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

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

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

Experiences and acceptance of intimate partner violence: associations with sexually transmitted infection symptoms and ability to negotiate sexual safety among young Liberian women

Women who experience intimate partner violence may be at elevated risk for poor sexual health outcomes including sexual transmitted infections (STIs). This association however, has not been consistently demonstrated in low-income or post-conflict countries; furthermore, the role that attitudes towards intimate partner violence play in sexual health outcomes and behaviour has rarely been examined. We examined associations between intimate partner violence experiences, accepting attitudes towards physical intimate partner violence, and sexual health and behavioural outcomes among 592 young women in post-conflict Liberia. Participants’ experiences with either moderate or severe physical violence or sexual violence were common. Additionally, accepting attitudes towards physical intimate partner violence were positively associated with reporting STI symptoms, intimate partner violence experiences and the ability to negotiate safe sex. Findings suggest that for sexual health promotion and risk reduction intervention efforts to achieve full impact, interventions must address the contextual influence of violence, including individual attitudes toward intimate partner violence

Sierra Leone's Child Soldiers: War Exposures and Mental Health Problems by Gender

Purpose: To examine associations between war experiences, mental health, and gender in a sample of male and female Sierra Leonean former child soldiers. Methods: A total of 273 former child soldiers (29% females) were assessed for depression and anxiety by using the Hopkins Symptoms Checklist, and for hostility, confidence, and prosocial attitudes by using an instrument developed for use with Sierra Leonean child soldiers. Results: The former child soldiers had witnessed and perpetrated violence at largely comparable rates, although females experienced higher rates of rape (p.0001). More females scored within clinical ranges for depression (p .008) and anxiety (p.0001). In multiple regression analyses, female gender was a significant predictor of lower levels of confidence but not of mental health problems. Children who perpetrated injury or killing reported greater levels of depression (p.0001), anxiety (p.0001), and hostility (p.0001). Surviving rape was associated with increased anxiety (p.05) and hostility (p.05), in males. Surviving rape was also related to higher confidence levels (p.05) and prosocial attitudes (p.05). Male former child soldiers who lost caregivers were also more vulnerable to depression (p.05) and anxiety (p.05), strong and significant effects noted among male child soldiers. Conclusions: In our sample, female and male child soldiers experienced comparable levels of most war exposures. Female soldiers reported higher rates of rape and lower levels of adaptive outcomes. Toxic forms of violence (killing or injuring; rape) were associated with particularly poor outcomes. Although all boys and girls who experience rape and loss of caregivers are generally at risk for mental health problems, boys in our sample demonstrated increased vulnerability; these findings indicate a need for more inclusive mental health services

Interventions for Children Affected by War

Background Children and adolescents exposed to armed conflict are at high risk of developing mental health problems. To date, a range of psychosocial approaches and clinical/psychiatric interventions has been used to address mental health needs in these groups. Aims To provide an overview of peer-reviewed psychosocial and mental health interventions designed to address mental health needs of conflict-affected children, and to highlight areas in which policy and research need strengthening. Methods We used standard review methodology to identify interventions aimed at improving or treating mental health problems in conflict-affected youth. An ecological lens was used to organize studies according to the individual, family, peer/school, and community factors targeted by each intervention. Interventions were also evaluated for their orientation toward prevention, treatment, or maintenance, and for the strength of the scientific evidence of reported effects. Results Of 2305 studies returned from online searches of the literature and 21 sources identified through bibliography mining, 58 qualified for full review, with 40 peer-reviewed studies included in the final narrative synthesis. Overall, the peer-reviewed literature focused largely on school-based interventions. Very few family and community-based interventions have been empirically evaluated. Only two studies assessed multilevel or stepped-care packages. Conclusions The evidence base on effective and efficacious interventions for conflict-affected youth requires strengthening. Postconflict development agendas must be retooled to target the vulnerabilities characterizing conflict-affected youth, and these approaches must be collaborative across bodies responsible for the care of youth and families

The psychological toll of slum living in Mumbai, India: A mixed methods study

In India, “non-notified” slums are not officially recognized by city governments; they suffer from insecure tenure and poorer access to basic services than “notified” (government-recognized) slums. We conducted a study in a non-notified slum of about 12,000 people in Mumbai to determine the prevalence of individuals at high risk for having a common mental disorder (i.e., depression and anxiety), to ascertain the impact of mental health on the burden of functional impairment, and to assess the influence of the slum environment on mental health. We gathered qualitative data (six focus group discussions and 40 individual interviews in July-November 2011), with purposively sampled participants, and quantitative data (521 structured surveys in February 2012), with respondents selected using community-level random sampling. For the surveys, we administered the General Health Questionnaire-12 (GHQ) to screen for common mental disorders (CMDs), the WHO Disability Assessment Schedule 2.0 (WHO DAS) to screen for functional impairment, and a slum adversity questionnaire, which we used to create a composite Slum Adversity Index (SAI) score. Twenty-three percent of individuals have a GHQ score ≥5, suggesting they are at high risk for having a CMD. Psychological distress is a major contributor to the slum’s overall burden of functional impairment. In a multivariable logistic regression model, household income, poverty-related factors, and the SAI score all have strong independent associations with CMD risk. The qualitative findings suggest that non-notified status plays a central role in creating psychological distress—by creating and exacerbating deprivations that serve as sources of stress, by placing slum residents in an inherently antagonistic relationship with the government through the criminalization of basic needs, and by shaping a community identity built on a feeling of social exclusion from the rest of the city

Family-based prevention of mental health problems in children affected by HIV and AIDS

Objective The objective of this study is to assess the feasibility and acceptability of an intervention to reduce mental health problems and bolster resilience among children living in households affected by caregiver HIV in Rwanda. Design Pre-post design, including 6-month follow-up. Methods The Family Strengthening Intervention (FSI) aims to reduce mental health problems among HIV-affected children through improved child–caregiver relationships, family communication and parenting skills, HIV psychoeducation and connections to resources. Twenty families (N=39 children) with at least one HIV-positive caregiver and one child 7–17 years old were enrolled in the FSI. Children and caregivers were administered locally adapted and validated measures of child mental health problems, as well as measures of protective processes and parenting. Assessments were administered at pre and postintervention, and 6-month follow-up. Multilevel models accounting for clustering by family tested changes in outcomes of interest. Qualitative interviews were completed to understand acceptability, feasibility and satisfaction with the FSI. Results Families reported high satisfaction with the FSI. Caregiver-reported improvements in family connectedness, good parenting, social support and children's pro-social behaviour (P<0.05) were sustained and strengthened from postintervention to 6-month follow-up. Additional improvements in caregiver-reported child perseverance/self-esteem, depression, anxiety and irritability were seen at follow-up (P<.05). Significant decreases in child-reported harsh punishment were observed at postintervention and follow-up, and decreases in caregiver reported harsh punishment were also recorded on follow-up (P<0.05). Conclusion The FSI is a feasible and acceptable intervention that shows promise for improving mental health symptoms and strengthening protective factors among children and families affected by HIV in low-resource settings