an audit of physical and mental health. However, it would also, for example, look at effects on children’s intellectual and emotional development [16]. An assessment of available labor would be relevant (for example, who is there to carry the water?), and also and assessment of skills. The notion of an audit directs us to be alert to increases in resources as well as losses. Whilst skills will be lost as people are injured or killed, so also will some people be acquiring new skills (use of firearms?) and the confidence to use them. These resources may of course be used for good or evil. The mapping of social ecology would look at issues such as unaccompanied children, and numbers of child-headed households. It should also be concerned with the destruction of friendships [17] and loss of trust. The disruption of civic and political

66

A.B. Strang and A. Ager / Psychosocial Interventions: Key Issues Facing Practitioners

authorities should be accounted, and the consequent loss of public services. Once again it is dangerous to view the impact of conflict as a simple reduction in resources. Some individuals or groups may experience beneficial effects, for example there can often be shifts in gender relations giving women more autonomy [16]. What benefits one group may well disadvantage another. For example, some children can experience a sense of empowerment on taking on an active role in armed combat. Conflict potentially strengthens bonds within a community, but by doing so may entrench negative attitudes towards those outside that group [18]. It has been shown that recent conflicts increasingly target the culture and values of communities [19]. Yet there are few if any examples of systematic attempts to assess these types of disruption [20]. This would include the destruction or desecration of religious or cultural places, and also attempts to prevent engagement in religious or cultural practices. Chronic conflict impacts the ways in which new generations develop their values [16]. Conflict between former friends and neighbors such as in Rwanda or Croatia, can fundamentally undermine what were core beliefs, destroying shared interpretations of the world. These effects also need to be mapped if the true impact of events is to be understood.

Effective Intervention If psychosocial well-being is seen as the ability to deploy resources effectively to shape your own world, then the primary purpose of psychosocial intervention must be to support that process of engagement. Fundamentally it is a task of facilitation, though it is also likely to include resource building. It follows that – as many practitioners would argue – any intervention that leads to long-term dependence on external support is not succeeding in building psychosocial well being. This can be applied at an individual level. For example, it is recognised that medication or counselling may be valuable as a means to independence, but should not be depended upon long-term [13,21]. Similarly, it can be applied at community through to the national level [22] The psychosocial well-being of a community is not best served by a strategy that depends on supplies of external resources, be it physical supplies or technical support, unless that community can generate internal marketable resources that enable them to have purchasing control over those supplies. If psychosocial well-being is characterised by the ability to take the initiative in mobilising your own (and external) resources to shape the world according to your own priorities, then psychosocial interventions should be driven as much as possible by the initiative of the affected population. Focus for action should be determined by the priorities of the so-called beneficiaries, and not by the external agency, nor indeed the donor community. This is not a simplistic solution and issues of conflicting priorities will be addressed below. However effective programmes can and do run on the principle of maintaining responsibility with those directly affected at the highest strategic level possible. Such priorities are reflected in psychosocial interventions emerging from the field of community development. For example in their recent report on working with children in Afghanistan, SAVE describe painstaking work setting up children’s forums where children can have a voice in a context with which their parents are happy. In these groups children have been encouraged to express their own fears and identify the issues that they feel most threaten their sense of security. As result some of the groups are directing their energies towards a road safety campaign on the streets of

A.B. Strang and A. Ager / Psychosocial Interventions: Key Issues Facing Practitioners

67

Kabul because they are acutely fearful of the chaotic traffic. At the same time of course they are gaining a sense of agency in their environment, and learning resource management skills [23].

Appropriate Intervention This approach addresses issues of cultural sensitivity at a fundamental level. If action is generated by those affected by the conflict, if they are leading the process of identifying how and why normal coping strategies are failing to meet current challenges; then the psychosocial intervention focuses on of reinforcing those normal coping strategies. Where the community is in a position to make choices, then the appropriate meaning frameworks that underpin their culture and values will guide those choices. As Alcinda Honwana points out, it is the definition of the problem, and not just the selection of a solution that is culturally specific [22]. Normal coping strategies are based on a worldview embodied in the culture. For example in Angola (at the time of the study) the troubled spirits of the ancestors were seen as a significant cause of health problems. Reasonably then, solutions to health problems would involve traditional rites understood to appease those spirits. Sometimes the issue would be seen as contamination of a person involved in killing, and part of the response would be to undertake a traditional cleansing ritual. In either case, the understanding of the cause of the problem will determine the range of solutions perceived to be relevant. In Angola for example, these rites would be used fist, followed by, or in conjunction with other solutions including western medical practices. Where the affected people themselves define the problems and potential coping strategies, then the question of the cultural appropriateness of external strategies doesn’t arise. Traditional solutions are employed, not on behalf of the external agency, but directly on behalf of the potential beneficiaries. External agencies may certainly share their experiences and perspective, but they do not have to take responsibility to endorse traditional practices of which they have little experience, and for which they have no valid means of evaluation. Equally where new strategies are being introduced, this should be on the invitation of the potential beneficiaries. The external community has a responsibility communicating options as effectively and honestly as possible and primarily for supporting the decision-making processes rather than directly providing services.

Ethical Intervention There are many different players with differing priorities. There may be various factions or interest groups within the affected community themselves, whilst the external community includes a range of humanitarian agencies (often competing with each other for limited resources); there are donor organisations and other international stakeholders. The distinction of ‘affected’ and ‘external’ is not an absolute distinction, but rather a relative term. The framework suggests that all of these ‘communities’ bring the same range of resource areas as any other. Humanitarian agencies themselves have finite resources that they can offer to support a community effected by conflict. The utilisation of these resources is mediated through the social ecology of the organisation, and according to its culture and values.

68

A.B. Strang and A. Ager / Psychosocial Interventions: Key Issues Facing Practitioners

External Community

Affected Community Figure 2. The ‘External’ Community in Complex Emergencies.

It is not difficult to find examples of where the profile of the ‘helper’ has determined the nature of the ‘help’ provided rather than the profile of needs. For example, Adjukovic reports that the importing of specialist psychiatric services to Croatia was seen as resource driven. This led to resentment in a country proud of their pioneering history in the area of psychiatry. The support that was most valued was with help with rebuilding infrastructure to enable their own qualified psychiatrists to travel about to areas where there was acute need [17]. Even where services are being provided by members of the community themselves, donor interests can inappropriately steer provision simply because of their purchasing power. Anika Mikus-Kos illustrates this when recalling the need to write job descriptions in terms of individual trauma counselling in order to get funds, when in fact the priority of her work had shifted to engagement in community mobilisation [24]. It is clear that priorities should not be derived from those of the external community; this will interfere with active engagement by the affected community themselves. Yet at same time the external community can never be purely passive resource providers. They are also actors. Their involvement is predicated on the recognition of a need that they are willing and able to address. Moreover, those people affected by the conflict are unlikely to form a homogeneous group. Some may want to see the restoration of the former state of their society, others may well have been disadvantaged by former ways, and indeed some of these earlier circumstances may well have contributed to the fuelling of conflict itself. In many cases the experience of armed conflict will have changed people’s priorities. The challenge for those aspiring to provide psychosocial support is to find constructive and ethical ways of working with different interest groups. In navigating through this complexity, it is perhaps valuable to return to reflections on the fundamental purpose of psychosocial intervention. There is a sense in which it has been argued that the external community only has a role in intervening where it can

A.B. Strang and A. Ager / Psychosocial Interventions: Key Issues Facing Practitioners

69

help to restore the ‘normal’ state of coping. In this it is important to recognise that the ‘normal’ or ‘healthy’ state of a community is one of responsiveness to circumstances, thus of ongoing evolution and change. Such a society is not merely vulnerable to damage from external influence, but can gain and learn from it. Outside organisations can play a constructive and ethical part in building peace by bringing the resources they have (human, social, cultural as well as physical, economic and so on). The ethical responsibility is to avoid using unequal power relationships to impose choices on vulnerable communities in crisis, instead offering them resources in a true spirit of empowerment.

The Ongoing Vision of the Psychosocial Working Group The theoretical framework described in this paper was formulated with the support of the Psychosocial Working Group (PWG), which constitutes a global partnership for defining and developing best practice in the field.ii It is based on the broad experiences and expertise of the members of the group, and in some sense represents their view of the ideal for psychosocial interventions. The PWG is currently extending its work in connecting theory and practice in the field of psychosocial intervention. It is reviewing available training materials in the field, and seeking to define core competencies for psychosocial work. It is defining key programming principles that should be adopted by agencies for field interventions. It is organizing forums that bring together practitioners and academics from north and south to consider key programming issues. It is commissioning a further series of field studies to bolster the evidence base for practice in the field. In the future the PWG seeks to address key needs recognized within the field of psychosocial interventions. First, is the need for learning, developing a clearer understanding of the effective basis of psychosocial intervention. Second, is the need for practice development within implementing agencies, based upon such understanding. Third, is the need for policy development, shaping the priorities and approaches of both funding agencies and implementing agencies.

References [1] Agger, I. (1994) Theory and practice of psychosocial projects under war conditions in BosniaHerzegovina and Croatia. Part 2. European Community Task Force, Zagreb, Croatia. [2] Strang, A.B. & Ager, A. (2001) Building a Conceptual Framework for Psychosocial Intervention in Complex Emergencies: Reporting on the work of the Psychosocial Working Group. Paper presented to the ISHHR Conference, Cavtat, Croatia, June 2001. http//www.ishhr.org/conference/articles/strang.pdf. [3] Galappatti, A. (2003) What is a psychosocial intervention? Mapping the field in Sri Lanka. International Journal of Mental Health, Psychosocial Work and Counselling in Areas of Armed Conflict, 1(2), 3–17. [4] International Federation of Red Cross and Red Crescent Societies (2001) Psychological support: best practices from Red Cross and Red Crescent programmes. Geneva. [5] UNICEF (Forthcoming) Working with children in unstable situations. A guiding manual for psychosocial interventions. Refugee Studies Centre and UNICEF. [6] Summerfield, D. (1995) Assisting survivors of war and atrocity: notes on ‘psychosocial’ issues for NGO workers. Development in Practice, 5, 352–356. [7] Bronfenbrenner, U. (1976) Reality and research in the ecology of human development. Washington: Journal Supplement Abstract Service, American Psychological Association.

70

A.B. Strang and A. Ager / Psychosocial Interventions: Key Issues Facing Practitioners

[8] Metraux, J.C. (2000) Broken Bridges – Community grief processes as a key factor for the development of individual, family and community resources. In van Willigen, L. (Ed.) Health hazards of organised violence in children (II) Coping and protective factors. Stitching Pharos, Utrecht. [9] Hobfoll, S. (1998) Stress, Culture and Community: The Psychology and Philosophy of Stress. New York: Plenum. [10] Colletta, N.J. & Cullen, M. (2000) Violent Conflict and the Transformation of Social Capital. World Bank: New York. [11] Goldberg, D. & Huxley, P. (1992) Common Mental Disorders: A Bio-social Model. London: Routledge. [12] Geertz, C. (1973) The Interpretation of Cultures. New York: Basic Books. [13] De Jong, K., Mulhearn, M., Ford, N., van der Kam S., Kleber, R. (2000) The trauma of war in Sierra Leone. In: The Lancet, 355 (June 10), 2067–2068. [14] Harvard Program in Refugee Trauma, Harvard Trauma Questionnaire. http://www.hprt-cambridge.org/ Layer3.asp?page_id=9 (accessed 20 October 2003). [15] Horowitz, M.J., Wilner, N., Alvarez, W. (1979) Impact of event scale: a measure of subjective stress. Psychosom Med. 41, 209–218. [16] Arias, J. (2003) Psychological implications of armed conflicts in children: A glimpse from gender and generational perspectives. Paper presented to the Psychosocial Working Group Annual Forum, New York, May 2003. [17] Adjukovic, D. & Adjukovic, S. (Eds.) (1998) Trauma Recovery Training: Lessons Learned. Zagreb: Society for Psychological Assistance. [18] Crisp, R., Hewstone, M. & Cairns, E. (2001) Multiple identities in Northern Ireland: Hierarchical ordering in the representation of group membership. British Journal of Social Psychology, 40, (4), 501–514. [19] Ager, A. (2002) Humanitarian Response to Conflict: A Psychological Perspective. Paper presented to the British Psychological Society Annual Conference, Blackpool March 2002. [20] Eyber, C. and Ager, A. (forthcoming). War, distress and healing: perspectives and interventions of independent churches in a province of Angola. Journal of Transcultural Psychiatry. Special Edition. [21] Losi, N. (2000) Understanding the needs of the displaced: some elements on the Kosovo case. Psychosocial Notebook. 1, 11–20. [22] Honwana, A. (2003) Okusiakala ondalo yokalye: Let us light a new fire. In Psychosocial Working Group, Grey Literature Inventory. http://earlybird.qeh.ox.ac.uk/cgi-bin/saxon.pl?psychsoc.l.xml? maintext.xsl?1 (accessed 17 October 2003). [23] De Berry J. (2003) The Children of Kabul. Discussions with Afghan Families. Save the Children Federation, Inc. [24] Mikus-Kos, A. (2000) Changing explanatory models, changing mental health practice. In van Willigen, L. (Ed.) Health hazards of organised violence in children (II) Coping and protective factors. Stitching Pharos, Utrecht.

i The Psychosocial Working Group is a consortium of humanitarian agencies and academic institutions working in psychosocial intervention in complex emergencies. The Group was set up in 2000 and has been involved in developing and defining best practice in the field. This has involved the formulation of a conceptual framework with respect to which psychosocial interventions can be understood; the development of a web-based resource of ‘grey literature’ materials and the specification of a research agenda identifying key questions that need to be addressed to develop and effective evidence base for psychosocial practice. The PWG has commissioned an ongoing programme of collaborative research studies and a series of meetings to bring together practitioners and academics from north and south to consider key programming issues. It is currently reviewing training materials in the field, and seeking to define core competencies for psychosocial work. Further details at: www.forcedmigration.org/psychosocial and www.qmuc.ac.uk/cihs. ii The membership of the Psychosocial Working Group comprises five academic partners (Centre for International Health Studies, Queen Margaret University College, Edinburgh; Columbia University, Program on Forced Migration & Health; Harvard Program on Refugee Trauma, Solomon Asch Center for the Study of Ethnopolitical Conflict and University of Oxford, Refugee Studies Centre) and five humanitarian agencies (Christian Children’s Fund; International Rescue Committee, Program for Children Affected by Armed Conflict; Medecins sans Frontieres – Holland; Mercy Corps and Save the Children Federation). The work of the group has been supported by a grant from the Andrew Mellon Foundation.

II. Implementation

This page intentionally left blank

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

73

Issues in the Development of Psychosocial Programs for Children, Adolescents, and Families in Kosovo Melissa J. BRYMER, Psy.D., Rune STUVLAND, M.A. and Peter J. MEDWAY, M.Sc National Center for Child Traumatic Stress, University of Los Angeles at California Abstract. This paper provides a summary of issues related to psychosocial and mental health programs for children, adolescents and families following the end of the conflict and mass displacement of Kosovar Albanians from Kosovo in 1999. The authors discuss the impact of war on children and families, their needs, and the recovery programs implemented by local and international agencies and institutions. A review of psychosocial programs within various service systems, including education, health, social services and mental health services, describes the challenges, successes and failures of creating a comprehensive, accessible system of care in an environment characterized by weak institutional and professional capacity, a relatively weak regulatory framework, and a plethora of actors, many with their own agendas and varying levels of expertise. The paper concludes that a public mental health approach is most effective when implemented within a continuum of care that provides a range of services for children, adolescents, and their families, ranging from public education to clinical psychiatric care.

Background Violence, ethnic cleansing, and large-scale crimes against humanity characterized the conflicts that accompanied the separation of the various countries of Yugoslavia in the 1990’s. During this time, President Milosevic of Yugoslavia vigorously implemented a policy of oppression against the majority ethnic Albanians in Kosovo, removing them from state jobs and causing segregation in social, education, and health services. Political participation, of course, was minimal. As the 1990’s progressed, peaceful resistance gave way to violent conflict of low-intensity war between the Kosovo Liberation Army (KLA) and the Yugoslav police and military. In 1998, the Yugoslav authorities launched a harsh military campaign against KLA strongholds in Kosovo, causing widespread international condemnation that ultimately led to the start of a NATO campaign of aerial bombardment between February and June 1999. The NATO campaign provided the Yugoslavs the motivation to escalate the conflict dramatically. It was in this period that mass destruction of ethnic Albanian homes, forced displacement internally and to neighboring countries, disappearances and massacres of suspected KLA members and others, rape, and other atrocities were carried out against the civilian population. The UN High Commissioner for Refugees (UNHCR) estimated that 840,000 people were forced to flee to neighboring countries, while more than 500,000 were displaced inside Kosovo.

74

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

The international community responded to the plight of the displaced Albanian population with a large-scale relief operation that followed the refugees back into Kosovo following the end of the NATO campaign. Many thousands of families returned to find their homes destroyed and their possessions looted. The UN effectively established a protectorate in Kosovo supported by more than 40,000 NATO and other peacekeepers, providing unprecedented security and autonomy for the ethnic Albanian majority of the estimated population of two million. Many members of ethnic minorities fled Kosovo after the conflict, especially Serbs and Roma. Those that remained moved to municipalities in which they were the majority, or they concentrated in mono-ethnic enclaves where their movement was restricted and they were isolated. There were numerous reports of crimes and human rights Kosovar Albanians on the General Health Questionnare-28 in total score, social dysfunction, and severe depression [1]. The report suggested that these differences in scores were likely related to the violations. The mental health of minorities was adversely affected by these circumstances. One study that evaluated the mental health status of Kosovar Serbs in 1999 showed that adults scored significantly higher than hostile environment, the uncertain future for minority populations, insecurity, economic hardships, and lack of access to healthcare. Vulnerable groups such as the elderly and the sick suffered disproportionately.

Impact of the Conflict on the Family In January 2000, it was reported that throughout Kosovo over a third of homes had been completely destroyed or damaged. Thousands of families returned to their villages to find everything destroyed and were faced with the prospect of rebuilding their lives. Yet many had no economic resources. During the summer months, most homeless families lived in tents or lived with multiple families in houses and public buildings that were not completely destroyed. Many occupied homes of their neighbor, where they had not returned and were constantly worried about eviction. As the winter months approached, several international organizations distributed emergency repair kits to rehabilitate at least one room in a house. This meant that one or several families had to live in a restricted area, with limited heating and no electricity. In fact, the United Nations Children’s Fund (UNICEF) reported that even before the war, conditions were difficult in the rural areas. Only 25% of people had access to sanitation facilities with a sewage system, and 33% to drinking water. To further understand the condition of families, a survey was conducted in August 1999 by Reiinvest, funded by Department for International Development (DFID), to evaluate the social and economic consequences of the conflict on a sample of approximately 3,500 Kosovar Albanian families. This report indicated that 54% of family members were under the age of 25, emphasizing the importance of programs targeting children and youth. Over 40% stated that their homes had been destroyed beyond repair. The survey also found that the unemployment rate had increased from 63% to 75%, and that the average monthly income had decreased significantly. Despite the high levels of stress, 88% of those surveyed indicated that they were optimistic that the situation in Kosovo would improve significantly after five years. The war had a significant impact on the cultural traditions of Kosovo Albanian families. In particular, the traditional social roles of men as economic providers and protectors of the family were shattered. As a result of the massive layoffs of Albanians

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

75

from public sector positions over the past decade, many men were unable to support their families. Many husbands and fathers had feelings of inadequacy and vulnerability. Assessments indicated that during the ten-year period leading up to and after the conflict, there was a major increase in alcohol abuse and domestic violence [2]. Many noted that the difficulties men faced during the war related to their inability to protect their family. The exact number of individuals murdered is not known and may never be known. In a December 1999 US State Department report, entitled, “Ethnic Cleansing in Kosovo,” it was estimated that 10,000 Kosovo Albanians were killed during the 1999 war, mainly males. Consequently, many women and children had to assume new responsibilities as heads of households. They became increasingly dependent on their extended families, and faced significant hardship. For example, in one family in which 14 members were massacred, the current leader of the family reported that he was now caring for his brothers’ wife and three children. He described that he barely had the economic means to support his own family, and that his sister-in-law would have to find other alternatives soon, even though she did not have the education or skills to obtain a job. In November 1999, the International Criminal Tribunal for the Former Yugoslavia (ICTY) reported that from June until October 1999, 195 mass gravesites were exhumed out of approximately 530 sites reported, uncovering approximately 2,108 bodies. Physicians for Human Rights reported that children were often around the gravesites during the exhumation process, and were allowed to view the bodies by their families. There are still thousands of missing persons. Many still hope that their loved one is alive in a detention center whose existence has not been acknowledged by the Serbian authorities. However, many will eventually have to cope with the awful fact that their loved one had been killed. Several organizations developed psychosocial programs to help children and families cope with the exhumation process, assisting them in understanding the identification procedures and giving them psychosocial support [3]. Since many of the mass gravesites were located in rural areas where there was considerable destruction, it was important that programs focus not only on psychosocial issues, but also address the community’s basic needs for food, shelter, and medical treatment. One such project by the International Rescue Committee (IRC) assisted numerous at-risk communities that had a history of atrocities, isolation of minorities, and a high level of physical destruction. In terms of sexual assault, there were numerous reports that Serbian forces raped Albanian women, but there was no consistent reporting and thus no clear data on the extent of sexual assaults. The lack of reporting was due to the negative social responses that a Kosovar Albanian woman faces as a survivor of sexual assault. Numerous cases have been reported of husbands leaving their wives, and families shaming the woman after she has been raped. Often a woman was coerced into silence. In fact, the Organization for Security and Co-operation in Europe (OSCE) human rights report noted, “The stigma of rape is so deep that it is often stated that a ‘good’ woman would rather kill herself than continue to live after having been raped.” Of those who were willing to discuss their experiences, the OSCE report indicated that the sexual assaults occurred in almost all situations, whether the women were at home, with their families, or in public places. It seems that young women were mostly targeted, and many were often minors. One woman who was suicidal reported being held captive for three months in a bar, where she was used for sexual acts by the Serbian paramilitaries.

76

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

Landmines have caused a wide variety of problems for the reconstruction and recovery of Kosovo. Many farmers were not able to harvest, and some lost livestock due to the mines on their land. The United Nations Mine Action Co-ordination Center (MACC) initially coordinated Mine Action in Kosovo, and reported that approximately 3.5% of the landmass in Kosovo was dangerous. From June 1 until September 30, 2000, MACC reported that there were a total of 516 verifiable injuries/deaths from unexploded ordinance. Of those that were injured or killed, the highest-risk group ranged from 10 to 25 years of age, with over 90% being male. These statistics strongly indicated that post-war recovery programs needed to focus on youth mine awareness. Consequently, international agencies promoted programs such as the inclusion of mine awareness in the secondary school curriculum, and training of all teachers. Organizations also established several child-to-child programs, targeting prevention and safe behaviors. More generally, a mine awareness component was mandatory in all youth centers opening throughout Kosovo, with one organization successfully including mine awareness with recreational activities (e.g. football). Finally, because many of the dangerous zones were in rural areas, a few organizations established a safer village program that targeted everyone in the community. In terms of support following accidents, Handicap International increased the level of physiotherapy assistance for amputees, improved facilities for rehabilitation, and set up prosthesis training in the hospitals. One local NGO, HANDIKOS, established ten community centers for the disabled, and planned to expand sub-branches into the rural areas. Since there was a lack of prosthetic equipment and services were limited immediately after the bombing, many of the children were sent abroad for rehabilitation. At Pristina hospital, where most of the children injured by mines or UXO were initially transported, UNICEF established a psychosocial program for the children and their families. The program consisted of a psycho-educational component, along with supervision with nurses from the pediatric surgery department in regard to the identification of psychological symptoms and ways to support the children and families. Psychosocial interventions were also conducted directly with the children and their families. To facilitate the transition from the hospital to the community, UNICEF partnered with the Vietnam Veterans of America Foundation, which established an assistance program for survivors, their families, and their communities. This program included material assistance, health services, education on survivor rights, and specially designed recreational activities. Efforts were also made to reach out to school staff to facilitate the reintegration of these children into their schools.

The Impact of the War on Adults and Children Few systematic studies have been carried out to assess the psychological impact of the war in Kosovo. The U.S. Centers for Disease Control conducted the earliest large-scale cross-sectional cluster sample study carried out in September 1999 [4]. Although the sample included adolescents 15 years and older, the results for this age group were clustered with those for adults up to the age of 34, with no conclusions generated for just youth. The results showed that Kosovar Albanians experienced a high prevalence of traumatic events, and that 17% met criteria for PTSD. It also found that geriatric populations, those with previous psychiatric illness or chronic health conditions, and those internally displaced during the crisis were at greater risk. Roughly half of the respondents reported strong feelings of revenge (51% of males, 44% of females) and

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

77

that over 1/3 stated that they would act on these feelings (44% of males, 33% of women). The authors replicated the study on Kosovar Albanians one year after the war, and found an increase in respondents meeting PTSD criteria (25%), while the desire for revenge and acting on these feelings did not significantly change [5]. A study conducted two years after the war in the emergency department of Pristina Hospital found that 18% of respondents still met criteria for PTSD, although only 2% of the respondents chief complaint centered on mental health issues [6]. These findings reveal that PTSD rates have remained high over several years, and indicate the importance of establishing long-term psychosocial programs and mental health services in Kosovo. Although these studies do not primarily focus on children, these results are similar to a longitudinal study conducted in Armenia where PTSD rates remained high 4.5 years after exposure to severe trauma [7]. These studies also point to the fact that that systematic training for health care professionals on the identification and treatment of patients who are suffering psychological symptoms is an essential component of psychosocial recovery programs. There have been no systematic studies in Kosovo evaluating the level of PTSD or other disorders that children were experiencing after the war. One study that examined exposure rates was carried out by the Center for Crisis Psychology/ UNICEF in August 1999. This study of 59 Kosovo Albanian school-aged children (ages 9–15 years) living in a refugee camp in Macedonia found that 63% of the children stated that they had been separated from a loved one for a significant amount of time when they greatly feared for their safety; 78% were forced by violence, or threat of violence to leave their home; 55% reported that someone threatened to seriously hurt or kill a family member or very close friend; and 50% stated that they had directly witnessed some type of violence. Older children reported experiencing more traumatic events than younger children [8]. A second study surveyed 813 school-age children from Pristina municipality schools. A factor analysis identified three cluster groups of stresses for these children: 1) lack of recreational and cultural resources; 2) health and mental health complaints; and 3) school-related problems [9]. Another study examined the effectiveness of using mind-body skills on 139 high school students that participated in a 6-week program in an area of Kosovo where there had been significant destruction and atrocities against the community [10]. This study included three separate groups of students who had participated in the program, and found a significant reduction in PTSD symptoms based on results from the UCLA PTSD Reaction Index [11]. Follow-up data was collected on two of the groups and scores remained decreased as compared to pretests. In interviews conducted by one of the authors with children and their families, many reported numerous atrocities that had been inflicted upon them or that they had witnessed. Children recounted that they were forced to witness violence against their parents, and some were intentionally kept alive to recount the massacres. For example, one 10-year-old boy recounted how he had witnessed the massacre of 53 people, which included his mother, brothers, and aunts. He described hearing the soldiers argue about whether they should kill him and how they decided to keep him as the only survivor so that he could retell the ordeal. He later witnessed the burning of the house where the bodies were left. During the interview, he was living in a tent with his father in front of their home that had been completely destroyed. There were also reports of children deliberately being killed to terrorize parents. For example, one teacher reported that paramilitary had entered his house when his wife was home, and that they killed his twin son in front of her but left his twin daughter unharmed. Children were also af-

78

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

fected by frequent intimidation, harassment, and humiliation, often resulting in fear of going to school. Following the war and displacement, some children showed signs of high levels of distress, trauma and grief reactions. Many children reported a high degree of anxiety (heart palpitations, shakiness, shortness of breath) and somatic complaints (headaches, stomach aches, excessive tiredness). Younger children showed symptoms of separation anxiety, speech problems, enuresis, and fears of the night. One mother brought her 4-year old girl to a pediatrician to determine if her daughter needed to see a specialist for her stuttering. It was reported that the child developed the speech difficulties after paramilitary forces took her father. Several months later she started preschool for the first time. Talking further with the child, she was able to acknowledge her fear of something happening to her mother while at preschool, and her longing for her father. In the classroom, schoolteachers reported that the students had greater difficulties concentrating and paying attention. Many teachers felt that the students had “lost everything that was taught to them in the past.” Others observed an increase in the level of aggression and smoking at a younger age.

Establishing Psychosocial Programs After Disasters Establishing a public disaster mental health psychosocial program for children and adolescents requires action at three levels [12–14]. The first level involves working with governmental agencies to define policy within services, including education, health, mental health and social systems. This requires evaluation of current responses and attitudes toward mental health, and facilitation of a response by these institutions. The second level involves working within the child-focused settings in the community, including schools, children’s hospitals, and juvenile detention centers. The third level involves development and training of intervention teams that may include professionals and paraprofessionals responsible for subpopulations of children. The practical realities in Kosovo called for adaptation of this public mental health approach to psychosocial programming. Following the conflict, the UN formed a provisional government, UN Mission in Kosovo (UNMIK), which meant establishing, inter alia, new education, health, mental health, and social services systems. While this created the ability for psychosocial principles to be integrated into the new laws and policies being developed, there remained significant challenges. These challenges were related, in particular, to the absence of infrastructure, staffing, and policies in UNMIK, and a lack of communication between UNMIK and the existing local institutions. Further, child-care services lacked sufficient professionally qualified staff, effective management structures and knowledge of up-to-date approaches to child mental health. The situation was further complicated by the arrival of several hundred international agencies, many of which brought different approaches, philosophies, and standards of care that proved extremely difficult to coordinate. Some NGOs provided programs that trained and strengthened various institutions and fostered sustainable psychosocial systems. Others undermined sustainable and culturally appropriate psychosocial systems, and weakened services through the development of numerous parallel and overlapping initiatives. All of this was set against a backdrop of an under-developed, post-conflict region that included a lack of reliable basic utilities (electricity, water), poverty and unemployment, high levels of crime, and sporadic conflict associated with an absence of effective policing.

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

79

In the initial months after the crisis, the UN and a few large NGOs attempted to establish a psychosocial plan by first organizing a Psychosocial Working Group that was led by UNICEF. As the establishment of psychosocial programs was new to many local partners and many international organizations worked under different conceptual frameworks, this group was tasked with coordinating psychosocial programs and establishing a core conceptual framework. This framework included: 1. Coordination of Psychosocial Programs: In the early stages of this working group, it was clear that due to the variability in psychosocial programs, there needed to be a continuum of care model. This continuum consisted of a hierarchy of interventions ranging from unstructured play activities (e.g. distribution of materials to stimulate groups to socialize and play), organized play activities (e.g., organization of structured play or sport activities), psychoeducation and guided psychosocial activities (e.g., providing training to teachers, parents on the effects of trauma on children), counseling (e.g., trauma/grief-focused individual and group treatment, psychological first aid), and specialized mental health services. The unstructured activities could be provided to all children, while, as the target population narrowed, activities would focus more on those displaying severe symptoms and disorders. The coordination also included the development of an outline of the standard components effective programs would need to have in each of the key service sectors. Guidelines were developed to communicate best practices for implementing agencies to incorporate into their activities. The goals of this effort were to ensure that psychosocial programs collectively reinforced and enhanced the capacity of existing service systems; that duplication and redundancy were eliminated; and that consistent principles and approaches were communicated to front-line personnel in schools, healthcare institutions and other settings. Despite these efforts, this coordination mechanism was limited by the absence of a well-organized authority to monitor and enforce best practices and coordination of care among agencies. Participation in coordination was entirely voluntary. This lack of authority to enforce best practices sometimes allowed for the continued operation of programs that were at best ineffective, or at worst harmful to participants and the institutions. This limitation also prevented monitoring and evaluation of outcomes generated by those programs that have been identified as key components for developing an effective mental health action plan during complex emergencies [15]. 2. Assessment of At-Risk Groups: When the working group began to design psychosocial programs it quickly encountered the problem of an absence of reliable public health data that could be used to identify children and families most at-risk. This problem was pervasive. Even the most basic information was unavailable. As a result, it was necessary to collect and review assessments that were being conducted for various purposes. The first level of assessment captured the most basic data on service systems, such as the number and condition of buildings for the provision of services, and the names and qualifications of professional staff. Community level impact assessments then examined the scale of damage and available resources within communities, for example, the number of houses damaged and the accessibility of health facilities. Psychological needs assessments were conducted primarily through ad hoc individual interviews or small focus group data, rather than larger scale, population-based surveys. The working group attempted to identify priorities, communities or groups most at risk by piecing together this patchwork of information. For example, assessments of hospital facilities uncovered relatively widespread abandonment of babies in maternity

80

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

wards who required immediate attention. The working group developed a comprehensive plan that included family tracing, developmental assessments, establishing playrooms and training for staff to care for these very young children. Eventually this led to the development of a province-wide fostering and adoption program. 3. Training and Education: The working group prioritized training professionals and paraprofessionals across child services to be able to understand, identify and refer children with symptoms of various psychological, behavioral, and developmental problems. Trainings emphasized a broad understanding of child development and child metal health issues rather than focusing predominately on posttraumatic stress disorder. The most effective approach to training stressed the importance of ongoing education, supervision and support, rather than one-time seminars or workshops. It was important to focus on building and sustaining capacity in existing systems by enhancing skills and competencies in institutions, staff and grassroots organizations. 4. Interventions: The UCLA Trauma Psychiatry Program has identified a three-tier model for disaster mental health interventions that were, broadly speaking, applied in Kosovo [14,16]. The first tier comprises general psychosocial support to a broad audience and includes psycho-education to normalize distress and Psychological First Aid interventions [17]. The primary objective of this tier is to promote adaptive postdisaster adjustment and normative developmental progression among children. The second tier includes specialized treatment services to reduce psychological distress, promote normative developmental progression, and promote adaptive post-disaster adjustment among moderately to severely traumatized children and adolescents. This tier includes identifying children with severe distress reactions (including PTSD, depression, and grief symptoms), and developmental disturbance and providing them with individual, group or family trauma/grief-focus interventions. The five therapeutic foci of these treatments, which are based on a developmental model, are traumatic experiences; trauma and loss reminders; grief; post-war stresses and secondary adversities; and developmental impact [12,18,14]. The third tier interventions include specialized treatment for high-risk cases that need more intensive psychiatric care to reduce severe psychological distress, suicidal risk, and other high-risk behaviors. In accordance with the core framework, specific psychosocial services were, to a large extent, implemented through child service institutions – schools, health facilities and social services. The following sections detail key activities and issues within the various service settings, and highlight some of the main accomplishments and challenges for UNICEF and other working group member organizations.

Educational Services During the ten years prior to the crisis in Kosovo, the educational system functioned in two parallel systems. Ethnic Albanian children were excluded from secondary and university school buildings, and were often educated at home. These students had limited access to resources and had few learning materials. The schools themselves had not been maintained and were deteriorating. Many schools functioned without water/sanitation systems or reliable electricity. Often schools were overcrowded, with most working on a shift schedule, with two to four shifts of students over the course of a school day. Initial efforts of the international organizations focused mostly on rehabilitation and equipping of the school buildings and revamping of the curriculum.

