A focus on adolescence to reduce neurological, mental health and substance-use disability.

Globally, there is a crucial need to prioritize research directed at reducing neurological, mental health and substance-use disorders in adolescence, which is a pivotal age for the development of self-control and regulation. In adolescence, behaviour optimally advances towards adaptive long-term goals and suppresses conflicting maladaptive short-lived urges to balance impulsivity, exploration and defiance, while establishing effective societal participation. When self-control fails to develop, violence, injury and neurological, mental health and substance-use disorders can result, further challenging the development of self-regulation and impeding the transition to a productive adulthood. Adolescent outcomes, positive and negative, arise from both a life-course perspective and within a socioecological framework. Little is known about the emergence of self-control and regulation in adolescents in low- and middle-income countries where enormous environmental threats are more common (for example, poverty, war, local conflicts, sex trafficking and slavery, early marriage and/or pregnancy, and the absence of adequate access to education) than in high-income countries and can threaten optimal neurodevelopment. Research must develop or adapt appropriate assessments of adolescent ability and disability, social inclusion and exclusion, normative development, and neurological, mental health and substance-use disorders. Socioecological challenges in low- and middle-income countries require innovative strategies to prevent mental health, neurological and substance-use disorders and develop effective interventions for adolescents at risk, especially those already living with these disorders and the consequent disability.

Mental health problems from direct vs indirect exposure to violent events among children born and growing up in a conflict zone of southern Thailand.

PURPOSE: This study aims to examine and compare the effects of direct and indirect exposure to armed conflicts on the mental health of primary school students in the three southernmost provinces of Thailand. METHODS: A school-based survey was conducted. Detailed exposure of traumatic events both directly and indirectly were measured by a self-completed questionnaire. Behavioral-emotional problems were measured by the Strength and Difficulty Questionnaire and screening for post-traumatic stress disorder (PTSD) was done using the Children's Revised Impact of Events Scale (CRIES). Multivariate analysis adjusted for gender and other covariates was used to determine the effect of direct and indirect exposure of armed conflict on mental health problems. RESULTS: Out of 941 students included in the study, almost half had direct exposure to an armed conflict event. Overall, 42.1% of students had at least one behavioral-emotional problem (47.6% and 38.5% in the direct- and indirect-exposed groups, respectively) and 30.5% was found to have PTSD (37.3% and 25.9% in the direct- and indirect-exposed groups, respectively). Students who had direct exposure to an armed conflict event had a two times higher odds of mental health problems than their peers. Other modifiable factors of mental health problems were receiving news from two sources including other adults and media, and exposure to other non-conflict-related traumatic life events. CONCLUSIONS: Children living in armed conflict areas of southern Thailand, although without any direct exposure to traumatic events, also suffered from mental health problems. Research on appropriate interventions for these children should be further conducted.

The role of parental negative world assumptions in the intergenerational transmission of war trauma.

PURPOSE: Among the most prevalent and adverse sequalae of traumatic experiences are negative world assumptions (WAs), which describe trauma-related negative cognitions regarding the self, the world, and others. Even though a wealth of studies has shown intrapersonal associations between negative WAs and posttraumatic stress symptoms (PTSS), there has been little research on how WAs may affect family systems. This study examined the intergenerational associations between parental WAs, paternal PTSS, and maternal secondary traumatic stress (STS) on adult-children's STS in veterans' families. It was hypothesized that negative paternal WAs would mediate the association between parental PTSS/STS and adult-children's STS. METHODS: Three domains of WAs (benevolence of the world, meaningfulness of the world, and self-worth) and PTSS were prospectively assessed in 123 father-mother-offspring triads of former Israeli veterans of the 1973 Yom Kippur War, their wives and adult offspring. Data were collected in 2003, 2008, and 2014, and analyzed using triadic path modeling. RESULTS: Mothers' STS was associated with children's STS via negative maternal WAs on world benevolence. Fathers' PTSS was related to children's STS via fathers' WAs on world benevolence and self-worth. Moreover, fathers' WAs on world benevolence and self-worth mediated the intergenerational transmission of STS from mothers to offspring. No effects were found for meaningfulness WAs. CONCLUSION: Findings suggest that parental WAs related to world benevolence and paternal self-worth contribute to intergenerational trauma transmission. Clinical implications favor cognitive and systemic approaches to therapy that address negative benevolence and self-worth assumptions and involve the entire family system.

