War exposure, post-traumatic stress symptoms and hair cortisol concentrations in Syrian refugee children.

Altered secretion of cortisol, the primary effector of the hypothalamus-pituitary-adrenal axis, has been proposed as a means by which traumatic experiences compromise later mental health. However, despite the popularity of cortisol as a potential biomarker for stress and adversity, findings are inconsistent, and little is known about the impact of war-related trauma on stress physiology of children and adolescents. Here we aimed to evaluate the relationships between war exposure, current living conditions, hair cortisol concentrations (HCC) and post-traumatic stress disorder (PTSD) symptoms in a large cohort of Syrian refugee children and adolescents (6-18 years) and their caregiver. This longitudinal observational study assessed Syrian refugee children and adolescents in two waves, 1 year apart, within informal tented settlements in Lebanon. The relationships between war exposure, time since leaving Syria, PTSD symptoms and HCC were investigated using linear mixed-model regression utilising both waves of data collected (Y1: N = 1574, Y2: N = 923). Hair cortisol concentration was positively, but weakly associated with the number of war-related events experienced. This was limited to those who were at least 12 years old at the time of war exposure. Conversely, HCC decreased with time since leaving Syria. HCC was also associated with PTSD symptoms but not with the quality of their current living conditions. This study revealed that changes to hypothalamic-pituitary-adrenal axis activity may accompany both earlier war exposure and current PTSD symptoms in children and adolescents. Additionally, early adolescence may be a particularly sensitive time in terms of trauma-related changes to the hypothalamic-pituitary-adrenal axis.

The role of environmental sensitivity in post-traumatic stress symptoms in Lebanese children and adolescents.

Children differ substantially in their sensitivity to the quality of their environment. Some are more sensitive and more likely to develop Post-Traumatic Stress Disorder (PTSD) in response to Childhood Adversities (CAs), but might also benefit more from Positive Home Experiences (PHE). The aim of this study is to investigate the role of Environmental Sensitivity (ES), CAs and PHEs in PTSD development in children and adolescents. Data was collected from N = 2,569 children/adolescents. PTSD symptoms, CAs, PHEs and ES were assessed with self-report measures. We found that higher ES and CAs emerged as risk factors for PTSD development whereas higher levels of PHEs protected against PTSD. ES moderated the effects of CAs (ß = 1.08, p < .001) on PTSD symptoms in the total sample. This moderating effect was more pronounced in girls, suggesting that highly sensitive girls with high childhood adversities were more likely to have higher PTSD symptoms than girls with low levels of sensitivity (ß = 1.09, p < .001). In conclusion, Environmental Sensitivity played an important role as a risk factor for PTSD and as a moderating factor that accentuated the main effects of childhood adversities, particularly in girls.

Predictors of psychological risk and resilience among Syrian refugee children.

OBJECTIVES: War-exposed refugee children are at elevated risk for mental health problems, but a notable proportion appear resilient. We aimed to investigate the proportion of Syrian refugee children who can be considered resilient, and applied a novel approach to identify factors predicting individual differences in mental health outcomes following war exposure. METHODS: The sample included 1,528 war-exposed Syrian refugee children and their primary caregiver living in refugee settlements in Lebanon. Children were classed as having low symptoms (LS) if they scored below clinically validated cut-offs for post-traumatic stress disorder (PTSD), depression and externalising behaviour problems. Children scoring above any cut-off were classified as having high symptoms (HS). Each LS child was matched with one HS who reported similar war exposure, to test what differentiates children with similar exposures but different outcomes. RESULTS: 19.3% of the children met our resilience criteria and were considered LS. At the individual level, protective traits (e.g. self-esteem; OR = 1.51, 95% CI [1.25, 1.81]) predicted LS classification, while environmental sensitivity (OR = 0.69, 95% CI [0.59, 0.82]), poorer general health (OR = 0.71, 95% CI [0.58, 0.87]) and specific coping strategies (e.g. avoidance; OR = 0.90, 95% CI [0.85, 0.96]) predicted HS classification. Social/environmental predictors included perceived social support (OR = 1.23, 95% CI [1.02, 1.49]), loneliness and social isolation (OR = 0.85, 95% CI [0.80, 0.90]), child maltreatment (OR = 0.96, 95% CI [0.94, 0.97]), and caregiver mental and general health (e.g. caregiver depression; OR = 0.94, 95% CI [0.92, 0.97]). CONCLUSIONS: Future research should take multiple dimensions of functioning into account when defining risk for mental health problems and consider the identified predictors as potential targets for interventions.