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

81

Through focus group interviews, teachers and other school personnel reported that difficulties in concentration, trauma-related reactions, grief symptoms, nightmares, and a general increase in disruptive behavior in schools were among the most common problems that the children were experiencing. School personnel also reported that they too were trying to cope with their own personal experiences, and felt that they did not have the skills to handle these new problems. Thus there was an urgent need to provide teachers, pedagogues (school counselors), and principals with training and support to enhance their capacity to help children and their families, and to help the schools as a system to develop psychosocial services. The education system in Kosovo did not have any well-developed school psychology services, unlike other parts of the Former Yugoslavia. This lack of trained personnel was especially prominent in the rural areas, yet these areas were the ones that had experienced the most pervasive atrocities and destruction. Many school personnel were not on contract, were not getting paid, and there were numerous staff changes. Due to these factors, a Tier II trauma/grief psychotherapy program that was developed in Armenia [19] and Bosnia-Herzegovina and other disaster emergency areas could not be implemented in Kosovo [18]. Instead, many NGOs established school-based Tier I psychosocial programs that included basic psycho-education, general coping and problem-solving skills, community-based activities, and referral strategies for those children most at-risk. One well-developed program is highlighted in another chapter in this book (see chaper by Anica Mikus Kos). When the UNMIK Education Department was established, it endorsed the creation of guidelines for school-based psychosocial programs to facilitate coordination and to provide a framework for the pre-implementation review of proposed school-based interventions. These psychosocial guidelines that were developed for Kosovo can be summarized in the following principles: Coordination with Governmental Agencies: The first step in assessing the needs for psychosocial school-based programs after a complex emergency is to contact the lead coordination agency to get an update on the current situation in the educational system, current activities, and how to connect with the local education authorities. Need to Consider the Education System as a Whole: Even when a program will be in a limited number of schools, there needs to consideration of how the program may impact the education system. When conducting professional development workshops and trainings across schools, it is important for agencies to train on similar core skills. In addition to training on trauma and grief, trainings need to also include information about child development and general child mental health issues. Programs Need to be Implemented Within the Existing Institutions: Psychosocial programs need to work within the structures of educational institutions. It is problematic to recruit additional school staff for sustainability reasons. Programs should not lure staff away from schools, as this only compromises school functioning. Programs Should Have a Long-Term Perspective: A system needs to be put in place that provides training, supervision, and consultation for an extended period. Activities for All Children: Psychosocial programs need to consider different activities for all children by providing general activities that encourage socialization, provide a structure and predictability, and normalize their lives. Programs Need to be Developed to Reach All Ethnic Groups: There needs to be a plan to develop psychosocial programs for all affected ethic groups. This includes mak-

82

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

ing sure that materials are translated into needed languages, and that programs are culturally informed and competent for the various ethnic groups in affected communities. Have a Referral System: It is important that a referral system be in place for children who may need more intensive psychiatric, psychological, or medical services. The UNICEF/Center for Crisis Psychology developed a wide-reaching schoolbased psychosocial program in coordination with working group partners that had the following goals: To increase the understanding of pedagogues, teachers, parents and children about the psychological effects of war and violence. To encourage open communication and exchanges of experience within the school community to build tolerance for their various experiences and to inform the psychosocial services being implemented. To understand and identify personal, school and community trauma and loss reminders, and to develop plans to deal with unnecessary reminders. To enhance effective coping and problem solving within the school community. To improve children’s learning capacities by reducing current levels of distress and to foster a return to normal school and family routines. To strengthen the capacity of regional and municipal education authorities to develop, implement and monitor school psychosocial projects. The program had a tiered implementation plan that provided for the creation of municipal monitoring / support teams and school-based psychoeducation teams to provide peer training in schools and to provide direct services. Following a standard briefing with the school principal, to create understanding and buy-in, the school based teams trained teachers and other stakeholders by presenting an overview of the developmental impact of disasters on children; the importance of open communication among school staff, parents, and students; and guidelines for classroom interventions. Implementation of school-based interventions provided psychoeducation information to teachers and parents; supervision of the teachers implementing group and classroombased activities; convening of parent meetings; and establishment of peer group support activities. Finally a network of more experienced staff trained in Psychological First Aid was established to provide support to teachers and others who have experienced their own severe traumatic events. This program was implemented in several areas of Kosovo, including in the north, primarily an ethnically Serbian area. For this area, some modifications were made to the curriculum to adjust to their needs and cultural traditions.

Social Services Psychosocial programs in social service systems addressed the needs of children and adolescents who were at-risk due to a number of reasons, and who often were not assisted by school-based psychosocial programs. These at-risk groups included out-ofschool youth, juvenile offenders, and homeless, orphans, displaced, trafficked or disabled children. Responsibility for the care of these children mainly fell to the Centers for Social Work (CSW). The CSW were also responsible for identifying families who needed financial assistance, shelter for the elderly, and guardianship authority. They were also charged with overseeing adoption, foster care, and child custody issues. Similar to the other service systems, the CSW typically had a chronic lack of capacity

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

83

and worked under poor conditions. The scale of need, the broad range of responsibilities, and the lack of professional capacity (untrained, unpaid staff) resulted in many of the CSW across Kosovo being overwhelmed, and providing inadequate services. The juvenile justice program highlights some of the challenges and opportunities faced in integrating psychosocial programs into social services in Kosovo. UNMIK International Police reported that youth from 10 to 25 years of age were responsible for over 25% of the criminal offenses in the first eight months of 2000 [20]. Many crimes went unreported, so this statistic was likely to underestimate the true incidence of juvenile crime. Human rights monitors found that youth rights were often violated during arrest and detention, including juveniles being incarcerated with adults. The Juvenile Justice taskforce, which was comprised of local and international organizations, quickly realized that many of the youth were reporting PTSD and depressive symptoms, and that psychiatric and psychosocial services were needed in these institutions. Subsequently, UNICEF led the development of a psychosocial program within detention facilities that was designed to identify at-risk juvenile detainees, and provide treatment assistance. Additionally, training was conducted to raise the awareness of Kosovar and International Police, and detention officers regarding psychosocial symptoms, and to enforce international standards of protection of juvenile detainees. UNICEF also recommended that the juvenile justice center being created should have on call psychiatric staff and full-time case managers. Further, rehabilitation and prevention activities were recommended to limit recidivism, and to promote pro-social choices upon release, including the possibility of re-entering education or the workforce. The program included interviewing of youth using a developmental psychopathology approach that included assessing their trauma and primary and secondary adversities, addressing effectiveness of coping strategies, impairments in peer, school/work or family functioning, and previous development and psychopathology [21]. During these interviews, some of the children reported that they had attempted suicide or were actively suicidal, and a few were going through drug withdrawal. The youth who were detained for violent crimes reported significant trauma exposures during the war, including witnessing the murder of family members or being victims of physical or sexual assault. The lack of social, educational or recreational activities for juvenile detainees increased their sense of isolation, and compounded psychosocial problems. For example, one youth, who was 16-years-old when he allegedly murdered an 18-year old male, reported in the initial interview that there was no hope for the future and that he was suicidal. He later reported that during the war, three of his cousins were massacred and two were currently missing. He reported that he witnessed the Serb military severely beat his neighbors and loved ones, and that he was physically forced out of his home. He reported also that as his family fled to a neighboring country, they were separated for an extended period of time, and that he had worried about their safety. He reported extreme rage for not being able to protect his family and revenge toward minorities. He reported feeling isolated at the detention center, as he was with adults and that there were limited activities for him. When he was transferred to the juvenile detention center, he reported an improvement in his mood, as he was with peers his age and there were structured activities for the youth. Interventions not only included alleviating his trauma and grief symptoms, but assisting him in his impulse control and moral development [22]. For young offenders under the age of 14, the juvenile justice code required them to be put under the jurisdiction of the Guardianship Authority of the CSW. This meant

84

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

that these children could not be detained even for the most serious of crimes. Because of inadequate staffing for CSW, many of these children did not receive the services they needed. In some rare cases, young people were encouraged to commit serious offences, including murder, by their parents with the knowledge that punishments would be light or non-existent.

Health Services In 1999 Kosovo had a young population in which 52.7% were under 20 years of age. The World Health Organization (WHO) reported that the birth rate in Kosovo ranged from 27,000 to 34,000 per year, and the infant mortality rate was the highest in Europe, over 50 per 1000 births. This was drastically higher than the average for the European Union (5.6 per 1000 births). In a health study conducted in September 1999, the U.S. Centers for Disease Control, funded by IRC and supported by the Kosovo Institute for Public Heath, found that infants under the age of one year accounted for 40% of all deaths in Kosovo, despite making up only 2% of the population. In February 2000, UNMIK Department of Health and Social Welfare became alarmed at the increasing number of babies being abandoned in hospitals. A few cases of infanticide were also discovered. After an assessment at each of the hospitals was completed with administration, doctors, and nurses, it was reported that social issues were not being addressed during visits due to a lack of staff and high birth rates (e.g., Pristina Hospital estimated 30 to 40 births per day). The majority of hospitals agreed to establish a 24-hour consultation service in the maternity departments, where women could talk in a one-to-one confidential environment about the social and psychological challenges they were facing. This project primarily focused on issues such as preventing abandonment or other forms of child abuse/neglect, consultation on abortion issues, on violence, trauma, and social/economic concerns, and providing information on prenatal and baby care. With the support of UNMIK and the health administrators who agreed to hire nurses for this program, UNICEF conducted trainings with the nurses, the Centers for Social Work for each participating region, local and international NGOs, and other relevant stakeholders on how to provide effective consultation to these women. A referral matrix was also developed to ensure that their families received services once issues were identified in these interviews. Ongoing supervision and training materials were developed for the nurses to enhance their skills. In a six-month time period, over 4,000 women went through the consultation services. Over a dozen cases of abandonment were prevented by either providing the women resources in the community to be able to keep the child, or by facilitating the adoption process. Some abortions were prevented by helping mother’s accept the sex of the child, or by providing them resources if they had economic concerns. In approximately 10–12% of the cases, women reported domestic violence, and over 1/3 complained about economic struggles. For example, one pregnant woman who was hospitalized due to injuries caused by her husband reported that since the war, her husband had been beating and kicking her on a regular basis. She also reported that he was beating her four daughters. She reported that during the war, the Serb military detained her husband for two days before he escaped, but he would not talk about what happened to him while detained. She stated that her family was putting pressure on her to leave him and the children, but she was worried about what would happen to them. With her consent, project staff connected her with the Center for Social Work and a

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

85

local woman’s group who focused on domestic violence issues to provide assistance to her, which included information on an emergency shelter that was just established in the region. The staff also discussed with her a strategy of working with a family member that her husband trusted to encourage him to receive counseling for his anger and experiences during the war. When she returned to the hospital to give birth to her child, she reached out to the project to thank them for their assistance. She reported that she was unaware of the resources available in the community, and that the situation with her husband was improving. In fact, many of the women reported not being aware of resources that were available in their community, and that these referrals greatly reduced their stress. The project staff was also able to dedicate time to prevention issues, such as breastfeeding, health promoting prenatal and babycare practices, and family planning, which were areas that the other staff was not able to spend enough time promoting. When the program first began, there was pessimism among administrators and other professionals that the women would not share their experiences of violence to strangers. However, as the program progressed and the project team would summarize the issues being reported, there was more awareness of the prevalence of these issues, and acceptance by some of the professionals of the need to assess for these types of issues as part of their complete history taking. These reports also went back to policy makers to ensure that enough resources were established to assist families, and that the laws supported the health and welfare of women and children.

Mental Health Services Mental health services were limited, based on a biological model, with little tradition of community-based psychiatry. It was estimated there was approximately one psychiatrist per 100,000 inhabitants, and one psychologist per 400,000, with few trained in child and adolescent psychiatry [23]. There was no psychology department at the university. Children and adolescents with acute psychiatric needs often went untreated, or were treated by a primary care physician. However, the majority of primary care physicians were not trained in child and adolescent mental health, resulting in a widespread failure to recognize symptoms, including PTSD and depression, and consequent failure to provide effective treatments. Following the war, there was a need to develop short, intermediate and long-term psychiatric programs to treat children with mental health conditions. Short-term interventions focused on training primary care physicians to recognize and treat children and adolescents with psychiatric illnesses. There were several medical NGOs who were operating out of more than 47 of the smallest primary health care facilities, known as ambulantas, throughout Kosovo. This approach was considered sustainable, as the services were provided within the existing health system, working in collaboration with the local professionals, and treating a broader array of psychiatric illnesses. On the other hand, many organizations established independent psychological outpatient clinics. By mid-2000, there were approximately 20 clinics established by local and international NGOs. There were many problems related to these clinics. First, most of the clinics only addressed problems related to trauma, and not all child and adolescent psychiatric disorders. Second, most programs operated with paraprofessionals who were only trained as counselors for several days. Third, none of these clinics were affiliated with the health system, and once funding stopped many of these services closed. Fourth, there was no coordinating or monitoring mecha-

86

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

nism to control whether an agency was qualified to operate a clinic or to establish the minimum level of training needed. Consequently, there was an uneven distribution and quality of services, with too many clinics running in some municipalities and no services elsewhere. A number of programs comprised promising approaches that addressed both the immediate and long-term needs of children and adolescents. One such program was implemented by Child Advocacy International, which created a child, and adolescent mental health service. The aim of the program was to train several psychiatry residents and nurses in child and adolescent psychiatry, creating a sustainable, culturally appropriate service and a training base within the health system that could continue to provide training in the future [24]. Similarly, the International Organization for Migration (IOM) implemented a promising program to train 50 students at Pristina University in counseling and psychosocial approaches. This was one of the only extended training programs available, lasting for one academic year that also included field experience under intense supervision. The program was run by the university, and led to the creation of a department of psychology in 2002. Any review of mental health in Kosovo must include the importance of family. In a Mental Health Conference in December, 1999, an Albanian physician, Dr. Nait Vrenezi, discussed the cultural practices of Kosovo Albanians and their influence on mental health. She indicated that since the past ten years were a period marked by intense fear and anxiety, and since the health institution was not considered a safe haven, individuals, generally, could only rely on their family. Due to the widespread post-war economic hardships, extended families were instrumental in providing social and psychological support to their members. Dr. Vrenezi noted that a study conducted prior to the war found that 44.6% of households had more than eight members. The implication was that when developing child mental health services, one could not treat only the child or their parents, but should also include work with the extended family. This was initially a problem, as the family was not typically included in treatment services. Later, however, the importance of providing family services was recognized and incorporated into the Strategic Plan for Mental Health Services, which is described at length later in this book (see Ferid Agani chapter).

Conclusions When responding to complex conflicts and disasters, it is important to design and implement comprehensive psychosocial programs embedded within existing institutions and service systems, that can identify all children at risk and provide access to effective and culturally appropriate services. Thorough needs assessment and triage is essential to identify groups most at risk so that resource allocation and service design are made on the basis of need. Psychosocial and mental health programs in complex emergencies should be implemented along a continuum of care that includes response for those with transient, mild reactions, and extend to those who have severe psychiatric disorders. Services must then be implemented in a manner that does not stigmatize groups. Strong and effective coordination is critical. A multitude of organizations wish to help the survivors of conflict and disaster by addressing mental health needs, yet not sufficiently aware of the specialist, peer-reviewed tools and protocols in existence around the world that would allow the development of rational, appropriate and effective services that are carefully designed to address objectively identified needs. Finally, psy-

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

87

chosocial and mental health needs should not be addressed in isolation from the full range of survival, social and economic issues that communities face during and after conflicts or disasters. Psychosocial programs are limited when people continue to face life-threatening risks. In fact, resolution of a person’s safety and well-being needs is a critical step in mitigating stress and other mental health disorders. The experience of developing and implementing child mental health programs in Kosovo should be carefully reviewed in order to determine which interventions and investments were most effective so that the lessons learned may be applied in similar situations elsewhere.

References [1] Salama, P., Spiegel, P., Van Dyke M., Phelps, L., Wilkinson, C. (2000). Mental health and nutritional status among the adult Serbian minority in Kosovo. Journal of the American Medical Association, 284, 578–615. [2] No Safe Place: Results of an Assessment on Violence against Women in Kosova, UNIFEM, April 2000. [3] Keough, M.E. & Samuels, M.E. (2004). The Kosovo family support project: offering psychosocial support for the families with missing persons. Social Work, 49, 587–594. [4] Cardozo, B.L., Vergara, A., Agani, F., Gotway, G. (2000). Mental Health, Social Functioning, and Attitudes of Kosavar Albanians Following the War in Kosovo. Journal of the American Medical Association, 284, 569–577. [5] Cardozo, B.L., Kaiser, R., Gotway, C.A., Agani, F. (2003). Mental Health Functioning, and Feelings of Hatred and Revenge of Kosovar Albanians one year after the war in Kosovo. Journal of Traumatic Stress, 16, 351–360. [6] Fernandez, W.G., Galea, S., Ahern, J., Sisco, S., Waldman, R.J., Koci, B., Vlahov (2004). Mental health status among ethnic Albanians seeing medical care in an emergency department two years after the war in Kosovo. Annals of Emergency Medicine, 43, E1–E8. [7] Goenjian, A.K., Steinberg, A.M., Najarian, L.M., Fairbanks, L.A., Tashjian, M., Pynoos, R.S. (2000). Prospective study of posttraumatic stress, anxiety, and depressive reactions after earthquake and political violence. American Journal of Psychiatry, 157, 911–916. [8] Stuvland, R. (1999). Psychosocial project for children and women affected by violence in Kosovo: project proposal to UNICEF Pristina Office. Center for Crisis Psychology. [9] Barath, A. (2002). Children’s well-being after the war in Kosovo: Survey in 2000. Croatian Medical Journal, 43, 199–208. [10] Gordon, J.S., Staples, J.K., Blyta, A., Bytyqi, M. (2004). Treatment of posttraumatic stress disorder in postwar Kosovo high school student using mind-body skills group: a pilot study. Journal of Traumatic Stress, 17, 143–147. [11] Steinberg A.M., Brymer M., Decker K., Pynoos R.S. (2004) The UCLA PTSD Reaction Index. Current Psychiatry Reports, 6, 96–100. [12] Pynoos, R.S., Goenjian, A.K., Steinberg, A.M. (1998). A public mental health approach to the postdisaster treatment of children and adolescents. Child and Adolescent Psychiatric Clinics of North America, 7, 195–210. [13] Pynoos, R.S., Goenjian, A.K., Steinberg, A.M. (1995). Strategies of disaster intervention for children and adolescents. In Hobfoll, S.E., deVries, M.W. (eds.). Extreme stress and Communities: Impact and Prevention. Dordrecht, The Netherlands, Kluwer Academic Publishers, 445–471. [14] Saltzman, W.R., Layne, C.M., Steinberg, A.M., Arslanagic, B., Pynoos, R.S. (2003). Developing a culturally and ecologically sound intervention program for youth exposed to war and terrorism. Child and Adolescent Psychiatric Clinics of North America, 12, 319–342. [15] Mollica, R.F., Cardozo, B.L., Osofsky, H.J., Ager, A., Salama, P. (2004). Mental health in complex emergencies. Lancet, 364, 2058–2067. [16] Pynoos, R.S., Steinberg, A.M., Schreiber, M.D., Brymer, M.J. (In press). Children and families: A new framework for preparedness and response to danger, terrorism, and trauma. In L.A. Schein, H.I. Spitz, G.M. Burlingame, P.R. Mushkin (Eds.) Group approaches for the psychological effects of terrorist disasters. New York, Haworth Press. [17] Pynoos, R.S., Schreiber, M.D., Steinberg, A.M., Pfefferbaum, B.J. (2005). Impact of terrorism on children. In B.J. Sadock & V.A. Sadock (Eds.) Comprehensive Textbook of Psychiatry (Eighth Edition). Lippencott Williams & Wilkins, Philadelphia, PA: 3551–3564.

88

M.J. Brymer et al. / Issues in the Development of Psychosocial Programs

[18] Layne, C.M., Pynoos, R.S., Saltzman, W.R., Arslanagic, B., Black, M., Savjak, N., Popovic, T., Durakovic, E., Mftic, M., Campara, N., Djapo, N., Houston R. (2001). Trauma/grief-focused group psychotherapy: School-based post-war intervention with traumatized Bosnian adolescents. Group Dynamics: Theory, Research and Practice, 5, 277–290. [19] Goenjian, A.K., Stilwell, B.M., Steinberg, A.M., Fairbanks, L.A., Galvin, M., Karayan, I., Pynoos, R.S. (1999). Moral development and psychopathological interference with conscious functioning among adolescents after trauma. Journal of American Academy of Child and Adolescent Psychiatry, 38, 376–384. [20] Making the choice for a better life: Promoting the Protection and Capacity of Kosovo’s Youth” Report of the Women’s Commission for Refugee Women and Children Mission to Albania and Kosovo 1999–2000, January 2001. [21] Pynoos, R.S., Steinberg, A.M., Piacentini. (1999). A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders. Society of Biological Psychiatry, 46, 1542–1554. [22] Goenjian, A.K., Pynoos, R.S., Karayan, I., Minassian, D., Najarian, L.M., Steinberg, A.M., Fairbanks, L.A. (1997) Outcome of psychotherapy among pre-adolescents after the 1988 earthquake in Armenia. American Journal of Psychiatry, 154, 536–542. [23] Agani, F. (2001). Mental health challenges in postwar Kosova. Journal of the American Medical Association, 285, 1217. [24] Jones, L., Rrustemi, A., Shahini, M., Uka A. (2003). Mental health services for war-affected children: Report of a survey in Kosovo. British Journal of Psychiatry, 183, 540–546.

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

89

Former Mozambican Child Soldier Life Outcome Study Neil BOOTHBY and Jason HALPRIN, MPH Program on Forced Migration and Health, Mailman School of Public Health, Columbia University

Over the past decade the number of child soldiers has increased–as small arms and light weight weapons become more available children become more easily armed, and as conflicts continue to simmer in forgotten corners of the post-Cold War world [1]. An estimated 300,000 boys and girls under the age of eighteen years are currently participating in ongoing conflicts in Asia, Africa, Europe, the Americas, and the former Soviet Union [2]. Fortunately, the problem of child soldiering has not gone unnoticed, and increased human rights attention to it has lead to new international legislation to protect under-aged children against armed recruitment.1 The protection and welfare of child soldiers also is now being included in the international community’s peace and security agenda through several Security Council resolutions [3]. These resolutions have lead to a range of operational initiatives, including the deployment of child protection professionals in UN peacekeeping missions and the earmarking of tens of millions of dollars from government donors for child soldier prevention, disarmament, demobilization, and rehabilitation programs. In light of these recent developments, it is important to learn more about how children are affected by child soldiering experiences and what kinds of assistance enable their psychological recovery and social-economic reintegration over time. This chapter offers preliminary findings on the life outcomes of Mozambican former child soldiers. Between 1988–2004, information was collected on male former child soldiers in Mozambique. Our research began at the Lhanguene Rehabilitation Center in Maputo, continued after these boys from the center were reintegrated into their families and communities, and culminated most recently in 2003–2004 with a study to document how these former child soldiers now fare as adults.2 1988–1990 journalistic accounts labeled Mozambique’s children as a “lost generation” and “future barbarians.” Our research suggests that this is not the case. To the contrary, the majority of this group of former child soldiers that we have followed for the past 16 years has become productive, capable, and caring adults. Most have regained a foothold in the economic life of rural Mozambique, are perceived by their spouses to be “good husbands”, are taking active steps to ensure their own children’s 1 The United Nations’ General Assembly adopted an Optional Protocol to the Convention on the Rights of the Child establishing eighteen as the minimum age for participation of children in conflict. The Rome Statues for the International Criminal Court, ILO and African Charter on the Rights and Welfare of the Child also have addressed child soldiering. 2 For the purposes of this study, we refer to a “child soldier” as any child under the age of 18 years who was in Renamo base camps regardless of their particular role as porters, servants, or combatants.

90

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

welfare, and are engaged in the collective affairs of their communities. Only a few continued their violent ways, or are so disordered that they have been unable to take hold of their lives. At the same time, none of these former child soldiers are truly free from their pasts. All continue to struggle with psychological distress linked to their childsoldiering experiences. When troubling memories from the past reappear these former child soldiers rely solely on themselves, their families, and friends for comfort and support. Many have managed to reduce the frequency of post-traumatic distress by identifying situations that have promoted painful thoughts and feelings in the past and avoiding them. They try not to dwell on troubling memories when they do emerge; rather, they consciously think about more positive aspects of their lives, re-engage in day-to-day work activities, or seek solace in religious institutions, prayers, rituals, and texts. Wives, for the most part, are aware of their husbands’ struggles. They tend to encourage their husbands not to become overwhelmed by evasive thoughts and feelings, and compensate in other ways when they do become despondent. Extended family members and neighbors also are aware of these tendencies, and typically respond with patience, advice, or support. Our research also identified specific interventions that were important to enabling these former child soldiers’ substantial recovery and reintegration. Activities that were identified as important were those that supported and strengthened individuals’ coping skills for anticipated trauma and grief, as well as those that supported normative life cycle milestones. Additionally, activities that instilled a sense of social responsibility and promoted safe codes of conduct, self-regulation and security seeking behavior were helpful. Over and above all this, however, was the need of the former child soldiers to be accepted by their families and communities after the war. Thus, apprenticeships, as well as community sensitization campaigns, community works projects and outward support of traditional community rites were some of the most important activities related to the successful recovery of many of the former child soldiers.

Methodology Any research done in a war-torn setting is difficult and fraught with practical and ethical constraints [4]. Such is the case here. The 39 boy soldiers who comprise this study were not randomly selected; rather, they were pulled from detention centers in southern Mozambique by the government to draw international attention to Renamo’s abuse of children and housed in the Lhanguene center. Save the Children was asked to assist these boys even though we did not support the Mozambican Government’s decision to house the boys in the Lhanguene center. It was our contention that the best course of action would be to return the boys to their families as soon as possible. Between 1989 and 1990, three members of our research team undertook a parallel study of 504 war-affected boys and girls (reported below). The results from this study reveal that the Lhanguene child soldiers’ experiences were similar to those of other abducted children in Renamo base camps. Unfortunately, no girls, who were also abducted and forced to take on different roles with Renamo, were selected by the government to be in the Lhanguene Center. When the Lhanguene Center opened in 1988, culturally sensitive assessments were conducted to guide the rehabilitation and reintegration efforts. War related experiences (events, severity, and duration) were recorded using a Life Events Profile. Children’s

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

91

ecologies were assessed using a Documentation, Tracing, and Reunification (DTR) protocol [5]. A Child Behavior Inventory Form (CBI) was also established to assess aggression, traumatic symptoms, and high-risk to pro-social behavior. After reunification with families, follow-up assessments were conducted in 1988, 1989, and 1990 in the boys’ communities. A number of these visits were video taped. For the 2003–2004 phase of our research, former Lhanguene staff led research teams and conducted interviews, as it was not possible to gain access into rural communities without the presence of these trusted individuals. We also used free listing 3 to identify relevant “social functioning” tasks important to local people [5]. The aim was to insure that our definition and measures of adult social functioning matched local perceptions of Mozambican adult social functioning. None of the former child soldiers declined to be interviewed nor did any terminate the interview once it had started. To triangulate the data, focus groups with families, community members, and community leaders were also conducted. Our overall aim was to gain as accurate a picture as possible of how the former child soldiers have adapted over time, paying particular attention to their psychosocial well-being, and their roles as husbands, fathers, economic providers, and neighbors.

Background Mozambique’s armed conflict lasted for almost 30 years. In 1964, Frelimo (The Mozambique Liberation Front) launched an armed insurgency for national liberation from the Portuguese colonists. Portugal bitterly resisted liberation efforts, but acquiesced after a ten-year war. In 1975, the minority regimes in South Africa and Rhodesia looked on in alarm when Mozambique declared itself an independent nation. Rhodesia, in particular, viewed this as a threat since it shared its eastern border with Mozambique and feared its own indigenous population would fight similarly for independence [6]. The Rhodesian secret police organized, trained, and armed anti-Frelimo groups and disgruntled ex-Frelimo soldiers into an organization called the Mozambique National Resistance (Renamo [7]). In 1977, after Mozambique gave sanctuary and support to guerrillas fighting the Rhodesian regime, Renamo infiltrated Mozambique and began its own brutal guerrilla operations. In 1980, Renamo lost its sponsorship in Rhodesia after the minority regime fell and the country became Zimbabwe. South Africa then intervened and offered its territory as a sanctuary and training ground. With South African support, Renamo returned to Mozambique and continued to wage a guerrilla campaign to undermine both the country’s infrastructure and the government’s ability to govern by destroying factories, schools, health clinics, and stores [8].

Mozambican Children in War Mozambique’s conflict had a devastating impact on children. Surveys during this time revealed that one third of Mozambique’s children died before they reached the age of 3 Free listing is a systematic data collection method where an informant is asked to list all the different kinds of some category (for example, all the different categories of depression). This method is used as a preliminary exploration to culturally determine the definition of a term.

92

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

five years through starvation, malnutrition, and preventable illnesses that paralleled the continuing conflict [9]. What happened to Mozambican children who did survive beyond the age of five? In 1989, in an effort to answer this question, members of our initial research team interviewed 504 children in 49 districts comprising seven of Mozambique’s ten provinces, covering a broad geographical range from Maputo in the south to Nampula in the north. Mozambican nationals asked a randomly selected sample of 227 boys and 227 girls between the ages of 6 and 15 years of age to describe their war-related experiences in detail. The results were staggering: 77% had witnessed murder, often in large numbers 88% had witnessed physical abuse and/or torture 51% had been physically abused or tortured 63% had witnessed rape and/or sexual abuse 64% had been abducted from their families 75% of the abducted children were forced to serve as porters or human cargo carriers 28% of the abducted children (all boys) were trained for combat. In addition to the above statistics, children’s descriptive accounts provided considerable insight into how Renamo socialized children into violence. Adults relied on physical abuse and humiliation as the main tools of indoctrination. In the first phase of indoctrination, Renamo members attempted to harden the children emotionally by punishing anyone who offered help or displayed feelings for others, thus conditioning them not to question the group’s authority. Children were then encouraged to become abusers themselves. A progressive series of tasks—taking the gun apart and putting it back together, shooting rifles next to their ears to get use to the sound, killing cows— culminated in requests to kill unarmed human beings. Children were expected to assist adult soldiers without question or emotion. Those that resisted were often killed. Those that did well became junior “chiefs” or garnered other rewards such as extra food or more comfortable housing. Upon reaching the final stages of training, normally after their first murder, Renamo marked the occasion with ceremonies that resembled traditional rites of passage. This process of mimicking traditional ceremonies appeared to be aimed at usurping children’s ties to their families, communities, and traditional ideas of right and wrong.

The Lhanguene Center In 1988, Save the Children began its Children and War Program in Mozambique. The Program’s initial focus was on 39 boy soldiers (between 6 and 16 years of age), all of whom had been abducted from their families by Renamo. They were trained to fight and, in many instances, encouraged to kill other human beings. Eventually, these boys escaped or were liberated from rebel strongholds. After brief stays in prisoner of war camps, the government decided to place them in the Lhanguene center in Maputo, and asked Save the Children to provide psychological and social assistance. Rehabilitation efforts at the Lhanguene Center focused on four inter-related components that were integrated into all Center activities:

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

93

Establish safety and appropriate codes of conduct: A safe place and appropriate behavioral norms were deemed to be baseline requirements. The former soldiers participated with the Center staff in setting acceptable behavior norms (including rewards and punishments) and a peer-adult monitoring system. A structured day-to-day activities-learning schedule was a key aspect of this component as well. Re-establish self-regulatory processes: An assumption was made that problematic behavior exhibited by former child soldiers (whether passive-withdrawn or aggressiveviolent) was in part the result of previous coping and survival strategies learned during the war. An “activities package” was developed to enable former child soldiers to regain proper impulse control and modulate aggressive as well as withdrawn behavior. Activities ranged from team sports to choreographed dance, music, and group art. All required cooperative, synchronized, and group-oriented behaviors in order to “win” or be “successful.” Promote security versus survival-seeking appraisal and behavior: Initially, the majority of former child soldiers continued to appraise events and human interactions from a survival perspective. Along with the activities package mentioned above, adultchild relations were also seen as a way to promote security-seeking versus survivalseeking appraisal and behavior. Program staff supported the efforts of the Mozambican Women’s Organization volunteer caretakers who were key actors in this effort to reestablish a sense of security and trust. Support meaning-making: Personal narratives, drawing, and child-adult discussions were employed to explore objective and subjective aspects of their child soldiering experiences. Traditional healers and religious leaders also provided ceremonies and services to help the boys come to terms with their past deeds and lost loved ones. Work in this domain also focused on efforts to reconnect former child soldiers to their national, family, and community identities. This occurred through ritualistic song-dance activities, as well as through socio-drama and theater performances. Three common themes were integrated and repeated in all these later activities: renouncement of Renamo, devotion to government, and love of family and community.4 Additionally, a family tracing and reunification program, community sensitization campaigns, traditional ceremonies, and apprenticeships were set up to assist the reintegration of these boys into their communities. Maputo-based Mozambican government officials believed that the families of these former child soldiers would never accept their return because of the crimes they had committed. As part of their long-term planning, Save the Children staff undertook investigative trips to rural communities to see if these government reports were accurate. They were not: overwhelmingly, family and community members who had lost their children to Renamo wanted them back. This was also true of community-level political leaders, but less so for senior district and provincial leaders. A family tracing and reunification program was developed and relatives for all the Lhanguene boys were eventually located. The Lhanguene center and the model of center-based care have significant limitations. Though the concentration of resources in a center-based setting assists in the expeditious provision of education, counseling and development of mentor relationships; the eventual closure of the center rendered the relationships, especially the positive role modeling, built at the center too short. Demobilizing the children at the Lhanguene 4 The Ministry of Education was formally responsible for the Lhanguene Center. It was at their request that devotion to the government was included in these routines.

94

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

center prolonged their return to their home communities where critical social learning takes place. As our investigative trips discovered family and community members who had lost their children to Renamo wanted them back immediately. The government’s first priority should have been to coordinate the boy’s safe return home and to engage local leaders, healers, and educators in recovery and healing processes.