Perceptions of War Trauma and Healing of Marital Relations Among Torture-surviving Congolese Couples Participating in Multicouple Therapy.

Citizens of the Democratic Republic of Congo (DRC) experienced widespread torture during national wars between 1998 and 2003. Couples who survived and stayed intact suffered tremendous relationship stress. This study used a critical ethnography framework to explore the prewar, wartime, and postwar experiences of 13 torture-surviving couples who participated in a 10-session Torture-Surviving Couple Group in 2008 in the DRC. The group was designed to address the relational effects of torture and war trauma. Participants reported profound negative effects of the war on their relationships; mostly positive experiences during the group, including marital and peer connection and relationship growth; and a number of improvements in their relationship after the group. Implications include support for the use of relational interventions informed by both treatments for traumatic stress and couple approaches to promote trauma healing. Future directions call for increased funding, research, training, and clinical action to treat the effects of traumatic stress on relational family dynamics.

Los ciudadanos de la República Democrática del Congo (RDC) sufrieron torturas generalizadas durante las guerras nacionales entre 1998 y 2003. Las parejas que sobrevivieron y se mantuvieron intactas sufrieron un estrés relacional enorme. Este estudio utilizó un marco etnográfico fundamental para analizar las experiencias en tiempos de preguerra, de guerra y de posguerra de 13 parejas sobrevivientes de la tortura que participaron en un grupo de parejas sobrevivientes de la tortura consistente en diez sesiones en 2008 en la RDC. El grupo se diseñó para abordar los efectos relacionales del trauma de la tortura y la guerra. Los participantes informaron efectos negativos profundos de la guerra en sus relaciones; mayormente experiencias positivas durante el grupo, por ejemplo, la conexión conyugal y entre pares y el crecimiento de la relación; y varias mejoras en su relación después del grupo. Entre las conclusiones se encuentran el respaldo del uso de intervenciones relacionales avaladas tanto por los tratamientos para el estrés traumático como por los enfoques de pareja para promover la recuperación del trauma. Las futuras direcciones requieren mayor financiamiento, investigación, capacitación y acción clínica para tratar los efectos del estrés traumático en la dinámica familiar relacional.

Terrorism Media Effects in Youth Exposed to Chronic Threat and Conflict in Israel.

PURPOSE OF REVIEW: This paper reviews the extant research on the effects of contact with terrorism media coverage on psychological outcomes in youth in the context of chronic threat and conflict in Israel. RECENT FINDINGS: The extant research is inconclusive with respect to the relationship between media contact and a variety of psychological outcomes in Israeli studies of youth exposed to ongoing threat and repeated terrorist attacks. Additional research is needed to examine potential differences in outcomes and the factors that influence youth coping and adaptation in an environment of chronic threat and extensive media coverage. Moreover, studies are needed to identify and evaluate potential parental, professional, and social strategies to enhance youth adjustment. Because political conflict in Israel is not likely to abate in the near future, the setting is ideal to conduct methodologically rigorous research including research using representative samples, prospective reporting, and longitudinal design.

Impact of war on child health in northern Syria: the experience of Médecins Sans Frontières.

