Catherine Panter-Brick

Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors.

We undertook a systematic search and review of individual, family, community, and societal risk and protective factors for mental health in children and adolescents who are forcibly displaced to high-income countries. Exposure to violence has been shown to be a key risk factor, whereas stable settlement and social support in the host country have a positive effect on the childs psychological functioning. Further research is needed to identify the relevant processes, contexts, and interplay between the many predictor variables hitherto identified as affecting mental health vulnerability and resilience. Research designs are needed that enable longitudinal investigation of individual, community, and societal contexts, rather than designs restricted to investigation of the associations between adverse exposures and psychological symptoms. We emphasise the need to develop comprehensive policies to ensure a rapid resolution of asylum claims and the effective integration of internally displaced and refugee children.

Resilience definitions, theory, and challenges: interdisciplinary perspectives

In this paper, inspired by the plenary panel at the 2013 meeting of the International Society for Traumatic Stress Studies, Dr. Steven Southwick (chair) and multidisciplinary panelists Drs. George Bonanno, Ann Masten, Catherine Panter-Brick, and Rachel Yehuda tackle some of the most pressing current questions in the field of resilience research including: (1) how do we define resilience, (2) what are the most important determinants of resilience, (3) how are new technologies informing the science of resilience, and (4) what are the most effective ways to enhance resilience? These multidisciplinary experts provide insight into these difficult questions, and although each of the panelists had a slightly different definition of resilience, most of the proposed definitions included a concept of healthy, adaptive, or integrated positive functioning over the passage of time in the aftermath of adversity. The panelists agreed that resilience is a complex construct and it may be defined differently in the context of individuals, families, organizations, societies, and cultures. With regard to the determinants of resilience, there was a consensus that the empirical study of this construct needs to be approached from a multiple level of analysis perspective that includes genetic, epigenetic, developmental, demographic, cultural, economic, and social variables. The empirical study of determinates of resilience will inform efforts made at fostering resilience, with the recognition that resilience may be enhanced on numerous levels (e.g., individual, family, community, culture).

Suffering, hope, and entrapment: Resilience and cultural values in Afghanistan

A critical health-related issue in war-affected areas is how people make sense of adversity and why they show resilience in a high-risk environment. In Afghanistan, the burden of poor mental health arises in contexts of pervasive poverty, social inequality, and persistent violence. In 2006, we conducted face-to-face interviews with 1011 children (age 11–16) and 1011 adult caregivers, randomly selected in a school-based survey in three northern and central areas. Participants narrated their experiences as part of a systematic health survey, including an open-ended questionnaire on major life stressors and solutions to mitigate them. Responses were analysed using an inductive thematic approach and categorised for quantitative presentation, producing a conceptual model. For adults, the primary concern is repairing their “broken economy,” the root of all miseries in social, educational, governance, and health domains. For students, frustrations focus on learning environments as well as poverty, as education is perceived as the gateway to upward social and economic mobility. Hope arises from a sense of moral and social order embodied in the expression of key cultural values: faith, family unity, service, effort, morals, and honour. These values form the bedrock of resilience, drive social aspirations, and underpin self-respect and dignity. However, economic impediments, social expectations, and cultural dictates also combine to create entrapment, as the ability to realise personal and social aspirations is frustrated by structural inequalities injurious to health and wellbeing. This study contributes to a small but growing body of work on resilience in public health and conflict settings. It demonstrates that culture functions both as an anchor for resilience and an anvil of pain, and highlights the relevance of ethnographic work in identifying what matters most in formulating social and public health policies to promote a hopeful future.