Family Reunification Overview: A family tracing and reunification program was developed to respond to the needs of children who were separated from their families as a result of the civil war. By the early 1990s, over 2,000 former Mozambican child soldiers were reunited with their families [10]. Procedures developed to identify, document, search and reunite children and families were organized into a six-part process: Identification: The tracing and reunification effort began with an active search to identify all children in need of assistance in locating their family members. Procedures were devised to identify and document unaccompanied children in orphanages and other child care institutions, hospitals and feeding centers, living on the streets in urban areas and with substitute families in refugee camps in neighboring countries. Documentation: Procedures and forms were produced to record biographical information on former child soldiers in need of assistance in locating lost family members. Tracing: Active searches for the documented children’s lost family members were initiated in various locations, including the child’s original communities, deslocado centers, towns and other urban locations where people from the children’s original communities might have fled, and refugee camps in neighboring countries. Techniques were outlined for disseminating information on lost children through word-of-mouth and written communications, mass community meetings, poster canvassing, and radio, newspaper and television announcements. Verification: After a child’s relative was identified, procedures were developed to verify whether or not both parties – the child and the relative – wanted to be reunited with one another. Reunification: Guidelines were developed for the safe return of the child to the family. At the time of reunification, the family was provided with a “kit” of basic food staples, farming tools, seeds as well as education and health vouchers to help with the transitional period. Follow-up: Home visits by social workers from the National Directorate of Social Action, the nation’s child welfare agency. Family members and neighbors also participated in reunification ceremonies. December 1988 and May 1989, all of the Lhanguene boys were reunited with parents, grandparents, aunts, uncles, or older siblings. Assessment reports and videotapes of initial reunifications reveal overt and reserved joy and excitement, as well as tears and words of sorrow over time spent apart. Subsequent follow-up visits in 1989 and 1990 found that all of the Lhanguene boys continued to be well received by their relatives. Only one boy required an alternative placement. He was initially returned to an uncle who shortly thereafter went to South Africa to work in the mines. The boy’s maternal aunt immediately came forward and took the boy into her family. The following recorded comments are indicative of how these boys viewed family acceptance a year after their reunification:

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

95

“I was well treated; no one ever said anything bad about my participation in the war.” “I was well received by my family, they made me part of the family and they shared their food with me.” “They were glad to see me because they knew that I had suffered. “They paid lots of attention to me.” “I was well received, they made a traditional ceremony of welcoming to inform and thank the ancestors for protecting me.” No negative comments were recorded during 1989–90. Lessons Learned: The greatest desire of Mozambican former child soldiers was to be reunified with their families.i There are basic lessons to be learned from Mozambique that could assist similar programs in Africa and other countries: reuniting children and families will be a high priority for war-affected communities, but not for government agencies or NGOs, especially in times of war, drought and starvation. As a result, no government agency or NGO can be very effective in documentation, tracing and reunification without the active involvement of refugees, internally displaced peoples and local volunteers. Moreover, since lost family members are motivated to find one another, informal networks of people will already be communicating with each other about these matters. It is essential to tap into these networks and support the organic reunification efforts that will exist whenever a child is separated from his/her family.

Traditional Ceremonies Traditional beliefs play a central role in the lives of rural Mozambicans. They are at the core of their culture and the customs carry tremendous significance for the outcome people’s lives: whether a person will have good fortune, find a spouse, be able to bear children, etc. Traditional ceremonies accompany every life stage and are important for the maintenance of family bonds, ancestral relationships, and personal strength. All of the Lhanguene boys went through traditional ceremonies upon return to their villages. In Mozambique, these ceremonies date from pre-colonial times, and are believed to be especially important when events, such as war and population displacement, upset the normal course of life. It is thought that the spirits of the victims of war or those slighted against will bring bad luck or death, not only to the perpetrator but also to members of his extended family or community [11]. Within this belief system, atrocities committed during the course of a brutal war become imbued with layers of spiritual meaning, necessitating such traditional ceremonies. The traditional ceremonies afford individuals a chance to be “cleansed” from their acts during the war as well as provided “protection” for the community from ancestral rebuke that may be brought on because of what the child had done. 2003–2004 interviews found that most former child soldiers believed these ceremonies had helped them return to civilian life. Their comments indicated that these ceremonies focused on a range of reintegration concerns, including repairing social ills, cleansing those that came home “contaminated” from the atrocities of war, and resolving social conflict in cases where normal social roles had been perverted. Not only were these ceremonies important for these former child soldiers as individuals, but they were also reported by the former child soldiers’ family members and neighbors to be

96

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

vital for rebuilding community trust and cohesion. These former child soldiers reported that thanking the ancestors was important for community and family cohesion as ancestors have much power over the events of daily life. Because they were highly mobile during the war, moving from base camp to base camp, their protective spirits might become confused and not know they had returned. Thus, it was important to let the spirits know that the child had returned safely, ensuring his further protection. As one former child soldier described: “When something special happens, like in this case my return home, it is necessary to give thanks to the ancestors.” The cleansing ceremony was characterized as a “door to pass through the house” for the child soldiers returning from the war. It was the first critical step towards psychological recovery. After the ceremonies people generally reported that they became “sane” and that their minds were restored to “this world.” Traditional practices helped to “clean the souls” of those who have been “altered from war.” The Lhanguene boys often spoke of traditional ceremonies as allowing them to start new lives and return to “the group from that side (Renamo) and acquire new values to fulfill the things on this side” (rural communities). “I came back from war and used language of the other side, the language from the war. After the ceremony, I was familiar with the language here. After the ceremonies people in general treated me well – before the ceremonies people treated me badly. When I returned some people didn’t talk to me as they thought I would teach them bad things that were learned there [in the war]. In a progressive way people started to like me more and stopped excluding me.” Traditional ceremonies also reportedly enabled those returning from war to “forget” their experiences and move on with their lives: “Yes, it was helpful because today I am leading a normal life.” “There is a definite difference between before and after the ceremony.” “The war memories never came back after the ritual.” “Before there was something missing in my body and in my life, but after, I am ok. I came back to normal life and now I feel like the others.” “It was helpful because it removed the evil that I was bringing with me. I was able to forget easily all the evils that I had, even though I still dream about it.” Our follow-up interviews indicated that “forgetting” had more to do with alleviation of feelings of guilt and shame than with not remembering actual events per se. Cleansing ceremonies thus appeared to foster an experience of being “forgiven,” and many former child soldiers spoke of “feeling like everyone else” after completion of these rituals. The transformation of self image from being a “child soldier” to becoming a “like everyone else” was a critical aspect of successful reintegration into rural Mozambican life. Relatives and neighbors reported that the traditional ceremonies were important because they gave the community a “defense” against problems that returning child soldiers could bring with them. During the war, children were forced to violate social hierarchies, sometimes killing elders and commanding their peers into battle. The righting of these wrongs and the re-establishment of social hierarchies with deceased ancestors was a priority. While social stigma based on one’s participation in the war appeared to be minimal, family and community members still were concerned that the Lhanguene boys might be disruptive due to their previous indoctrination into violence. Other researchers have also found that purification ceremonies create a spirit of com-

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

97

munal tranquility because community members see themselves as being protected and capable of confronting any situation that reintegration might bring about [12]. Sensitization Campaigns In addition to traditional cleansing rituals, our research indicates that community sensitization campaigns also had a positive impact on community acceptance of former child soldiers. Local military, police, teachers, and community leaders were targeted and encouraged to support the reintegration of former child soldiers by taking collective responsibility for the fate of the returnees. Community projects, such as reparation of hospitals, water systems and other needs identified by community members, were initiated in these communities as a way of supporting collective child welfare efforts. During the course of our 2003–2004 focus group discussions, community members reported that they remembered government officials coming and talking to them about the children returning and that it made an impact on them. “I remember the government people coming to tell us that our sons were going to come home and that we should treat them like everyone else. That is what we have done.” “We listened to the advice of the people that came from Maputo. We have accepted these boys and they live with us now. There is no difference.” “The big men came and told us what to expect from our boys. Now we eat what they eat, we live together. We are all the same.” “They are our sons; what they did they were forced to do, so we cannot blame them for such bad things.” Community Acceptance In 1989 and 1990, all of these former child soldiers reported being accepted by their communities with two exceptions. One boy reported that the community was not happy with his return and accused him of having killed their relatives. “A few boys called me a bandito when I came home, but my family stood for me and soon they stopped saying those things.” A second boy described how his lack of money led to a poor reception by his community. “People in my community did not pay attention to me when I came back. I don’t feel trusted because I am poor and have nothing to give to people when they ask or need things. They just say hello as they pass on the path.” Here, the boy’s sense of not being accepted was linked to his economic situation, which he blamed on the war, rather than his child soldiering experiences per se. All other boys reported that they were received without problems or discrimination: “I have been well received by the community.” “People came to speak with me and welcome me.” “They received me well because the government brought me and they respected me.” “The community treated me well, they even sacrificed a hen to commemorate my return and inform the spirits of my arrival.” Our 2003–2004 follow-up research employed a feeling of acceptance scale to which the former child soldiers overwhelming reported that they have been accepted by members of their communities. As adults, they largely feel respected by their friends,

98

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

that their families care for them very much, and that their friends look out for them. Indicative comments include: “I can rely on my friends.” “When I need something, I ask my neighbors and friends, and if they can help me, they will.” “If I died tomorrow, I think that people would miss me.” “Members of my community rely on me and I rely on them. It is how we live here.” In 2003–2004, many of the Lhanguene boys recalled that the adult caretakers at the Maputo Center helped them to recovery their own sense of caring for other human beings. They did this through their concern for the boys’ well-being, including appropriate discipline, and by consistently modeling of good behavior. As one former child soldier explained, “I overcame the things I lived in the war because I admired how the (Lhanguene) director and others at the Center lived, and I wanted to be like them.” This same modeling was later achieved through community-based apprenticeships. Apprenticeships Apprenticeships with local carpenters, masons, and other skilled laborers were established for older boys so they could learn basic employment and business skills. Although it was not feasible to take this program to scale for the larger population of former child soldiers and separated children in the region, our research does indicate that these apprenticeships contributed to the ability of these former child soldiers to increase their earnings in comparison with other off-farm labor options. Additionally, boys that took part in apprenticeships reported that these opportunities gave them important role models in their lives, helping them to ease the transition to civilian life and leave behind destructive behavior patterns. Protection A shortcoming of our program was the lack of focus on protection measures for the young boys. Continuing protection is a big factor in such programs that work with vulnerable children. Developing community structures to help children stay out of armed forces is vital. Some of the boys we interviewed were threatened by Renamo right after they left the Lhanguene Center. The government forces found these boys to be experienced combatants and did try to recruit several of them despite the government’s decree that former Renamo child soldiers were not to be drafted. Community mechanisms could have been established to ensure this government policy was enforced, and more livelihood schemes established as an economic alternative to military life.

Economic Findings To what extent has this group of former child soldiers been able to overcome the time spent away from fulfilling their normal life milestones and regain a foothold in the normative life cycle of rural Mozambique? Several indicators were employed to ex-

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

99

plore this question: household income, housing and food security, as well as children’s health and educational status. Despite disruptions to their life trajectories, this group of former child soldiers is faring as well as, and often better than, national averages for these socio-economic and child welfare indicators. The national average for household ownership is 91.7%, which matches the average of the former child soldiers, 91%. While 100% of these former child soldiers are engaged in farming, 63% of them also earn additional income from wage labor endeavors. The national average for offfarm activities of rural inhabitants in Mozambique is estimated at 38% [13]. Off-farm wage labor for this population includes working in the mines in South Africa, working as guards, working on local construction projects, and doing odd jobs in their communities. Many also are engaged in other informal sector-income activities, including making charcoal, cutting and selling reeds from the river for cash, and running small kiosks to sell agricultural produce. Mozambique is in the midst of a serious food crisis in its rural areas. General estimates suggest one third of the population is classified as chronically food insecure, mostly coming from the south and central regions of Mozambique, where this study took place [14]. All of these former child soldiers and their families are affected by this crisis. 80% reported that they are not always able to eat or provide their children balanced meals. A vast majority also said that the adults in their households have reduced portion sizes or skipped meals almost every month during the past year. Despite this food shortage, the weight for height of their children (under five years of age) is above the national average. All scored above the median using the WHO/NCHS normalized referenced weight for height scale [15]. Most of the former child soldiers or their spouses reported their children to be in either good or excellent health. In the context of Mozambique’s chronic food shortage, these findings bode quite well for the resiliency of the Lhanguene boys following their harrowing experiences with Renamo. While the former child soldiers seem to be doing well, all reported that their daily economic situation has been, and continues to be, one of the major obstacles in their transition to civilian life. Historically in Mozambique, individual welfare has been linked to informal sector enterprise and collective help networks. The extended family normally provides a form of “social security” to its members that follow longstanding patterns of personal and kinship relationships. Indeed, many former child soldiers indicated that obstacles to reintegration often stemmed from economic difficulties and their inability to be able to help others when asked for money or other necessities. When asked what external assistance could have been provided by the Lhanguene initiative, most reported that they wished they had received a professional skill set that would have made them viable contributors to their family economy. As stated above, apprenticeships were highly successful for the few boys that were able to take part, however apprenticeships and targeted vocational training are not feasible on a national or regional level. Ultimately, field practitioners must model economic interventions along the lines of the various livelihood or micro-credit programs in place around the world in order to reach the number of young people that need assistance while remaining cognizant of the limits of local economies. One of the most devastating legacies of child soldiering was the years of lost economic opportunity that, in turn, made the key life cycle tasks of choosing a wife and building a family difficult. Many of these former child soldiers reported these challenges to be more problematic than the actual experiences of the war.

100

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

“I had no problems choosing a wife but I have had problems because of a lack of money.” “I had no resources; I had to begin everything from the beginning.” “Those who did not go to the war had the time to earn some money but I had nothing after the war.” “I think the war was evil. It delayed my life. I lost ten years.”

Social Indicators We asked our Mozambican interviewers to provide general observations about the parenting styles of these former child soldiers. In light of socio-economic and cultural differences in parenting styles, and the risk of misinterpretation, this was a simple exercise in which the interviewers provided either a “supportive” or a “non-supportive rating” in those situations where parent-child interactions could be observed as they were naturally taking place. These generalized observations, while falling far short of addressing the complexities of parent-child relationships, indicated that former child soldiers were in general far more supportive and engaging in interactions with their children than they were harsh and punitive. Moreover, all of the former child soldiers who were parents spoke, often at length, about their desires for their children to experience a better childhood than they had had. Most, in turn, indicated that the schooling that they had been denied due to their child soldiering experiences was the “best way” to ensure a “good future” for their children. Indeed, 75% of this group’s school-aged daughters and sons were attending primary school, which is considerably above the national average of 52%. Almost all the Lhanguene boys are married and, according to our questionnaire, the overwhelming majority of their spouses perceive them to be “good husbands.” Wives concurred with the economic hardships in these areas of Mozambique, noting that jobs were scarce for everyone, and indicated that they appreciated their husbands’ efforts to earn extra income. They also indicated that this extra income was usually used for food and educational support for their children. Most wives approved of the roles and commitments their husbands had in their relationships, house maintenance, and childcare and support. “I am happy with my husband. Even though he was in the war, he is just like everyone else.” “My husband helps me with the children. When I ask for money, he gives it to me if he has any. He doesn’t spend it on drinking like some other husbands.” “He often looks for work. Usually, he does not find any, but when he does it helps us a lot.” “I can’t complain. I am fortunate.” “He is a good man. He is kind to me and takes good care of our daughters.” Often we hear that children who have been abused become abusers themselves. How is it, then, that children who were so brutalized have been able to overcome their hardships and demonstrate altruistic attitudes and behavior with their spouses and children? When asked where and how they learned to be good parents and partners, former child soldiers reported that they learned this behavior from their families and communities after they returned home from the war. Most young men reported the importance of having strong role models in their lives, others who could advise them through hard-

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

101

ships and teach them appropriate behavior. Indeed, the comparative few former child soldiers who were deemed to be socially dysfunctional during in our 2003–2004 research phase reported that they had few if any people to advise or support them. The reestablishment of relationships with positive adult role models facilitated former child soldier’s transitions from survival seeking behavior to security seeking behavior and mitigated the cycle of violence. Furthermore, most former child soldiers reported wanting more for their children, including opportunities for education and employment that they had not had.

Psychological Well-Being While our research indicates that most of these former child soldiers have made significant progress in returning to civilian life, none of them are truly free from their violent pasts. All of the boys experienced recurrent thoughts or memories of traumatic events while at the Lhanguene Center, and all still do so 16 years later. While psychological distress symptoms persist, the number of former child soldiers experiencing them as adults is considerably less than those who experienced them as children. Six common elements in the 1988 and 2003 assessments reveal the following: Question

Recurrent thoughts or memories of the most hurtful or traumatic events Feeling as though the traumatic event(s) is happening again Recurrent Nightmares Sudden emotional or physical reaction when reminded of the most hurtful or traumatic moments Inability to remember parts of the most hurtful or traumatic events Avoid activities that remind you of the most hurtful or traumatic events

Percentage of FCSs that responded either “Sometimes” or “Frequently” 1988

2003

100%

70%

63% 52%

39% 45%

48%

50%

61%

45%

35%

78%

Two variables appear to be associated with decreases in psychological distress over time: the individual’s use of cognitive strategies and avoidance to manage their symptoms, and duration of time as a child soldier. As shown above, five symptoms decreased in frequency over time while, one, avoidance activities, increased over the course of the past 16 years. This rise in avoidance activities, when further explored in interviews proved to be adaptive, as these former child soldiers were actively managing their symptoms more consciously and effectively. Moreover, those who reported using avoidance as a coping mechanism have fewer and severe symptoms than those that do not employ these same strategies. Avoidance, as described by the former child soldiers, included actively identifying social situations, physical locations, or activities that had triggered an emergence of

102

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

post-traumatic stress symptoms in the past, and making efforts to avoid them in the future. One of the strongest traumatic re-experience triggers was physical location: some former child soldiers are now avoiding places where they witnessed or participated in violent and inhumane events. For one former child soldier, it was a large tree in his village where Renamo guerillas killed his father and abducted him. For another, it was a village footpath where, as a 12 year-old boy, he came across a row of decapitated heads impaled on poles. Four former child soldiers cited social drinking with other male companions as a traumatic re-experience trigger. Boisterous drinking rekindled memories of rowdy, drug and alcohol induced Renamo base camp experiences. All four of these former child soldiers now actively avoid social drinking. Two young men reported that they no longer slaughter animals because this routine chore “reminds me of the war.” Their wives now assume this function. Several found they could no longer use machetes or other farming tools, as they had been used as instruments of torture and death during Renamo’s reign of terror. Secondly, the severity of post-traumatic stress symptoms is reduced by conscious efforts to not dwell on troubling thoughts and feelings when they emerge. Former child soldiers with lower distress frequency and severity outcomes described a kind of cognitive “change of menu” strategy to ward off painful thoughts and memories: “Thinking about what I did in the war is wasting time because it [the war] helped nothing.” “When I start to think about the war, I go to church and read the bible. I keep reading until the bad thoughts disappear.” “I try to think about the present and the future, not the past.” “When bad thoughts enter my mind, I replace them as quickly as possible with better ones. “I think about my children or my wife.” Conversely, former child soldiers with higher frequency and severity tendencies do not actively use avoidance or employ other identifiable cognitive coping strategies. Instead, when confronted with painful memories, they tend to become consumed by them, often withdrawing from daily activities and routines. The following comments are indicative of these less adaptive tendencies: (Wife): “Sometimes he is fine and sometimes he is not. I can tell when things are bad for him because he stops working and spends time alone. Sometimes he tells me about what’s bothering him, but most of the time he does not. I try to do my best to help him forget, like doing more work and selling things (normally the husband’s responsibility) so when he returns from his bad thoughts things will be in order. Eventually, he goes to work, forgets, and gets better.” (Mother): “He will suddenly get irritated and then very quiet. He’ll go into the house and refuse to leave. We all know that his mind is back in the past. I tell everyone that we must be patient with him, but sometimes this is difficult. We all know he has suffered. We talk to him about the war, how it is over, and how he must also get over it. We try to do this with a good attitude and patience. Sometimes he threatens us when we talk to him this way, but so far nothing bad has happened. We will continue live as we have and accept him as part of the family. He can change, it is just a matter of perseverance.” A second variable is time spent child soldiering. Former child soldiers who spent six months or less as a child soldier exhibited less severe symptoms and behavioral

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

103

problems at the Lhanguene Center than those who spent one year or longer with the guerilla group. This trend continues into adulthood: adults who spent six months or less as a child soldier experience psychological distress less often and less severely than those who spent one year or longer. Three former child soldiers who continue to suffer significantly psychological distress and are socially ill-adapted as young men were with Renamo for two years or longer. Two were youth leaders and one was only 6 years old when abducted. All three were deemed to be “troubled boys” while at the Center and continue to be so as adults.

Conclusion Most of these former child soldiers emerged from violent childhoods to become trusted and productive adult members of their communities and nation. Their life stories underscore human resiliency as a dynamic process involving active quests to derive existential “meaning” from violent events, to be “cleansed” from their pasts and “forgiven” for their wrongdoings, to regain their “true” identity by “being like everyone else,” and to find their place in community by helping others. Family and community acceptance and spiritual and religious beliefs and practices—so entwined with individual wellbeing in rural Mozambique—are at the core of this resiliency s well. A number of interventions aided these former child soldiers’ transitions into society. Most of these young men described the time they spent with adult caretakers and other former child soldiers at the Lhanguene Center positively. In addition to the healing that took place through attachments with positive adult caretakers, program efforts to promote safe codes of conduct, self-regulation, and security-seeking behavior also appear to have engendered a sense of social responsibility among these former child soldiers that is evident today. We cannot, however, conclude that a center-based program is the most effective way to provide these restorative and healing elements. Indeed, most of what took place at the Maputo Center could have been provided by leaders, healers and educators in the boys’ home communities. One of the advantages of this decentralized approach is that important attachments can continue for longer periods of time. It is also more cost effective and capable of reaching large numbers of former child soldiers throughout the country. One of the main challenges, of course, is to maintain quality of training, supervision and support. Traditional cleansing ceremonies also played key reconciliation roles. They helped to repair relationships with their families and communities to re-align the boys’ wellbeing with the spirit world. The rituals enabled these boys to feel “like everyone else” and deepened their sense of acceptance. This, in turn, ameliorated degrees of guilt and shame over past misdeeds, and also represented a form of protection for community members who worried about what these boys might do once they came home. Numerous community members recalled the government-led sensitization campaigns organized 16 years earlier. They, too, helped to foster community acceptance and forgiveness. Other forms of assistance that supported normative life cycle milestones, such as employment, housing, farming, and marriage, were viewed by these former child soldiers as helpful. Apprenticeships, income generation projects, and the provision of seeds and tools were cited as positive forms of support. In contrast, education stipends (for fees, books, and clothes) were not deemed to be helpful. They tended to cause ten-

104

N. Boothby and J. Halprin / Former Mozambican Child Soldier Life Outcome Study

sions in several families because they singled out one child for support over the others. Also, most of these boys were not motivated to stay in school, but instead felt compelled to earn money, find a wife, and build a house. Understanding the normative life cycle—including key developmental milestones and how the social systems that support them have been affected (and may be assisted to become re-aligned)—proved to be a pragmatic framework for assessing, designing and evaluating this child soldier reintegration program.

References [1] [2] [3] [4]

[5] [6] [7] [8] [9] [10] [11] [12] [13] [14]

[15] [16]

Machel, G. (2001). The Impact of War on Children. London, Hurst and Company. www.child-soldiers.org downloaded 1/4/05. United Nations Security Resolutions, U. N. S. C. 1261, 1314, 1379 and 1460. Jensen, P.S. (1996). Practical Approaches to Research with Children in Violent Settings. Minefields in their Hearts: The Mental Health of Children in War and Communal Violence. R. J. a. S. Apfel, B. New Haven, Yale University Press: 206–217. The DTR Protocol was used to document over 25,000 separated children nationwide, including former child soldiers (Boothby, N., 1993). Bolton, P., Tang, A.M. (2002). “An Alternative Approach to Cross-Cultural Function Assessment.” Social Psychiatry Social Epidemiology 37: 537–543. Vines, A. (1991). Renamo: Terrorism in Mozambique. London, Villiers Publications. Hanlon, J. (1984). Mozambique: The Revolution Under Fire. London, Zed Books. Morgan, G. (1990). “Violence in Mozambique: Towards an Understanding of Renamo.” The Journal of Modern African Studies 28(4): 603–619. UNICEF (1987). Children in on the Front Line: The Impact of Apartheid, Destabilization and Welfare on Children in Southern and South Africa. New York, UNICEF. UNICEF Assistance to Ex-Child Soldiers in Mozambique. UNICEF Child Soldier Project http://www. ginie.org/ginie-crises-links/childsoldiers/mozambique2.html accessed 01/24/05. Chicuecue, N. M. (1997). “Reconciliation: The Role of Truth Commissions and Alternative Ways of Healing.” Development in Practice 7(4): 483–486. Mausse, M. A. (1999). The Social Reintegration of the Child Involved in Armed Conflict in Mozambique. Monograph 37. Maputo, The Institute for Security Studies. Amimo, O., Larson, D., Bittencourt, M., Graham, D. (2003). The Potential for Financial Savings in Rural Mozambican Households. 25th International Conference of Agricultural Economists, Durban, South Africa, Ohio State University. WFP (2001). Visit of WFP Executive Board to Mozambique, June 2–9, 2001. WHO (1994). Assessing Nutritional Status and Recovery.

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

105

Building Child and Adolescent Mental Health Services in a Post-War Kosova Ferid AGANI Department of Strategic Management, Ministry of Health, Kosova

Introduction Kosova was the poorest province of the former Federal Republic of Yugoslavia, with its economy primarily based on agriculture despite some investments in the mining industry in the northern part of the province. The suspension of the autonomy of the Province by the Government of Serbia in 1989 and a series of draconian measures following this led to a deterioration of the living standards of the population in Kosova, particularly affecting the ethnic Albanian group of the population. This group, constituting by far the majority of the Kosovar population, lost its employment opportunities in the public sector which was the main employment source, was refused formal education in the Albanian language, suffered discrimination in terms of access to social security, and mostly fell through the health system network. The escalating ethnic cleansing in 1998 and particularly during the war in 1999 resulted in more than 800,000 Kosovars taking refuge in other countries, 500,000 becoming internally displaced within Kosova, and more than fifteen thousand deaths and missing persons. This and its accompanying destruction of habitat, loss of material possessions, decimation of livestock, and collapse of industrial output, further disintegrated the economy and strained the social fabric. Since June 1999, Kosova has been administered as an autonomous entity, first by the United Nations Interim Administration in Kosova (UNMIK). Elections took place in the autumn of 2001, creating an Assembly with legislative powers and establishing a Government that is assuming increasing responsibilities. On a higher level, the final political status of Kosova is still under discussion. Massive donor assistance after the end of the conflict, domestic savings and remittances from the Kosovar diaspora are contributing to put the economy back on the way to recovery. The population of Kosova was estimated at 1.9 million in 2000 (UNMIK data), with the following distribution by ethnic affiliation: 88% Albanians, 7% Serbs, 2% Muslim Slavs, 1.7% Roma and 1.3% others (World Bank Survey). The Kosovar population is very young (average: 24.6 years) with 50% under 16 years and only 8% above 60 years. Women of childbearing age constitute 56% of the female population, and Kosova has the highest fertility rate in Europe but also the highest infant mortality rate in Europe (37%). Psychosocial problems in a post-war Kosova are highly prevalent. A survey conducted in Kosova in 2000 (JAMA, 2000, 284:569–77) reported that 62% of those surveyed had been close to death, 49% had been victims of torture or abuse, 42% had been separated from family members, 26% had experienced the murder of a family

106

F. Agani / Building Child and Adolescent Mental Health Services in a Post-War Kosova

member or friend, 10% had been imprisoned, and 4% had been sexually abused. Mental health consequences for general population were extremely high. There is a large child and adolescent population in Kosova. Approximately 55% of the total population is under 19 years of age, around 10% are under 4, another 22% between 5 and 14 and approximately 52.8% of the total population in Kosova is under 16 years of age.1

Hard Post-War Reality: Mental Health Services Kosovar psychiatric services concentrated resources on a biological and institutional approach to serious mental disorder in adults. In the summer of 1999, the health services were in disarray. Most Serbian doctors chose to leave, or move to one of the Serbian enclaves. There were 17 adult Albanian neuropsychiatrists in the province, and just one of them who had a special interest in children. There were no functioning social services, and only two clinical psychologists. Institutional facilities were degraded and understaffed. A number of NGO’s had set up psychosocial programs to provide some training in the identification of psychological disorders in children, but there was no local service as a back-up. Such programs gave little attention to serious psychological difficulties. The main approach of Kosova mental health professionals was to attend to severe un-addressed needs and avoid an overextended role that could arise from treating the whole population as traumatized.

Hard Post-War Reality: Child & Adolescent Mental Health Needs There are no epidemiological studies regarding the prevalence of child psychiatric disorders in Kosova. After the war rural health houses reported seeing two to three children with serious psychological difficulties each day. Many of these children had psychological difficulties of some kind prior to the period of conflict. Many children’s mental health problems, particularly behavior disturbance, were seen as primarily the concern of the family and severe cases were taken to the general practitioner, or pediatrician. Neuro-developmental problems often remained un-assessed and untreated. Recent upheavals had left many families feeling that their own capacity to cope was not sufficient for the severity of the problems, while the displacement of large numbers from countryside to city had left them with out their usual networks of support. In November 1999 multidisciplinary task force start drafting Strategic Plan for Mental Health in Kosova. Strategic Plan for Mental Health developed by Kosovar professionals (Task Force for Mental Health Strategic Plan) and WHO has been approved by the Department of Health (predecessor of the Ministry of Health) in the January 2001. Task Force for Mental Health has been systematically supported by Department of Psychiatry, University of Illinois at Chicago. Development of Child and Adolescent mental health (C&A MH) services was identified as priority of the Strategic 1

Source Albanian health survey report 1999, produced jointly by the Institute of Public health, WHO, Centres For Disease Control and the Institute of Public health, these figures have not changed much in the last few years.

F. Agani / Building Child and Adolescent Mental Health Services in a Post-War Kosova

107

Plan and multidisciplinary Task Force for drafting a Plan for development of Child&A MH services, was established. Strategic Plan for C&AMH services was based on core principles, as follows: 1)

2) 3)

4) 5)

6)

7)

8) 9)

Emphasize community: Community based C&A MH service, rather than a psycho-trauma service with the aim to optimise the access and reduce the stigma; Long-term strategy: operational and mid-term plans approved; Appropriate training of the staff: Three-year clinical and academic programme provided in the main by experienced British child and adolescent psychiatrists, based on the Royal College of Psychiatrists model. Supervision of clinical staff: Balance between direct clinical work, indirect clinical work, supervision and academic learning; Extended family context: Treatment approaches to be provided with the family not to the individual through sustainable, culturally appropriate service that met the locally identified mental health needs of children and adolescents; Multidisciplinary teams: Professionals from a range of disciplines has to be in the core of C&A MH teams, recognizing that effective functioning will require liaison with other public services, notably social services and education. Play down the role of in-patient provision: Effective in-patient treatment requires an experienced, trained team. It is expensive, stigmatising and without much of an evidence base. At the same time, rehabilitation after admission is also an intensive process. Develop day-programmes, where possible; Develop collaboration with NGO’s dealing in the C&AMH field; Particular interest for health promotional and preventive work with teachers within the elementary school system, ensuring maximal sustainability.

According to the Strategic Plan, services should be integrated with pediatric, primary health care, and adult psychiatric services that were also being transformed into community-based services. Two main Kosovar community resources needed to be addressed: Families and Teachers. We tried to reach families through our growing Family Medicine Service and Kosovar Family Professional Educational Collaborative, an international project developed by Kosova mental health professionals, American Family Therapy Academy and University of Illinois at Chicago. Project carried out by Kosovar NGO of teachers and Foundation “Together” from Ljubljana, Slovenia (see Mikus-Kos, Chapter 2), has put teachers in the core of preventive activities with school children and adolescents. Organizational and Institutional Reforms In order to carry out ambitious mental health reforms, institutional capacity building and reform of the organizational infrastructure has been undertaken: • •

Mental health office in the Ministry of Health has been established as well as mental health offices in the six districts; Administrative act regarding the establishment and development of C&A MH service within primary health care has been issued;

108

F. Agani / Building Child and Adolescent Mental Health Services in a Post-War Kosova

• •

Faculty of Psychology and Institute for mental health of C&A has been established; The Ministry of Health has adopted sub-specialty program in Child Psychiatry.

Setting Up the C&A MH Service To ensure sustainability, two psychiatry residents from Department of Neuropsychiatry were seconded to Child Advocacy International (CAI) an NGO that has received three years funding from the US Bureau of Population Refugees and Migration to develop C&MH services in Kosova. They worked during two-years under systematic supervision of an expatriate specialist on a daily basis, remaining on hospital contract with a guarantee to return to hospital posts when their training was completed. They were then in a position to embark on the training of others. Two additional part-time residents and four nurses joined in the second year on a similar basis. Clinics were located in primary health care facilities. The residents and nurses also made home and school visits. The service was open to children of all ethnicities up to the age of eighteen and their parents. In each town local health professionals, schools, and NGO’s were informed about the presence of the project. Services were advertised on the local radio by providing talks on children’s mental health problems. In the first year, the clinics were located in small towns in two of the most conflictaffected areas and in Prishtina, capital of Kosova, which had doubled in size because of the displaced population. In the second year, these two former clinics moved to four main towns in order to be integrated with the overall development of community based mental health services in Kosova, and to provide access to the greatest number of people. The aim of this three-year project was to provide both a clinical service and a training opportunity. Training took the form of supervision and mentoring in the clinics on a daily-basis, and a regular weekly programme of seminars, lectures and case discussions for all the psychiatry residents. Funding was also used to set up internet access, create a comprehensive library, and provide two residents with the opportunity to study for between one and three months in the UK. Because the consultant supervisors changed every three months, the residents encountered a wide variety of approaches, and engaged in a two-way exchange as to the appropriateness of western systems of diagnosis and treatment in the Kosovar context. Numbers of new and follow up appointments were collected at every clinic. Each attending patient and their family completed a simple data collection sheet regarding biographical data, living circumstances, education, and the source of referral and referring problem. At discharge the form was completed regarding ICD-10 diagnosis if any, mode of treatment, number of sessions attended and disposal. The data was entered on a computer database and audited. Results of this study are going to be presented in the British Medical Journal.

F. Agani / Building Child and Adolescent Mental Health Services in a Post-War Kosova

109

Challenges War acted as a precipitant to psychological problems in a variety of ways, not simply through exposure to trauma. Post war living conditions: the lack of material resources and the destruction of networks of support, made previously manageable difficulties less manageable. The sudden improvement in the political and security conditions, combined with the influx of humanitarian agencies, allowed families who had had no previous opportunity, to access health care for longstanding problems.

Obstacles Main obstacles identified were: • • • • • • • •

Very small number off mental health professionals in this field; Lack of expertise regarding early recognition of the mental health disorders among C&A by general practitioners, pediatricians, nurses, teachers; Total lack of institutional resources for C&A MH services; Lack of the research project opportunities; Lack of institutional resources for C&A, victims of abuse; High mental health needs in this category of the population; Access difficulties for children and adolescents involved in criminal activities, children in the street, adolescents involved in the prostitution; Lack of the specified budget for C&AMH services.

Opportunities Task force for C&AMH was a highly motivated multi-disciplinary group ready to perform its activities in the systematic manner; Short-term and mid-term goals as a part of the strategy for development of the C&A MH services have been identified; Strong international commitment at the University level is available; Important link with general development of the community based mental health services in Kosova has been achieved; Eight residents in C&A psychiatry have undergone a one-year academic program, conducted by teaching staff of the Cambridge University and other Universities from the UK (as a part of the last year of the above mentioned international project carried out by CAI); Integration of C&AMH module as a part of family medicine training curriculum, both for medical doctors and for nurses, has been done; Very successful community based project with teachers realized by the consortium of NGO’s under the coordination of Foundation “Together”, Ljubljana, Slovenia; Ongoing reorganization and capacity building in the old-fashioned institutions for children with special needs; Growing number of programs for children with special needs and establishment of the Rehabilitation Center and Protected apartments for these children;

110

F. Agani / Building Child and Adolescent Mental Health Services in a Post-War Kosova

Growing opportunities for international collaboration, particularly with countries in the region. Building of C&AMH services in Kosova based on the above mentioned Strategic Plan, is the ultimate necessity keeping in mind how demographic structure of the population is unique in Europe. Addressing mental health needs of the Kosovar children and adolescents represents direct investment in the bright future of Kosova and in the peace of the region. In this process Kosovar mental health professionals need, in the next period of, at least, ten years, considerable help and support from international professional and donor organizations at the level that was available after the war in Kosova. I’m convinced that inadequately addressed mental health needs of the majority of the Kosova population would represent a substantial risk for the stability in the region, especially when considering the economical constraints and political tensions within which Kosovar youth are growing.

