Role of childhood adversities and environmental sensitivity in the development of post-traumatic stress disorder in war-exposed Syrian refugee children and adolescents.

BACKGROUND: Increased post-traumatic stress disorder (PTSD) rates have been documented in children exposed to war. However, the contribution of childhood adversities and environmental sensitivity to children's responses to adversities and trauma are still far from settled.AimsTo evaluate the relative roles of war, childhood adversities and sensitivity in the genesis of PTSD. METHOD: Data on childhood adversities and sensitivity was collected from 549 Syrian refugee children in Lebanon. PTSD symptoms were assessed using the PTSD Reaction Index. RESULTS: Although childhood adversities, war events and sensitivity were all significantly related to PTSD in bivariate analyses, multivariate analyses showed that childhood adversities were the most important variable in predicting PTSD. The effect of war on PTSD was found to be dependent on the interplay between childhood adversities and sensitivity, and was most prominent in highly sensitive children with lower levels of adversities; in sensitive children experiencing high levels of adversities, the effects of war exposure on PTSD were less pronounced. CONCLUSIONS: When considering the effects of war on PTSD in refugee children, it is important to take account of the presence of other adversities as well as of children's sensitivity. Sensitive children may be more vulnerable to the negative effects of war exposure, but only in contexts that are characterised by low childhood adversities.Declaration of interestNone.

Dissemination of an evidence-based intervention to parents of children with behavioral problems in a developing country.

This project describes the dissemination of an evidence-based parenting skills intervention by training social and health workers with little or no mental health background so that they themselves train mothers of children with behavioral problems in impoverished communities in a developing country. The Strengths and Difficulties Questionnaire was completed by mothers to screen for children with behavioral problems and was repeated at the end of the intervention. Pre- and post-tests of knowledge and parenting attitudes were administered to mothers. Mental health workers trained social and health workers in social development centers and dispensaries. Each social and health worker trained mothers of children with behavioral problems under supervision utilizing an Arabic adaptation of the treatment manual for externalizing disorders "Helping Challenging Children" developed by the Integrated Services Taskforce of the World Psychiatric Association Child Mental Health Presidential Programme. A total of 20 workers and 87 mothers participated in the training. The proportion of children who obtained an SDQ total difficulties score in the abnormal range decreased from 54.4 to 19.7% after the training. Whereas 40.2% of mothers used severe corporal punishment with their children before the intervention, this decreased to 6.1% post-intervention. Three-fourths of mothers related that the program helped them develop new parenting skills. This pilot project demonstrated the feasibility of dissemination of a manual-based intervention and training of workers who have little background in mental health to offer effective services to families in impoverished communities who otherwise would have not received them. Successful replication in other developing countries would pave the way to incorporating such programs in national policies given their potential sustainability and cost-effectiveness.

Lifetime prevalence of mental disorders in Lebanon: first onset, treatment, and exposure to war.

BACKGROUND: There are no published data on national lifetime prevalence and treatment of mental disorders in the Arab region. Furthermore, the effect of war on first onset of disorders has not been addressed previously on a national level, especially in the Arab region. Thus, the current study aims at investigating the lifetime prevalence, treatment, age of onset of mental disorders, and their relationship to war in Lebanon. METHODS AND FINDINGS: The Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation study was carried out on a nationally representative sample of the Lebanese population (n = 2,857 adults). Respondents were interviewed using the fully structured WHO Composite International Diagnostic Interview 3.0. Lifetime prevalence of any Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) disorder was 25.8%. Anxiety (16.7%) and mood (12.6%) were more common than impulse control (4.4%) and substance (2.2%) disorders. Only a minority of people with any mental disorder ever received professional treatment, with substantial delays (6 to 28 y) between the onset of disorders and onset of treatment. War exposure increased the risk of first onset of anxiety (odds ratio [OR] 5.92, 95% confidence interval [CI] 2.5-14.1), mood (OR 3.32, 95% CI 2.0-5.6), and impulse control disorders (OR 12.72, 95% CI 4.5-35.7). CONCLUSIONS: About one-fourth of the sample (25.8%) met criteria for at least one of the DSM-IV disorders at some point in their lives. There is a substantial unmet need for early identification and treatment. Exposure to war events increases the odds of first onset of mental disorders.

Prevalence and treatment of mental disorders in Lebanon: a national epidemiological survey.

