Connectedness, Social Support and Mental Health in Adolescents Displaced by the War in Chechnya

This study presents an exploratory, cross-sectional investigation of factors associated with internalizing emotional and behavioral problems (anxiety/depression, emotional withdrawal, and somatic complaints) in a sample of adolescents displaced by the war in Chechnya and interviewed in the fall of 2000. Social support and connectedness with family, peers, and the larger community were given particular attention as potential protective processes explaining variation in internalizing mental health problems as measured by the Achenbach Youth Self Report (YSR) scale (1991). It was hypothesized that family, peer and community connectedness, and global ratings of social support would be associated with lower levels of internalizing mental health problems in this population. Findings indicated that, consistent with other studies of war-affected children, internalizing behaviors in this sample of displaced adolescents were higher compared to rates in samples published on non-war-affected Russian adolescents. Expected gender differences were observed, with girls reporting higher internalizing problems than boys. No differences by gender on social support or family connectedness were observed; however, males reported higher peer connectedness and community connectedness than did females. In multivariate analyses, family connectedness was indicated as an enduring and significant predictor of lower internalizing mental health problem scores upon adjusting for covariates and all other forms of support investigated

Stressors, Supports, and the Social Ecology of Displacement: Psychosocial Dimensions of an Emergency Education Program for Chechen Adolescents Displaced in Ingushetia, Russia

This study explores the psychosocial benefits of an emergency education intervention serving adolescents displaced by the war in Chechnya. Interviews with 55 Chechen adolescents living in spontaneous settlements in Ingushetia, Russia were collected in the fall of 2000. The study set out to describe key stressors and sources of social support available to youth being served by the International Rescue Committee’s (IRC) emergency education program. Of particular interest was the degree to which the education program addressed psychosocial goals such as increasing social support and alleviating strains including idleness, the lack of safe and structured places for youth to spend time, and concerns about lost years of schooling expressed by children and families. Findings indicated that young people and their families were facing a number of physical and emotional stressors. Regarding physical stressors, adolescents described the “living conditions” in the spontaneous settlements as the most difficult thing they faced. The physical and material deprivations experienced in the settlements were described in terms of living in an “abnormal” or “inhuman” way, including poor or crowded living conditions; infrequent supplies of food, medicines and educational materials; and concerns about parents and older adolescents being able to find work. Regarding emotional stressors, participants identified a variety of sources including loss of home, loss of time/idleness, separation from loved ones, tensions with the Ingush host community, and concerns about their ability to be productive in the future. Furthermore, a sense of humiliation linked to deprivation pervaded the experience of Chechen youth in these IDP settlements. The data indicated a number of ways in which the emergency education program provided benefits by enriching sources of support, providing meaningful activity and opportunities to learn, and a place and space for young people to spend time and connect to others. In particular, youth leaders described how the program had improved their confidence in working with others and had influenced their career goals. However, the contrast between the desire of adolescents “to live like other kids” and the options available to them presented a dilemma for the emergency education program: adolescents were craving normality, but for any intervention to be delivered, it had first to begin with creative and adaptive strategies that were by no means a complete replacement for formal, mainstream education. The programmatic and policy implications of these findings are presented in the discussion

Long term mental health outcomes of Finnish children evacuated to Swedish families during the second world war and their non-evacuated siblings: cohort study