III. Program Evaluation and Research

This page intentionally left blank

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

113

Post-War Communities Overcoming Traumas and Losses Matthew J. FRIEDMAN, MD, PhD National Center for PTSD, White River Junction, Vermont, Dartmouth Medical School, Hanover, New Hampshire

I. Scope of the Problems It is difficult to appreciate how much communities have been destroyed or disrupted by war and other catastrophic events in recent decades. Between 1960 and 2000, the number of refugees worldwide has increased tenfold from 1.4 to 11.5 million. An additional 17–25 million were internally displaced people (IDPs) within their own countries because of armed conflict or generalized violence and an additional 30 million people were uprooted because of natural environmental or technological disasters [1]. The social consequences of traumatic stress include: cultural disintegration, erosion of the social fabric, community fragmentation, loss of social authority and institutions, ethnic discrimination and hatred, forced migration, violence against women and children, and genocide. Communities disrupted by such catastrophic events can no longer meet the basic economic, social, and cultural needs of their citizens. They can no longer provide basic needs such as: safety, security, food, shelter, protection of human rights, health services or education. The emotional consequences to people affected by community disruption due to war, terrorism or forced migration are far-reaching. People are distressed, fearful and anxious about the loss of loved ones and homes, angry at their oppressors and full of the frustration embodied in feelings of hopelessness and helplessness. Refugees and IDPs who go into exile as a community or group and remain together in camps, can sometimes maintain ongoing family and community support, thereby retaining their cultural identity, traditions and mores. In this regard, they may fare better than people who have been unable to reconstruct some semblance of the community of origin they have lost. Individuals, families and communities exposed to war, terrorism and forced migration have experienced or witnessed many catastrophic events including: torture, rape, abductions, sexual violation, war wounds, premature death, deprivation of basic needs, persecution and harassment, loss of home, ethnic cleansing, and genocide. No wonder that the risk of psychiatric disorder and suicide is much higher among these individuals. In order to appreciate the magnitude and duration of pain and suffering encountered it is important to recognize that traumatization is usually not a specific traumatic event but rather an enduring, cumulative, “chain of traumatic stress experiences that confront… (individuals) with utter hopelessness and interfere with his or her personal development over an extended period of time.” [2]

114

M.J. Friedman / Post-War Communities Overcoming Traumas and Losses

At least half of all refugees and IDPs are children who have been deprived of many of the basic rights listed in the United Nations Convention on the Rights of the Child [3]. These include the right to remain with parents, the right to protection from all forms of physical and mental abuse and neglect, access to health care and education, protection from sexual exploitation and abuse, prevention of abduction, sale and exploitative trafficking, and other rights [4,3]. As noted by Yule and associates (2003) [3] the effects of war on children can be far-reaching. Whether or not they are directly affected by their traumatic experiences, they are indirectly affected by what they witness and by the impact of traumatic exposure on parents and caretakers. Both direct and indirect experiences have an adverse impact on children’s psychological development and in a worse case scenario may be the precipitating cause of psychiatric disorders among children. At the outset, it is important to emphasize that most adults and children exposed to extreme stress are resilient. Even after severe traumatic events, the majority of people will cope effectively and be able to move forward in their lives, once the danger is past. It is important, however, to understand that within the context of community disruption/disintegration due to war or violence, a wide spectrum of responses may occur. These vary from mild, transient distress to severe, chronic and incapacitating disability. Three domains have received most attention, in this regard; a) transient psychological distress that may progress to psychiatric disorders; b) temporary physical symptoms and discomfort that may escalate to serious medical problems; and c) temporary functional incapacity that may evolve into persistent marital, family, social, occupational, and financial problems. It is now well recognized that exposure to traumatic stress may precipitate chronic psychiatric disorders such as depression, post-traumatic stress disorder (PTSD), alcoholism and substance abuse, and other anxiety disorders. Significant impairment in marital, social and occupational function as a result of psychiatric disability is also generally acknowledged. Less well understood is the growing evidence that PTSD and depression appear to be associated, if not causally related, to the onset and chronicity of medical disorders [5]. A meta-analysis of epidemiological research from over 160 disasters has shown that school-age youth and survivors in developing countries are at greater risk for postdisaster mental health problems than appropriate comparison groups [6,7]. Individuallevel risk factors for poor mental health outcomes taken from that same metaanalysis [6] include magnitude of traumatic stress, life threat, personal and material losses, and living in a neighborhood or community that has been highly disrupted or traumatized. Other risk factors for children are: the presence of parental distress, interpersonal conflict or lack of a supportive atmosphere at home, and possessing few, weak, or deteriorating social resources. Milgram and associates (1995) [8] have identified the following high risk groups during the psychosocial disruption occurring after a war: the elderly, children, rural residents, economically disadvantaged and poorly educated individuals, people without kin support and previously traumatized people who receive little support. II. Assessing Community Stress A thorough and comprehensive assessment is the key to planning an effective community intervention and for appreciating the many aspects of community function that

M.J. Friedman / Post-War Communities Overcoming Traumas and Losses

115

may be adversely affected by war, terrorism and forced migration. Figley (1995) [9] has provided an excellent template for such an assessment. Here is a slightly modified version of Figley’s checklist. Demographic profile of the stricken population a) what is the primary affected population (racial, ethnic, religious, etc)? b) what is the primary exposed population (victims closest to the destruction, rescue workers, etc.)? c) what was the target population (selected victims in war/terrorism)? d) who was made homeless because of the event? Nature of the disaster a) what is the magnitude of loss (deaths, number injured, material losses)? b) what is the known or potentially unknown hazard due to the event (landmines, radiation, toxins, biological agents, etc.)? c) what is the scope of the impact on community functioning and infrastructure (was the major destruction central, intermediate or peripheral)? d) to what degree was escape possible during or immediately after the event? Channels of communication a) how much has communication (telephones, media, community sources) been disrupted? b) how open, public, accurate and credible are the surviving channels of communication? Authority structure a) did political structures and agencies survive? b) how effectively can they function? c) are they credible and trusted by the community? National resources a) how available are material resources needed for recovery? b) if they are available elsewhere, what is the likelihood that they may be efficiently transported to the disaster area? c) how available and effective are rescue and emergency health services (e.g., military, NGOs, Red Cross, etc.)? Social Support at the Community and Family Level a) availability of voluntary associations and mutual support systems? b) availability of support within the extended family or kinship system? c) presence of family and community leadership? d) how free is the family to act and move as it wishes (in contrast to repression by authorities)? Attitudes towards and institutions dealing with loss and mourning a) this factor attempts to assess the degree to which indigenous cultural priorities are preserved and integrated into community-wide recovery and reconstruction efforts such as: funeral rites, memorial services, rituals, monuments and culture-specific coping behavior.

116

M.J. Friedman / Post-War Communities Overcoming Traumas and Losses

Post-traumatic stress responses a) degree of social/cultural inequalities in mortality (especially among underprivileged or socially deprived individuals)? b) magnitude of serious injury or illness from which recovery is unlikely? c) amount of physical illness and/or injury associated with severe psychological reactions? d) relative contagion (or epidemic) of fear and anxiety manifesting itself as treatment-seeking behavior e) prevalence of depression, anxiety, suicidal behavior, psychosis, PTSD, alcoholism and substance abuse? f) the longitudinal course of the above problems extended over the recovery and reconstruction period?

III. Risk Factors Among Children and Adolescents Among children and adolescents, the major psychological problems occurring during recovery and reconstruction following war or other major catastrophes are: posttraumatic stress disorder (PTSD), depression, and anxiety disorders. It appears that if PTSD is to occur, it will do so within the first weeks or months following the event [10]. Depression, which may occur as a single problem or as a comorbid disorder along with PTSD, is often associated with loss of a loved one. Anxiety disorders are often associated with fears about safety and security. Among younger children it may be manifested as separation anxiety or school phobia whereas older children may exhibit phobic behavior and generalized anxiety disorder [11]. Although PTSD, depression and anxiety disorders observed during post-conflict recovery and reconstruction may be expressed at sub-diagnostic levels, the behavioral impact of such symptoms may be clinically important since they may significantly disrupt familial, interpersonal, social and educational function. Given the fact that the above problems may not emerge until the post-traumatic recovery and reconstruction phase, usually months after the initial event(s), there is a potential opportunity to identify children and adolescents at greatest risk for such problems and to provide early psychosocial intervention that may avert chronic psychological problems. As noted by Silverman and LaGreca (2002) [11], there are four domains of predictor variables that may help identify children and adolescents at greatest risk for subsequent problems: aspects of traumatic exposure, preexisting characteristics of the child, characteristics of the recovery environment, and the child’s psychological resources. Aspects of traumatic exposure include perception of life threat, death of a loved one (especially if the death was violent and was witnessed by the child), parental posttraumatic distress, loss of possessions and disruption of daily routines (especially displacement from home, school and community), proximity to the event, physical injury, and the duration and intensity of life-threatening events. With regard to the latter, protracted and unpredictable violence, as with terrorism, is a major exacerbating factor. Pre-existing characteristics are not well understood because the potential influence of age, gender, ethnicity, race, cultural and sociodemographic backgrounds have not been well studied. Pre-disaster anxiety, depression and ruminative coping styles appear to predict the later development of PTSD, depression and anxiety disorders [12]. Finally, there is evidence that children with pre-disaster academic difficulties, low

M.J. Friedman / Post-War Communities Overcoming Traumas and Losses

117

achievement and problems sustaining attention are at greater risk for post-traumatic problems [11]. Aspects of the recovery environment have been well studied. Perceived social support [13,14] appears to buffer children and adolescents against the adverse psychological impact of traumatic events. Receipt of substantial help, in additional to social support, also appears to be a protective factor [15]. Parental behavior and psychopathology also predict the quality of psychological adjustment with higher levels of parental symptoms predicting PTSD, emotional distress and behavioral difficulties among children and adolescents [16–18]. Psychological resources of children and adolescents (e.g., resilience) has not been well-studied in post-traumatic settings. In general, negative coping styles for dealing with stress (e.g., anger, blaming others) predict PTSD among children and adolescents [19,14]. As a result, Silvermann and LaGreca (2002) [11] suggest that efforts to encourage problem solving and adaptive coping skills may be useful post-traumatic interventions. Vernberg (1999) [20] has suggested that resilience may also be associated with average-or-greater intelligence, good communication skills, strong beliefs of self-efficacy, an internal locus of control and adaptive coping skills.

IV. Towards Promotion of the Psychosocial Well-Being of Children During Recovery and Reconstruction Klingman (2002) [21] generalizing from his experience with Israeli children and adolescents has suggested a number of strategies to mobilize personal resources in order to promote better psychological outcomes. He proposes strategies that enhance both problem-focused coping (to improve personal safety) and emotion-focused coping (to minimize trauma-induced distress through avoidance, distancing, distraction, disengagement and minimization). Mobilizing energy in a positive capacity or for a cause (as in caring for the disabled) is also adaptive since it enhances a sense of control over one’s destiny and generates hope for the future. Staying active in helpful behaviors, self-expression (through art), community/cooperative initiatives are all effective ways to promote resilience. Finally, helping children understand and “make sense” of their environment, fostering a sense of humor and promoting positive expectations about the future are methods of mobilizing psychological resources of children and adolescents that will all contribute to better outcomes during the recovery and reconstructive phase. Omer and Alon (1994) [22] have proposed a continuity principle for children and adolescents that stipulates that “throughout all stages of the war cycle, intervention should be aimed at preserving and restoring continuities that had been disrupted as result of war. The more an intervention is built on the child’s existing individual, familial, organization and communal (e.g., schools, neighborhood support services) strengths and resources, the more effective it will be in counteracting the disruptive effects of war” [21]. Implementation of the continuity principle has many components, all of which serve to help the child bridge important gaps in continuity. Restoring personal (historical) continuity includes restoration of basic needs and encouraging children to discuss and reframe personal traumatic events in a way that will integrate such events into a coherent personal narrative and generate positive expectations for the future. Interpersonal continuity involves restoration of social bonds, and establishing or enhancing interpersonal support with significant others. Functional continuity involves reestab-

118

M.J. Friedman / Post-War Communities Overcoming Traumas and Losses

lishment of pretraumatic home routines and duties. Finally, organizational continuity refers to efforts to rebuild the child’s sense of order within a familiar neighborhood, if possible, or to provide a social context, such as a school setting, that will promote feelings of belonging and stability. It is clear, that schools provide one of the best arenas in which to achieve these goals, especially if the schools are working closely with community mental-health support services [21]. It should be evident from the previous discussion that “community-wide interventions are necessarily complex and require multimodal programs with extended community involvement because the effects of traumatization extend into many domains of a child’s life, such as family, school, peers and health” [23]. There is growing consensus that the major components of trauma-specific intervention should include psychoeducation and a number of cognitive behavioral strategies such as anxiety management, trauma focus/exposure work, and confronting inaccurate and maladaptive cognitions [24]. Parallel treatment for parents and caregivers is also very important [25,23]. Ayalon (1993) [26] has developed a post-traumatic intervention for children that includes a variety of tools for enhancing coping skills in emotionally expressive, cognitive, and behavioral areas through participation in work groups designed to promote self-expression through play, creative expression and structured group therapy exercises. After the Oklahoma City bombing, Gurwitch and Messenbaugh (2002) [23] drawing on the work of LaGreca et al. (1994) [19] developed a manualized treatment for children aged 5 to 12 that had many of the key elements discussed previously. It included educational material on basic safety skills during the immediate post-traumatic aftermath, psychoeducation, and treatment exercises to address symptoms and behavioral difficulties associated with trauma and loss. This intervention has been utilized in both school and more traditional mental health settings. It can be applied in individual, group, or classroom formats. Most importantly, parents and caregivers are also included [23]. The exciting school-based intervention developed by Mikus-Kos and associates is described elsewhere in this volume (see Chapter 2) as are other approaches utilized in Europe and the Middle East. We have reached a stage where there are many excellent conceptual and practical treatment options to consider. What is lacking at this time, however, is a solid body of rigorous research on these various approaches. This is the next step on which we must focus our energies. The goal, of course, is the development of the best evidence-based interventions to promote the psychosocial wellbeing of children during post-traumatic recovery and reconstruction.

References [1] Baron, N., Jensen, S.B., & deJong, J.T.V.M. (2003). Refugees and internally displaced people. In Green, B.L., Friedman, M.J., deJong, J.T.V.M., Solomon, S.D., Keane, T.M., Fairbank, J.A., Donelan, B., & Frey-Wouters, E. (Eds.) Trauma interventions in war and peace: Prevention, practice and policy (pp. 243–270). New York: Kluwer Academic/Plenum Publishers. [2] Van der Veer, G. (1995). Victims of organized violence: A symptom-oriented approach in psychotherapy. Croatian Medical Journal, 36, 238–242. [3] Yule, W., Stuvland, R., Baingana, F.K., & Smith, P. (2003). Children in armed conflict. In Green, B.L., Friedman, M.J., deJong, J.T.V.M., Solomon, S.D., Keane, T.M., Fairbank, J.A., Donelan, B., & FreyWouters, E. (Eds.) Trauma interventions in war and peace: Prevention, practice and policy (pp. 217–241). New York: Kluwer Academic/Plenum Publishers. [4] United Nations (1987). Convention on the Rights of the Child (CRC). New York: Author.

M.J. Friedman / Post-War Communities Overcoming Traumas and Losses

119

[5] Schnurr, P.P. & Green, B.L. (Eds.) (2004). Physical health consequences of exposure to extreme stress. Washington, DC: American Psychological Association. [6] Norris, F., Friedman, M., & Watson, P. (2002b). 60,000 disaster victims speak, Part II: Summary and implications of the disaster mental health research. Psychiatry, 64, 240–260. [7] Norris, F., Friedman, M., Watson, P., Byrne, C., Diaz, E., & Kaniasty, K. (2002a). 60,000 disaster victims speak, Part I: An empirical review of the empirical literature, 1981–2001. Psychiatry, 65, 207–239. [8] Milgram, N. (1995). Catalyzing community support. In Hobfall, S.E., deVries, M.W. (Eds.), Extreme stress and communities: Impact and intervention (pp. 473–488). Dordrecht, Kluwer Academic Publishers (in cooperation with NATO Scientific Affairs Division). [9] Figley, C. (1995). Prevention and treatment of community stress: How to be a mental health expert at the time of disaster. In Hobfall, S.E., deVries, M.W. (Eds.), Extreme stress and communities: Impact and intervention (pp. 489–497). Dordrecht, Kluwer Academic Publishers (in cooperation with NATO Scientific Affairs Division). [10] Yule, W. (1994). Posttraumatic stress disorder. In T.H. Ollendick, N.J. King & W. Yule (Eds.), International handbook of phobic and anxiety disorders in children and adolescents (pp. 223–240). New York: Plenum Press. [11] Silverman, W.K., LaGreca, A.M. (2002). Children experiencing disasters: Definitions, reactions, and predictors of outcomes. In LaGreca, A.M., Silverman, W.K., Vernberg, E.M., & Roberts, M.C. (Eds.), Helping children cope with disasters and terrorism (pp. 11–33). Washington, DC: American Psychological Association. [12] Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. Journal of Personality and Social Psychology, 61, 115–121. [13] LaGreca, A.M., Silverman, W.K., Vernberg, E.M., & Prinstein, M.J. (1996). Symptoms of posttraumatic stress after Hurricane Andrew: A prospective study. Journal of Consulting and Clinical Psychology, 64, 712–723. [14] Vernberg, E.M (1999). Children’s responses to disaster: Family and systems approaches. In R. Gist & B. Lubin (Eds.), Response to disaster: Psychosocial, community, and ecological approaches (pp. 193–210). Philadelphia: Brunner/Mazel. [15] Kaniasty, K., & Norris, F. (1999). The experience of disaster: Individuals and communities sharing trauma. In R. Gist & B. Lubin (Eds.), Response to disaster: Psychosocial, community, and ecological approaches (pp. 25–61). Philadelphia, PA: Brunner/Mazel. [16] Green, B., Korol, M., Grace, M., Vary, M., Leonard, A., Gleser, G., & Smitson-Cohen, S. (1991). Children and disaster: Age, gender, and parental effects on PTSD symptoms. Journal of American Academy Child and Adolescent Psychiatry, 30, 945–951. [17] Korol, M., Green, B.L., & Gleser, G.C. (1999). Children’s responses to a nuclear waste disaster: PTSD symptoms and outcome prediction. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 368–375. [18] Swenson, C.C., Saylor, C.F., Powell, M.P., Stokes, S.J., Foster, K.Y., & Belter, R.W. (1996). Impact of a natural disaster on preschool children: Adjustment 14 months after a hurricane. American Journal of Orthopsychiatry, 66, 122–130. [19] LaGreca, A.M., Vernberg, E.M., Silverman, W.K., Vogel, A., & Prinstein, M.J. (1994). Helping children prepare for and cope with natural disasters: A manual for professionals working with elementary school children. Miami, FL: Author. [20] Vernberg, E.M., LaGreca, A.M., Silverman, W.K., & Prinstein, M.J. (1996). Predictors of children’s post-disaster functioning following Hurricane Andrew. Journa of Abnormal Psychology, 105, 237–248. [21] Klingman, A. (2002) Children under stress of war. In LaGreca, A.M. (2002). Children experiencing disasters: Definitions, reactions, and predictors of outcomes. In LaGreca, A.M., Silverman, W.K., Vernberg, E.M., & Roberts, M.C. (Eds.), Helping children cope with disasters and terrorism (pp. 359–380). Washington, DC: American Psychological Association. [22] Omer, H., & Alon, N. (1994). The continuity principle: A unified approach to disaster and trauma. American Journal of Community Psychology, 22, 273–283. [23] Gurwitch, R.H., Sitterle, K.A., Young, B.H., & Pfefferbaum, B. (2002). The aftermath of terrorism, In LaGreca, A.M. (2002). Children experiencing disasters: Definitions, reactions, and predictors of outcomes. In LaGreca, A.M., Silverman, W.K., Vernberg, E.M., & Roberts, M.C. (Eds.), Helping children cope with disasters and terrorism (pp. 327–357). Washington, DC: American Psychological Association. [24] Cohen, J.A. (2003). Treating acute posttraumatic reactions in children and adolescents. Biol Psychiatry, 53, 827–833.

120

M.J. Friedman / Post-War Communities Overcoming Traumas and Losses

[25] Deblinger, E., Lippman, J., & Steer, R. (1996). Sexually abused children suffering post-traumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1, 310–321. [26] Ayalon, O. (1993). Posttraumatic stress recovery of terrorist survivors. In J. Wilson & B. Raphael (Eds.), International handbook of traumatic stress syndromes (pp. 855–866). New York: Plenum Press.

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

121

Screening and Assessment for Children’s Psychosocial Needs Following War and Terrorism Victor F. BALABAN a, Alan M. STEINBERG b, Melissa J. BRYMER c, Christopher M. LAYNE d, Russell T. JONES e and John A. FAIRBANK f a National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia b,c,f UCLA-Duke University National Center for Child Traumatic Stress b,c UCLA, Los Angeles, California d Brigham Young University, Provo, Utah e Virginia Polytechnic Institute and State University, Blacksburg, Virginia f Duke University Medical Center, Durham, North Carolina

Abstract. The current heightened international concern regarding the short and long-term impact of large scale catastrophic events on children and their families has stimulated efforts to develop assessment batteries that can accurately identify youth whose exposure to trauma, loss, and post-event adversities greatly increases their risk for severe, persisting distress, functional impairment and behavioral/developmental disturbance. Measures are needed for a variety of stages of data collection, including those for acute post-impact triage, needs assessment, surveillance, screening, clinical evaluation, intervention outcome and program evaluation. This chapter reviews selected literature on what is known about children’s responses and course of recovery after terrorism and war, with a specific focus on assessment domains and metrics for progressive implementation of data collection post-event. The report also presents examples of specific measures that have been constructed and used after a variety of catastrophic events, discusses special issues in regard to the psychometrically, developmentally, psychosocially, and clinically sound assessment of children, the necessity of broadening areas of assessment using multiple informants, cultural competence in designing, adapting and adopting instruments, timing of assessment, and training and supervision issues. Finally, a critical review of available assessment tools is presented, along with recommendations for future research to advance the assessment of children after terrorism and disaster.

Introduction The prevalence of war and terrorism on an international scale during the past decade has brought a renewed focus on the need for understanding the psychological, behavioral and functional impact of large-scale disasters on children and adolescents [1]. The physical and emotional consequences of experiencing or witnessing man-made or natural disasters can continue long after the initial event and affect many children who are not in the immediate vicinity at the time of the event. Children’s immature abilities to understand and process the immediate and long-term effects of emergencies – their own injuries and exposure to traumatic events, traumatized or injured parents, loss of

122

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

loved ones, disruptions of daily routines, frightening images in the media – make children among the most vulnerable members of affected communities [2–8]. As recently as the 1980s, it was widely assumed that children’s psychological responses to many types of traumatic events were mild and transient. It is now accepted that disasters and emergencies can have devastating effects on children and families. The study of children’s psychological responses to disasters and emergencies is still at an early stage, however, and the answers to basic questions such as the range of posttraumatic symptoms and their prevalence at different ages have not yet been definitively established [9]. Nonetheless, excellent research has been conducted on children and families’ responses to warfare, bombings, and refugee status, as well as a variety of natural and man-made disasters, including: the terrorist attacks on the World Trade Centers in new York City [10], the Oklahoma City bombing [11], Cambodian refugees exposed to war [12–14]; the earthquake in Armenia [15,16]; and SCUD missile attacks on civilians [17,18]. Although reported rates have varied widely, the traumatized children in these studies have been found to have very high prevalence rates of mental health problems. Studies over the past few decades have documented the prevalence of a variety of post-trauma psychological reactions among children and adolescents after disasters and mass violence that can occur immediately or some time after the experience. As a group, traumatized children manifest significantly higher rates of behavioral and emotional problems and academic failure than non-traumatized children. Common problems include complicated bereavement, somatization, depression, anxiety, dissociative reactions, aggression, conduct disorder, eating disorders, substance abuse, diminished self-efficacy and self-esteem, learning problems, diminished school interest, distressing reactivity to trauma and loss reminders, and disturbances in moral development and conscience functioning. Exposure to trauma in childhood may contribute significantly to the development of traumatic expectations and maladaptive cognitions (including those concerning interpersonal relationships, future orientation, career ambitions, plans for family life, trust in government and the social contract, etc.). Children who have witnessed violence in their families, schools, or communities are also vulnerable to serious long-term problems, such as depression, posttraumatic stress disorder (PTSD), substance abuse, poor medical health and low occupational attainment [3,11,19–22,8]. Early and wellorganized intervention is an essential component of promoting psychosocial resilience among children and families after disasters, and in preventing the development of problems in the future [4,5,23]. Many of the published studies on children’s responses to disasters and trauma are conflicting, and even basic questions such as age and gender effects have not been resolved. One reason for the lack of definitive knowledge about the epidemiology of traumatic responses in children is that assessments have been carried out using a variety of instruments of differing levels of reliability. Methodologies have also varied greatly according to factors such as the type of disaster, age, gender, length of time since the events, single versus multiple events, whether or not the trauma is still ongoing, etc. As a result, there is a tremendous need for systematic psychological assessment of children and adolescents after disasters and emergencies in order to better establish the prevalence, etiology and course of children’s post-traumatic reactions, and to be able to more effectively direct resources. The heightened international concern regarding the short and long-term impact of large-scale catastrophic events on youth and their families has stimulated efforts to

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

123

develop assessment batteries that can accurately identify youth whose exposure to trauma, loss and post-event adversities greatly increases their risk for severe, persisting distress, functional impairment and behavioral/developmental disturbance. The focus on assessment is related to the need to be able to intervene in the course of recovery for different trauma/loss/adversity exposed groups. The use of reliable and valid measures that can assist in carrying out this formidable task will benefit intervention efforts by facilitating the identification of affected subpopulations to be targeted for intervention. Two main considerations should guide the development and use of instruments to measure disaster-related psychosocial impact on youth. These considerations include sound psychometric properties and psychosocial, clinical and practical utility.

1. Validated Assessment Instruments Validated behavioral and psychosocial assessment instruments are useful public health tools that can be used to assess the prevalence of psychological distress and symptoms among children and adolescents after disasters, even in emergency settings. Use of validated rating scales allows fast, cost effective assessment of behavior and psychopathology which can facilitate screening and identification of children in need of help and be used to direct resources in times of crisis. Using validated scales will allow subsequent comparisons across time, population and place. Information collected with validated, psychometrically sound scales can also provide data for further program evaluations, treatment planning, and longitudinal studies to track patterns of development and course of post-traumatic effects in children and adolescents [24–27]. Thousands of rating scales have been developed for assessing hundreds of different disorders and constructs, and simply using a well known instrument without taking into consideration the needs of affected children and families and the specific characteristics of the instrument and the context in which it will be used can result in wasted opportunities, effort and resources. For example, the majority of psychological instruments were not developed for assessing children and adolescents who have experienced war or terrorism, and do not assess symptoms that are empirically known to be associated with child and adolescent trauma. Many older scales may have impressive bodies of psychometric data behind them but were not developed explicitly for children or may be based on older or unclear definitions of underlying constructs. Newer scales often have been designed to overcome these problems, but may not have been used long enough to make definitive conclusions on their validity or reliability [24,27,28].

2. Factors Associated with Child and Adolescent Assessment A body of research has emerged which suggests several important factors that should be taken into account whenever conducting post-emergency mental health assessments of children and adolescents. These factors include: 1) severity and type of trauma, 2) the necessity of assessing multiple disorders, 3) independent assessment of children’s behaviors, 4) assessment of family members, especially mothers, 5) functional status, 6) age and developmental differences, 7) pre-existing risk factors, and 8) cultural competence.

124

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

2.1. Type and Severity of Trauma (Objective and Subjective Features of Exposure) It is essential that the type, nature, and duration of trauma be assessed in children exposed to disasters and emergencies. Children in war situations may have been exposed to a variety of traumas over long periods of time, while children in the aftermath of a natural disaster may be dealing with a single, relatively circumscribed event. Several studies have suggested that there are significant relationships between the type and severity of trauma children are exposed to, and the outcome in relation to PTSD, anxiety, and depression [29–39]. There are a variety of instruments that have been specifically designed to assess levels of exposure to various types of disasters including wars, hurricanes, earthquakes and fires. These questionnaires are not mental health assessment tools themselves, but they can provide an important way to identify children and adolescents who may be at higher risk for developing post-traumatic symptoms and whenever possible should be used as part of post-disaster mental health assessments [27]. While there are a number of exposure instruments that are designed to be administered to children, others are designed to be administered to adults. It would be most appropriate to administer these instruments to parents, adolescents, and school-age children, rather than to younger children. Some relevant instruments for measuring exposure to trauma are summarized in Table 1. The first items typically included in mental health needs assessment, surveillance or screening batteries in the aftermath of disaster/mass violence have been questions about objective and subjective features of exposure to the event. Both aspects of exposure have been shown repeatedly to be independently positively associated with postdisaster levels of distress and impairment. They constitute well-documented risk factors for psychiatric morbidity and adverse functional impact. Event-specific exposure items vary with the type of event, i.e., earthquake, hurricane, catastrophic school violence or forms of terrorism. Before designing specific exposure items, interviews with key informants must be conducted to ascertain salient event-specific features of exposure. During the acute post-impact phase, exposure variables can be of use in identifying subgroups of an affected population that are at increased risk for severe and persistent distress reactions and behavioral and functional impairment. During this acute stage, inclusion of exposure and post-event adversity variables may add incremental validity to the assessment battery because most members of an affected population may be highly distressed, often with undifferentiated presentation. Therefore, distress measures alone may have inadequate discriminatory power. That segment of the population with the most severe trauma and loss exposures constitute a primary risk group. The literature suggests that there are other subgroups that may need screening and acute intervention. These may include groups with (a) severe post-event stresses and adversities; (b) pre-existing anxiety disorders; (c) pre-existing trauma/loss; (d) family disturbances; (e) low income; (f) low social support; (g) frequent exposure to distressing reminders; and (h) children with special needs. Another important part of the exposure section of any post-disaster/mass violence battery are questions related to loss of loved ones, along with questions about normal grief and complicated grief reactions. For example, the UCLA Trauma Psychiatry Service Grief Inventory includes questions about loss exposure and normal and complicated grief reactions [40].

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

125

2.2. Assessment of Multiple Disorders Post-emergency assessment should not be limited to the prevalence of any single psychological disorder. A great deal of the current knowledge of children’s psychological responses to disasters is based on research on PTSD. However, PTSD is only one of a range of possible responses to trauma. As noted above, traumatized children can also exhibit trauma-related symptoms such as somatic disturbances, learning problems, anxiety, depression, oppositional behaviors, and conduct disorder. There is evidence that the prevalence of PTSD in children and adolescents may be related to the severity of the original trauma, while rates of depression may be related to ongoing secondary adversities. This suggests that different assessments and interventions may be needed in the aftermath of emergencies and disasters [8,16,19,41–44]. 2.3. Independent Assessment of Children’s Behavior Assessing child mental health often requires input from several informants. Adults are generally reliable observers of children’s behaviors, but may underestimate children’s internal distress. Whenever possible, assessments of children should include an adult’s assessment of the child’s behavior. Parent and/or teacher completed behavior rating scales can provide reliable, inexpensive, and relatively easy to administer measures of children’s disruptive behaviors. However, this should not be a substitute for an assessment of the children themselves [45–48]. 2.4. Assessment of Family Members, Especially Mothers If possible, the mental health status of primary caretakers should be assessed at the same time as children. A few disaster studies have indicated that parental adjustment is an important predictor of children’s mental health outcomes, particularly maternal reactions. More studies are needed to independently assess the mental health of mothers and children, in order to determine the extent to which mothers’ ratings of their children’s mental health status reflects their own levels of distress or the children’s actual mental health [49–52,17,18,54,26,36]. 2.5. Functional Status Whenever possible, instruments that include questions of social and behavioral functioning should be used when assessing children and adolescents in disaster and emergency contexts. Empirical data on the relationship between psychopathology and functional status for childhood diagnoses are still very limited, but it has been estimated that only between one half and one third of children with a psychiatric diagnosis show some significant impairment at home, in school or with peers [13]. Epidemiological studies have generally reported the prevalence of psychiatric diagnoses, but not the proportion of those with impaired functioning. Furthermore, appropriate and adaptive behaviors may be very different in the aftermath of emergencies; so the presence of symptoms does not always indicate functional disability, nor does the absence of reported symptoms indicate lack of distress [53,55,56]. Ideally future research will address strengths and protective factors that contribute to children’s recovery in postdisaster situations.

126

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

In addition to psychological sequelae, recent post-event assessment efforts have included a broader range of potential behavioral and functional outcomes. These have included (a) alcohol and drug use; (b) delinquency and antisocial behavior; (c) teenage sexual activity; (d) school underachievement and failure; (e) empathic and prosocial behavior/citizenship; (f) quality of peer relationships; (g) quality of family relationships; (h) quality of romantic relationships; (i) quality of work performance; and (j) physical health. 2.6. Age and Developmental Differences Although the contribution of age to children’s post-traumatic behavior and psychopathology are not yet well understood, it is critically important that any assessment instruments be age and developmentally appropriate. There is evidence that younger children may be at higher risk for developing PTSD than adolescents and adults, and that girls may be at greater risk than boys, but overall the evidence on whether age and developmental level constitute risk factors remains ambiguous. In particular, there is a great need for data on the effects of post-traumatic stress on children younger than age 8 [9,57–59]. 2.7. Pre-Existing Risk Factors A variety of studies have identified risk factors that influence response to trauma and affect recovery. These include: exposure to previous traumas, pre-existing psychopathology, and lack of social support. Other studies of traumatized child populations have also indicated that family displacement, parental loss, and other secondary adversities can add to the effects of the original trauma. Ideally, post-disaster assessments and screenings should include questions to assess these factors, as well as other potential risk factors, as a way to identify populations of children and adolescents who may be at higher risk for developing trauma-related psychopathology [6,16,60]. Some assessment batteries have typically included items assessing exposure to prior trauma and loss. Some debate has arisen concerning whether a history of prior trauma/loss constitutes a risk factor, although this remains an area for further empirical study. A post-disaster/mass violence battery should also include items related to the experience of post-event stresses and adversities, as these also can constitute independent risk factors for adverse psychosocial consequences. A number of post-disaster studies among children and adolescents have strongly suggested that severe post-disaster adversities can exacerbate posttraumatic stress reactions, interfere with recovery from posttraumatic stress reactions, and contribute independently to the presence and severity of other co-morbid conditions, including depression, grief, anxiety, somatization, hostility, etc. [16]. Factors embedded within the post-disaster ecology that may be etiologic, or mediate/moderate the impact of disaster on intermediate and long-term recovery include (a) frequency of exposure to trauma reminders; (b) frequency of exposure to loss reminders; and (c) type and severity of secondary adversities. These include (a) impairment in caregiver mental health; (b) quality of family functioning; (c) overcrowded or adverse living conditions; (d) school and community milieu; (e) quality of peer relationships; and (f) physical injury and disability.