BACKGROUND: Mental disorders are believed to account for a large portion of disease burden worldwide. However, no national studies have been undertaken to assess this assumption in the Arab world. METHODS: As part of the WHO World Mental Health (WMH) Survey Initiative, a nationally representative psychiatric epidemiological survey of 2857 adults (aged 18 years) was done in Lebanon between September, 2002, and September, 2003, through a study called LEBANON (Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation). 12-month prevalence and severity of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) disorders, and treatment were assessed with the WHO Composite International Diagnostic Interview (CIDI, version 3.0). Information was also obtained for sociodemographics and exposure to traumatic events in the Lebanon wars. FINDINGS: 308 (17.0%) of respondents met criteria for at least one 12-month DSM-IV/CIDI disorder, 108 (27.0%) of whom were classified serious and an additional 112 (36.0%) moderate. Nearly half of respondents had a history of exposure to war-related traumatic events. Significantly elevated odds ratios (OR) of mood, anxiety, and impulse-control disorders were associated with two (OR 2.0-3.6) or more (2.2-9.1) war-related traumatic events, resulting in substantially higher proportions of moderate and severe 12-month mental disorders in respondents exposed to multiple war-related traumata (16.8-20.4%) compared with other respondents (3.3-3.5%). Only 47 (10.9%) respondents with 12-month disorders obtained treatment. 85% of people were treated in the general medical sector and the mental-health-care system, and the rest by religious or spiritual advisers, counsellors, herbalists, or fortune-tellers. INTERPRETATION: Mental disorders are common in Lebanon, with a prevalence equivalent to that in Western Europe. However, the number of individuals with mental disorders who are not receiving treatment is considerably higher in Lebanon than in Western countries.

Displaced Children: The Psychological Implications.

Millions of people across the world have been displaced or live in exile and/or as refugees largely as a consequence of wars, acts of terrorism, and catastrophic natural disasters. There are serious psychological consequences as a result of these extremely difficult life circumstances. Adults often can express their needs and have them be heard, whereas children are unable to do so. The children may be provided food, shelter, and clothing and have their medical needs attended to, but their emotional and psychological needs go unrecognized and unmet, with dire and monumental long-term consequences.

Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys.

CONTEXT: Little is known about the extent or severity of untreated mental disorders, especially in less-developed countries. OBJECTIVE: To estimate prevalence, severity, and treatment of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) mental disorders in 14 countries (6 less developed, 8 developed) in the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative. DESIGN, SETTING, AND PARTICIPANTS: Face-to-face household surveys of 60 463 community adults conducted from 2001-2003 in 14 countries in the Americas, Europe, the Middle East, Africa, and Asia. MAIN OUTCOME MEASURES: The DSM-IV disorders, severity, and treatment were assessed with the WMH version of the WHO Composite International Diagnostic Interview (WMH-CIDI), a fully structured, lay-administered psychiatric diagnostic interview. RESULTS: The prevalence of having any WMH-CIDI/DSM-IV disorder in the prior year varied widely, from 4.3% in Shanghai to 26.4% in the United States, with an interquartile range (IQR) of 9.1%-16.9%. Between 33.1% (Colombia) and 80.9% (Nigeria) of 12-month cases were mild (IQR, 40.2%-53.3%). Serious disorders were associated with substantial role disability. Although disorder severity was correlated with probability of treatment in almost all countries, 35.5% to 50.3% of serious cases in developed countries and 76.3% to 85.4% in less-developed countries received no treatment in the 12 months before the interview. Due to the high prevalence of mild and subthreshold cases, the number of those who received treatment far exceeds the number of untreated serious cases in every country. CONCLUSIONS: Reallocation of treatment resources could substantially decrease the problem of unmet need for treatment of mental disorders among serious cases. Structural barriers exist to this reallocation. Careful consideration needs to be given to the value of treating some mild cases, especially those at risk for progressing to more serious disorders.

ADHD in the Arab world: a review of epidemiologic studies.

OBJECTIVE: Epidemiological studies on psychiatric disorders are quite rare in the Arab World. This article reviews epidemiological studies on ADHD in all the Arab countries. METHOD: All epidemiological studies on ADHD conducted from 1966 through th present were reviewed. Samples were drawn from the general community, primary care clinical settings, and populations of traumatized children. Data on prevalence, gender differences, risk factors, comorbidity, and burden of ADHD were reviewed. RESULTS: ADHD rates in Arab populations were similar to those in other cultures. Comparisons within Arab studies were difficult given the variability of methodology and instruments used. CONCLUSION: There is an important need for research on ADHD in the Arab World, not only to assess the national prevalence in children and adolescents, but also to look at the differential burden and treatment of this disorder, which has high levels of mental comorbidities and high impact across the life span.