Few data are available to evaluate the impact of Syrian war on civilian population; to describe this impact on child health, this article uses data from Médecins Sans Frontières-Operational Centre Amsterdam's activities in Tal-Abyad and Kobane cities, northern Syria (2013-2016). Data were obtained from routine medical datasets and narrative reports, for out-patient clinics, immunisation, nutritional monitoring and assessments, and in-patient care, and were analysed quantitatively and qualitatively. Infections were the largest contributor to morbidity. The proportion of < 5 year out-patient consultations of infectious diseases that are listed for outbreak monitoring in emergencies was 15% in 2013, 51% in 2014, 75% in 2015 and 70% in 2016. Thalassemia was recorded in 0.5% of 2014 < 5 year out-patient consultations and 3.4% of 2013-2014 < 18-year in-patient admissions. Measles immunisation activities and routine Extended Programme for Immunisation were re-activated across northern Syria; however, immunisation coverage could not be calculated. Results from our routine data must be compared cautiously, due to differences in settings and disease categories. CONCLUSION: With such scattered interventions, routine data are limited in providing a quantified evidence of emergency's health impact; however, they help in drawing a picture of children's health status and highlighting difficulties in providing curative and preventive services, in order to reflect part of population's plight. What is Known • Few data exist to evaluate the impact of the Syrian war on the health of children; • Médecins Sans Frontières (MSF-OCA) has worked in northern Syria during different times since 2013. What is New • Quantitative and qualitative analysis of MSF's routine medical data and situtation reports show that one fifth of all consultations in children < 5 years in MSF health facilities in northern Syria 2013-2016 were due to communicable diseases; • The analysis also highlights the burden of chronic conditions that were prevalent in Syria before the war, e.g. thalassemia.

Risk Factors for and Consequences of Substance Use in Post-Conflict Liberia: A Qualitative Study.

Substance use has a significant impact on post-conflict populations; however, little is known about this critical issue in Liberia. This study examined the current risk factors for and consequences of substance use in Monrovia, Liberia. In-depth interviews were conducted with 20 substance users and 21 key informants. Findings support that Liberia's civil war played a role in increasing substance use, but also that additional risk factors continue to generate substance use today. This study provides insights into the roles of civil war and additional risk factors for substance use in Liberia. Recommendations for substance use-related policies and programs are provided.

Behavioral and neural correlates of disrupted orienting attention in posttraumatic stress disorder.

Prior work has revealed that posttraumatic stress disorder (PTSD) is associated with altered (a) attentional performance and (b) resting-state functional connectivity (rsFC) in brain networks linked to attention. Here, we sought to characterize and link these behavioral and brain-based alterations in the context of Posner and Peterson's tripartite model of attention. Male military veterans with PTSD (N = 49; all deployed to Iraq or Afghanistan) and healthy age-and-gender-matched community controls (N = 26) completed the Attention Network Task. A subset of these individuals (36 PTSD and 21 controls) also underwent functional magnetic resonance imaging (fMRI) to assess rsFC. The behavioral measures revealed that the PTSD group was impaired at disengaging spatial attention, relative to the control group. FMRI measures further revealed that, relative to the control group, the PTSD group exhibited greater rsFC between the salience network and (a) the default mode network, (b) the dorsal attention network, and (c) the ventral attention network. Moreover, problems with disengaging spatial attention increased the rsFC between the networks above in the control group, but not in the PTSD group. The present findings link PTSD to both altered orienting of spatial attention and altered relationships between spatial orienting and functional connectivity involving the salience network. Interventions that target orienting and disengaging spatial attention may be a new avenue for PTSD research.

Psychological distress of parents in conflict areas: the mediating role of war atrocities, normative stressors and family resources.

BACKGROUND: Despite the ongoing controversy regarding which types of stressors or resources contribute to psychological distress, there has been little research examining the relationship between war trauma, normative stressors, family resources for management and psychopathology. AIMS: This study investigated the differences between mothers and fathers in psychological distress, normative stressors and war atrocities experienced, and family's resources for management. It was hypothesized that a combination of risk variables and protective variables would be predictive of psychological distress in parents. METHODS: Questionnaires were used with 205 Palestinian parents from Gaza Strip. RESULTS: Mothers had more psychiatric disorders than did fathers. Although, mothers and fathers were exposed to comparable levels of normative stressors, mothers concerns about intrafamily strains, and family legal violations were greater than they were for fathers. Results revealed that fathers possess a larger repertoire of resources for management when compared to mothers reflected in esteem and communication, mastery and health, extended family social support and financial well-being. However, mastery and health seem to buffer the effect of war traumas and normative stressors on neuroticism in both parents. CONCLUSION: The different patterns of predictor-outcome relations have practical as well as theoretical implications.