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

127

2.8. Cultural Relevance and Competence of Assessment Approaches The methodological problems inherent in psychological assessment are made even more complex in the context of working with ethnic and cultural groups who may have differing levels of exposure to previous traumas, differing vulnerabilities and strengths, differing levels of coping resources, and differing culturally sanctioned ways to express grief, pain and loss. Any scale must be used with caution when the population being assessed is different from the one that the test was validated on. Many assessment instruments may not be appropriately sensitive to cultural and ethnic variability; simply translating an instrument into another language does not necessarily mean that the same symptoms or the same disorders are being assessed. Since nearly all tests have been validated in Western, clinical populations, this is a serious, but not insurmountable problem that calls for further research. Other methodological issues that can arise in cross-cultural assessments include: issues of translation; relevance of cultural categories of mental health and illness; biases against confiding personal feelings to people from other cultures; and difficulty in finding control groups of non-traumatized populations [25,42,52,61–65].

3. Timing of Post-Disaster/Mass Violence Assessments Data collection can occur during the acute post-impact phase during which there is typically a reliance on exposure measures in combination with other salient risk factors. Subsequent data collection metrics (e.g., one month post-event and onward) can be expanded to include selected distress measures, along with measures of behavioral and functional impairment, and mediating/moderating variables. The timing of stages of data collection will be heavily influenced by (a) the nature of the event (war, terrorism or natural disaster); (b) the extent of destruction, morbidity and mortality; and (c) the post-event ecology and logistical factors. 4. Seamless System of Tracking, Triage, Clinical Care and Recovery Initial Contact – High risk objective features. Needs Assessment/Surveillance – Brief Scale: tailored exposure, trauma and loss items; abbreviated subjective distress measures; specific adversities, new events. Clinical Screening – Expanded Brief: Continuous distress measures; brief evaluation of functional impact. Clinical Evaluation – Full scale instruments, including structured interview and functional impairments. Monitoring Course of Recovery – Monitoring of Recovery Environment, including new exposures, new adversities and maladaptive adjustment. Data collection in the aftermath of mass casualty events can occur in phases. Data collection should ideally be carried out in the context of a broader public mental health response and recovery program, a “disaster system of care” [66]. Assessment in the acute post-impact phase sets the stage for psychological first aid and triage. Clinical assessments, using valid and reliable methods, should be conducted in order to identify vulnerable, high-risk individuals and groups, provide for emergency hospitalization, and refer children and adolescents for further evaluation when indicated.

128

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

The initial screening should include basic exposure information about where the children were during the event and what happened to them and those around them. This should be followed by specific questions about high-risk experiences for example, direct life-threat, being trapped or injured, witnessing grotesque injury, hearing screams of distress, being separated from family members or caretakers, or, injury or death of family members. Additional exposure screening questions should address the child's subjective appraisal of the event and associated emotional responses. These exposure questions should be complemented by a brief evaluation of prior trauma, posttraumatic stress, depressive, and grief reactions. (For examples of stressor exposure instruments, refer to Appendix A, Table 1). For the initial recovery phase, abbreviated versions of instruments can be used to address a victim’s level of distress when appropriate psychometric studies have been conducted. For example, Project Liberty Enhanced in New York City used an abbreviated version of the UCLA PTSD Reaction Index for DSM IV [67]. Where sensitivity and specificity are high, abbreviated scales provide an efficient means for needs assessment and screening. For example, eight items from the UCLA PTSD Index do almost as well as the full scale in predicting PTSD caseness. These items include: Here is a list of problems people sometimes have after very bad things happen. As you read each problem, think about the WTC attack. Then, circle the number that indicates how often the problem happened to you DURING THE LAST 4 WEEKS. Please be sure to answer all questions. T1. I get very upset, afraid or sad when something makes me think about what happened.

None 0

Some 1

Little 2

Much 3

Most 4

T2. I have upsetting thoughts or pictures of what happened come into my mind when I do not want them to.

None 0

Some 1

Little 2

Much 3

Most 4

T3. I feel grouchy, or I am easily angered.

None 0

Some 1

Little 2

Much 3

Most 4

T4. I try not to talk about, think about, or have feelings about what happened.

None 0

Some 1

Little 2

Much 3

Most 4

T5. I have trouble going to sleep, or wake up often during the night.

None 0

Some 1

Little 2

Much 3

Most 4

T6. I have trouble concentrating or paying attention.

None 0

Some 1

Little 2

Much 3

Most 4

T7. I try to stay away from people, places, or things that make me remember what happened.

None 0

Some 1

Little 2

Much 3

Most 4

T8. I felt as the WTC attack hadn’t happened or was unreal.

None 0

Some 1

Little 2

Much 3

Most 4

During the response phase, methodologies and strategies for collecting tracking and triage information are available, for example using Web-based systems like PsySTART, that capture risk markers and contact information. Such data collection could be carried out by collaborating community, state and federal systems. These can include emergency medical services, disaster relief organizations (such as the International Committee of the Red Cross), first responders, state and county public and mental health, and schools.

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

129

During the recovery phase, mental health needs assessment data collection is gathered for the purpose of making an estimate of the nature, severity and extent of adverse psychological, behavioral and functional impact on an affected population for the purpose of planning needed response strategies and resources. 5. Training Issues for Peri- and Post-Disaster Assessment Needs The competent use of psychological test materials can be divided into three basic components: test administration, test scoring, and test interpretation. At a minimum, all test administrators must be properly trained and monitored/supervised in the competent administration of tests. Training/supervision should thus cover such aspects as obtaining informed consent/assent, explaining test directions to subjects, managing distress reactions if they occur, and adhering to the standardized test protocol. It may not be necessary for test administrators to be trained also in test scoring and interpretation, as these tasks may be conducted either using computer algorithms or by other more highly trained mental health personnel. It may be necessary to conduct “pulsed” training and supervision meetings to problem-solve difficulties as they arise, and to work out standardized and reliable protocols for administration, scoring, and interpretation. For conducting population-based needs assessment and surveillance data collection, specialized training is needed in such domains of expertise as: Sampling methodology (e.g., obtaining a representative and generalizable sample, modularized assessment protocols (some measures are given to all subjects, with strategies to collect a subset of additional data from various subgroups), power/precision analysis, standardized governmental and non-governmental databases for comparability) Research design (e.g., repeated cross-sectional vs. longitudinal cohort designs, etc.) Psychiatric epidemiology Statistical analytic techniques Natural recovery and regression towards the mean Integrating data collection within a framework of response and clinical care Overall program evaluation 6. Recommended Screening/Assessment Tools Psychological instruments that have been used in complex emergencies, or in longitudinal studies of the victims of disasters after the immediate crisis has passed, fall into four categories: 1) post-traumatic stress reactions/disorder, 2) depression, 3) anxiety, and 4) behavioral problems/disorders. A brief description of each instrument is provided, followed by a summary of previous post-disaster assessments that have used it and recommendations for the most appropriate instruments in different emergency contexts. 7. Methodology Searches were conducted in the MEDLINE, PSYCHINFO and Health and Psychosocial Instruments (HAPI) databases for studies using validated psychological instru-

130

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

ments to assess child or adolescent victims of complex emergencies (defined as wars, natural disasters and large-scale transportation or industrial accidents). Four categories of instruments were reviewed: 1) post-traumatic stress disorder, 2) depression, 3) anxiety, and 4) behavioral assessments. Instruments that met the following five criteria were included. The instrument must: a) be brief, defined as instruments designed to be administered in 60 minutes or less; b) be in questionnaire format (i.e. structured and semi-structured interviews were not included); c) be able to be administered by nonclinicians; d) have been used in disaster and emergency contexts or in longitudinal studies of child and adolescent victims of complex emergencies; and e) have published validation data. Because the focus of this review is on using instruments for screening, rather than for diagnoses, validation data are reported regarding internal consistency, test-retest and interrater reliability coefficients; and convergent validity with other measures of the same diagnoses. Measures of the construct validity of the underlying diagnostic categories are not reported. Furthermore, because the field of pediatric disaster mental health is still relatively new, several instruments were identified that met only four of the criteria; these were included in the review either because they have been widely used in emergency settings or they have not been used in post-disaster assessments but would be appropriate for such contexts. Other potential post-disaster/mass violence scales are listed in Appendix B.

8. Post Traumatic Stress Disorder PTSD is an anxiety disorder that can occur after exposure to traumatic stress. Symptoms of PTSD are among the most common types of psychological distress observed in children after disasters. The DSM-IV diagnostic criteria for PTSD were originally designed for adults, and then adapted for children. Instruments used in post-emergency assessment of young children must take into account their limited verbal skills and different ways of reacting to stress. For example, children too young to verbalize their symptoms may not be able to express signs of numbing and withdrawal, and they may show re-experiencing symptoms in the form of play reenactment, rather than flashbacks or intrusive thoughts [68,69]. Studies that have assessed PTSD in children and adolescents in disaster and emergency contexts are summarized in Appendix A, Table 2. 8.1. UCLA PTSD Reaction Index for DSM IV (UCLA PTSD-RI) The UCLA PTSD-RI (formerly the Child PTSD Reaction Index, CPTSD-RI) is one of the mostly widely used measures in childhood PTSD research. It is a three-part scale for assessing post-trauma symptoms and PTSD in children ages 6–17 after exposure to a broad range of traumatic events. It is designed to be administered by someone with at least graduate level training under the supervision of a Master’s level clinician, but can be administered as a self-report scale for children ages 8 and older. Part I consist of a brief lifetime trauma screen; Part II allows for evaluation of objective and subjective features of exposure to a traumatic event; and Part III consists of 22 questions, scored 0–4 according to presence of symptoms that assess the frequency of post-traumatic symptoms in the previous four weeks. UCLA PTSD-RI items are written in ageappropriate language and the test takes 20–30 minutes to administer. It has been used with children and adolescents in the aftermath of many different types of disasters and

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

131

emergencies, and has been translated into several different languages, although crosscultural validation data has not been published. The UCLA PTSD-RI has more psychometric research behind it than most other assessment scales for child and adolescent trauma. A variety of studies have found internal consistency reliability coefficients ranging from 0.69 to 0.8, interrater reliability of 0.88, test-retest reliability of 0.93 over one week, and convergent validity scores of 0.91 with measures of PTSD [15,67,70,71]. 8.2. Harvard Trauma Questionnaire (HTQ) The HTQ is a culturally validated instrument designed to measure war and disasterrelated trauma and torture events, and to assess post-traumatic symptoms in adolescents and adults. While not designed for children, it has been used with adolescents as young as age 14 and a modified version has also been developed for children ages 12–13. The HTQ consists of four sections which can be administered together or separately; the complete scale takes approximately 45 minutes to administer. Part I asks 46 questions about war and disaster-related traumatic life events. Part II is an open-ended question that asks respondents for a subjective description of the most traumatic event(s) they experienced. Part III asks about war and disaster-related events that may have led to head injuries. Part IV consists of 40 questions that assess PTSD symptoms, symptoms specifically related to refugee trauma (i.e. dissociative experiences, feelings of shame hopelessness), and the individual’s perception of his/her ability to function in everyday life. Questions in Part IV include four categories of response: “Not at all,” “A little,” “Quite a bit,” “Extremely,” rated 1 to 4, respectively. The HTQ has been translated and validated in several languages including Bosnian, Croatian, Cambodian, Japanese, Laotian and Vietnamese. Studies have tested the validity of the Cambodian, Laotian, and Vietnamese versions of the HTQ and found internal consistency reliability coefficients of 0.90–0.96, interrater reliability coefficients 0.93–0.98, test-retest reliability coefficients 0.89–0.92 for one week, and convergent validity 0.84–0.93 with measures of PTSD [72,73]. Since the HTQ was not specifically designed for children, the results of assessments using it are not reviewed in detail in this paper. However, the HTQ has been used in a variety of disaster and emergency contexts including: war traumas among Bosnian refugee children and adolescents [55,74]; Kurdish children in Afghanistan exposed to war traumas [53,75]; adolescent Afghan refugees settled in the United States [76]; and Nicaraguan adolescents exposed to Hurricane Mitch [77]. 8.3. Impact of Event Scale-Revised (IES-R) The IES-R is a widely used instrument in adult PTSD research. It consists of 22 items which measure symptoms of intrusion, avoidance and arousal and takes approximately 10–15 minutes to administer and score. It has been translated into several different languages and been used with adolescents in post-disaster contexts. Dyregrov and Yule (1995) [78] have validated a subset of 8 items for use with children and adolescents. Scores on the eight items have been found to be an efficient cutoff for PTSD, with a sensitivity and specificity of 90%. Several studies have tested the psychometric properties of the IES-R in adults and found internal consistency reliability coefficients ranging from 0.79–0.90 for subscales and 0.60–0.90 total, test-retest reliability coefficients from 0.79–0.89 for one week, (interrater reliability not reported), and concurrent validity scores 0.41–0.78 with measures of anxiety and depression [55,70,79,80].

132

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

It is important to note that the IES-R has not been modified to assess specific manifestations of child and adolescent traumatic responses and the psychometric properties of the instrument have not yet been studied in younger children. A new developmentally appropriate test based on the IES, the Children’s Reaction to Traumatic Events Scale (CRTES), has been developed. It is a 15-item self-report scale designed for children ages 8–12. Initial validation studies have found internal consistency reliability coefficients of 0.53–0.68 for subscales and 0.73 for the scale, and interrater reliability coefficients of 0.91 (test-retest reliability and convergent validity scores not reported) [55,70,80,79,81]. 8.4. Posttraumatic Stress Symptoms in Children (PTSS-C) The PTSS-C is a new instrument developed for identifying pediatric post-traumatic symptoms in chaotic disaster contexts. It has been used on samples of children ages 6–18, takes approximately 30 minutes to administer and consists of 30 yes/no items. The first 17 questions are based on the DSM criteria for PTSD, the rest are designed to assess child-specific posttraumatic symptoms such as feelings of guilt, hyperactivity, etc. The limited validation data available have shown internal consistency reliability coefficients of 0.78–0.88, interrater reliability coefficient of 0.94, and concurrent validity 0.64–0.95 with measures of PTSD (test-retest reliability coefficients not reported) [82]. 8.5. Child PTSD Symptom Scale (CPSS) The CPSS is a self-report scale that assesses DSM-IV defined symptoms for PTSD and functional impairment related to PTSD, in a format and language that are developmentally appropriate for children and adolescents ages 8 to 18. It is a children’s version of the Posttraumatic Diagnostic Scale (Foa et al., 1997 (83)). It consists of 17 questions that assess the frequency of symptoms of PTSD in the previous month, and seven additional questions that assess daily functioning (i.e., school performance, relationships with friends). The test takes approximately fifteen minutes to administer and score. Preliminary validation data for the CPSS has found internal consistency scores of 0.70–0.80 for subscales and 0.89 total, test-retest reliability 0.63–0.85 for subscales and 0.84 total, and convergent validity 0.80 with measures of PTSD (interrater reliability not reported) [70]. 8.6. Trauma Symptom Checklist for Children (TSCC) The TSCC is a self-report scale that assesses distress and post-traumatic symptoms after acute or chronic trauma in children ages 7–16. It has been used primarily to assess children’s responses to sexual abuse. While the TSCC has not been used in disaster contexts, it may be appropriate for assessing children and adolescents in emergency settings where sexual traumas are an issue. The scale consists of 54 items that are divided into six subscales: anxiety, depression, anger, post-traumatic stress, dissociation and sexual concerns; it takes 15–20 minutes to administer. Shorter versions (44 and 40-items) of the TSCC that do not contain items relating to sexual concerns are also available. Several validation studies have found internal consistency reliability coefficients between 0.70–0.90 for subscales and 0.89 total, and convergent validity between 0.75–0.82 with measures of PTSD, anxiety and behavior scale (test-retest and interrater reliability not reported) [70,84].

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

133

8.7. Discussion: Instruments for Assessing PTSD The PTSD assessment instrument which is most likely to be appropriate for assessing children and adolescents across a wide variety of disasters and emergency contexts is the UCLA PTSD Reaction Index for DSM-IV (UCLA PTSD-RI). It has been used in a variety of emergency contexts and translated into many languages. In addition, it is inexpensive, simple, fast to administer and score, and has a body of psychometric research to support it. The Harvard Trauma Questionnaire (HTQ) may be an appropriate test for adolescents in war, disaster and refugee contexts. Like the UCLA PTSD-RI, it has been used in emergency contexts and translated into many languages, is inexpensive, simple, fast to administer and score, and has psychometric research to support it. Although not designed for younger children, as a PTSD assessment instrument specifically designed and validated in refugee and disaster populations, the HTQ can be a useful instrument for assessing adolescents in certain types of disasters and emergencies. The Child PTSD Symptom Scale (CPSS) is also quickly administered. However, it is a relatively new instrument with much less validation data available. Because it has not yet been used in emergency contexts, it may be more difficult to compare results with those using other post-emergency assessment scales. The Posttraumatic Stress Symptoms in Children (PTSS-C) is also fast to administer. It is designed specifically for assessing younger children exposed to chaotic war environments and traumas, and may be a useful instrument in those contexts. However, it is a relatively new instrument with little validation data available, which can make it difficult to compare results to those using other post-emergency assessments scales. The Impact of Events Scale – Revised (IES-R) may be appropriate for screening adolescents who have been exposed to a specific, discrete trauma. However, the IESR’s focus on effects of a specific event may limit its applicability in contexts where children have been exposed to multiple or ongoing traumas. In addition, although it has been used with children and adolescents, it was designed for adults and may not be the best instrument for child assessments. The Trauma Symptom Checklist for Children (TSCC) may be useful for assessing children and adolescents in emergencies where rape and sexual traumas are an issue. It has not been used in disaster contexts and so may not be the best choice for an emergency PTSD assessment instrument. (This issue is discussed in more depth in the conclusion.)

9. Depression Depression is one of the most common responses to stress and trauma. It is extremely important to assess symptoms of depression in post-emergency settings since depressive disorders in children and adolescents can have long-term effects on functioning and adjustment, including increased risk for illness and interpersonal and psychosocial difficulties that can persist long after the depressive episode is resolved. Depression in children and adolescents is also associated with an increased risk of suicidal behaviors and in adolescents there is also an increased risk for substance abuse [43,85,86]. Studies that have assessed depression in children and adolescents in disaster and emergency contexts are summarized in Appendix A, Table 3.

134

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

9.1. Children’s Depression Inventory (CDI) The CDI is the most widely used self-rating scale for depression in children. It is a selfreport, symptom-oriented scale with a first-grade reading level, designed to measure depressive symptom severity in children and adolescents, ages 7–17 years, and has been translated into many different languages. The CDI consists of 27 items, and takes approximately 5–10 minutes to administer. Each item consists of three choices where the child or adolescent is instructed to select one of three sentences for each item that best describes him or her for the previous two weeks. The CDI generates a total score as well as scores for five factors: negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem. Parent and teacher versions are available, as well as a 10-item CDI Short Form developed to provide very quick assessment of a child or adolescent’s depressive symptoms. The 10-item short form correlates 0.89 with the full CDI [87,88]. The CDI has been the subject of a great deal of validation research. Many studies have found internal consistency reliability coefficients from 0.70–0.89, test-retest reliability coefficients ranging from 0.38–0.87 with better test-retest reliability found when the test was re-administered within two weeks, and concurrent validity scores 0.44–0.62 with measures of depression (interrater reliability nor reported) [28,89]. 9.2. Depression Self-Rating Scale (DSRS) The DSRS is a 26-item self-report questionnaire that measures depression in children ages 6–13 and takes approximately 30 minutes to administer and score. Parent and teacher versions are also available. It was designed after the Zung Depression Scale to measure affective, cognitive and somatic symptoms of depression in the previous week. While the DSRS does not have the same body of psychometric data that the CDI does, several studies have found internal consistency reliability coefficients from 0.54–0.94, test-retest reliability coefficients of 0.74, and concurrent validity of 0.84 with measures of depression (interrater reliability not reported) [28,90–92]. 9.3. Hopkins Symptom Checklist-25 (HSCL-25) The HSCL-25 is a widely used screening instrument which measures symptoms of anxiety and depression in adolescents and adults and has been used in disaster and emergency contexts. It consists of 25 items: Part I has 10 items for anxiety symptoms; Part II has 15 items for depression symptoms. The scale for each question includes four categories of response (“Not at all,” “A little,” “Quite a bit,” “Extremely,” rated 1 to 4, respectively). Two scores are calculated: the total score is the average of all 25 items, while the depression score is the average of the 15 depression items. The HSCL-25 is derived from the Symptom Checklist-90 (SCL-90), a widely-used self-report inventory designed to assess patterns of current psychological symptoms, and several studies have assessed the validity of SCL-90 finding internal consistency reliability coefficients of 0.77–0.90, test-retest reliability coefficients of 0.78–0.90 for one week, and interrater reliability coefficients of 0.74–0.91. Cambodian, Laotian and Vietnamese version of the HSCL-25 have also been validated, finding test-retest reliability coefficients of 0.82–0.89 over two weeks, interrater reliability coefficients of 0.98, and convergent validity 0.73–0.88 with measures of depression [93,94].

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

135

The HSCL-25 is not designed for children, but it has been used with adolescents as young as age 14. It has been translated and validated in several languages including Bosnian, Cambodian, Croatian, Dari, Japanese, Laotian, and Vietnamese. Since the HSCL-25 was not designed for children, the results of assessments using it are not reviewed in detail in this paper. However, the HSCL-25 has been used in a variety of disaster and emergency contexts including: Bhutanese refugee torture survivors [95], Rwandan genocide survivors [96]; Cambodian refugees [25,97], Bosnian refugees [98], Tamil asylum seekers [99], Vietnamese immigrants [100] adolescent and young adult Afghan refugees [32] and Iraqi refugee torture survivors [101]. 9.4. Discussion: Instruments for Assessing Depression The Depression Self-Rating Scale (DSRS) and the Children’s Depression Inventory (CDI) are both good scales to quickly and easily screen for depressive symptoms in younger children and adolescents in disaster and emergency contexts. Both have been used in emergency contexts and translated into many languages, are inexpensive, simple, fast to administer and score, and have bodies of psychometric research to support them. While the CDI has a more extensive body of psychometric data, the response format of comparing and choosing from three similar sentences might be confusing to some children, particularly younger children and those in non-Western settings. For adolescents in war, disaster and refugee contexts, the Hopkins Symptom Checklist (HSCL-25) may also be an appropriate test. It has been used in emergency contexts and translated into many languages, is inexpensive, simple, fast to administer and score, and has a body of psychometric research to support it. Because it is a brief depression and anxiety assessment instrument that has been validated in refugee and disaster populations, it can be a useful instrument for many types of disasters and emergencies.

10. Anxiety Disorders Anxiety disorders are among the most common mental health problems that occur in children and adolescents. Since anxiety is also a normal part of childhood and adolescence, it is important that rating scales used in disasters and emergencies discriminate between transient anxiety and more serious anxiety symptoms. There is evidence that pre-existing anxiety disorders are a risk factor for developing post-disaster PTSD symptoms, so assessments should ideally include items to differentiate pre-existing anxiety disorders from post-disaster symptoms [24,89,90]. Studies that have assessed anxiety symptoms in children and adolescents in disaster and emergency contexts are summarized in Appendix A, Table 4. 10.1. Revised Children’s Manifest Anxiety Scale (RCMAS) The RCMAS, also known as the “What I Think and Feel” scale, is the most widely used self-rating scale for childhood anxiety. It provides a measure of general anxiety for children 6–19 years old and consists of 37 yes/no items which provide a score for total anxiety as well as for four subscales: worry/oversensitivity, psychological anxiety, social concerns/ concentration and a lie scale. It takes approximately 10 minutes to administer. Many studies have assessed the psychometric properties of the RCMAS,

136

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

finding internal consistency coefficients of 0.64–0.76 for subscales and 0.69–0.83 total, test-retest reliability coefficients of 0.63–0.85, and convergent validity 0.78–0.85 with measures of anxiety (interrater reliability not reported) [28,89,102,103]. A limitation of the RCMAS is that it is based on older models of anxiety and so the symptoms it assesses do not entirely match the current DSM-IV symptoms for anxiety disorders [28]. 10.2. Fear Survey Schedule for Children (FSSC) The FSSC is designed to provide quantitative information about children’s reactions to a great variety of possible sources of maladaptive emotional reactions, with a particular focus on fears and phobias. It consists of 108 items rated on a five-point scale and is appropriate for children ages 9–12. The Revised Fear Survey for Children (FSSC-R) is a further revision consisting of 80 questions appropriate for children ages 7–18. It takes approximately 30 minutes to administer and score. The FSSC and the FSSC-R have been translated into many languages and have been shown to be useful in differentiating among anxiety disorders in children and the relationship of fears to anxiety and depression, and in studying emotional reactions of children with PTSD symptoms. Studies of the psychometric properties of the FSSC have found internal consistency reliability coefficients of 0.90, and test-retest reliability coefficients of 0.80 (interrater reliability coefficients and convergent validity scores not reported) [70,104–106]. 10.3. State and Trait Anxiety Inventory for Children (STAI-C) The STAI-C, also called the “How I Feel Questionnaire,” consists of two, 20-item scales each relating to symptoms of anxiety. The first, the State scale, assesses the subject’s current level of anxiety, and the second, the Trait scale, tests a subject’s general tendency to become anxious in response to stressful events. The psychometric properties of the STAI-C have been assessed in many studies, finding internal consistency reliability coefficients of 0.82–0.87, test-retest reliability coefficients 0.31–0.71, and concurrent validity of 0.63–0.75 with measures of anxiety. A limitation of the STAI-C is that the questions on the STAIC do not cover all DMS-IV anxiety symptoms, and the concept of a state-trait distinction has also been questioned in the literature [89,107,108]. 10.4. Multidimensional Anxiety Scale for Children (MASC) The MASC consists of 39 items scored on a 4-point likert scale. It is designed for children ages 8 to 19, takes approximately 15 minutes to administer, and is becoming one of the preferred research and clinical anxiety scales. A parent-report form is also available. The MASC has not been used in disaster or emergency contexts, but would be appropriate for those settings. Results are divided into four scales: physical symptoms, social anxiety, harm avoidance and separation/panic. Three indices are also produced: anxiety disorders, total anxiety and inconsistency. It is an empirically derived scale that assesses all the DSM-IV symptoms of anxiety rather than an underlying anxiety construct. Several studies have assessed the psychometric properties of the MASC, finding internal consistency reliability coefficients of 0.60–0.90, test-retest reliability coefficients of 0.65–0.93, and convergent validity of 0.63 with measures of anxiety (interrater reliability not reported). A 10-question version, the MASC-10 has also been developed that combines the four basic anxiety scales of the MASC into a single dimension [28,107].

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

137

10.5. Discussion: Instruments for Assessing Anxiety Disorders Of the anxiety scales reviewed, only the Multidimensional Anxiety Scale for Children (MASC) is based on current conceptual models of anxiety disorders and has adequate psychometric properties. It has not yet been used in emergency contexts, but should be appropriate for post-disaster assessments. The Revised Children’s Manifest Anxiety Scale (RCMAS) and the State and Trait Anxiety Inventory for Children (STAI-C) are still widely used, but are being supplanted by newer scales. Both have been used in disaster and emergency contexts and have bodies of psychometric data behind them. However, they do not assess all DSM-IV symptoms of anxiety disorders and are based on older conceptual models of anxiety. Therefore, the MASC may be the most appropriate child anxiety instrument for use in emergencies. The Revised Fear Survey for Children (FSSC-R) is narrowly focused on phobic symptoms and so not a useful instrument for assessing a wide range of anxiety disorders. However, children’s fears are an important area to assess in determining children’s post-disaster functioning, so it could be used in conjunction with other assessment instruments if time and resources allow. (This issue is discussed in more depth in the conclusion.) 11. Behavioral Disorders Exposure to traumatic events can result in a variety of disruptive behaviors and behavioral disorders in children and adolescents. Children are not always reliable reporters of their own behaviors. Assessing adult perceptions of child and adolescent disruptive behaviors is therefore extremely important for both screening and interventions, providing a useful way to measure changes in child behavior over time, and assessing the effectiveness of interventions and programs [64,109,110]. Studies that have assessed behavioral disorders in children and adolescents in disaster and emergency contexts are summarized in Appendix A, Table 5. 11.1. Pediatric Emotion Distress Scale (PEDS) The PEDS is a post-traumatic parent report scale that measures post-traumatic behavioral problems in children ages 2–10. The 21-item parent-report rating scale includes 17 general behavior items such as include “seems worried,” “has bad dreams,” “seems easily startled,” “complaining about aches and pains,” which are scored on a 4-point likert scale; as well as 4 trauma-specific items. The PEDS produces three factors: Anxious/Withdrawn, Fearful, and Acting Out. It is one of the only instruments for screening behavioral problems in very young children. Preliminary studies have assessed the psychometric properties of the PEDS and found internal consistency scores of 0.72–0.78 for subscales and 0.85 total, interrater reliability 0.47–0.64 for subscales and 0.65 total, test-retest reliability 0.55–0.61 for subscales and 0.56 total over 6–8 weeks, convergent validity of 0.59–0.86 for subscales with measures of externalizing behaviors and 0.62 total with measures of PTSD [70,110,111]. 11.2. Revised Behavior Problem Checklist (RBPC) The RBPC is used to rate problem behaviors observed in adolescents and young children. It consists of 89 items that parents or teachers mark as present or absent in a

138

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

child. It is designed for children 5–18 years, and takes approximately 20 minutes to administer. The RBPC produces a total score and six subscales which measure conduct disorder, socialized aggression, attention problems-immaturity, anxiety-withdrawal, psychotic behavior, and motor tension-excess. Several studies have assessed the psychometric properties of the RBPC, finding internal consistency reliabilities from 0.73–0.94 for the 6 subscales, test-retest reliability coefficients of 0.79–0.91, and interrater reliability coefficients from 0.52–0.85 (convergent validity not reported) [112,113]. 11.3. Child Behavior Checklist (CBCL) The CBCL is one of the most widely used general behavior scales for assessing children and adolescents. The original CBCL (now known as the CBCL/6-18 for children ages 6–18) has been translated into more than 30 languages. Several other CBCL forms have also been developed, producing a family of assessment instruments, including the CBCL/1½-5 designed for younger children ages 1½–5, the Teachers Report Form (TRF) designed to be filled out by teachers of children ages 5–18, and the Youth SelfReport Form (YSR) designed to be filled out by adolescents ages 11–18. The most common version, the CBCL/6-18, can be used by parents of children and adolescents ages 6–18. Parents rate their child for how true 118 items describing behavioral and emotional problems are for the child now or within the past 6 months. The CBCL/6-18 gives a total score for behavior problems as well as subscores for Internalizing and Externalizing Problems, Social Competence and School Competence. Many studies have found internal consistency reliability coefficients 0.78–0.97, test-retest reliability coefficients 0.95–1.00, interrater reliability coefficients 0.93–0.96, and convergent validity 0.88 with measures of behavior disorders [114,115]. 11.4. The Conners Rating Scales-Revised (CRS-R) The CRS-R is a popular instrument for screening and assessing attention deficit/hyperactivity disorder (ADHD) in children and adolescents ages 3 to 17. The CRS-R is composed of an 80-item parent rating scale, a 59-item teacher rating scale, and an 87-item self-report scale for adolescents. It requires approximately 15–20 minutes to complete. The CRS-R includes scales for seven factors – Oppositional, Cognitive Problems, Hyperactivity-Impulsivity, Anxious/Shy, Perfectionism, Social Problems, and Psychosomatic. A 27-question version that includes Oppositional, Hyperactivity, Cognitive Problems/Inattention and ADHD subscales is also available. Several studies have assessed the psychometrics of the CRS-R, finding internal consistency reliability coefficients of 0.73 to 0.94, test-retest reliability coefficients 0.47–0.85, and convergent validity 0.84–0.96 with measures of ADHD (interrater reliability not reported) [64,116]. 11.5. Rutter Scales The Rutter Scale A2 for completion by parents consists of 31 statements concerning behaviors in children ages 7 to 13. The parent is asked to indicate on a 0 to 2 scale, the frequency of occurrence of a behavior, the degree of its severity, and the extent to which the statement applies to the child. The scale also gives “neurotic” and “antisocial” subscores. A second scale, the Rutter Scale B2, is a similar 26-item question-

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

139

naire for completion by teachers The few validation studies of the Rutter Scale have found test-retest reliability coefficient of 0.89 over two months, interrater reliability coefficient 0.72, and convergent validity 0.43 with interview ratings of psychiatric disorders (internal consistency reliability coefficients not reported) [117]. 11.6. Discussion: Instruments for Assessing Behavioral Disorders Of the behavioral measures reviewed, the Pediatric Emotion Distress Scale (PEDS) is the only one designed for rapid behavioral assessment of young children after trauma; it may be the most appropriate for behavioral assessment in post-disaster settings where testing must be conducted quickly. It is a new instrument, however, with relatively little validation data available which may make it more difficult to compare results to those from other post-emergency assessments. The other scales reviewed, the Revised Behavior Problem Checklist (RBPC), the Child Behavior Checklist (CBCL) and the Conners Parent Rating Scale (CPRS) are excellent instruments that have more extensive bodies of psychometric data behind them. They may be useful for long-term follow-up of traumatized children. However, they do not include specific trauma-related items and may not be appropriate for postemergency assessments. The Rutter Scales are not designed for younger children and have limited validation data available.