Objectives To compare the risks of admission to hospital for any type of psychiatric disorder and for four specific psychiatric disorders among adults who as children were evacuated to Swedish foster families during the second world war and their non-evacuated siblings, and to evaluate whether these risks differ between the sexes. Design Cohort study. Setting National child evacuation scheme in Finland during the second world war. Participants Children born in Finland between 1933 and 1944 who were later included in a 10% sample of the 1950 Finnish census ascertained in 1997 (n=45 463; women: n=22 021; men: n=23 442). Evacuees in the sample were identified from war time government records. Main outcome measure Adults admitted to hospital for psychiatric disorders recorded between 1971 and 2011 in the Finnish hospital discharge register. Methods We used Cox proportional hazards models to estimate the association between evacuation to temporary foster care in Sweden during the second world war and admission to hospital for a psychiatric disorder between ages 38 and 78 years. Fixed effects methods were employed to control for all unobserved social and genetic characteristics shared among siblings. Results Among men and women combined, the risk of admission to hospital for a psychiatric disorder did not differ between Finnish adults evacuated to Swedish foster families and their non-evacuated siblings (hazard ratio 0.89, 95% confidence interval 0.64 to 1.26). Evidence suggested a lower risk of admission for any mental disorder (0.67, 0.44 to 1.03) among evacuated men, whereas for women there was no association between evacuation and the overall risk of admission for a psychiatric disorder (1.21, 0.80 to 1.83). When admissions for individual psychiatric disorders were analyzed, evacuated girls were significantly more likely than their non-evacuated sisters to be admitted to hospital for a mood disorder as an adult (2.19, 1.10 to 4.33). Conclusions The Finnish evacuation policy was not associated with an increased overall risk of admission to hospital for a psychiatric disorder in adulthood among former evacuees. In fact, evacuation was associated with a marginally reduced risk of admission for any psychiatric disorder among men. Among women who had been evacuated, however, the risk of being admitted to hospital for a mood disorder was increased.Peer reviewe

A Longitudinal Study of Psychosocial Adjustment and Community Reintegration among Former Child Soldiers in Sierra Leone

The phenomenon of children associated with armed forces and armed groups is an issue of increasing global concern. The forceful conscription of children (both boys and girls) into armed forces has been documented in at least 86 countries (Coalition to Stop the Use of Child Soldiers 2008). Available research suggests that these children may face heightened risk for psychological and social problems (Wessells 2009; Blattman and Annan in press). However, there is little evidence about the long-term effects of child soldiers' wartime experiences. In 2002, a collaboration between the Harvard School of Public Health and the International Rescue Committee (IRC) led to the launch of a longitudinal study of war-affected youth in Sierra Leone. The study was designed to identify risk and protective factors in psychosocial adjustment and social reintegration. The research was informed by an ecological approach to child health and well-being which examines the interaction of influences at the individual, familial, peer, community and cultural/collective level (Bronfenbrenner 1979; Betancourt and Khan 2008). The study was also shaped by contemporary theory and research related to resilience in the mental health and development of children and families in adversity

The impact of measurement differences on cross-country depression prevalence estimates: A latent transition analysis

Background Depression is currently the second largest contributor to non-fatal disease burden globally. For that reason, economic evaluations are increasingly being conducted using data from depression prevalence estimates to analyze return on investments for services that target mental health. Psychiatric epidemiology studies have reported large cross-national differences in the prevalence of depression. These differences may impact the cost-effectiveness assessments of mental health interventions, thereby affecting decisions regarding government and multi-lateral investment in mental health services. Some portion of the differences in prevalence estimates across countries may be due to true discrepancies in depression prevalence, resulting from differential levels of risk in environmental and demographic factors. However, some portion of those differences may reflect non-invariance in the way standard tools measure depression across countries. This paper attempts to discern the extent to which measurement differences are responsible for reported differences in the prevalence of depression across countries. Methods and findings This analysis uses data from the World Mental Health Surveys, a coordinated series of psychiatric epidemiology studies in 27 countries using multistage household probability samples to assess prevalence and correlates of mental disorders. Data in the current study include responses to the depression module of the World Mental Health Composite International Diagnostic Interview (CIDI) in four countries: Two high-income, western countries—the United States (n = 20, 015) and New Zealand (n = 12,992)—an upper-middle income sub-Saharan African country, South Africa (n = 4,351), and a lower-middle income sub-Saharan African country, Nigeria (n = 6,752). Latent class analysis, a type of finite mixture modeling, was used to categorize respondents into underlying categories based on the variation in their responses to questions in each of three sequential parts of the CIDI depression module: 1) The initial screening items, 2) Additional duration and severity exclusion criteria, and 3) The core symptom questions. After each of these parts, exclusion criteria expel respondents from the remainder of the diagnostic interview, rendering a diagnosis of “not depressed”. Latent class models were fit to each of the three parts in each of the four countries, and model fit was assessed using overall chi-square values and Pearson standardized residuals. Latent transition analysis was then applied in order to model participants’ progression through the CIDI depression module. Proportion of individuals falling into each latent class and probabilities of transitioning into subsequent classes were used to estimate the percentage in each country that ultimately fell into the more symptomatic class, i.e. classified as “depressed”. This latent variable design allows for a non-zero probability that individuals were incorrectly excluded from or retained in the diagnostic interview at any of the three exclusion points and therefore incorrectly diagnosed. Prevalence estimates based on the latent transition model reversed the order of depression prevalence across countries. Based on the latent transition model in this analysis, Nigeria has the highest prevalence (21.6%), followed by New Zealand (17.4%), then South Africa (15.0%), and finally the US (12.5%). That is compared to the estimates in the World Mental Health Surveys that do not allow for measurement differences, in which Nigeria had by far the lowest prevalence (3.1%), followed by South Africa (9.8%), then the United States (13.5%) and finally New Zealand (17.8%). Individuals endorsing the screening questions in Nigeria and South Africa were more likely to endorse more severe depression symptomology later in the module (i.e. they had higher transition probabilities), suggesting that individuals in the two Western countries may be more likely to endorse screening questions even when they don’t have as severe symptoms. These differences narrow the range of depression prevalence between countries 14 percentage points in the original estimates to 6 percentage points in the estimate taking account of measurement differences. Conclusions These data suggest fewer differences in cross-national prevalence of depression than previous estimates. Given that prevalence data are used to support key decisions regarding resource-allocation for mental health services, more critical attention should be paid to differences in the functioning of measurement across contexts and the impact these differences have on prevalence estimates. Future research should include qualitative methods as well as external measures of disease severity, such as impairment, to assess how the latent classes predict these external variables, to better understand the way that standard tools estimate depression prevalence across contexts. Adjustments could then be made to prevalence estimates used in cost-effectiveness analyses