First Onset in Adulthood of Mental Disorders: Exposure to War vs. Non-war Childhood Adversities: A National Study.

Background: There is evidence that some childhood trauma increases the risk of the first onset of mental disorders and for the first time into adulthood. There are no studies that assessed whether exposure to war has this delayed long-term effect. Objectives: To fill this gap by investigating the comparative roles of war and non-war trauma on the first onset of adulthood mood and anxiety disorders. Methods: A nationally representative sample of 2,857 Lebanese was assessed using the World Health Organization Composite International Diagnostic Interview 3.0. with the onset of exposure to trauma and of first onset of mood and anxiety disorders. Results: Non-war childhood traumata especially those belonging to family malfunctioning continue to exert their effect for the first time well beyond their occurrence as they were the most universal predictors for adult onset of both mood and anxiety disorders. War trauma during childhood predicted mood anxiety and mood (anxiety only in males) only below age 18 y. war childhood trauma predicts the first onset of mood and anxiety disorders before age 18 y in females, but only anxiety in males. Conclusion: Childhood traumata are not equal in predicting the first onset of mood and anxiety disorders into adulthood. Family malfunctioning looks to carry the longest such risk and war more of shorter immediate effects. This might change though with re-exposure to war in adulthood which might unravel dormant vulnerability.

Cohort profile: biological pathways of risk and resilience in Syrian refugee children (BIOPATH).

The BIOPATH cohort was established to explore the interplay of psychosocial and biological factors in the development of resilience and mental health problems in Syrian refugee children. Based in Lebanon, a middle-income country significantly impacted by the refugee crisis, it is the first such cohort of refugees in the Middle East. Families were recruited from informal tented settlements in the Beqaa region using purposive cluster sampling. At baseline (October 2017-January 2018), N = 3188 individuals participated [n = 1594 child-caregiver dyads; child gender, 52.6% female; mean (SD) age = 11.44 (2.44) years, range = 6-19]. Re-participation rate at 1-year follow-up was 62.8%. Individual interviews were conducted with children and primary caregivers and biological samples collected from children. Measures include: (1) children's well-being and mental health problems (using tools validated against clinical interviews in a subsample of the cohort); (2) psychosocial risk and protective factors at the level of the individual (e.g. coping strategies), family (e.g. parent-child relationship), community (e.g. collective efficacy), and wider context (e.g. services); (3) saliva samples for genetic and epigenetic (methylation) analyses; (4) hair samples to measure cortisol, dehydroepiandrosterone (DHEA) and testosterone. This cohort profile provides details about sampling and recruitment, data collection and measures, demographic data, attrition and potential bias, key findings on resilience and mental health problems in children and strengths and limitations of the cohort. Researchers interested in accessing data should contact Professor Michael Pluess at Queen Mary University of London, UK (e-mail: m.pluess@qmul.ac.uk).

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.

Trauma and psychotic experiences: transnational data from the World Mental Health Survey.

BackgroundTraumatic events are associated with increased risk of psychotic experiences, but it is unclear whether this association is explained by mental disorders prior to psychotic experience onset.AimsTo investigate the associations between traumatic events and subsequent psychotic experience onset after adjusting for post-traumatic stress disorder and other mental disorders.MethodWe assessed 29 traumatic event types and psychotic experiences from the World Mental Health surveys and examined the associations of traumatic events with subsequent psychotic experience onset with and without adjustments for mental disorders.ResultsRespondents with any traumatic events had three times the odds of other respondents of subsequently developing psychotic experiences (OR = 3.1, 95% CI 2.7-3.7), with variability in strength of association across traumatic event types. These associations persisted after adjustment for mental disorders.ConclusionsExposure to traumatic events predicts subsequent onset of psychotic experiences even after adjusting for comorbid mental disorders.

The role of religious advisors in mental health care in the World Mental Health surveys.