12. Discussion There is a tremendous need for systematic assessment of children and adolescents after disasters and emergencies using validated instruments in order to better establish the prevalence and etiology of post-traumatic symptoms and psychopathology, and to more effectively direct resources. An ideal child and adolescent post-emergency assessment battery would include an assessment of traumas suffered and measures for symptoms of multiple disorders i.e. post-traumatic stress disorder (PTSD), depression and anxiety, and an independent assessment of the child’s behavior by an adult. Assessment instruments for disasters and emergencies should be fast and cost-effective to administer, and clinically and psychometrically sound. Shorter instruments are almost always preferable in order to avoid burdening families, aid workers, health care professional as well as the children themselves. When conducting post-emergency assessments, there is generally not a single “best” instrument. Different instruments that are appropriate for different contexts, and even those instruments that are psychometrically sound may have other characteristics that could limit their usefulness in different types of populations or emergencies. Several examples follow: Example When assessing children in a post-conflict or post-disaster setting, an excellent assessment battery could be assembled using the following instruments: 1) an appropriate 10–20 item questionnaire designed for assessing levels of exposure to stressors associated with particular types of disaster i.e. a war, hurricane, or earthquake questionnaire; 2) the 20-item Child PTSD Reaction Index (CPTSD-RI) for assessing symptoms of PTSD; 3) either the 26-item Depression Self-Rating Scale (DSRS) or the 27-item Chil-

140

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

dren’s Depression Inventory (CDI) for assessing symptoms of depression; and 4) the 26-item Multidimensional Anxiety Scale for Children (MASC) for assessing symptoms of anxiety. In addition, the 17-item Pediatric Emotion Distress Scale (PEDS) could be administered at the same time to the children’s parents and/or primary caretakers in order to independently assess trauma-related behaviors. Used together, these instruments would form a battery of approximately 82–92 questions for children and 17 for adults that would be inexpensive, relatively easy to administer in less than one hour, and would provide data that would provide excellent data for directing resources and designing psychosocial relief programs. If time and resources allow, tests designed for specific issues and contexts should also be kept in mind. Examples for several situations follow: For adolescents who have been exposed to war, disaster and refugee contexts, the 40-item long Part IV of the Harvard Trauma Questionnaire (HTQ) and the 25-item Hopkins Symptom Checklist (HSCL-25) can be used as a brief assessment battery to assess PTSD, anxiety, depression and social functioning. The two tests have been used together in emergency contexts and translated into many languages, are inexpensive, simple and fast to administer and score, and have a body of psychometric research to support them. Mental health workers and researchers working in situations where rape, sexual abuse and gender-based violence are issues may want to consider using the Trauma Symptom Checklist for Children (TSCC) or the Revised Children’s Impact of Traumatic Events Scale (CITES-R), as part of an assessment battery. Both assess children’s responses to sexual abuse. In post-emergency child or adolescent populations who may have suffered Traumatic Brain Injury (TBI), Part III of the Harvard Trauma Questionnaire (HTQ) which assesses head injuries could be incorporated into a battery of tests. Children’s fears are an important area to assess in determining children’s postdisaster functioning and in helping them return to normal family and school routines, so if time and resources allow, the Revised Fear Survey for Children (FSSC-R) could be added to assessment batteries in the wake of disasters and emergencies as a way to assess children’s fears. Finally, it should be emphasized that while self-report symptom checklists and questionnaires such as the ones reviewed in this paper are important public health mental health tools and are extremely useful for screening and for epidemiological research, they should not be used as the sole criteria for making clinical decisions. No checklist can replace the role of a mental health professional. However, when properly administered, with awareness of their strengths and limitations, validated behavioral and psychosocial assessment instruments can be essential public health measures to assess the prevalence of psychological distress and behavioral symptoms among children and adolescents during and in the aftermath of disasters and emergencies.

13. Future Research Overall, the kind of program evaluation that is needed to improve screening and assessment of children’s needs in post-conflict and mass casualty environments includes [66]:

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

• • • • • • • •

141

Developing effective methods and instrumentation for conducting rapid needs assessment and collection of triage information within and across specific types of war and terrorism events. Identifying protective factors that moderate and mediate the impact of war and mass casualty events for children and families. Determining how best to integrate needs assessment and public health and mental health surveillance programs within schools. Determining the best training platforms and methods for conducting various stages of post-war and post-terrorism data collection. Adapting instruments that are developmentally, culturally and ecological sound, especially for culturally diverse groups and special needs populations. Documenting the long-term impact of mass casualty events on children and families. Evaluating the ethical acceptability of different methods of conducting data collection among children and adolescents after disaster and terrorism. Determining psychological responses by specific disaster or terrorism agent (biological, chemical, nuclear, conventional or radiological), and by specific sub-type (e.g., Marburg, Anthrax, Ricin, VX), as medical risks and public health strategies vary quite specifically by type of agent.

In the future, post-disaster assessments of children and adolescents would ideally be carried out using comparable methodologies in order to expand the available body of information on pediatric and adolescent trauma in a systematic manner allowing for valid comparisons to be made. In particular, longitudinal studies will be necessary to understand the variability in post-traumatic symptom onset and duration in children and adolescents. Therefore, whenever possible, instruments that allow for one or more follow-up assessments over time should be selected [13,17,18,42,44,118–127]. In addition, data collection in the aftermath of wars and other forms of mass violence can usefully include items that relate to potential mediating or moderating variables. These can include measures of putative vulnerability and resilience factors summarized in Appendix A, Table 6. As a guide to research efforts, several generic etiological theories of posttraumatic stress disorder (PTSD) have been proposed. These theories posit that exposure to trauma leads to acute, and potentially chronic, post-trauma psychological, behavioral, and functional consequences. The theories also propose that the pathways linking trauma exposure to these reactions are mediated and/or moderated by vulnerability and resiliency variables that increase or decrease risk, respectively. To date, supportive evidence for the basic tenets of these theoretical models has been provided by the documentation of dose-response relationships between exposure to objective threat and PTSD symptoms in a wide variety of traumatized child and adolescent populations. However, the child and adolescent PTSD literature indicates that rates of PTSD can be highly variable across trauma-exposed samples, and that the strength of association between trauma exposure and distress may be influenced by psychological and socioenvironmental factors that mediate and/or moderate the exposure-distress relationship. Future studies should also focus on assessing patterns of symptom expression in different contexts and different types of disasters, especially comparing Western diagnostic categories to culture-specific disorders and exploring symptom patterns in different ethnocultural groups with the same diagnoses. Simply translating an instrument into another language does not necessarily mean that the same symptoms or the same

142

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

disorders are being assessed across cultures. Even when language is not an issue, original validation studies of an instrument may not be sufficient to establish cutoff scores in a new setting or population i.e. a test validated in a middle class clinical population may need to be re-validated for use in a non-Western context or in an inner city population exposed to chronic violence. Since nearly all psychological instruments tests are validated in Western, clinical populations, instruments should always be reassessed when they are used in a cultural context different from the one they were initially validated in. The fact that very few instruments have been validated in non-Western populations does not mean that psychological assessment using existing instruments cannot be carried out. Guarnaccia et al.’s (1993) [64] comparison of anxiety and depression disorders with a local disorder “ataques de nervios” in the aftermath of floods in Puerto Rico, and Bolton’s (2001) [62] comparison of depression and a locally recognized grief syndrome “agahinda gakabije” in post-genocide Rwanda are examples of how this can be accomplished. No studies currently exist which directly compare the psychological responses to disaster of children in one culture to those of another, and future research should focus on understanding the impact of cultural factors on responses to disasters and emergencies. The work necessary to validate assessment instruments in nonWestern populations, (i.e. comparing indigenous psychiatric diagnoses with Western ones and finding appropriate control groups of non-traumatized children and adolescents), will be crucial to understanding the impact of social and cultural factors in identifying factors that promote recovery and resiliency in the aftermath of mass trauma [8,14,42,52].1

References [1] Shaw, J.A. (2003). Children exposed to war/terrorism. Clinical Child Family Psychology Review, 6, 237–246. 1 In addition to conceptual issues, a number of bureaucratic and logistical barriers have also emerged in efforts to collect needs assessment, surveillance, and screening data on children and adolescents. Given that assessment activities are ideally conducted within school settings, a common set of administrative, logistical, ethical and clinical obstacles have been consistently encountered. These include:

• School administration resistance to conducting classroom assessments (“The students have already lost too much time;” “This will disturb the classroom milieu and disrupt our recovery;” “We are afraid of being sued and don’t want to do anything controversial”). • Difficulties in obtaining informed consent from parents and assent from children (active vs. passive consent) • Logistical difficulties (getting enough time to conduct the screening) • Ethical concerns about retraumatization • Governmental regulations concerning confidentiality • Student refusal/avoidance, underreporting, overreporting • Risk of stigmatizing students (removing them from the classroom for in-depth assessment, treatment) • Traumatic avoidance within the school and the larger community (“If the kids don’t talk about it, it’s not affecting them”) • Clinical and ethical concerns relating to having trained and supervised personnel available to handle emotional reactions to the assessment • Ethical concerns regarding an obligation to provide appropriate intervention for individuals identified as being at high risk (e.g., suicide, abuse within the family, etc.) when resources available for providing treatments are limited • Issues regarding coordination of competing or complementary data collection and research activities in regard to overburdening affected populations in the aftermath of mass casualty events.

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

143

[2] Norris, F.H., Friedman, M.J., Watson, P.J., Byrne, C.M., Diaz, E., Kaniasty, K. (2002). 60,000 disaster victims speak. Part I: An empirical review of the empirical literature 1981–2001. Psychiatry, 65:207–239. [3] La Greca, A.M, Silverman, W.K., Vernberg, E.M., Roberts M.C. (Eds). Helping children cope with disasters and terrorism. Washington, DC: American Psychological Association. [4] National Advisory Committee on Children and Terrorism. (2003). Recommendations to the Secretary. [5] National Pediatric Disaster Preparedness and Response Consensus Meeting (2003) Report. [6] Pfefferbaum, B. (1997). Posttraumatic stress disorder in children: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36(11):1503–1511. [7] Pynoos, R.S., Steinberg, A.M., Goenjian, A.K. (1996). Traumatic stress in childhood and adolescence: Recent developments and current controversies. In Van der Kolk, B.A., McFarlane, A.C., Weisaeth, L. (Eds.). Traumatic stress: The effects of overwhelming experience on mind, body, and society. (pp. 331–358). New York: Guilford Press. [8] Yule, W. (2001). Posttraumatic stress disorder in the general population and in children. Journal of Clinical Psychiatry, 62(17):23–28. [9] Yule, W. (2000). From pogroms to “ethnic cleansing”: Meeting the needs of war affected children. Journal of Child Psychology & Psychiatry & Allied Disciplines, 41(6):695–702. [10] Hoven, C.W., Duarte, C.S., Lucas, C.P., Wu, P., Mandell, D.J., Goodwin, R.D., Cohen, M., Balaban, V., Woodruff, B.A., Bin, F., Musa, G.J., Mei, L., Cantor, P.A., Aber, J.L., Cohen, P., & Susser, E. (2005). Psychopathology among New York city public school children 6 months after September 11. Archives of General Psychiatry, 62, 545–552. [11] Pfefferbaum, B., Nixon, S.J., Krug, R.S., Tivis, R.D., Moore, V.L., Brown, J.M., Pynoos, R.S., Foy, D., Gurwitch, R.H. (1999). Clinical needs assessment of middle and high school students following the 1995 Oklahoma City bombing. American Journal of Psychiatry, 156:1069–1074. [12] Kinzie, J.D., Boehnlein, J., Sack, W.H. (1998). The effects of massive trauma on Cambodian parents and children. In Danieli, Y. (Ed.). Interternational handbook of multigenerational legacies of trauma. The Plenum series on stress and coping (pp. 211–222). New York, NY. [13] Savin, D., Sack, W.H., Clarke, G.N., Meas, N., Richart, I. (1996). The Khmer Adolescent Project: III. A study of trauma from Thailand’s Site II refugee camp. Journal of the American Academy of Child & Adolescent Psychiatry, 35(3):384–391. [14] Mollica, R.F. Poole, C., Son, L., Murray, C.C., Tor, S. (1997). Effects of war trauma on Cambodian refugee adolescents’ functional health and mental health status. Journal of the American Academy of Child & Adolescent Psychiatry, 36(8):1098–1106. [15] Pynoos, R.S., Goenjian, A., Tashjian, M., Karakashian, M., Manjikian, R., Manoukian, G., Steinberg, A.M., Fairbanks, L.A. (1993). Post-traumatic stress reactions in children after the 1988 Armenian earthquake. British Journal of Psychiatry, 163:239–247. [16] Goenjian, A.K., Pynoos, R.S., Steinberg, A.M., Najarian LM., Asarnow JR., Karayan I., Ghurabi M., Fairbanks L.A. (1995). Psychiatric comorbidity in children after the 1988 earthquake in Armenia. Journal of the American Academy of Child and Adolescent Psychiatry, 34(9):1174–1184. [17] Laor, N., Wolmer, L., Mayes, L.C., Gershon, A., Weizman, R., Cohen, D.J. (1997). Israeli preschool children under Scuds: a 30-month follow-up. Journal of the American Academy of Child & Adolescent Psychiatry, 36(3):349–356. [18] Laor, N., Wolmer, L., Cohen, D.J. (2001). Mothers’ functioning and children’s symptoms 5 years after a SCUD missile attack. American Journal of Psychiatry, 158(7):1020–1026. [19] Saigh, P.A., Fairbank, J.A., Yasik, A.E. (1998). War-related posttraumatic stress disorder among children and adolescents. In Miller, T.W. (Ed.). Children of trauma: Stressful life events and their effects on children and adolescents. (pp. 119–140). International Universities Press Stress and Health Series, Monograph 8. [20] Saigh, P.A., Yasik, A.E., Sack, W.H., Koplewicz, H.S. (1999). Child-adolescent posttraumatic stress disorder: Prevalence, risk factors, and comorbidity. In Saigh, P.A., Bremner, J.D. (Eds.). Posttraumatic stress disorder: A comprehensive text. (pp. 18–43). Needham Heights, MA, US: Allyn & Bacon. [21] Stein, B.D., Jaycox, L.H., Kataoka, S.H., Wong, M., Tu, W., Elliot, M.N., Fink, A. (2003). A mental health intervention for schoolchildren exposed to violence: A randomized controlled trial. Journal of the American Medical Association, 290:603–611. [22] Saltzman, W.R., Pynoos, R.S., Layne, C.M., Steinberg, A.M., Aisenberg, E. (2001). Trauma- and grief-focused intervention for adolescents exposed to community violence: Results of a school-based screening and group treatment protocol. Group Dynamics: Theory, Research and Practice, 5: 291–303.

144

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

[23] Shalev, A.Y., Freedman, S., Peri, T., Brandes, D., Sahar, T., Orr, S.P., Pitman, R.K. (1998). Prospective study of posttraumatic stress disorder and depression following trauma. American Journal of Psychiatry, 155(5):630–637. [24] Myers, K., Winters, N.C. (2002a). Ten-year review of rating scales. I. Overview of scale functioning, psychometric properties, and selection. Journal of the American Academy of Child & Adolescent Psychiatry, 41(2):114–122. [25] Mollica, R.F., Cui, X., Mcinnes, K., Massagli, M.P. (2002). Science-based policy for psychosocial interventions in refugee camps: A Cambodian example. Journal of Nervous and Mental Disease, 190:158–166. [26] Pynoos, R.S., Goenjian, A.K., Steinberg, A.M. (1998). A public mental health approach to the postdisaster treatment of children and adolescents. Child & Adolescent Psychiatric Clinics of North America, 7(1):195–210. [27] Saylor, C., DeRoma, V. (2002). Assessment of children and adolescents exposed to disaster. In La Greca, A.M, Silverman, W.K., Vernberg, E.M., Roberts, M.C. (Eds.). Helping Children Cope with Disasters and Terrorism. (pp. 35–53). Washington, DC: American Psychological Association. [28] Myers, K., Winters, N.C. (2002b). Ten-year review of rating scales. II. Scales for internalizing disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 41(6):634–659. [29] Chimienti, G., Nasr, J.A., Khalifeh, I. (1989). Children’s reactions to war-related stress: Affective symptoms and behaviour problems. Social Psychiatry & Psychiatric Epidemiology, 24(6):282–287. [30] Kuterovac, G., Dyregrov, A., Stuvland R. (1994) Children in war: a silent majority under stress. British Journal of Medical Psychology, 67(4):363–375. [31] Macksoud, M.S. (1992). Assessing war trauma in children: A case study of Lebanese children. Journal of Refugee Studies, 5:1–15. [32] Mghir, R., Freed, W., Raskin, A., Katon, W. (1995). Depression and posttraumatic stress disorder among a community sample of adolescent and young adult Afghan refugees. Journal of Nervous and Mental Disease, 183:24–30. [33] Nader, K.O., Pynoos, R.S., Fairbanks, L.A., al-Ajeel M., al-Asfour, A. (1993). A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis. British Journal of Clinical Psychology, 32(4):407–416. [34] Papageorgiou, V., Frangou-Garunovic, A., Iordanidou, R., Yule, W., Smith, P., Vostanis, P. (2000). War trauma and psychopathology in Bosnian refugee children. European Child & Adolescent Psychiatry, 9(2):84–90. [35] Pynoos, R.S., Nader, K. (1988). Children who witness the sexual assaults of their mothers. Journal of the American Academy of Child & Adolescent Psychiatry, 27(5):567–572. [36] Smith, P., Perrin, S., Yule, W., Rabe-Hesketh, S. (2001). War exposure and maternal reactions in the psychological adjustment of children from Bosnia-Hercegovina. Journal of Child Psychology & Psychiatry & Allied Disciplines, 42(3):395–404. [37] Yule, W., Bolton, D., Udwin, O., Boyle, S., O’Ryan, D., Nurrish, J. (2000). The long-term psychological effects of a disaster experienced in adolescence: I: The incidence and course of PTSD. Journal of Child Psychology & Psychiatry & Allied Disciplines, 41(4):503–511. [38] Goenjian A.K., Molina L., Steinberg A.M., Fairbanks L.A., Alvarez M.L., Goenjian H.A., Pynoos R.S. (2001). Posttraumatic stress and depressive reactions among Nicaraguan adolescents after hurricane Mitch. American Journal of Psychiatry, 158, 788–794. [39] Roussos, A., Goenjian, A.K., Steinberg, A.M., Sotiropoulou, C., Kakaki, M., Kabakos, C. (In press) Posttraumatic Stress and Depressive Reactions after the 1999 Ano Liosia Earthquake in Greece. American Journal of Psychiatry. [40] Layne, C.M., Steinberg, A., Savjak, M., Pynoos, R.S. (1998). Grief Screening Scale. Unpublished psychological test, University of California, Los Angeles. [41] Berman, H. (2001). Children and war: current understandings and future directions. Public Health Nursing, 18(4):243–252. [42] Sack, W.H., McSharry, S., Clarke, G.N., Kinney, R., Seeley, J., Lewinsohn, P. (1994). The Khmer Adolescent Project. I. Epidemiologic findings in two generations of Cambodian refugees. Journal of Nervous & Mental Disease, 182(7):387–395. [43] Weissman, M.M., Wolk, S., Goldstein, R.B., Moreau, D., Adams, P., Greenwald, S., Klier, C.M., Ryan, N.D., Dahl, R.E. Wickramaratne, P. (1999). Depressed adolescents grown up. Journal of the American Medical Association, 281:1701–1713. [44] Yule, W. (1999). Post-traumatic stress disorder. Archives of Disease in Childhood, 80(2):107–109. [45] Achenbach, T.M., McConaughy, S.H., Howell, C.T. (1987). Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity. Psychological Bulletin, 101:213–232.

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

145

[46] Bird, H., Gould, M., Staghezza, B. (1992). Aggregating data from multiple informants in child psychiatry epidemiological research. Journal of the American Academy of Child and Adolescent Psychiatry, 31:78–85. [47] Jensen, P.S., Rubio-Stipec, M., Canino, G., Bird, H.R., Dulcan, M.K., Schwab-Stone, M.E., Lahey, B.B. (1999). Parent and Child Contributions to Diagnosis of Mental Disorder: Are Both Informants Always Necessary? Journal of American Academy of Child & Adolescent Psychiatry, 38(12):1569–1579. [48] Loeber, R., Green, S.M., Lahey, B.B., Stouthamer-Loeber, M. (1991). Differences and similarities between children, mothers, and teachers as informants on disruptive child behavior. Journal of Abnormal Child Psychology, 19(1):75–95. [49] Boyle, M.H., Pickles A. (1997). Maternal depressive symptoms and ratings of emotional disorder symptoms in children and adolescents. Journal of Child Psychology & Psychiatry & Allied Disciplines, 38(8):981–992. [50] Bryce, J., Walker, N., Ghorayeb, F., Kanji, M. (1989). Life Experiences, Response Styles and Mental Health among Mothers and children in Beirut, Lebanon. Social Science and Medicine, 7:685–695. [51] Dawes, A., Tredoux, C., Feinstein, A. (1989). Political Violence in South Africa: some effects on children of the violent destruction of their community. International Journal of Mental Health, 18: 16–43. [52] Green, B.L., Korol, M., Grace, M.C., Vary M.G., Leonard A.C., Gleser G.C., Smitson-Cohen S. (1991). Children and disaster: Age, gender, and parental effects on PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 30:945–951. [53] Ahmad, A., Sofi, M.A., Sundelin-Wahlsten, V., von Knorring, A.L. (2000). Posttraumatic stress disorder in children after the military operation “Anfal” in Iraqi Kurdistan. European Child & Adolescent Psychiatry, 9(4):235–243. [54] McFarlane, A.C., Policansky, S.K., Irwin, C. (1987). A longitudinal study of the psychological morbidity in children due to a natural disaster. Psychological Medicine, 17(3):727–738. [55] Jones, L., Kafetsios, K. (2002). Assessing adolescent mental health in war-affected societies: The significance of symptoms. Child Abuse & Neglect, 26(10):1059–1080. [56] Terr, L. (1983). Chowchilla Revisited: The Effects of Psychic Trauma Four Years after a Schoolbus Kidnapping. American Journal of Psychiatry, 140:1543–1550. [57] Kerig, P.K. (2000). Assessment and intervention for PTSD in children exposed to violence. Journal of Aggression, Maltreatment & Trauma, 3(1):161–184. [58] Shannon, M.P., Lonigan, C.J., Finch, A.J., Taylor, C.M. (1994). Children exposed to disaster: I. Epidemiology of post-traumatic symptoms and symptom profiles. Journal of the American Academy of Child & Adolescent Psychiatry, 33(1):80–93. [59] Gurwitch, R.H., Sullivan, M.A., Long, P. (1998). The impact of trauma and disaster on young children. Psychiatric Clinics of North America, 7:19–32. [60] Caffo, E., Belaise, C. (2003). Psychological aspects of traumatic injury in children and adolescents. Child & Adolescent Psychiatric Clinics of North America, 12:493–535. [61] Bird, H.R. (1996). Epidemiology of childhood disorders in a cross-cultural context. Journal of Child Psychology & Psychiatry & Allied Disciplines, 37(1):35–49. [62] Bolton, P. (2001) Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. Journal of Nervous & Mental Disease, 189(4):238–242. [63] Guarnaccia, P.J. (1993). Ataques de nervios in Puerto Rico: culture-bound syndrome or popular illness? Medical Anthropology, 15(2):157–170. [64] Hinshaw, S.P., Nigg, J.T. (1999). Behavior rating scales in the assessment of disruptive behavior disorders in childhood. In Shaffer, D., Lucas, C., Richters, J.E. (Eds.). Assessment in child and adolescent psychopathology. (pp. 91–126). New York: Guilford. [65] Kleinman, A., Good, B. (1986). Culture and Depression: Studies in Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. Los Angeles: University of California Press. [66] Pynoos, R.S., Steinberg, A.M., Schreiber, M.D., Brymer, M. (In press) Children and families: A new framework for preparedness and response to danger, terrorism and trauma. In Schein, L.A., Spitz, H.I., Burlingame, G.M., Mushkin, P.R. (Eds.). Group approaches for the psychological effects of terrorist disasters. New York: Haworth Press. [67] Steinberg, A.M., Brymer, M., Decker, K., Pynoos, R.S. (2004). The UCLA PTSD Reaction Index. Current Psychiatry Reports, 6:96–100. [68] Eth, S., Silverstein, S., Pynoos R.S. (1985). Mental health consultation to a preschool following the murder of a mother and child. Hospital & Community Psychiatry, 36(1):73–76. [69] Scheeringa, M.S., Zeanah, C.H., Drell, M.J., Larrieu, J.A. (1995). Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood. Journal of the American Academy of Child & Adolescent Psychiatry, 34(2):191–200.

146

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

[70] Ohan, J., Myers K., Collett, B. (2002). Ten-year review of rating scales. IV: Scales assessing trauma and its effects. Journal of the American Academy of Child & Adolescent Psychiatry, 41(12): 1401–1422. [71] Pynoos, R.S., Frederick, C., Nader, K., Arroyo, W., Steinberg, A.M., Eth, S., Nunez, F., Fairbanks, L. (1987). Life threat and posttraumatic stress in school-age children. Archives of General Psychiatry, 44(12):1057–1063. [72] Mollica, R.F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S., Lavelle, J. (1992). The Harvard Trauma Questionnaire: Validating a Cross-Cultural Instrument for Measuring Torture, Trauma and Posttraumatic Stress Disorder in Indochinese Refugees. Journal of Nervous and Mental Disease; 180:111–116. [73] Mollica, R.F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S., Lavelle, J. (1996). Harvard Trauma Questionnaire: Brief summary of its development, statistical properties, use, and scoring. In Goldfeld, N., Pine, M., Pine, J. (Eds.) Measuring and Managing Health Care Quality: Procedures, Techniques, and Protocols, Volume 1. Gaithersburg, MD: Aspen Publishers. [74] Goldin, S., Levin, L., Ake Persson, L., Haeggloef, B. (2003). Child war trauma: A comparison of clinician, parent and child assessments. Nordic Journal of Psychiatry, 57(3):173–183. [75] Sundelin, W.V., Ahmad, A., von Knorring, A.L. (2001). Traumatic experiences and posttraumatic stress reactions in children and their parents from Kurdistan and Sweden. Nordic Journal of Psychiatry, 55(6):395–400. [76] Mghir, R., Raskin, A. (1999). The psychological effects of the war in Afghanistan on young Afghan refugees from different ethnic backgrounds. International Journal of Social Psychiatry, 45(1):29–36. [77] Cladera, T., Palma, L., Penayo, U., Kullgren, G. (2001). Psychological impact of the hurricane Mitch in Nicaragua in a one-year perspective. Social Psychiatry & Psychiatric Epidemiology, 36(3): 108–114. [78] Dyregrov, A., Yule, W. (1995). Screening measures: The development of the UNICEF screening battery. Presented at the annual meeting of the International Society of Traumatic Stress Studies, Boston, MA. [79] Horowitz, M., Wilner, N., Alvarez, W. (1979). Impact of Event Scale: A measure of subjective stress. Psychosomatic Medicine, 41:209–218. [80] Weiss, D., Marmar, C. (1997). The Impact of Event Scale -Revised. In Wilson, J., Keane, T. (Eds.). Assessing psychological trauma and PTSD. (pp. 399–411). New York: Guildford. [81] Briere, J. (1997). Psychological Assessment of Adult Posttraumatic States. Washington, D.C.: American Psychological Association. [82] Ahmad, A., Sundelin-Wahlsten, V., Sofi, M.A., Qahar, J.A., von Knorring, A.L. (2000). Reliability and validity of a child-specific cross-cultural instrument for assessing posttraumatic stress disorder. European Child & Adolescent Psychiatry, 9(4):285–294. [83] Foa, E.B., Cashman, L., Jaycox, L., Perry, K. (1997) The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale. Psychological Assessment, 9:445–451. [84] Briere, J. (1996). Trauma Symptom Checklist for Children: Professional Manual. Florida: Psychological Assessment Resources Inc. [85] Birmaher, B., Brent, D.A., Benson, R.S. (1998). Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 37(11):1234–1238. [86] Ryan, N.D., Puig-Antich, J., Ambrosini, P., Rabinovich, H., Robinson, D., Nelson, B., Iyengar, S., Twomey, J. (1987). The clinical picture of major depression in children and adolescents. Archives of General Psychiatry; 44:854–861. [87] Kovacs, M. (1981). Rating scales to assess depression in school-aged children. Acta Paedopsychiatrica, 46:304–315. [88] Kovacs, M. (1992). Children’s Depression Inventory. Canada: Multi-Health Systems. [89] Silverman, W.K., Rabian, B. (1999). Rating scales for anxiety and mood disorders. In Shaffer, D., Lucas, C., Richters, J. (Eds.). Diagnostic assessment in child and adolescent psychopathology. (pp. 127–166). New York: Guilford Press. [90] Asarnow, J.R., Carlson, G.A. (1985). Depression Self-Rating Scale: utility with child psychiatric inpatients. Journal of Consulting & Clinical Psychology, 53(4):491–499. [91] Birleson, P. (1981). The validity of depressive disorder in childhood and the development of a rating scale: A research report. Journal of Child Psychology and Psychiatry, 22:73–78. [92] Birleson, P., Hudson, I., Buchanan, D.G., Wolff, S. (1987). Clinical evaluation of a self-rating scale for depressive disorder in childhood (Depression Self-Rating Scale). Journal of Child Psychology & Psychiatry & Allied Disciplines, 28(1):43–60.

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

147

[93] Derogatis, L.R., Savitz, K.L. (1999). The SCL-90-R, Brief Symptom Inventory, and Matching Clinical Rating Scales. In Maruish, M.E. (Ed). (1999). The use of psychological testing for treatment planning and outcomes assessment (2nd ed.). (pp. 679–724). Mahwah, NJ: Lawrence Erlbaum Associates. [94] Derogatis, L.R., Lipman, R.S., Rickels, K., Uhlenhuth, E.H., Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19(1):1–15. [95] Van Ommeren, M., Sharma, B., Sharma, G.K., Komproe, I., Cardena, E., de Jong, J.T.V.M. (2002). The relationship between somatic and PTSD symptoms among Bhutanese refugee torture survivors: Examination of comorbidity with anxiety and depression. Journal of Traumatic Stress, 15:415–421. [96] Bolton, P., Neugebauer, R., Ndogoni, L. (2002). Prevalence of depression in rural Rwanda based on symptom and functional criteria. Journal of Nervous and Mental Disease, 190:631–637. [97] Carlson, E.B., Rosser-Hogan, R. (1994). Cross-cultural response to trauma: A study of traumatic experiences and posttraumatic symptoms in Cambodian refugees. Journal of Traumatic Stress, 7:43–58. [98] Mollica, R.F., Sarajlic, N., Chernoff, M., Lavelle, J., Vukovic, I.S., Massagli, M.P. (2001). Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. Journal of the American Medical Association, 286(5):546–554. [99] Silove, D., Steel, Z., McGorry, P., Mohan, P. (1998). Trauma exposure, postmigration stressors, and symptoms of anxiety, depression and post-traumatic stress in Tamil asylum-seekers: Comparison with refugees and immigrants. Acta Psychiatrica Scandinavica, 97:175–181. [100] Shapiro, J., Douglas, K., de la Rocha, O., Radecki, S., Vu, C., Dinh, T. (1999). Generational differences in psychosocial adaptation and predictors of psychological distress in a population of recent Vietnamese immigrants. Journal of Community Health, 24:95–113. [101] Gorst-Unsworth, C., Goldenberg, E. (1998). Psychological sequelae of torture and organised violence suffered by refugees from Iraq: Trauma-related factors compared with social factors in exile. British Journal of Psychiatry, 172:90–94. [102] Montgomery, L.E., Finch, A.J. (1974). Validity of two measures of anxiety in children. Journal of Abnormal Child Psychology, 2:293–297. [103] Reynolds, C.R., Richmond, B.O. (1985). Revised Children’s Manifest Anxiety Scale. [104] Wolpe, J., Lang, P.J. (1964). A fear schedule for use in behaviour therapy. Behaviour Research and Therapy, 2:27–30. [105] Scherer, M., Nakamura, C. (1968). A fear survey schedule for children (FSS-FC): A factor analytic comparison with manifest anxiety (CMAS). Behavioral Research Therapy, 6:173–182. [106] Ollendick, T.H. (1983). Reliability and validity of the Revised Fear Survey Schedule for Children (FSSC-R). Behaviour Research & Therapy, 21(6):685–692. [107] March, J., Parker, J. (1999). The Multidimensional Anxiety Scale for Children (MASC). In Maruish, M.E. (Ed.). The Use of Psychological Testing for Treatment Planning and Outcome Assessment (2nd ed.). (pp. 299–322). Mahwah, NJ: Lawrence Erlbaum Associates. [108] Spielberger, C.D., Gorsuch, R.L., Lushene, R.E. (1968). The StateTrait Anxiety Inventory: preliminary test manual. Tallahassee, FL: Florida State University Psychology Department. [109] Halgin, R.P., Whitbourne, S.K. (1994). Abnormal Psychology: The human experience of psychological disorders. Harcourt Brace & Co, Orlando, Fl. [110] Saylor, C.F., Swenson, C.C., Reynolds, S.S., Taylor, M. (1999). The pediatric emotional distress scale: A brief screening measure for young children exposed to traumatic events. Journal of Clinical Child Psychology, 28(1):70–81. [111] Page, T.F., Nooe, R.M. (1999). Relationships between psychosocial risks and stress in homeless children. Journal of Social Distress Homeless, 8:255–267. [112] Quay, H.C., Peterson, D.R. (1979). Manual of the Behavior Problem Checklist (unpublished). [113] Quay, H., Peterson, D. (1983). Quay-Peterson Revised Behavior Problem Checklist. Miami, FL: University of Miami. [114] Achenbach, T.M. (1999). The Child Behavior Checklist and related instruments. In Maruish, M.E. (Ed.). The use of psychological testing for treatment planning and outcomes assessment (2nd ed.). (pp. 429–466). Mahwah, NJ: Lawrence Erlbaum Associates. [115] Achenbach, T.M. & Edelbrock, C.S. (1985). Manual for the Revised Child Behavior Checklist and Profile. Burlington, VT: University Associates in Psychiatry. [116] Conners, C.K., Sitarenios, G., Parker, J.D., Epstein, J.N. (1998). Revision and restandardization of the Conners Teacher Rating Scale (CTRS-R): factor structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26(4):279–291. [117] Rutter, M. (1967). A children’s behavior questionnaire for completion by teachers: Preliminary findings. Journal of Child Psychology and Psychiatry, 8:1–11. [118] Kinzie, J.D., Sack, W.H., Angell, R.H., Manson, S., Rath, B. (1986). The psychiatric effects of massive trauma on Cambodian children, I: the children. Journal of the American Academy of Child and Adolescent Psychiatry, 25(11):370–376.