Developing and Validating the Youth Conduct Problems Scale-Rwanda: A Mixed Methods Approach

This study developed and validated the Youth Conduct Problems Scale-Rwanda (YCPS-R). Qualitative free listing (n = 74) and key informant interviews (n = 47) identified local conduct problems, which were compared to existing standardized conduct problem scales and used to develop the YCPS-R. The YCPS-R was cognitive tested by 12 youth and caregiver participants, and assessed for test-retest and inter-rater reliability in a sample of 64 youth. Finally, a purposive sample of 389 youth and their caregivers were enrolled in a validity study. Validity was assessed by comparing YCPS-R scores to conduct disorder, which was diagnosed with the Mini International Neuropsychiatric Interview for Children, and functional impairment scores on the World Health Organization Disability Assessment Schedule Child Version. ROC analyses assessed the YCPS-R’s ability to discriminate between youth with and without conduct disorder. Qualitative data identified a local presentation of youth conduct problems that did not match previously standardized measures. Therefore, the YCPS-R was developed solely from local conduct problems. Cognitive testing indicated that the YCPS-R was understandable and required little modification. The YCPS-R demonstrated good reliability, construct, criterion, and discriminant validity, and fair classification accuracy. The YCPS-R is a locally-derived measure of Rwandan youth conduct problems that demonstrated good psychometric properties and could be used for further research

Family-centred approaches to the prevention of mother to child transmission of HIV

Background: Prevention of mother to child transmission (PMTCT) programmes have traditionally been narrow in scope, targeting biomedical interventions during the perinatal period, rather than considering HIV as a family disease. This limited focus restricts programmes' effectiveness, and the opportunity to broaden prevention measures has largely been overlooked. Although prevention of vertical transmission is crucial, consideration of the family environment can enhance PMTCT. Family-centred approaches to HIV prevention and care present an important direction for preventing paediatric infections while improving overall family health. This paper reviews available literature on PMTCT programmatic models that have taken a broader or family-centred approach. We describe findings and barriers to the delivery of family-centred PMTCT and identify a number of promising new directions that may achieve more holistic services for children and families. Methods: Literature on the effectiveness of family-centred PMTCT interventions available via PubMed, EMBASE and PsycINFO were searched from 1990 to the present. Four hundred and three abstracts were generated. These were narrowed to those describing or evaluating PMTCT models that target broader aspects of the family system before, during and/or after delivery of an infant at risk of acquiring HIV infection (N = 14). Results: The most common aspects of family-centred care incorporated by PMTCT studies and programme models included counselling, testing, and provision of antiretroviral treatment for infected pregnant women and their partners. Antiretroviral therapy was also commonly extended to other infected family members. Efforts to involve fathers in family-based PMTCT counselling, infant feeding counselling, and general decision making were less common, though promising. Also promising, but rare, were PMTCT programmes that use interventions to enrich family capacity and functioning; these include risk assessments for intimate partner violence, attention to mental health issues, and the integration of early childhood development services. Conclusions: Despite barriers, numerous opportunities exist to expand PMTCT services to address the health needs of the entire family. Our review of models utilizing these approaches indicates that family-centred prevention measures can be effectively integrated within programmes. However, additional research is needed in order to more thoroughly evaluate their impact on PMTCT, as well as on broader family health outcomes