OBJECTIVES: To examine the role of religious advisors in mental health care (MHC) according to disorder severity, socio-demographics, religious involvement and country income groups. METHODS: Face to face household surveys in ten high income (HI), six upper-middle income (UMI) and five low/lower-middle (LLMI) income countries totalling 101,258 adults interviewed with the WMH CIDI plus questions on use of care for mental health problems and religiosity. RESULTS: 1.1% of participants turned to religious providers for MHC in the past year. Among those using services, 12.3% used religious services; as much as 30% in some LLMI countries, around 20% in some UMI; in the HI income countries USA, Germany, Italy and Japan are between 15 and 10% whenever the remaining countries are much lower. In LLMI 20.9% used religious advisors for the most severe mental disorders compared to 12.3 in UMI and 9.5% in HI. For severe cases most of religious providers use occurred together with formal care except in Nigeria, Iraq and Ukraine where, respectively, 41.6, 25.7 and 17.7% of such services are outside any formal care. Frequency of attendance at religious services was a strong predictor of religious provider usage OR 6.5 for those who attended over once a week (p < 0.0001); as seeking comfort "often" through religion in case of difficulties OR was 3.6 (p = 0.004) while gender and individual income did not predict use of religious advisors nor did the type of religious affiliation; in contrast young people use them more as well as divorced and widowed OR 1.4 (p = 0.02). Some country differences persisted after controlling for all these factors. CONCLUSIONS: Religious advisors play an important role in mental health care and require appropriate training and collaboration with formal mental healthcare systems. Religious attitudes are strong predictors of religious advisors usage.

Resilience-promoting factors in war-exposed adolescents: an epidemiologic study.

Studies of war-exposed children have not investigated a comprehensive array of resilience-promoting factors, nor representative samples of children and adolescents. A representative sample of N = 710 adolescents was randomly selected from communities recently exposed to war. All those who had experienced war trauma were administered questionnaires measuring war exposure, family violence, availability of leisure activities, school-related problems, interpersonal and peer problems, socialization, daily routine problems, displacement, availability of parental supervision and contact and medical needs as well as coping skills related to religious coping, denial, self-control, avoidance and problem solving. Mental health was measured by the Strengths and Difficulties Questionnaire (SDQ) and the Child-Revised Impact of Events Scale (CRIES). Resilient adolescents were defined as those who experienced war trauma, but did not manifest any symptoms on the SDQ or CRIES. Resilience was related to being male, using problem-solving techniques, having leisure activities, and having parents who spent time with their adolescents and who supported them with school work. Interventions designed for war-traumatized youth must build individual coping skills of children and adolescents, yet at the same time target parents and teachers in an integrated manner.

Prevalence, Correlates, and Treatment of Mental Disorders among Lebanese Older Adults: A National Study.

OBJECTIVES: Data on the mental health of older adults in the Middle East is lacking. Prevalence of mental disorders in Lebanese older adults (age: 60+ years) as well as accounts of their attitude towards seeking professional help for mental disorders were investigated. The results of older adults were compared to a younger age group (18-59 years). DESIGN: Cross-sectional nationally representative study, using data from the Lebanese Evaluation of the Burden of Ailments and Needs of the Nation. SETTING: Community-based epidemiologic survey. PARTICIPANTS: Community-dwelling adults (N = 2,857) in Lebanon. MEASUREMENTS: Mental disorders were evaluated using the World Health Organization Composite International Diagnostic Interview. RESULTS: The lifetime and 12-month prevalences of having "any mental disorder" in older adults (N = 593) were 17.4% and 10.6%, respectively, and were significantly lower than the prevalence in younger adults (25.7% and 18.5%, respectively). Female sex, low household income, social disability, and exposure to war trauma were significant correlates of 12-month mental disorders in older adults. Of those with a 12-month mental disorder, 16.0% sought professional help for their condition in the past year. CONCLUSIONS: As shown in other epidemiologic studies, the prevalence of mental disorders in Lebanon was lower in older adults as compared to younger adults. Several factors in epidemiologic studies, however, may contribute to the underdiagnosis of mental disorders in older adults. No significant differences in attitude towards mental health services were found between older and younger age groups. The importance of interventions that improve the social relationships of older adults is highlighted.

Major depressive disorder subtypes to predict long-term course.