148

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

[119] Sack, W.H., Angell, R.H., Kinzie, J.D., Rath, B. (1986). The psychiatric effects of massive trauma on Cambodian children, II: The family, the home and the school. Journal of the American Academy of Child and Adolescent Psychiatry, 25(11):377–383. [120] Sack, W.H., Him, C., Dickason, D. (1999). Twelve-year follow-up study of Khmer youths who suffered massive war trauma as children. Journal of the American Academy of Child & Adolescent Psychiatry, 38(9):1173–1179. [121] Schwarzwald, J., Weisenberg, M., Waysman, M., Solomon, Z., Klingman, A. (1993). Stress reaction of school-age children to the bombardment by SCUD missiles. Journal of Abnormal Psychology, 102(3):404–410. [122] Schwarzwald, J., Weisenberg, M., Solomon, Z., Waysman, M. (1994). Stress reactions of school-age children to the bombardment by Scud missiles: A 1-year follow-up. Journal of Traumatic Stress, 7(4):657–667. [123] Thabet, A.A., Vostanis, P. (1999). Post-traumatic stress reactions in children of war. Journal of Child Psychology & Psychiatry & Allied Disciplines, 40(3):385–391. [124] Thabet, A.A., Vostanis, P. (2000). Post traumatic stress disorder reactions in children of war: A longitudinal study. Child Abuse & Neglect, 24(2):291–298. [125] Yule, W., Udwin, O., Murdoch, K. (1990). The ‘Jupiter’ sinking: Effects on children’s fears, depression and anxiety. Journal of Child Psychology & Psychiatry & Allied Disciplines, 31(7):1051–1061. [126] Yule, W., Udwin, O. (1991). Screening child survivors for post-traumatic stress disorders: Experiences from the ‘Jupiter’ sinking. British Journal of Clinical Psychology, 30(2):131–138. [127] Yule, W. (1992). Post-traumatic stress disorder in child survivors of shipping disasters: The sinking of the ‘Jupiter’. Psychotherapy & Psychosomatics, 57(4):200–205. [128] Azarian, A.G., Miller, T.W., Skripchenko-Gregorian, V. (1996). Baseline assessment of children traumatized by the Armenian earthquake. [129] Milgram, N.A. & Toubiana, Y.H. (1996). Children’s selective coping after a bus diasaster: Confronting behavior and perceived support. Journal of Traumatic Stress, 9, 687–702. [130] Cheever, K.H. & Hardin, S.B. (1999). Effects of traumatic events, social support, and self-efficacy on adolescents’ self-health assessments. Western Journal of Nursing Research, 21, 673–684. [131] Mollica, R.F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S. & Lavelle, J. (1992). The Harvard Trauma Questionairre: Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. Journal of Nervous and Mental Disease, 180, 111–116. [132] Vernberg, E.M., La Greca, A.M., Silverman, W.K., Prinstein, M.J. (1996). Prediction of posttraumatic stress disorder symptoms in children after Hurricane Andrew. Journal of Abnormal Psychology, 105, 237–248. [133] Anthony, J.L., Lonigan, C.J. & Hecht, S.A. (1999). Dimensionality of posttraumatic stress disorder symptoms in children exposed to disaster: results from confirmatory factor analyses. Journal of Abnormal Psychology, 108, 326–336. [134] Carr, V.J., Lewin, T.J., Webster, R.A., Hazell, P.L., Kenardy, J.A., Carter, Gregory L. (1995). Psychological sequelae of the 1989 Newcastle earthquake: I. Community disaster experiences and psychological morbidity 6 months post-disaster. Psychological Medicine, 25, 539–555. [135] Jones, R.T., Ribbe, D.P., Cunningham, P.B. (1994). Psychosocial correlates of fire disaster among children and adolescents. Journal of Traumatic Stress, 7, 117–122. [136] Nader, K., Pynoos, R., Fairbanks, L., Frederick, C. (1990). Children’s PTSD reactions one year after a sniper attack at their school. American Journal of Psychiatry, 147(11):1526–1530. [137] Realmuto, G.M., Bernstein, G.A., Maglothin, M.A. & Pandey, R.S. (1992). Patterns of utilization of outpatient mental health services by children and adolescents. Hospital Community Psychiatry, 43, 1218–1223. [138] Vernberg, E.M., Silverman, W.K. LaGreca, A.M. & Prinstein, M.J. (1996) Prediction of posttraumatic stress symptoms in children after hurricane Andrew. Journal of Abnormal Psychology, 105, 237–248. [139] Macksoud, M.S. & Aber, J.L. (1996). The war experiences and psychosocial development of children in Lebanon. Child Development, 67, 70–88. [140] Arsanow, J.R. & Carlson, G.A. (1985). Depression Self-Rating Scale: utility with child psychiatric inpatients. Journal of Consulting and Clinical Psychology, 53, 491–499. [141] Chemtob, C.M., Nakashima, J., Carlson, J.G. (2002). Brief treatment for elementary school children with disaster-related posttraumatic stress disorder: a field study. Journal of Clinical Psychology, 58(1):99–112. [142] Vila, G., Witkowski, P., Tondini, M.C., Perez-Diaz, F., Mouren-Simeoni, M.C., Jouvent, R. (2001). A study of posttraumatic disorders in children who experienced an industrial disaster in the Briey region. European Child & Adolescent Psychiatry, 10(1):10–18.

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

149

[143] Foa, E.B. Johnson, K.M., Feeny, N.C., & Treadwell, K.R. (2001). The child PTSD Symptom Scale: a preliminary examination of its psychometric properties. Journal of Clinical Child Psychology, 30, 376–384. [144] Saigh, P.A. (1989). A comparative analysis of the affective and behavioral symptomology of traumatized and nontraumatized children. Journal of School Psychology, 27(3):247–255. [145] Najarian, L.M., Goenjian, A.K., Pelcovitz, D., Mandel, F., Najarian, B. (1996). Relocation after a disaster: Posttraumatic stress disorder in Armenia after the earthquake. Journal of the American Academy of Child and Adolescent Psychiatry, 35(2):374–383. [146] Kristal, L. (1978). Bruxism: An anxiety response to environmental stress. In C.D. Spielberger & I.G. Sarason (Eds.) Stress and anxiety. (pp. 45–58) New York: Wiley. [147] Handford, H.A. Mayes, S.D. Mattison, R.E., Humphrey, F.J. Bagnato, S., & Bixler, E.O. (1986). Child and parent reaction to the Three Mile Island nuclear accident. Journal of the American Academy of Child and Adolescent Psychiatry, 25, 346–356. [148] Lonigan, C.J., Shannon, M.P., Taylor, C.M., Finch, A.J., Sallee, F.R. (1994). Children exposed to disaster: II. Risk factors for the development of post-traumatic symptomatology. Journal of the American Academy of Child and Adolescent Psychiatry, 33:94–105. [149] Saigh, P.A. (1985). An experimental analysis of chronic posttraumatic stress among adolescents. Journal of Genetic Psychology, 146(1):125–131. [150] Stokes, S.J., Saylor, C.F., Swenson, C.C., Daugherty, T.K. (1995). A comparison of children’s behaviors following three types of stressors. Child Psychiatry & Human Development, 26(2):113–123.

150

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

Appendix A. Tables Table 1. Examples of Stressor Exposure Instruments.

Type of Trauma General

Instruments

Ages cited

Method

Trauma Severity Scale [28]

13–48 months

Observation

Number of Items NR

Child Fernald Mental Experience Questionnaire [52] Personal Loss Scale [129] A Lifestyle Disruption Measure [130]

7–15 years

Self-report

13

13 years

Interview

1

13–17 years

Self-report

5

War/ Displacement

Harvard Trauma Questionnaire (Part I) [131]

Adult/Adolescent

Self-Report

46–82

Hurricane

Hurricane Exposure Instrument [1] Hurricane Related Traumatic Experiences [132] Hurricane Exposure Measure [133]

6–11 years

Self-Report

17

9–15 years

Self-Report

26

9–19 years

Self-report/ observation

NR

Earthquake

Earthquake Impact Survey [134]

Adult/adolescent

Fire

Fire Questionnaire – Child [135]

7–18 years

NR

Self-report

NR

Table 2. Child and adolescent post-disaster studies of PTSD.

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

151

152

Table 2. (Continued.)

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

Table 2. (Continued.)

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

153

154

Table 3. Child and adolescent post-disaster studies of Depression.

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

Table 3. (Continued.)

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

Table 4. Child and adolescent post-disaster studies of Anxiety Disorders.

155

156

Table 4. (Continued.)

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

Table 4. (Continued.)

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

Table 5. Child and adolescent post-disaster studies using Behavioral Measures.

157

158

Table 5. (Continued.)

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

Table 5. (Continued.)

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

159

160

Table 6. Putative Vulnerability and Resilience Factors to be Incorporated into Future Research.

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

V.F. Balaban et al. / Screening and Assessment for Children’s Psychosocial Needs

Appendix B Other Selected Child and Adolescent Post-Disaster/Mass Violence Scales DSM-IV PTSD Children’s PTSD Inventory (CPTSD-I) Clinician Administered PTSD Scale for Children and Adolescents for the DSMIV (CAPS-CA) My Worst Experience Scale (MWES) Schedule for Affective Disorders and Schizophrenia for School-Age ChildrenPresent and Lifetime Version (K-SADS-PL) Diagnostic Interview Schedule Diagnostic Interview for Children and Adolescents Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) TRAUMA HISTORY Childhood Trauma Questionnaire (CTQ) Childhood Trauma Interview (CTI) Assessing Environments Scale (AEIII) History of Victimization Form (HVF) Children’s Report of Exposure to Violence (CREV) Traumatic Event Screening Inventory (TESI) Adolescent-Family Inventory of Life Events and Changes (A-FILE) COMPLEX POST-TRAUMATIC STRESS DISORDER Structured Interview for Disorders of Extreme Stress (SIDES) Child Dissociative Checklist (CDC) Adolescent Dissociative Experience Survey (A-DES) Children’s Perceptual Alteration Scale (CPAS) SOMATIZATION Children’s Somatization Inventory (CSI) Satisfaction With Life Scale (SWLS) COGNITIVE PROCESSING OF TRAUMA Children’s attributions and perceptions scale (CAPS) Children’s Perceptions of Interparental Conflict Scale (CPICS) COPING Response to Stress Questionnaire (RSQ)

161

This page intentionally left blank

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

163

Psychological Impact of Military Violence on Children as a Function of Distance from Traumatic Event: The Palestinian Case Ahmad M. BAKER, Ed.D. a,1 and Hana M. KANAN, Ed.D.B b a Qatar University, Doha, Qatar b Qatar Academy, Doha Qatar Abstract. The psychological well-being of 114 Palestinian children aged 5–16 was assessed in terms of whether they lived within proximal, moderate, and remote distance from a bombarded target. Arabized versions of the Children’s Depression Inventory, PTSD Reaction Index, and Cooper Smith Self-Esteem Inventory were administered to the subjects to assess their psychological well-being. Discriminate analysis was conducted on the data to determine what variable or linear combination of variables best separates the three groups of children. The results showed that only depression score was able to differentiate the three groups with statistical significance. The analysis predicted proximal distance group membership with extre accuracy, but failed to predict group membership for the moderate and remote distance groups. The findings were discussed in terms of their relevance to practicing professionals and researchers in traumatology.

Children have been subjected increasingly within the past several decades to greater traumatic experiences emanating from military and political conflicts. The literature shows a dramatic increase in the number of studies devoted to the impact of war, political oppression, and combat violence on the mental health and wellbeing of children [1]. Furthermore, these studies encompass a wide geographic and ethnic spectrum although the majority of victims are from Africa [2–4] the Middle East [5–15]. An examination of these studies also shows that researchers investigated the relationship between traumatic events and a host of variables such as gender, age, severity of trauma, social support provided, and the impact of the trauma on the psychological health and adjustment of children. Although the effects of direct and vicarious trauma have been studied extensively, no study was found to examine trauma as a function of geographic distance. Given the nature of modern warfare in terms of precision bombing, laserguided ordinance, and select targeting, physical safety may not be correlated with psychological safety. This study was conducted in an attempt to shed light on this supposition. In other words, do children who reside in close proximity to the traumatic event (e.g., bombardment, special operations, etc.) develop variant psychological responses than those of their counterparts who live within “safe” physical proximity of the event 1 Corresponding Author: Professor Ahmad M. Baker, Qatar University, P.O. Box 2713, Doha, Qatar, Email: [email protected].

164

A.M. Baker and H.M. Kanan / Psychological Impact of Military Violence on Children

but who hear or see it? The repeated Israeli “incursions” into Palestinian cities and communities during the second Intifada using guided aerial and ground ordinance serves as an ideal situation to answer this question. A review of the pertinent literature and description of the political and military conflict in the West Bank and Gaza Strip is necessary in order to establish a proper psycho-political context for the interpretation of the data.

1. Nature and Psychological Reaction of Palestinian Children to First and Second Intifadas The degree of traumatization inflicted on Palestinians during the first Intifada was well documented in the psychological [7,6] and human rights literature [16]. Death, injury, incarceration, detention, and severe restrictions on mobility and personal freedoms were incurred daily on Palestinian children living in the occupied Palestinian territories of the West bank and Gaza Strip. The studies conducted on Palestinian children during that period showed that they suffered from anxiety, depression, and PTSD symptoms (Thabet &Vostanis, 2000 [16]; Khamis, 1993 [17]; Garbarino & Kostelny, 1996 [18]). Self esteem, however, was elevated due mainly to the role, status, and participation of the children in the Intifada [19]. Furthermore, the Israelis did not resort to the use of aircraft or heavy armor during the first Intifada. The conflict was between demonstrating civilians (children and adults) armed with stones and Israeli soldiers using live ammunition, teargas, rubber coated and plastic bullets, and sound bombs. Many of the dire psychological effects of the first Intifada were found to have been mitigated by the resiliency of Palestinian children [20] and the relative peace brought about by the establishment of the Palestinian National Authority as the result of the Oslo Agreements in 1993 [11]. The second Intifada (September, 2000), however, witnessed a major shift in tactics on the Israeli and Palestinian sides. Although it began in a similar manner (widespread demonstrations by civilians, including children) as its predecessor, it soon escalated to the use of firearms and weapons reaching new magnitudes of destruction in March, 2002 when Israeli forces began to make repeated and systematic “incursions” into Palestinian cities and towns. The Israelis resorted to the use of Apache helicopters, F-16 fighter jets, and tanks and armored personnel carriers to target buildings, instillations, individuals, and vehicles. Palestinians, on the other hand, counter reacted by employing light weapons (mainly AK-47 rifles) and suicide bombings. Statistics on the number of deaths and injuries the Israelis incurred on Palestinian children below the age of 16 reveal that the second Intifada is (was) far more deadly than its predecessor. While approximately eight children per month lost their lives during the first intifada [7], the figure more than doubled (18.4) during the second Intifada [21]. Hence, while children were not primarily direct participants or actors in the second Intifada, the casualties they sustained were far more frequent and serious than those which they suffered during the first Intifada. Furthermore, the use of targeted bombardment and shelling of residential areas during the second Intifada posed real and serious dangers to the residents in the targeted areas. Palestinian children during the first Intifada feared for their safety while being on the street. Previous research on Palestinian children related to their exposure to political and military violence revolved around providing prevalence figures for symptoms of anxiety, depression, and PTSD. Analyses were conducted to determine if region (West

A.M. Baker and H.M. Kanan / Psychological Impact of Military Violence on Children

165

Bank or Gaza Strip), gender, age, or residence (urban, rural, camp) influenced the prevalence or severity of these symptoms, and the mechanisms employed by Palestinian children and their families to cope with the stress-related symptoms. Distance, however, was not considered a major factor because the streets were the main arena of confrontation. In comparison, the confrontation during the second Intifada was far more violent but more focused. Anecdotal data gathered from mental health field workers during the second Intifada suggested that severity of psychological reaction observed amongst the children may be a function of distance.

2. Methodology Sample The sample for this study was constructed from the population of Palestinian children living in the West Bank whose age at the time of sampling was 5–16 years old, and who lived in cities or towns that were subjected to aerial or land strafing. The data gatherers were instructed to map out the residential neighborhoods of these towns in terms of proximity to the bombardment to form the following three categories: 1.

2.

3.

Close Proximity Distance. This area encompassed all homes falling within a 500 meter radius of ground zero (bombed target). This category represents areas where physical safety of the residents is threatened. Group 1 represents children living within this area. Moderate Proximity Distance. Homes that fell within a 500–1000 meter radius from the bombed target constituted this category. Although physical safety is not compromised within these areas, psychological pressure is inflicted on the residents due to sound and vibration effects caused by the bombing. Children living within this zone are represented by Group 2. Remote Proximity Distance. All areas falling outside the 1000 meter radius of the bombed target, but which remain within hearing distance from ground zero represent this category. Group 3 depicts children living within this zone.

The data gatherers were instructed to select randomly ten residences from the close proximity area, and five residences from each of the moderate and remote distance areas. Residences that did not have children within the targeted age group were excluded. Due to the severe restrictions on travel and mobility imposed by the Israeli Army in the West Bank during the data gathering period (March–May, 2002), the data gatherers could not canvass all the targeted neighborhoods. Despite this limitation, the data gatherers were able to obtain at least one sample from each of the cities and towns that were subjected to bombardment. Furthermore, the data gatherers were instructed to give priority to those areas that were subjected to military activity within a six week period. This scheme yielded 79 children who lived in the “Close Proximity Area”, 30 children who resided in the “Moderate Proximity Area”, and 31 children who came from the “Remote Proximity Area”.

3. Instruments The following instruments were used in the present study:

166

A.M. Baker and H.M. Kanan / Psychological Impact of Military Violence on Children

3.1. Child PTSD Reaction Index (Arabized Version) This instrument is a translation of the Child PTSD Reaction Index (CPTSD-RI) developed by Frederic, Pynoos and Nader (1987) [22]. It consists of a 20-item self-report (interview format) questionnaire based on DSM-III criteria for PTSD. Items are rated on a five-point scale ranging from 0 (none of the time) to 4 (most of the time). CPTSDRI score ranges and associated degrees of PTSD symptom severity are as follows: 0 to 11, none; 12 to 24, mild; 25 to 39, moderate; 40 to 59, severe; and 60 to 80, very severe. The Arabized instrument was used previously on Palestinian children and was found to be appropriate for this population [20,16]. 3.2. Arabized Version of the Children’s Depression Index (CDI) This instrument consists of 27 items related to depression symptoms measured on a three-point (always, sometimes, never) scale. It is based on the original instrument developed by Kovacs (1982) [23], and was translated and normed on Arab children by Gharib (1988) [24]. Reliability and validity data for the Arabized version are comparable to those provided for the original instrument. 3.3. The Cooper Smith Self-Esteem Inventory (Arabized Version) This 25 item scale was translated, Arabized, and normed on Arab children by Musa and Dassouki (1981) [25]. The instrument was used widely on Arab children, including Palestinian children, and was found to be appropriate for such populations [26]. 4. Procedure The data were gathered by graduate students enrolled in a Master’s degree program in public health, and who conducted the exercise as an assignment for the research methodology class. Hence, the students were trained not only in data gathering procedures, but also how to conduct interviews and avoid situations that threaten the integrity of the research. The students were requested to administer the instruments according to a counter-balanced design to control for administration order effect. Furthermore, the students were instructed to establish rapport with the family and children prior to gathering the data. Predata collection visits were made to the homes in order to secure permission for participation in the study, and provide the families with a brief description of the study, its purpose, and how the data will be used. None of the households canvassed refused to participate in the study. The data were gathered during a three-month (March–May, 2002) period in which Israeli incursions into Palestinian cities and towns in the West Bank were intensive and extensive. The data were scored, coded, and analyzed using descriptive statistics and discriminate analysis (method = rao) on the scores of the three groups of children according to age, gender, PTSD, depression, and self-esteem scores. 5. Results Table 1 Depicts the means, standard deviations, and ranges for the subjects in the three groups. It shows that age scores for the three groups were comparable in terms of

A.M. Baker and H.M. Kanan / Psychological Impact of Military Violence on Children

167

Table 1. Means, S.D., and Ranges of Age, PTSD, Depression, and Self-Esteem Scores Distributed According to Group Membership.

Variable Group 1

Group 2

Group 3

M S.D. Range M S.D. Range M S.D. Range

Age 10.25 2.12 6–14 10.47 2.64 6–15 10.71 2.16 6–14

PTSD¹ 34.33 10.73 18–67 30.5 11.48 8–52 31.61 9.5 18–62

Depression² 21.57 3.6 9–30 22.07 3.45 15–29 23.9 4.41 18–36

Self-Esteem³ 15.61 3.17 9–20 15.1 3.65 6–20 14.42 4.81 3–22

Notes: Theoretical Range = 0–80 Theoretical Range = 0–54 Theoretical Range = 0–25

means (10.25, 10.47, 10.71) and standard deviations (2.12, 2.64, 2.16), the average age being approximately 10 – the youngest being six and the oldest 16. The Table also shows that mean PTSD score for each group (Group 1 = 34.33, Group 2 = 30.5, Group 3 = 31.61) fell within the moderate (25–39) PTSD symptomology range. The scores, however, varied widely amongst the three groups, ranging between experiencing mild symptoms (12–24) to very severe ones (greater than 60) with the exception of Group 2 in which one subject scored in the range (< 12) in which PTSD cannot be determined. Mean depression scores depicted in Table 1 reveal that all three groups displayed moderate (45–55 percentile) symptoms of depression. Table 2, however, shows that those who live within remote proximity (Group 3) of the traumatic event displayed depression scores significantly (p = .015) more elevated (M = 23.9) than their counterparts who lived within close (M = 21.57) or moderate proximity (M = 22.07) of the bombardment. Dispersion of depression scores was most pronounced in the Close Proximity Group (Range = 9–30) compared with the Moderate Proximity (15–29) and Remote Proximity (18–36) groups. The results depicting self-esteem scores show that the means (Group 1 = 15.61, Group 2 = 15.1, Group 3 = 14.42) of the three groups did not fall outside the norms (fifth stanine) for their peers in the Arab World. Furthermore, although the scores exhibited wide variance (11, 14, and 19 for groups 1, 2, and 3 respectively) they did not differ from each other significantly as shown in Table 2. Results of the discriminate analysis revealed that depression score was the only variable able to discriminate between the three groups with any statistical significance (p = .015). Furthermore, the analysis showed that group membership can be predicted with 58% accuracy as shown in Table 3. A closer examination of the Table, however, reveals that the analysis redicted group one membership with astonishing accuracy (93.6%), but failed to predict membership in groups two and three (0.0%, 19.2% respectively).

168

A.M. Baker and H.M. Kanan / Psychological Impact of Military Violence on Children

Table 2. F Values for Age, Gender, PSTD, Depression and Self-Esteem Means According to Group Membership.

Variable Gender Age PTSD Depression Self-Esteem

F 0.037 0.476 1.704 4.303 1.18

Sig n.s. n.s. n.s. 0.015 n.s.

Table 3. Predicting Group Membership.

Group Group 1 Group 2 Group 3 Total

Group Prediction Group 1 Group 2 74 0 28 0 26 0 128 0

Group 3 5 2 5 12

Total 79 30 31 140

1. Total percent group predication accuracy = 58% 2. Percent accuracy for predicting Group 1 membership = 93.6% 3. Percent accuracy for predicting Group 2 membership = 0.0% 4. Percent accuracy for predicting Group 3 membership = 19.2%

6. Discussion This study attempted to investigate the effect of trauma as a function of distance from the traumatic event. Indexes of psychological well-being were collected on children who lived within close, moderate, and remote proximity of bombarded targets. The results of the study clearly showed that the well-being of Palestinian children was affected negatively by the military and political violence to which they were subjected. Symptoms of depression, psychosomatic conditions, sleep disturbances, and PTSD were found to be above normal levels. These findings are congruent with previous findings on children traumatized by war conditions (Miller, el-Masri, Allodi, & Qouta, 1997 [27]). The results of the study also showed that symptoms of depression constituted the only index able to discriminate between the three groups with statistical significance. Living within hearing distance was not found to be a significant factor in how children respond to aerial and land bombardment. All three groups displayed moderate PTSD reactions to the bombardment irrespective of how distant they lived from the target zone. The data also showed that acute symptoms of PTSD were found in all three groups. This result is not in contradiction with previous studies on the prevalence of PTSD in Palestinian children [16]). A recent unpublished survey conducted by Quouta (2003) [28] shows that nearly one-third (32.7%) of Palestinian children displayed acute symptoms of PTSD during the second Intifada. Although PTSD symptoms tend to subside when exposure to the traumatic condition is terminated, the persistence and prevalence of PTSD symptoms need to be interpreted with great caution. The available data seem to suggest that PTSD symptoms resulting from exposure to military trauma often tend to be persistent and delayed in manifestation [29,30].

A.M. Baker and H.M. Kanan / Psychological Impact of Military Violence on Children

169

The result that distance was not found to be a function of trauma could have more than one interpretation. It may imply that being within hearing distance of bombardment serves the function of being witness to the stress provoking event. The element of psychological safety is, therefore, compromised by the elements of anticipation and lack of control over the outcome of the event. Being sequestered in the house does not afford information regarding the gravity of the situation outside. The child’s safety, therefore, is compromised by the anticipation that the next shell or missile could result in his/her injury or death. This fear could also have been magnified by the resonating sound effects of the bombardment due to the topography (open hills) of the area (West Bank) where the data were collected. It is also difficult to locate the source of sound within such a topography, especially during the night when most of the bombardment took place, thus exacerbating the feeling of not being able to have control over the situation. Although the discriminate analysis was able to predict modestly (58%) overall group membership, closer analysis of the prediction distribution depicted in Table 3 shows that membership in the proximate distance group was predicted with extreme accuracy (93.6%). None of the children in the moderate distance group were predicted accurately but were assigned overwhelmingly to the proximate distance group. A similar pattern was detected for those who fell within the remote distance group. In other words, irrespective of how far a child lives within hearing distance of the stressful or traumatic event, (s)he is vulnerable to develop psychological reactions similar to those of children who live within the target zone. The results depicted in this study confirm what mental health researchers have found. Exposing children to military violence is detrimental to their psychological well-being. This study, however, has also demonstrated that psychological safety is as crucial as physical safety to the well-being of children. Researchers and mental health practitioners need to consider not only the direct exposure of children to traumatic events, but also must examine the effect of psychological safety. It may be not sufficient to determine trauma in terms of physical distance, but also in terms of psychological distance. Although the results of this study may pose a new variable for researchers and practitioners in traumatology, the measurement of distance from the target zone needs to be elaborated in future research. At what distance from the target zone does psychological safety begin to take hold. Perhaps the inability of the discriminate analysis to separate the three groups in this study may be the result of not separating the groups sufficiently in terms of distance. The results, however, appear to indicate that the physical range of a traumatic event such as bombardment may be far more encompassing than is believed to be. The clinical and practical ramifications of such a finding are enormous and, perhaps, ominous. The psychological fallout of bombardment may be just as devastating as its physical destruction. References [1] Allwood, M.A. (2002). Children’s trauma and adjustment reactions to violent and nonviolent war experiences. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 450–458. [2] Cliff, J. & Noormahomed, A.R. (1993). The impact of war on children’s health in Mozambique. Social Science and Medicine, 36, 834–848. [3] Dawes, A. (1990). The effects of political violence on children: A consideration of South African and related studies. International Journal of Psychology, 25, 13–31.

170

A.M. Baker and H.M. Kanan / Psychological Impact of Military Violence on Children

[4] McIntyre, T.M. & Ventura, M. (1995). Children of war: A study of PTSD in Angolan adolescents. A paper presented to the 103 rd Annual Meeting of the American Psychological Association in New York, August, 12. [5] Baker, A.M. (1993). Psychological problems experienced by Palestinian adolescents associated with military occupation. In Health hazards of organized violence in children: Program papers. Meeting of the Advisory Group on the Health Situation of Refugees and Victims of Organized Violence. London, February, 10–12. [6] Baker, A.M. (1991). Psychological response of Palestinian children to environmental stress associated with military occupation. Journal of Refugee Studies, 4, 237–247. [7] Baker, A.M. (1990). The psychological impact of the Intifada on Palestinian children in the occupied West Bank and Gaza: An exploratory study. American Journal of Orthopsychiatry, 60, 496–504. [8] Elbedour, S., Baker, A.M. & Charlesworth, W. (1997). Political violence and moral reasoning in children. Child Abuse and Neglect, 19, 053–1066. [9] Dyregrov, A. (1993). Children in Iraq. Paper presented to the First International Congress on Mental Health: The Challenge of Peace. Gaza, Palestine, September 13–15. [10] Macksoud, M., Aber, J.L., & Cohn, I. (1996). Assessing the impact of war on children. In R.J. Apfel and B. Simon (Eds.) Minefields in their hearts: The mental health of children in war and communal violence (pp. 219–230) New Haven, CT: Yale University Press. [11] Qouta, S., Punamaki, R.L. & El Sarraj, E. (1995). Impact of peace treaty on psychological well-being: A follow-up study on Palestinian children. Child Abuse and Neglect, 19, 1197–1208. [12] Garbarino, J. (1993). Challenges we face in understanding children war: A personal essay. Special Section: Children War. Child Abuse and Neglect, 17, 787–793. [13] Miller, K. (1996). The effects of state terrorism and exile on indigenous Guatemalan refugee children: A mental health assessment and an analysis of children’s narratives. Child Development, 67, 89–106. [14] Allodi, F. (1989). The children of victims of political persecution and torture: A psychological study of a Latin American refugee community. International Journal of Mental Health, 18, 3–15. [15] Al-Haq (1988). Punishing a nation. A report made by Law in the Service of Man (Al-Haq). Ramallah, West Bank. [16] Thabet, A.A. & Vostanis, P. (2000). Psttraumatic stress disorder reactions in children of war: A longitudinal study. Child Abuse and Neglect, 24(2), 291–298. [17] Khamis, V. (1993). Post-traumatic stress disorder among the injured of the Intifada. Journal of Traumatic Stress, 6, 555–559. [18] Garbarino, J., & Kostelny, K. (1996). The effects of political violence on Palestinian children’s behaviour problems: Arisk accumulation model. Child Development, 67, 33–45. [19] Baker, A.M. (1992). Gender, urban-rural-camp, and regional differences among self-esteem scores of Palestinian children. The Journal of Psychology, 126, 109–120. [20] Quouta, S., El-Sarraj, E., & Punamaki, R.L. (2001). Mental flexibility as resiliency factor among children exposed to political violence. International Journal of Psychology, 36, 1–7. [21] Defence for Children International – Palestine Section (2002). Violations of Palestinian children’s rights stemming from the Israeli occupation. Report submitted to the Special Rapporteur, UN Commission on Human Rights, 28 August, 2002. [22] Frederick, C., Pynoos, R., & Nader, K. (1992). Child post-traumatic stress disorder reaction index. (Available from Pynoos, Adult Psychiatry, 300 UCLA medical Plaza, Los Angeles, CA. 90024-6968). [23] Kovacs, M. (1982). Children’s depression inventory (CDI). Western Psychiatric Institute and Clinic, University of Pitsburgh, Pitsburgh, PA. [24] Gharib, A.G. (1988). Children’s depression inventory (1988). Cairo: Dar Al-Nahda (in Arabic). [25] Musa, F., & Dassouki, M. (1981). A test of self-esteem for children (in Arabic). Cairo: Al-Nahda Publishers. [26] Baker, A.M. (1993). Taqdir al-that ind al-tifl al-filistini fi dakhil al-daffah al-gharbiyyeh wa qita ghazzah al-muhtallain (Self-esteem amongst Palestinian children int eh occupied West Bank and Gaza Strip). Afaq Filistinyyeh, 7, 58–84 (in Arabic). [27] Miller. T., el-Masri, M., Allodi, F., & Qouta, S. (1997). Emotional and behavioral problems and trauma exposure of school-age Palestinian children in Gaza: Some preliminary findings. Medicine Conflict and Survival, 15, 368–378. [28] Quouta, S. (2003). Prevalence of PTSD among Palestinian children. Unpublished report, Gaza Community Mental Health Program, Gaza, Palestine. [29] Allwood, M.A., Bell-Dolan, D., & Hussain, S.A. (2002). Children’s truma and adjustment reactions to violent and nonviolent war experiences. Journal of the American academy of Child and Adolescent Psychiatry, 41, 450–457. [30] Sack, W.H. (1999). Twelve-year follow-up study of Khmer youth who suffered massive trauma as children. Journal of the American Academy of Child and Adolescent Psychiatry. 38, 1173–1179.

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

171

Growing Up in Communities Affected by War Veronika ISPANOVIC-RADOJKOVIC, MD, PhD Professor of Child and Adolescent Psychiatry, Institute for Mental Health, Belgrade Abstract. The war in ex-Yugoslavia, displacement, rapid economic changes and a deteriorated social context, exposed a hundred thousand children and adolescents to very intensive, often multiple traumatic experiences followed by a chain of chronic and increasing adversities in their everyday lives. During the past 10 years more than 3 million people from ex-Yugoslavia became “refugees”, “expellees”, or “internally displaced persons”. Approximately a million of them found shelter, permanent or temporary, in Serbia. Nearly half of this number were children and young people. Many of them, before finding refuge, witnessed destruction, atrocities, torment and the death of close family or friends or their own lives were endangered, exposed to violence, deprivation or uncertainty. Although child refugees found safety and shelter, the painstaking everyday realities of refugee life and an uncertain future continued to torment them and mark their developmental passage towards adulthood. The aim of the paper is to present the reactions of children and adolescents in Serbia, both refugees and domicile ones, to those traumatic experiences and to discuss how they have coped with such experiences during the last 10 years. The paper is based on several studies done by the research team of the Psychotrauma Center for Children and Adolescents of the Institute for Mental Health in Belgrade in that period [1–5].

1. Traumatic Experiences of Young in Serbia The number of “domicile” young people in Serbia with traumatic, and in particular with multiple traumatic experiences drastically increased in the last 10 years. In 1991 this percentage, which amounted to 26.4%, doubled itself in 1999 to 55.9%. The most frequent traumatic experiences quoted were family conflicts or family breakdown (17%), direct exposure to life threat (16.8%), death of a close person (10.9%), violence related to school (7.4%) and violence related to peer relationships (5.8%). The experiences of young refugees were even more severe: 74.1% of boys and 88% of refugee girls went through severe traumatic experiences related to war. Direct life threat was experienced by 41% of young refugees and 14.4% witnessed the killing or wounding of a family member or other close persons. The exposure to multiple traumas during several months prior to seeking refuge was a frequent finding. 2. Reactions of Young to Traumatic Experiences The life in the shade of war, under sanctions, in isolation, in the context of drastic impoverishment of the society, not only in material but also in a spiritual sense, significantly affected the mental health of all young people in Serbia, both in the refugee and domicile populations.

172

V. Ispanovic-Radojkovic / Growing Up in Communities Affected by War

Our clinical experience indicated increasing psychological and behavioral disorders in adolescents, to the abuse of psychoactive substances, peer violence, joining different gangs, as well as to a nihilistic, aggressive or hedonistic attitude towards the world and the future. Detailed assessment has indicated that underlying unrecognized depression was frequently manifested by aggressive or auto-destructive behavior and an inclination of the young towards anti-social activities (fights, stealing, use of alcohol and psychoactive substances). The results of the research confirmed our clinical observations. The investigation carried out during 1995–98 with the Achenbach Youth Self Report questionnaire [6], showed that secondary school pupils in Belgrade, aged 15–18 years, had significantly more psychological problems manifested both by externalization (attention problems, delinquent and aggressive behavior), and internalization (withdrawal, somatic complaints, anxiety and depression) than their peers in the USA. This was more frequent in girls than in boys, in refugees than in non-refugees, and in those who had traumatic experiences than in those without them. The level of traumatization of refugee secondary school pupils, measured by the Impact of Event Scale (IES) [7] was remarkably high, both on intrusion as well as on avoidant scales. This applied particularly to girls. On Achenbach’s scale, the refugee boys most frequently displayed symptoms of internalization and thinking disorders, while the scores in girls were very high on all scales. According to our research results, those at greatest risk for the occurrence of lasting negative effects are children and young people who 1) experienced serious and multiple traumatic experiences, 2) were without adequate parental support in traumatic situations, 3) lost family or friends, 4) lived in collective refugee centers, 5) experienced traumatic experiences or losses in early childhood, and 6) previously suffered from somatic and/or psychiatric disorders. The follow up of young refugees revealed that the symptoms of a chronic reaction to stress was present in 35.5% after 1.5–2 years of refugee life, and in 25.5% of those living in refugee camps even after 3–4 years.

3. Vulnerable Children Drastic decreases in resources for health and social welfare and education affected all children, although its greatest impact was on the most vulnerable groups of children whose development, recovery, and survival depended on social support and solidarity. Beside refugees and displaced children, the most vulnerable were children without parents, abused and neglected children, children with chronic illnesses and handicaps, and children in institutions. 3.1. Children Without Parental Care The drastic deterioration in economic and social conditions was associated with an increased number of abandoned and neglected children. According to data of the Ministry for Social Welfare currently 9,000 children without parental care are cared for by social services, 45% (4,150) of them are abandoned children, and 27% (2,555) are children whose parents are not able to take care of them. In this category the risk of abuse and neglect (physical, emotional, health) is the greatest for the youngest children, aged 3 years and under.