Attention training improves aberrant neural dynamics during working memory processing in veterans with PTSD.

Posttraumatic stress disorder (PTSD) is associated with executive functioning deficits, including disruptions in working memory (WM). Recent studies suggest that attention training reduces PTSD symptomatology, but the underlying neural mechanisms are unknown. We used high-density magnetoencephalography (MEG) to evaluate whether attention training modulates brain regions serving WM processing in PTSD. Fourteen veterans with PTSD completed a WM task during a 306-sensor MEG recording before and after 8 sessions of attention training treatment. A matched comparison sample of 12 combat-exposed veterans without PTSD completed the same WM task during a single MEG session. To identify the spatiotemporal dynamics, each group's data were transformed into the time-frequency domain, and significant oscillatory brain responses were imaged using a beamforming approach. All participants exhibited activity in left hemispheric language areas consistent with a verbal WM task. Additionally, veterans with PTSD and combat-exposed healthy controls each exhibited oscillatory responses in right hemispheric homologue regions (e.g., right Broca's area); however, these responses were in opposite directions. Group differences in oscillatory activity emerged in the theta band (4-8 Hz) during encoding and in the alpha band (9-12 Hz) during maintenance and were significant in right prefrontal and right supramarginal and inferior parietal regions. Importantly, following attention training, these significant group differences were reduced or eliminated. This study provides initial evidence that attention training improves aberrant neural activity in brain networks serving WM processing.

Well-being and associated factors among adults in the occupied Palestinian territory (oPt).

BACKGROUND: The World Health Organization (WHO) incorporated well-being into its definition of health in 1948. The significance given to this concept is due to its role in the assessment of people's quality of life and health. METHODS: Using the WHO Well-being Index, we estimated well-being among adults and identified selected associated factors in the occupied Palestinian territory (oPt) using data obtained from the National Time Use Survey conducted by the Palestinian Central Bureau of Statistics (PCBS) 2012-2013 on a representative sample of persons living in the West Bank and Gaza Strip. Univariate and bivariate analyses were conducted among participants 18 years old and above. Multivariate analysis (Regression) was performed with factors found significant in cross-tabulations, using SPSS® version 20. RESULTS: Overall, 33.8 % (2395) of respondents reported low levels of well-being (ill-being). Neither age, nor sex, nor region were found significant in regression analysis. People who were married, working 15 h or more, with a higher standard of living, who reported participating in community, cultural, and social events, or in religious activities reported high levels of well-being. Those who reported regularly following the mass media, or living in Palestinian refugee camps reported low levels of wellbeing. CONCLUSIONS: Overall, about one-third of adult Palestinians reported low levels of well-being (ill-being), a finding which in itself requires attention. Marriage, employment, high living standards, community participation, and religious activities were found to be protective against ill-being. Further investigations are required to determine additional causes of ill-being in the oPt, taking into consideration the possible effects of chronic exposure to political violence on subjective well-being.

Trauma and Child Health: An Introduction to the Special Issue.

Potentially traumatic events are common occurrences that can lead to significant psychological distress, and yet, there has been remarkably little attention to the associations between traumatic events and youth's physical health. The articles contained in this Special Issue of the Journal of Pediatric Psychology represent a significant step forward in the establishment of "Trauma and Child Health" as a major area of study within the field of pediatric psychology. In this introductory article, we briefly describe several contextual issues that may help to set the stage for the articles contained in this Special Issue. These contextual issues include the most common types of traumatic events that are studied, as well as the features of traumatic events that may affect physical and mental health outcomes, such as whether casualties or interpersonal violence is involved.

War Experiences and General Health Among People in Bosnia-Herzegovina and Kosovo.

