Ebook: Promoting the Psychosocial Well Being of Children Following War and Terrorism

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 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 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 adoles-cents 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 post-traumatic 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 makers 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

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.

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.

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.

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.

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].

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.