BACKGROUND: Variation in the course of major depressive disorder (MDD) is not strongly predicted by existing subtype distinctions. A new subtyping approach is considered here. METHODS: Two data mining techniques, ensemble recursive partitioning and Lasso generalized linear models (GLMs), followed by k-means cluster analysis are used to search for subtypes based on index episode symptoms predicting subsequent MDD course in the World Mental Health (WMH) surveys. The WMH surveys are community surveys in 16 countries. Lifetime DSM-IV MDD was reported by 8,261 respondents. Retrospectively reported outcomes included measures of persistence (number of years with an episode, number of years with an episode lasting most of the year) and severity (hospitalization for MDD, disability due to MDD). RESULTS: Recursive partitioning found significant clusters defined by the conjunctions of early onset, suicidality, and anxiety (irritability, panic, nervousness-worry-anxiety) during the index episode. GLMs found additional associations involving a number of individual symptoms. Predicted values of the four outcomes were strongly correlated. Cluster analysis of these predicted values found three clusters having consistently high, intermediate, or low predicted scores across all outcomes. The high-risk cluster (30.0% of respondents) accounted for 52.9-69.7% of high persistence and severity, and it was most strongly predicted by index episode severe dysphoria, suicidality, anxiety, and early onset. A total symptom count, in comparison, was not a significant predictor. CONCLUSIONS: Despite being based on retrospective reports, results suggest that useful MDD subtyping distinctions can be made using data mining methods. Further studies are needed to test and expand these results with prospective data.

Outcome of depression and anxiety after war: a prospective epidemiologic study of children and adolescents.

Prospective studies of children exposed to war have not investigated disorders other than posttraumatic stress disorder (PTSD) and have methodological limitations. From a stratified random sample of 386 children and adolescents who had been interviewed 3 weeks after war exposure (Phase 1) a random subsample (N = 143) was interviewed a year later (Phase 2). PTSD, major depressive disorder (MDD), separation anxiety disorder (SAD), overanxious disorder (OAD), and psychosocial stressors were assessed using structured interviews administered to both children and adolescents and their parents. The prevalence of disorders among the 143 at Phase 1 was MDD 25.9%, SAD 16.1%, OAD 28.0%, and PTSD 26.0%, with 44.1% having any disorder. At Phase 2 the prevalence was MDD, 5.6%; SAD, 4.2%; OAD, 0%; and PTSD, 1.4%, with 9.2% having any disorder. Occurrence of disorders at Phase 1 was associated with older age, prewar disorders, financial problems, fear of being beaten, and witnessing any war event (ORs ranged from 2.5 to 28.6). Persistence of disorders to Phase 2 was associated with prewar disorders (OR = 6.0) and witnessing any war event (OR = 14.3). There are implications for detection of at-risk cases following wars by screening for adolescents exposed to family violence, those with prewar disorders, and those who directly witnessed war events to target them for specific interventions.

Childhood adversities and traumata in Lebanon: a national study.

BACKGROUND: The goal of this paper is to map the total occurrence and evaluate the risk of co-occurrence of childhood adversities (CA) and a wide variety of childhood traumatic events (including war) in a national sample. METHOD: The nationally representative sample included 2,857 respondents and the instrument used was the Composite International Diagnostic Interview which screened for all CAs and traumatic events. RESULTS: 27.9% experienced CAs; the most common were parental death and parental mental/substance use disorder. 70.6% experienced a war-related traumatic event during their lifetime, and around half of them (38.1%) experienced it below the age of 18 years. 51.3% of the subjects experienced a traumatic event not related to war during their lifetime, and 19.2% experienced it before the age of 18 years. Sexual abuse, being a refugee during war, and experiencing a natural disaster were associated with female gender. Having any CA was associated with active war exposure (OR: 4.2, CI: 2.0-8.6); war-related direct personal trauma (OR: 3.9, CI: 1.5-10.0); war-related trauma to others (OR: 2.4, CI: 1.3-4.4); non-war direct personal trauma (OR: 3.8, CI: 2.0-7.4); and any non-war childhood traumatic event (OR: 1.9, CI: 1.1-3.1). CONCLUSION: Childhood is awash with adversities and traumatic events that co-occur and should be measured simultaneously; otherwise, the effects of a subset of traumata or adversities could be wrongly thought to be the contributor to negative outcomes under study.

Premarital mental disorders and physical violence in marriage: cross-national study of married couples.