War experiences may have an extensive impact on the health status of the exposed populations. This population-based study aimed to examine the relationship between war experiences and self-reported general health in representative sample surveys from Bosnia-Herzegovina (n = 3,313) and Kosovo (n = 1,000). Data were collected with face-to-face interviews fielded in the winter of 2003-2004. Logistic regression analysis was used to compute unadjusted and adjusted odds ratios (ORs). The adjusted effects of the extensiveness of war experiences on poor health were positive in both countries, but they were statistically significant only for Bosnia-Herzegovina: OR = 1.04, 95% CI [1.00, 1.08] for Bosnia-Herzegovina and OR = 1.03, 95% CI [0.98, 1.09] for Kosovo. The strongest observed effect was found for Kosovo only: The extensiveness of war experiences was relatively strongly related to longstanding health problems, OR = 1.09, 95% CI [1.03, 1.15]. We found that war experiences may contribute to increased poorer health in the exposed populations; however, the effects 4-9 years after the war ended were modest. Hence, war experiences seemed to be more strongly related to war-related distress and posttraumatic stress disorder than to self-reported general health.

Psychotic-like experiences in a conflict-affected population: a cross-sectional study in South Sudan.

PURPOSE: This study investigates the prevalence of psychotic-like experiences (PLEs) and examines exposure to potentially traumatic events and other relevant risk factors for PLEs in the general population of a conflict-affected, low-income country. METHODS: We conducted a cross-sectional community based study of four Greater Bahr el Ghazal States, South Sudan (n = 1200). The Harvard Trauma Questionnaire was applied to investigate exposure to potentially traumatic events. The Mini-International Neuropsychiatric Interview was used to detect PLEs. RESULTS: The estimated prevalence of lifetime PLEs was 23.3 % and the rate of PLEs which were evaluated as bizarre was 9.5 %. Exposure to higher number of potentially traumatic events, younger age, rural residency, being unemployed, not having a regular income and having traditional religion were significantly associated with having PLEs. PLEs were significantly associated with reporting of psychological distress when controlling for other covariates. CONCLUSIONS: The finding of association between traumatic exposure and PLEs calls for greater attention to the diversity of negative mental health outcomes in conflict-affected populations.

Prevalence and factors associated with Posttraumatic Stress Disorder seven years after the conflict in three districts in northern Uganda (The Wayo-Nero Study).

BACKGROUND: Research on the prevalence of Posttraumatic Stress Disorder (PTSD) is still limited in low income countries yet PTSD can be a public health problem in post conflict areas. In order to respond to the burden of PSTD in northern Uganda, an area that experienced civil strife for over two decades, we need accurate data on its (PTSD) prevalence and the associated risk factors to facilitate public mental health planning. METHODS: This study employed a cross-sectional study design and data collection was undertaken in three districts in northern Uganda: Gulu, Amuru and Nwoya. Respondents were aged 18 years and above and were randomly selected at community level. A total of 2400 respondents were interviewed using a structured questionnaire in the three study districts. In this study, multivariate logistic regression was employed to analyze the associations of socio-demographic factors, trauma related variables and the outcome of PTSD. RESULTS: The prevalence of Posttraumatic Stress Disorder (PTSD) in the study population was 11.8 % (95 % CI: 10.5 %, 13.1 %) with a prevalence of 10.9 % (95 % CI: 9.3 %, 12.5 %) among female respondents and 13.4 % (95 % CI: 11.2 %, 15.7 %) among male respondents. Quite a number of factors were strongly associated with PTSD. Overall, a respondent had experienced 9 negative life events. In a multivariate logistic regression, the factors that were strongly associated with PTSD were: exposure to war trauma events, childhood trauma, negative life events, negative copying style and food insecurity. The findings also indicate no association between sex, age and PTSD. CONCLUSION: The prevalence rate of PTSD in the study communities is unacceptably high. Quite a number of factors were associated with PTSD. Effective public mental health services are needed that combine treatment (medical) psychological and social welfare programs especially at community level to address the high burden of PTSD. Longitudinal studies are also recommended to continuously assess the trends in PTSD in the study communities and remedial action taken.