V. Ispanovic-Radojkovic / Growing Up in Communities Affected by War

173

3.2. Abused and Neglected Children Family violence has been a frequent reaction of the family system to stress, traumatic experiences, losses, chronic deprivation and humiliation experienced by individual family members or the family as a whole. The victims of such violence most frequently have been women and children. Reliable data documenting the number of abused and neglected children cannot be obtained in Serbia because there is no system for registration of such children, but we may assume that their number is increasing. As an illustration, more then 400 children were referred because of serious abuse and neglect to the Center for Child Protection which started to operate two years ago at the Institute of Mental Health in Belgrade. It is well known that growing up in a family with a high level of violence constitutes a great risk not only for the child who is the victim of violence but also for future generations. Through the process of “identification with the aggressor” the child-victim of violence frequently turns into the perpetrator and in this way the violence is transmitted from one to the next generation. 3.3. Children from Multiple Problem Families Negative life events to which our families were exposed for many years was reflected in the functioning of families. During 1999 the Centres for Social Work in the territory of Belgrade registered 4,803 children who came from families with disturbed relationships. In two thirds of such families emotional, and frequently physical abuse or serious forms of neglect of children were detected. The most threatened were the children who came from families in which somebody, most frequently the father, displayed psychopathology in the form of alcohol or drug abuse, aggressive behavior, depression as a reaction to war experiences and/or adverse life events. 3.4. Children in Institutions The social and economic crisis has most drastically affected children in institutions. There are currently 6,000 children in institutions in Serbia and Montenegro. In institutions for mentally retarded children (Kuline, Stamnica, Popovac) the situation has assumed a catastrophic scale. The placement of children into institutions in the past has been a standard practice in cases of children without parental care, more seriously handicapped children, and particularly mentally retarded children and children with disturbed behaviour. The policy of gradual termination of institutional placement of handicapped children and caring for them in an open environment, preferably in the family, is an imperative but also a great challenge for all services responsible for the well-being and development of children.

4. Psychological Healing and Ways Forward Following Traumatic Experiences Despite the concern the above data may cause, they also show that more than two thirds of young people who experienced serious traumatic events did not developed psychopathology. They were able to activate mechanisms for successfully coping with traumas and to develop new forms of adjustment.

174

V. Ispanovic-Radojkovic / Growing Up in Communities Affected by War

By investigating the factors affecting the outcome of exposure to traumatic experiences in childhood and youth, we have concluded that in addition to severity and the number of traumatic experiences, a significant role is played by individual characteristics of adolescents (maturity, cognitive style, self-esteem, quality of previous life experiences, and especially the history of previous traumas and pre-existing psychopathology), their family reaction and, finally, by the attitude of social environment in which the recovery is taking place. The outcome also depended on the behavior of parents, that is the response of the parental system to the situation. Exaggerated emotional responses, panic, intolerance or depression of parents in traumatic situations have significantly increased the risk for the occurrence of psychopathology in adolescents. There is a lot of research and debate nowadays concerning the so-called “protective and vulnerability factors” after traumatic experiences. In my belief, the term “protective factors” is not the most adequate one as it may deceive and make us think that there is something that may protect us, make us impenetrable, insensitive to traumatic experience. And, that is not true. We may recover from traumatic experiences, more easily or with difficulty. We may even get empowered. But these experiences will change us forever – we can never be the same as before the traumatic experience. It is more appropriate to speak about “systems of support” that enable and facilitate the recovery after traumatic experiences, than about protective factors. Of special significance for the impact on adolescent development after traumatic experiences is the social framework in which the recovery is taking place. Man is, namely, “a being in search of meaning”, a being seeking meaning in its experiences. Finding the meaning, giving the meaning to the world, according to Neo-piagetian developmental theory, represents the principal driving power in the developmental process of a child and a young person. The decisive factor for a positive developmental outcome after catastrophic events is not the severity or duration of the event, but the extent to which such an event damages, breaks or makes it impossible for the child or adolescent to get a coherent understanding or interpretation of the world he/she has experienced. In situations of organized violence the pre-existing “conceptual maps” are often inadequate. Frequently, even the mechanisms for development of new “maps” get broken down, or destroyed [8]. The breakdown of family, of connections with relatives and friends, closing of schools and other social institutions, in one word the breakdown of a social network, represents in fact the destruction of these mechanisms which provide the child or adolescent with the norms and context for interpretation and understanding of traumatic events. The research in many environments with lasting conflicts and violence (Israel, Palestine, Lebanon, Northern Ireland) has shown that the cohesion of political motivation and the community’s attitude towards conflicts, i.e., whether the social community condemns the war or considers it justified, as well as high support of the social community offered to victims of conflict, may mollify negative effects of war experiences and violence on children and adolescents. There is no doubt that ideology, as a way of viewing the world, or put in contemporary wording, as a public expression of one’s personal “conceptual map of the world”, plays a significant role in strategies for coping under extreme dangers. In his consideration of psychological survival mechanisms in Nazi camps, Bruno Bettelheim (1943) [9] noted that those strongly committed to a certain ideology, either to religion or communism, were most able to endure the brutality of everyday camp life. In such

V. Ispanovic-Radojkovic / Growing Up in Communities Affected by War

175

situations, fanatic allegiance to a certain ideology represented an essential defense mechanism against the unbearable, destructive severity of reality in concentration camps, prisons or refugee camps. However, the allegiance to an ideology is a sword with two edges. The same ideology that gives meaningfulness to life in a war zone may lead to dehumanization, and later to satanization which, in turn, deepens the conflict, decreases capabilities for compromise and teaches young people to view the destruction of their enemies as a way for emotional survival and personal integration. A young person may conclude: “The behavior of the enemy is inhuman. The enemy, therefore, is not a man, he is a devil, a Satan. To destroy Satan is not only essential, but it is justified. Killing is, therefore, a sublime, morally justified act”. By desperately clinging to an ideology which explicates and justifies their fates and acts, the young may successfully cope with war traumatic experiences. When they grow up, however, this same ideology forces them to continue the war and, thus, to expose future generations to suffering. The experience of violence makes them insensitive to brutality and the lesson they learn is that “everything is allowed and nothing is forbidden”. In this way ideology, particularly when in the service of evil easily motivates and becomes a source of unnecessary suffering and death, not only in the present but in future generations as well. Many conflicts in the world confirm this horrible dynamic, and we have, ourselves, experienced this in our recent and more distant history. Research also indicates the possibility that war and social crises may also promote the advancement of moral development of young people. This can only occur when adults help the young heal their wounds by placing their painful experiences into a more humanistic framework in which dehumanization and satanization are unacceptable, and in which the development of empathy and tolerance are stimulated. Yet this is surely easier to say than do. A significant place in the process of restoration of trust in people divided by mutual hate and fear belongs to social memory. Social memory has two aspects: the stories about good and the stories about bad experiences [10]. The community that went through bad experiences during history, that has been persecuted, destroyed, traumatized, divided and betrayed keeps this in its memory. These memories continue to live in the individual memory of victims, witnesses and criminals, and also in the collective memory of people, in the stories, songs and traditions. However, social memory also contains positive experiences, joint life, marriages, children, neighbors and friends. When people find themselves under strong stress it may frequently happen that images of others get spliced into good and bad parts, so that others are seen exclusively as bad or exclusively as good. In the context of war, of immediate life threat, it is dangerous to retain memories of positive aspects from history, of times when tolerance and shared social arrangements were possible. Therefore under war conditions enemies are generally seen as bad, while one’s own people, the members of one’s own group, are seen exclusively as good which only leads towards further deepening of the conflict. It is also dangerous if war traumatic experiences are pushed back, denied. This happens, for instance, after peace has been proclaimed by those in power, when people are told that the bad side of history has to be “forgotten” – that one has to keep silent about it. The victims of violence and abuse in such situations are silenced, with no op-

176

V. Ispanovic-Radojkovic / Growing Up in Communities Affected by War

portunity to express themselves publicly. The experience of war crimes remains a shameful secret of individuals, groups or of an entire people. One knows, nevertheless, what happens when the unresolved past is kept in “the iceberg of history” [11]. The experience hidden for a long time, cut off, held back or fenced in – but never completely forgotten – remains a permanent source of new conflicts, particularly if a new traumatic experience flares it up. Unresolved shame and rage produced by narcissistic injury will further feed the flame, and low self-esteem will spur an excessive need for group identity. In this way a culture that is being created will take the shape of aggressor. Inability of the previous generation to grieve their losses after jointly experiencing a traumatic event and failure to undo the narcissistic injury and humiliation inflicted by the other antagonistic group, may lead towards inter-generation transmission of violence. In the explanation of the process of inter-generation transmission of violence Volkan introduces the concept of “selective trauma” under which he understands the mental representation of the past event during which one group experiences a serious loss or helplessness and humiliation in the conflict with a neighboring group [12]. Namely, each individual in the traumatized group has his or her own, unique identity and personal reaction to trauma, but at the same time all group members share a mental representation of the tragedy that was inflicted on the group. Adults, parents “deposit” nonintegrated, damaged representations of self linked with the mental representation of the joint traumatic event, onto the next generation of developing children – in expectation that these children will be able to mourn the loss or wipe out the humiliation. If the children fail to work out what has been “deposited” onto them, when they grow up they will transfer their mental representation of the event to the next generation. In this way trauma is transmitted from one to the next generation. In its passing from one generation to the other, “selective” trauma changes its function, states Volkan. Historical truth about the event loses significance for the community and instead the fact that group members through sharing of the “selective” trauma become tied to each other. “Selective trauma” becomes an inseparable part of the group identity. In situations when the community is in conflict or when it is passing through drastic changes and needs to confirm or strengthen its identity, “big leaders” easily succeed to reactivate these repressed, unresolved traumatic experiences and push the group into new conflicts, violence, and even war. Such considerations lead us to conclude that psychological healing processes following traumatic experiences will require, in addition to interventions at the individual level, significant interventions at the social level, the so called psychosocial interventions. Psychosocial intervention under extraordinary conditions is defined as activity that strengthens psychosocial protective factors and reduces psychosocial stressors in the effort to preserve mental health and promote human rights. In each individual case the “protective” or “supportive” value of each factor should be assessed in relation to the extent to which this will contribute towards “giving of meaning” or integration of experiences. Classical therapeutic intervention thus is not obligatory after traumatic experiences but it becomes justified in situations in which other supportive mechanisms are absent, or in cases where the giving of meaning, integration of experiences is very complex or delicate in view of the social or emotional state of the child or young person.

V. Ispanovic-Radojkovic / Growing Up in Communities Affected by War

177

One of the sources of mental health is a consequent and generally accepted story about the traumatic event, which supports individual feelings of self-esteem and which basically offers an understandable, all-inclusive picture of the world that will pave the way towards the future. In practice, it is essential to help young people create new, individual and collective memories which will not be tainted by violence but which will preserve the conceptions of peace, positive human and social values and which will make it possible for young people to come out of their aloneness, to open up towards others and to respect the diversity of others. In order to be able to help young people, to prevent the creation of a cycle of violence, we have to explore ourselves, to keep changing, to find meaning in all that we made meaningless during these years, to learn respect for others, and to honor their attitudes and diversity. A difficult but noble challenge.

References [1] Bojanin S., Ispanovic-Radojkovic V. (1993): Adolescents and the Stresses of War, In: Kalicanin P., Bukelic J., Ispanovic-Radojkovic V., Lecic-Tosevski D., (eds.) The Stresses of War, Institute for Mental Health, Belgrade. [2] Bojanin S., Ispanovic-Radojkovic V., Lazic D. (1994): Friendship Club: The Prevention of Psychological Disorders in Adolescents, In: Kalicanin P., Bukelic J., Lecic-Tosevski D., IspanovicRadojkovic V., (eds.) The Stresses of War and Sanctions, Institute for Mental Health Belgrade. [3] Ispanovic-Radojkovic V., Tadic N., Bojanin S. et al. (1994) War Traumatized Children: Reactions, Disorders and Help. In: Kalicanin P., Bukelic J., Lecic-Tosevski D., Ispanovic-Radojkovic V., Stresses of War and Sanctions, Institute for Mental Health, Belgrade. [4] Ispanovic-Radojkovic V. (1996): YOUTH CLUBS, Outcome of a Community-Based Intervention for Prevention of Mental Health Disorders in Adolescence; Paper presented at European Child Psychiatry Research Group-Invitational Meeting, Oslo, 5–7 September 1996. [5] Išpanovic-Radojkovic V. (2000): Factors Influencing the Outcome of Traumatic Experiences in Childhood, In: Health Hazards of Organized Violence in Children (II), Coping and Protective Factors, ed.: L. van Willigen, Stichting Pharos, Utrecht. [6] Achenbach, T.M. (1991): Manual for the Youth Self-Report and 1991 Profile; Burlington VT., University of Vermont, Department of Psychiatry. [7] Horowitz M.J., Wilner N.R., Alvarez W., (1979): Impact of Event Scale: A Measure of Subjective Ispanovic-Radojk Stress; Psychosomatic Medicine, 41, 209–218. [8] Garbarino J., Kostelny K. and Dubrow N. (1991): No Place to Be a Child – Growing Up in War Zone, Lexington Books, Toronto. [9] Bettelheim, B. (1943). Individual and Mass Behavior in Extreme Situations. Journal of Abnormal and Social Psychology, 38, 417–452. [10] Agger, I. (1994): Peace-building and social memory; In: Arcel L.T. (ed.): War Victims, Trauma and Psychosocial Care, Nakladništvo Lumin, Zagreb. [11] Herman J.L., (1992): Trauma and Recovery, New York, Basic Books. [12] Volkan V.D. (1991): On Chosen Trauma, Mind and Human Interaction, 4; 3–19.

This page intentionally left blank

IV. Education and Influence

This page intentionally left blank

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

181

Basic Principles in Training Trainers for Counsellors and Psychosocial Workers in Areas of Armed Conflict Guus VAN DER VEER

Abstract. Training counselors or psychosocial workers in areas of armed conflict, requires an explicit vision on the relationship between theoretical knowledge, practical knowledge and counselling. This article describes how, with minimal means, a training of trainers for counsellors or psychosocial workers can be put together. The basic principles are discussed, and the training is described as an interactive process in which both the participants and the trainer develop their expertise. Keywords. Development of expertise, grass-root counsellors, psychosocial workers, training methods

Academic Knowledge, Practical Knowledge and Counselling In western countries, counselling and psychosocial work is taught at universities and institutes for higher professional education. This suggests that counselling and psychosocial work implicitly is seen as academic, theoretical knowledge put into practice. Counselling and psychosocial work are seen as the use of therapeutic techniques. During years of academic training, the students learn about the theoretical background of these techniques, and exercise these techniques in practice under supervision. Some authors [1] have argued that the importance of techniques has been overrated, and that the quality of the contact that develops between the counsellor and the client determines the effect of the counselling process. When the contact between the counsellor and the client is experienced as personal and meaningful by both, counselling can become effective. Specific techniques may contribute to the development of this contact, in that sense they are of secondary importance. Training for counsellors therefore should focus primarily on developing more openness to meaningful personal contacts with relative strangers. The use of specific therapeutic techniques should come second. This approach could be characterised as a ‘contact-focussed’ training. In this approach, the trainer tries to create a safe, therapeutic space during the training sessions, in which the participants can share their personal problems as well as their already available skills for helping other people. An academic training focussing on theory and techniques could easily tempt the participants to keep too much distance from their future clients. In areas of armed conflict, there simply is no opportunity to provide years of academic training to counsellors and psychosocial workers. However, some trainers try to provide slimmed down copies of the academic training they received themselves.

182 G. van der Veer / Basic Principles in Training Trainers for Counsellors and Psychosocial Workers

A few years ago, I was invited to contribute to a training of trainers of psychosocial workers in a conflict area. The training had started already, it was planned to last for a year, and the 20 participants met 5 days per week full time. They all were university graduates, who just had finished their studies, and their future task was to train psychosocial workers. When I asked the organisers of the training what exactly they wanted me to do, they told me that the program so far included various subjects, such as psychology, mental health and psychopathology. Presently they needed a trainer who could fill in a gap in the schedule for one day a week in which counselling should be the main subject. When I started the training, the trainees were sitting in rows; the first row was empty. I invited the participants to sit in a circle. After introductions I asked them to inform me about the problems of the local population. I have experienced such discussions with numerous groups in diverging areas. Usually, the participants easily follow my suggestion to discuss the problems they have observed in their own social environment: the problems of friend, neighbours, relatives or themselves. But with this group, the discussions were held in general, abstract terms. Moreover, the atmosphere was competitive, not mutually supportive. Some of the participants actually tried to ridicule the remarks of their peers. In order to make things more concrete, I tried to engage some of the participants in a demonstration role play, in which they would play a person they knew with a problem, and I would play a helper trying to understand the problem. It was very difficult to get volunteers to contribute to the role play, it seemed as if the participants were very much afraid of their peers. At the end of the day, the atmosphere in the group had changed. It felt safer, less competitive, more supportive; and I felt I had made personal contact with at least some of the participants. But during our next meeting, a week later, things seemed to back at square one. I started with asking the group if they had questions about the things we discussed during our previous meeting; nobody responded. The participants looked tense. I tried to start a dialogue with the group on the purpose of a first interview with somebody requesting assistance, but the interaction remained slow and laborious. After a few hours, the atmosphere seemed to be safe again. Week after week I battled uphill with the group: at the start the participants seemed scared of one-another; at the end of the day they seemed to interact more freely, and a week later all progress seemed to be lost again. Trust of the participants in me as a trainer seemed to be the issue: in fact several members visited me for private counselling sessions. During the training described in the above example, two approaches to training collided. Four days the participants were taught in a traditional, not very much empowering way by about ten different teachers. Knowledge on most of the subject matter was transferred through lectures. It was only during the psychopathology classes that the participants had the opportunity to look from a distance at patients from the local psychiatric clinic while they were interviewed by a psychiatrist; but they never really met them. The subject matter during these four days was mostly theoretical, and the theory was never related to their personal experience (although many of them had undergone traumatic war-experiences) and thus stayed at a huge distance from the experiential world of the participants.

G. van der Veer / Basic Principles in Training Trainers for Counsellors and Psychosocial Workers 183

Then, during one day, when I was with the group, the training was contactoriented. During this day the personal experiences of the participants suddenly became the central topic of discussion. That must have been a confusing experience for the participants. The combination of a traditional scholastic training with a ‘contact focussed’ training approach does not work. A month after the training year had finished, I had the opportunity to observe four of the participants of this training of trainers during a meeting with grassroots psychosocial workers who now wanted to become active as trainers of psychosocial workers. During the introduction round, most workers introduced themselves by telling something about the problems of their target group and the project they were involved in. The ‘trainers’ introduced themselves by reviewing their diploma’s and certificates, mentioning the names of some of the distinguished professors that had contributed to their training. Later during the training, one of the psychosocial workers started to share some of the difficulties she experienced during her work. Two of the ‘trainers’ took that as an opportunity for severely criticising the psychosocial worker in question, using theoretical terms the psychosocial worker probably never had heard of. They humiliated her, instead of creating a safe atmosphere, exploring the difficulty she had described, encouraging her and providing ideas for an alternative approach. These ‘trainers’ had been trained with the objective that they would support psychosocial workers. But the two that took part in the meeting with grassroots psychosocial workers, were unable to do that. This experience convinced me of the importance of rethinking basic principles in training trainers of counsellors and psychosocial workers in areas of armed conflict.

Grassroots Counsellors and Psychosocial Workers The approach to training trainers described in this article fits within a community approach. Psychosocial projects with such an approach have the following characteristics. 1.

2. 3.

Active participation of members of the community. The project is started in such a way that members of the community actively participate in both designing and carrying out the project. Empowerment. The project is meant to give the community members more control over their life situation. Bottom-up strategy. What the members of the community see as the problem or needs the project is meant to address is taken very seriously. They cooperate closely with the professionals involved in the project.

The skills and knowledge needed by psychosocial workers depend upon the exact nature of the psychosocial interventions they need to carry out. For example, befriending alcoholics and trying to support them when they want to stop drinking requires different skills and knowledge than organizing playgrounds for children. But all psychosocial workers need basic listening skills. A short training can prepare future psychosocial workers to use listening skills during psychosocial interventions [2]. Such training then should be aimed at stimulating the participants to use their natural talents for helping other people. The trainer can encourage the participants to use the memories of

184 G. van der Veer / Basic Principles in Training Trainers for Counsellors and Psychosocial Workers

their own painful experiences and their ways of coping with the after-effects as resources. These resources can help them to empathise with members of their community. In that way they can stimulate these community members to use their common sense for problem solving in every-day life. When counselling is part of a community approach, it is often offered in combination with other psychosocial interventions such as support groups for widows and other vulnerable groups, psycho-education on the consequence of traumatisation and of uprooting, income-generating or expenses-saving projects, after-school programs for children and adolescents, and so on. Counselling as part of a community approach departs form the assumption that, in addition to a small body of theoretical knowledge, counselling victims of armed conflict require a relatively simple set of skills that are similar to the basic social skills for helping others that many people acquire spontaneously. In counselling victims of armed conflict by grassroots counsellors, the focus should be on creating a safe atmosphere, making contact with the client, trying to understand his experiential world, and empowering the client; rather than on using sophisticated psychotherapeutic techniques or carrying out treatment protocols for mental disorders [1]. Therefore, a short, intensive training of a few weeks [3,4] for a detailed training manual) may be sufficient for making motivated people ready to start counselling as grassroots counsellors. Expertise Required by the Trainer Grassroots counsellors and psychosocial workers should be trained by experienced, still practising counsellors and psychosocial workers who are able to account for their choices with regard to training method and subject matter. The educational method used during training is an important part of the message conveyed throughout the training. For example: a trainer may use training methods that stimulate the participants to reflect upon and learn from their own personal experience, including their coping with very painful events. The trainees then may develop more tolerance for reflecting on painful matters and get into the habit of trying to learn from their own experiences, even when these are painful. Similarly, if trainers use methods aimed at making the participants active partners in increasing their knowledge and expanding their skills, their trainees are more likely to become counsellors who search for opportunities to activate their clients and stimulate them to use and expand coping skills they already possess. Such a result cannot be expected from a training in which the participants spend most of their time listening passively to lectures. It is the author’s experience that some trainers and trainers-to-be rarely reflect on their educational methods in relation to the needs of the future grassroots counsellors or psychosocial workers they want to train. Instead they copy the educational methods they underwent during their own studies. These often are methods designed for people with sophisticated prior education during lengthy programs. They are an appropriate model for short courses that must be provided to barely educated people. Other trainers see training as a form of parachuting knowledge and skills on the participants in their training. The alternative approach is to help the participants recognise what they know already and which skills they have already acquired without any specialist education the trainer’s task is to empower them to use their existing abilities in a more conscious and effective way.

G. van der Veer / Basic Principles in Training Trainers for Counsellors and Psychosocial Workers 185

Trainers of grass-root counsellors and psychosocial workers often are consultants from outside the organisation the grass-root counsellors belong to. As temporary guests and outsiders, they have to join the traffic in the organisation. In addition to working with the future fieldworkers, they must put much energy into connecting with all keyfigures in the organisation. Obtaining high level approval of the training’s main messages and securing co-operation from leadership is also an important part of their task. The Input from the Participants in a Training of Trainers Training is an interaction between the trainer and the participants as well as an interaction among the participants. The participants can make an important contribution. Training is not just transfer of expertise from the trainer to the participants. It is an interactive process, in which expertise is developed. At the end of the training sessions, the trainer may have learned just as much as the participants. During a training of trainers of grassroots counsellors and psychosocial workers, the participants have several types of personal experience that can be used as resources in the training process: their experiences as persons with personal problems, their ongoing practical experience as counsellors or psychosocial workers, their experiences as pupils in some form of education, and their existing skills in educating others. Experiences as persons with personal problems. Discussions of these experiences in a group of future trainers may have therapeutic value, for example for participants suffering from the psychological consequences of traumatic experiences or participants on the edge of a burnout. Such discussions can help all participants become more aware of what is needed to create a safe atmosphere in a training group. Ongoing practical experience as a counsellors or psychosocial workers. Discussions of these experiences is indispensable for getting an overview of the problems and difficult situations the participants and the people they will train in the future face in the field. Such an overview is necessary for developing a curriculum that connects with the experiential world of the future trainees. Experiences as pupils in some form of education. Discussion of the experience of being a pupil can make the participants aware of group dynamics, different educational methods, diverging forms of giving feedback and so on. In practice, the majority of the participants in training courses in areas of armed conflict have more experience with authoritarian, top-down educational methods and punitive feedback than with egalitarian methods and encouraging feedback. A training using egalitarian methods therefore can make them at first feel quite insecure, as if they are participating in a game where they don’t know the rules. Counselling and psychosocial work are by definition egalitarian and non-punitive approaches, and thus often contradictory to the educational traditions in many conflict areas. Future trainers should be aware of this fact and be prepared for the task of overcoming a ‘cultural’ gap. Promoting an egalitarian and non-punitive approach to education may be the most important task for the trainer of trainers. Existing skills in educating others. The existing skills of the participants in educating others in an egalitarian and non-punitive way may be limited. But they can sometimes be identified, for example in the way some of the participants ‘teach’ their parents to adapt to the changed circumstances after the armed conflict. Despite the limitations in a trainer’s skills, they also are, potentially, an important resource, for they may sometimes be more culturally appropriate than the skills of the trainer.

186 G. van der Veer / Basic Principles in Training Trainers for Counsellors and Psychosocial Workers

The trainer can use all these resources by stimulating the participants to discuss their own experiences and by inviting them to demonstrate their skills through roleplay. The Input of the Trainer The trainer assumes the role of leader in this process of sharing these experiences and demonstrating skills to one-another. He does that through creating and guarding a safe atmosphere in which personal experiences of the various kinds mentioned above, including painful ones, can be openly discussed. As a contribution to this goal, he may at times be the first to discuss some of his own personal experiences: as a human being with personal problems, as a counsellor, as a pupil, or as a trainer. In addition, he is a model for giving respectful, encouraging feedback (in contrast to being a model for neglect by withholding positive feedback, or, worse yet, giving only punitive or humiliating feedback). Whatever he says or shows by his non-verbal behaviour, should never be perceived as an attack on one of the participants. This requires a strong awareness by the trainer of his own irritations, sources of impatience, positive and negative prejudices towards some of the participants, tendencies to ignore less attractively looking participants, aggressive impulses and so on. Lastly, he must be prepared to offer a simple conceptual framework for ordering, summarising and making sense of the experiences discussed during the training sessions and for describing the skills that were shown. This framework is meant to serve the participants, and not to force anything upon them.

Making a Program for Training Trainers A training program can be characterised by it’s main message, by a description of the attitude the trainer wants the participants to have at the end of the training, by the knowledge he hopes to transfer, and by the skills the participants are supposed to have available at the end of the training. Main message. In the type of training for trainers I recommend, the main message is that a trainer for grassroots counsellors, when it comes to helping people with personal problems, is not all-knowing, but that he assumes leadership of a shared search for ways of helping clients. The attitude to be developed during the training. This attitude can be described as non-judgemental, warm, respectful, encouraging and supportive towards the counsellors-to-be. The knowledge transferred during the training. For a trainer of counsellors, this knowledge could include: 1.

2.

Theoretical knowledge on general psychological subjects: at least one theory introducing the concept of unconscious mental activity, a basic introduction to learning theories, a basic introduction to developmental psychology with at least one description of developmental stages, a basic introduction to social psychology at least including the concepts of communication, conformity, group pressure and obedience to authority. Information on problems often occurring in individuals and families within traumatised communities, such as alcoholism, family conflicts, sexual prob-

G. van der Veer / Basic Principles in Training Trainers for Counsellors and Psychosocial Workers 187

3. 4.

5.

lems, depressive complaints, complaints and symptoms related to traumatic experiences including sexual violence. Basic knowledge on psychopathology: knowledge on the core symptoms of psychotic disorders. At least one theory on the use of various counselling strategies in practice that can be applied in areas of armed conflict and developing countries, for example the one described by Van der Veer [3,4]. Knowledge related to training: training methods and how to select them, how to make a program and how to evaluate the effect of a training.

For a trainer of psychosocial workers, an even more limited knowledge repertoire could be selected, by omitting some of general psychological subjects and the theory on the use of various counselling strategies in practice. The skills the participants should have acquired at the end of the training. These can be summed up as follows: 1.

2.

3.

4.

Basic presentation skills: they are able to keep the attention of a group, they can speak quietly with clear articulation, they can lead a group discussion, they can interrupt punitive feedback by one participant to the other in a respectful way and rephrase it as encouraging feedback. Generic training skills: they are able to establish contact with the participants, they are able to explain complicated matters step by step, they are able to ensure a secure atmosphere in which personal experiences of the participants can be discussed, they are able to monitor themselves during the training sessions, they are able to monitor the participants during the training sessions, they are able to write a report on a training. Specific training skills: they are able to use most of the following trainingmethods: dialogue-lecture, brain storming, group discussion, demonstration of some counselling skill by the trainer(s), dramatic expression by the participants, role-play counselling by the participants and counselling by the participants of one-another about real problems, questions and answers, the use of dolls or similar material to clarify the social context of individual problems, the use of dolls or similar material to clarify inner problems of individuals, and the use of a video-recorder (Van der Veer, 2003). Designer skills: they are able to design a training program for psychosocial workers or grassroots counsellors, tailor made for the particular needs and problems of the community in which the counsellors will work. This program should be based on an explicit view on what knowledge, skills, attitude and level of personal development is needed for a counsellor within the community in question.

A training for trainers can best be given in parts, alternated with training under supervision of an experienced trainers. The Initial Training in a Training for Trainers Program: An Example In 2003, the author was invited to train a group of 12 experienced counsellors and community health promotors in Vavuniya, Sri Lanka [2]. These people often were asked to give a basic training to workers in psychosocial projects. This first introductory training of trainers lasted 5 days and focussed on training skills.

188 G. van der Veer / Basic Principles in Training Trainers for Counsellors and Psychosocial Workers

Purpose: The purpose was formulated as follows: after the training the participants feel more confident about themselves as trainers on basic skills of helping and they have become more skilled in preparing and presenting a program for a training-course within a psychosocial project. During the training the participants have become acquainted with a training approach that is aimed at mobilizing existing skills and knowledge of the participants and actively involving them in the training sessions. Program. The program included the following core items: 1. 2. 3.

4. 5. 6.

7.

positive experiences at school as a pupil or during participation in a training negative experiences at school as a pupil or during participation in a training concepts for describing a training program: such as training item, purpose of the item, content of the item in terms of the knowledge, skills or attitude change, educational methods used while facilitating the item designing a global program for a training on HIV and Sexually Transmitted Diseases for Psychosocial Field assistants and working out one item in detail giving feedback to participants in a training an overview of training methods (such as: Dialogue lecture, Lecture, Structured group discussion, Brainstorm, Discussion in small groups or couples, Demonstration role play, Role play, Practice in pairs, Instruction) preparing a three days training in helping skills for groups of teachers, midwifes and volunteer community workers.

Educational tools. Big paper sheets, white board and markers, video, handouts (these were handed out after the training and meant to function as concise reminders of the subject matter). Evaluation: as a result of the training, the participants were able to develop a training program when co-operating in small groups. All participants experienced more self-confidence as a team worker with regard to presenting a program and reacting to questions from participants. Some of them clearly had progressed with regard to their presentation skills. Example of a Follow-Up Training After a Year After the training described above, the participants carried out various training courses based on the program developed during this training. After a year they were offered a follow up training, in which the participants could discuss their experiences over the past year. Purpose: The purpose was formulated as follows: after the follow up training, the participants feel that they have developed with regard to the learning needs they mentioned during the learning needs assessment at the start of the training. They have more insight in basic principles of a training approach that is aimed on mobilising existing skills and knowledge of the participants and actively involving them in the training sessions. They believe they have greatly improved their presentation skills. They understand the concept of inner mental processes and can discuss these inner processes during a training session, especially when discussing case-material. Program. The program included the following core-items: 1. experiences as trainers during the past year and present needs for training. The participants mentioned the following difficulties spontaneously:

G. van der Veer / Basic Principles in Training Trainers for Counsellors and Psychosocial Workers 189

• •

•

difficulties related to their attitude towards their trainees: dealing with their tension when training people who are older and more experienced, when training age mates, when trainings people they know personally. Difficulties in relation to skills: how to deal with a person who is showing off his knowledge, how to deal with a persons that claims too much attention, how to summarize a brainstorm discussion or another group session, how to give critical feedback to older, experienced people, how to bring participants back to the topic when they become sidetracked during a discussion. How to deal with participants who become overwhelmed by their feelings when traumatic experiences are discussed.

2. Other needs for education. The trainer then offered the participants a questionnaire about their training skills. As a result of this questionnaire, the following skills were identified for inclusion in the program because some of the participants felt that it was necessary to develop these skills Basic presentation skills: •

to interrupt punitive feedback from one participant towards another in a respectful way and rephrase it as encouraging feedback Generic training skills: • to monitor one’s own feelings during the training sessions, • to monitor the feelings of the participants during the training sessions, • to write a report on a training. Specific training skills: • • •

to give a dialogue-lecture, to demonstrate some helping skills in front of the trainees to use dolls or similar material to clarify the social context of individual problems, • to use of dolls or other teaching materials to help clarify inner processes of individuals, Designer skills • • •

to assess the training needs of a particular group to design a training program based on the identified needs to plan the evaluation of this training program

3. the main message of a training course. 4. designing a training for Community Health Promotors (CHP’s), aimed at making the participants aware of inner processes and how these processes may influence their work with clients 5. preparation of training items for a training for CHP’s training 6. carrying out the prepared CHP training course 7. evaluating the CHP training course 8. carrying out a revised training program with a second group of CHP’s 9. evaluation the second CHP training course 10. evaluating the revised course. 11. an item that went wrong in a previous training 12. role and attitude of a trainer for psychosocial workers

190 G. van der Veer / Basic Principles in Training Trainers for Counsellors and Psychosocial Workers

Educational tools: these were the same as in the initial training. Evaluation. On the job training of a group of 12 trainers is possible. During the program most of the participants show increasing insight in their own functioning and increasing awareness of their emotions.

References [1] Van der Veer, G. & A. van Waning (2004) (in book Drozdek & Wilson). [2] Onyut, L.P., F. Neuner, E. Schauer, V. Ertl, M. Odenwald, M. Schauer & T. Elbert (2004). The Nakivale Camp Mental Health Project: Building local competency for psychological assistance to traumatised refugees. Intervention, 2, 90–107. [3] Van der Veer, G. (2003) Training counsellors in areas of armed conflict within a community approach. Utrecht, Pharos. [4] Van der Veer, G. (2005) Former les conseillers dans les regions en conflit armé dans le cadre de l’approche communautaire. Amstelveen, War Trauma Foundation.

Promoting the Psychosocial Well Being of Children Following War and Terrorism M.J. Friedman and A. Mikus-Kos (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

191

Author Index Agani, F. Ager, A. Ajdukovic, D. Baker, A.M. Balaban, V.F. Boothby, N. Brymer, M.J. Fairbank, J.A. Friedman, M.J. Friedman, Z. Halprin, J. Ispanovic-Radojkovic, V. Jones, R.T.

105 61 3 163 121 89 73, 121 121 v, 113 33 89 171 121

Kanan, H.M. Knobler, H.Y. Laor, N. Layne, C.M. Medway, P.J. Métraux, J.-C. Mikus-Kos, A. Spirman, S. Steinberg, A.M. Strang, A.B. Stuvland, R. van der Veer, G. Wolmer, L.

163 33 33 121 73 45 v, 11 33 121 61 73 181 33

This page intentionally left blank

This page intentionally left blank

This page intentionally left blank