BACKGROUND: Mental disorders may increase the risk of physical violence among married couples. AIMS: To estimate associations between premarital mental disorders and marital violence in a cross-national sample of married couples. METHOD: A total of 1821 married couples (3642 individuals) from 11 countries were interviewed as part of the World Health Organization's World Mental Health Survey Initiative. Sixteen mental disorders with onset prior to marriage were examined as predictors of marital violence reported by either spouse. RESULTS: Any physical violence was reported by one or both spouses in 20% of couples, and was associated with husbands' externalising disorders (OR = 1.7, 95% CI 1.2-2.3). Overall, the population attributable risk for marital violence related to premarital mental disorders was estimated to be 17.2%. CONCLUSIONS: Husbands' externalising disorders had a modest but consistent association with marital violence across diverse countries. This finding has implications for the development of targeted interventions to reduce risk of marital violence.

Early cannabis use and estimated risk of later onset of depression spells: Epidemiologic evidence from the population-based World Health Organization World Mental Health Survey Initiative.

Early-onset cannabis use is widespread in many countries and might cause later onset of depression. Sound epidemiologic data across countries are missing. The authors estimated the suspected causal association that links early-onset (age <17 years) cannabis use with later-onset (age > or =17 years) risk of a depression spell, using data on 85,088 subjects from 17 countries participating in the population-based World Health Organization World Mental Health Survey Initiative (2001-2005). In all surveys, multistage household probability samples were evaluated with a fully structured diagnostic interview for assessment of psychiatric conditions. The association between early-onset cannabis use and later risk of a depression spell was studied using conditional logistic regression with local area matching of cases and controls, controlling for sex, age, tobacco use, and other mental health problems. The overall association was modest (controlled for sex and age, risk ratio = 1.5, 95% confidence interval: 1.4, 1.7), was statistically robust in 5 countries, and showed no sex difference. The association did not change appreciably with statistical adjustment for mental health problems, except for childhood conduct problems, which reduced the association to nonsignificance. This study did not allow differentiation of levels of cannabis use; this issue deserves consideration in future research.

Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys.

BACKGROUND: Although significant associations of childhood adversities with adult mental disorders are widely documented, most studies focus on single childhood adversities predicting single disorders. AIMS: To examine joint associations of 12 childhood adversities with first onset of 20 DSM-IV disorders in World Mental Health (WMH) Surveys in 21 countries. METHOD: Nationally or regionally representative surveys of 51 945 adults assessed childhood adversities and lifetime DSM-IV disorders with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Childhood adversities were highly prevalent and interrelated. Childhood adversities associated with maladaptive family functioning (e.g. parental mental illness, child abuse, neglect) were the strongest predictors of disorders. Co-occurring childhood adversities associated with maladaptive family functioning had significant subadditive predictive associations and little specificity across disorders. Childhood adversities account for 29.8% of all disorders across countries. CONCLUSIONS: Childhood adversities have strong associations with all classes of disorders at all life-course stages in all groups of WMH countries. Long-term associations imply the existence of as-yet undetermined mediators.

European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe. METHODS: The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated. RESULTS: Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated? CONCLUSIONS: ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.

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.

Diffusion of efficacious interventions for children and adolescents with mental health problems.

BACKGROUND: Child and adolescent mental health problems are prevalent and require adequate interventions. Despite several evidence-based interventions for these problems described in the literature, few studies addressed strategies to diffuse efficacious interventions for child mental disorders especially in developing countries. METHODS: An extensive but not systematic review of the literature was performed aiming to identify evidence-based interventions for children and adolescents with mental disorders, professionals to target in disseminating these interventions, and the available strategies to diffuse information. RESULTS: Substantial evidence-based information is available to guide preventive, psychosocial and psychopharmacological interventions. The effectiveness of treatments in real-world settings and the cost-effectiveness of interventions are rarely tested. Professionals at different levels (teachers, school counselors, social workers, general practitioners, pediatricians, child psychologists and psychiatrists) should be targeted in diffusing efficacious interventions for child mental health problems worldwide. Telepsychiatry and the internet seem to be the most promising strategies to diffuse knowledge with lower costs. CONCLUSIONS: Medical and allied professionals must incorporate child and adolescent mental health issues in their under- and postgraduate curricula, and be better prepared to critically evaluate available information. Professionals need to disseminate evidence-based programs to guide parents and teachers in developing countries to deal with child and adolescent difficulties. Countries need to explore internet solutions for dissemination of medical information.