Biologic monitoring and surveillance results for the department of veterans affairs' depleted uranium cohort: Lessons learned from sustained exposure over two decades.

BACKGROUND: A small group of Gulf War I veterans wounded in depleted uranium (DU) friendly fire incidents have been monitored in a clinical surveillance program at the Veterans Affairs Medical Center, Baltimore since 1994. METHODS: An in-patient clinical surveillance protocol was performed on 35 members of the cohort, including exposure monitoring for total and isotopic uranium concentrations in urine and a comprehensive assessment of health outcomes. RESULTS: Although urine U concentrations continue to be elevated in this group, illustrating on-going in situ mobilization of U from embedded fragments, no consistent U-related health effects have been observed. CONCLUSIONS: Now more than 20 years since first exposure to DU, an aging cohort of military veterans continues to show no U-related health effects in known target organs of U toxicity. As tissue concentrations continue to accrue with exposure duration, critical tissue-specific U concentration thresholds may be reached, thus recommending on-going surveillance of this veteran cohort.

Exploring the mental health effects of political trauma with newly arrived refugees.

We explored the mental health effects of war trauma and torture as described by 111 refugees newly arrived in the United States. We used ethnocultural methodologies to inform 13 culture-specific focus groups with refugees from Bhutan (34), Burma (23), Ethiopia (27), and Somalia (27). Contrary to the belief that stigma prevents refugees from discussing mental health distress, participants readily described complex conceptualizations of degrees of mental health distress informed by political context, observation of symptoms, cultural idioms, and functional impairment. Recommendations for health care providers include assessment processes that inquire about symptoms in their political context, the degree of distress as it is culturally conceptualized, and its effect on functioning. Findings confirm the cross-cultural recognition of symptoms associated with posttraumatic stress disorder; however, refugees described significant cultural variation in expressions of distress, indicating the need for more research on culture-bound disorders and idioms of distress.

The long-term effects of war exposure on psychological health: An experimental study with Turkish conscript veterans.

The study of the effects of war exposure on the psychological health of combatants has so far been constrained by possible selection biases which limits the establishment of causality, the clear identification of dynamics, and the generalizability of findings. In this study, we make use of a population-level natural experiment enabled by the strict military conscription system in Turkey which uses a draft lottery to randomly allocate conscripts to bases across the country, including those south-eastern areas experiencing a long running civil conflict. We build on this setting with a representative field survey of 5024 adult males. Our results indicate that those exposed to high intensity armed conflict environments during their service are more likely to experience depressive symptoms even long after their discharge. Further detailing conflict exposure, we find war traumas to be the primary drivers of the effects we observe.

Early-Life Exposure to War and Later-Life Physical Functional Health.

OBJECTIVES: A growing body of research shows that early-life exposure to war has adverse effects on later-life health. Research has emphasized the importance of exposure timing implicating domain-specific developmental processes and associated critical/sensitive periods. This study looks at the impacts of early childhood war exposure and the repercussions for later-life physical and functional health, with a focus on time of exposure as a source of variability. METHODS: We use residential histories from the Survey of Health Ageing, and Retirement in Europe linked to external data on the location and timing of hostilities to examine the impact of early-life exposure to World War II on later-life physical and functional health. RESULTS: Exposure to war increases the risk of objective (grip strength, chair rise, and peak expiratory flow) and self-reported (mobility limitations and activities of daily living) measures of functional health. Effects are especially pronounced for those born during the war and for those with more prolonged exposures. There is little evidence that the impact of war is mediated by war-related hardships, socioeconomic conditions, health behaviors, or adult chronic disease. DISCUSSION: Our results suggest early-life exposure to war has a lasting impact on physical functional health. Exposure appears to largely operate via direct effects, indicative of altered initial development of physical capacity in early life. Because exposure was so pervasive among some cohorts of older individuals, understanding the health of present older European populations requires wrestling with the residual consequences of wartime exposure at the start of their lives.