A qualitative case study of child protection issues in the Indian construction industry: investigating the security, health, and interrelated rights of migrant families

Background: Many of India’s estimated 40 million migrant workers in the construction industry migrate with their children. Though India is undergoing rapid economic growth, numerous child protection issues remain. Migrant workers and their children face serious threats to their health, safety, and well-being. We examined risk and protective factors influencing the basic rights and protections of children and families living and working at a construction site outside Delhi. Methods: Using case study methods and a rights-based model of child protection, the SAFE model, we triangulated data from in-depth interviews with stakeholders on and near the site (including employees, middlemen, and managers); 14 participants, interviews with child protection and corporate policy experts in greater Delhi (8 participants), and focus group discussions (FGD) with workers (4 FGDs, 25 members) and their children (2 FGDs, 9 members). Results: Analyses illuminated complex and interrelated stressors characterizing the health and well-being of migrant workers and their children in urban settings. These included limited access to healthcare, few educational opportunities, piecemeal wages, and unsafe or unsanitary living and working conditions. Analyses also identified both protective and potentially dangerous survival strategies, such as child labor, undertaken by migrant families in the face of these challenges. Conclusions: By exploring the risks faced by migrant workers and their children in the urban construction industry in India, we illustrate the alarming implications for their health, safety, livelihoods, and development. Our findings, illuminated through the SAFE model, call attention to the need for enhanced systems of corporate and government accountability as well as the implementation of holistic child-focused and child-friendly policies and programs in order to ensure the rights and protection of this hyper-mobile, and often invisible, population

Validation of the “World Health Organization Disability Assessment Schedule for Children, WHODAS-Child” in Rwanda

Overview: The World Health Organization Disability Assessment Schedule for children (WHODAS-Child) is a disability assessment instrument based on the WHO's International Classification of Functioning, Disability and Health for children and youth. It is modified from the original adult version specifically for use with children. The aim of this study was to assess the WHODAS-Child structure and metric properties in a community sample of children with and without reported psychosocial problems in rural Rwanda. Methods: The WHODAS-Child was first translated into Kinyarwanda through a detailed committee translation process and back-translation. Cognitive interviewing was used to assess the comprehension of the translated items. Test-retest reliability was assessed in a group of 64 children. The translated WHODAS-Child was then administered to a final sample of 367 children in southern Kayonza district in rural southeastern Rwanda within a larger psychosocial assessment battery. The latent structure was assessed through confirmatory factor analysis. Reliability was evaluated in terms of internal consistency (Cronbach's alpha) and test-retest reliability (Pearson's correlation coefficient). Construct validity was explored by examining convergence between WHODAS-Child scores and mental disorder status, and divergence of WHODAS-Child scores with protective factors and prosocial behaviors. Concordance between parent and child scores was also assessed. Results: The six-factor structure of the WHODAS-Child was confirmed in a population sample of Rwandan children. Test-retest and inter-rater reliability were high (r = .83 and ICC = .88). WHODAS-Child scores were moderately positively correlated with presence of depression (r = .42, p<.001) and post-traumatic stress disorder (r = .31, p<.001) and moderately negatively correlated with prosocial behaviors (r = .47, p<.001). The Kinyarwanda version of the WHODAS-Child was found to be a reliable and acceptable self-report tool for assessment of functional impairment among children largely referred for psychosocial problems in the study district in rural Rwanda. Further research in low-resource settings and with more general populations is recommended

Mitigating toxic stress in children affected by conflict and displacement

Anushka Ataullahjan and colleagues describe the myriad stressors related to conflict and displacement experienced by children and how best to reduce their negative effec