Practitioner Review: Engaging fathers – recommendations for a game change in parenting interventions based on a systematic review of the global evidence

Background Despite robust evidence of fathers’ impact on children and mothers, engaging with fathers is one of the least well-explored and articulated aspects of parenting interventions. It is therefore critical to evaluate implicit and explicit biases manifested in current approaches to research, intervention, and policy. Methods We conducted a systematic database and a thematic hand search of the global literature on parenting interventions. Studies were selected from Medline, Psychinfo, SSCI, and Cochrane databases, and from gray literature on parenting programs, using multiple search terms for parent, father, intervention, and evaluation. We tabulated single programs and undertook systematic quality coding to review the evidence base in terms of the scope and nature of data reporting. Results After screening 786 nonduplicate records, we identified 199 publications that presented evidence on father participation and impact in parenting interventions. With some notable exceptions, few interventions disaggregate ‘father’ or ‘couple’ effects in their evaluation, being mostly driven by a focus on the mother–child dyad. We identified seven key barriers to engaging fathers in parenting programs, pertaining to cultural, institutional, professional, operational, content, resource, and policy considerations in their design and delivery. Conclusions Barriers to engaging men as parents work against father inclusion as well as father retention, and undervalue coparenting as contrasted with mothering. Robust evaluations of father participation and father impact on child or family outcomes are stymied by the ways in which parenting interventions are currently designed, delivered, and evaluated. Three key priorities are to engage fathers and coparenting couples successfully, to disaggregate process and impact data by fathers, mothers, and coparents, and to pay greater attention to issues of reach, sustainability, cost, equity, and scale-up. Clarity of purpose with respect to gender-differentiated and coparenting issues in the design, delivery, and evaluation of parenting programs will constitute a game change in this field.

Mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors

Children and adolescents who are forcibly displaced represent almost half the worlds internally displaced and refugee populations. We undertook a two-part systematic search and review of the evidence-base for individual, family, community, and societal risk and protective factors for the mental health outcomes of children and adolescents. Here we review data for displacement to low-income and middle-income settings. We draw together the main findings from reports to identify important issues and establish recommendations for future work. We draw attention to exposure to violence as a well established risk factor for poor mental health. We note the paucity of research into predictor variables other than those in the individual domain and the neglect of other variables for the assessment of causal associations, including potential mediators and moderators identifiable in longitudinal work. We conclude with research and policy recommendations to guide the development and assessment of effective interventions.

Violence, suffering, and mental health in Afghanistan : a school-based survey.

Summary Background Studies in Afghanistan have shown substantial mental health problems in adults. We did a survey of young people (11–16 years old) in the country to assess mental health, traumatic experiences, and social functioning. Methods In 2006, we interviewed 1011 children, 1011 caregivers, and 358 teachers, who were randomly sampled in 25 government-operated schools within three purposively chosen areas (Kabul, Bamyan, and Mazar-e-Sharif municipalities). We assessed probable psychiatric disorder and social functioning in students with the Strength and Difficulties Questionnaire multi-informant (child, parent, teacher) ratings. We also used the Depression Self-Rating Scale and an Impact of Events Scale. We assessed caregiver mental health with both international and culturally-specific screening instruments (Self-Reported Questionnaire and Afghan Symptom Checklist). We implemented a checklist of traumatic events to examine the exposure to, and nature of, traumatic experiences. We analysed risk factors for mental health and reports of traumatic experiences. Findings Trauma exposure and caregiver mental health were predictive across all child outcomes. Probable psychiatric ratings were associated with female gender (odds ratio [OR] 2·47, 95% CI 1·65–3·68), five or more traumatic events (2·58, 1·36–4·90), caregiver mental health (1·11, 1·08–1·14), and residence areas (0·29, 0·17–0·51 for Bamyan and 0·37, 0·23–0·57 for Mazar-e-Sharif vs Kabul). The same variables predicted symptoms of depression. Two thirds of children reported traumatic experiences. Symptoms of post-traumatic stress were associated with five or more traumatic events (3·07, 1·78–5·30), caregiver mental health (1·06, 1·02–1·09), and child age (1·19, 1·04–1·36). Childrens most distressing traumatic experiences included accidents, medical treatment, domestic and community violence, and war-related events. Interpretation Young Afghans experience violence that is persistent and not confined to acts of war. Our study emphasises the value of school-based initiatives to address child mental health, and the importance of understanding trauma in the context of everyday forms of suffering, violence, and adversity. Funding Wellcome Trust.

Mental Health and Childhood Adversities: A Longitudinal Study in Kabul, Afghanistan

Objective To identify prospective predictors of mental health in Kabul, Afghanistan. Method Using stratified random-sampling in schools, mental health and life events for 11-to 16-year-old students and their caregivers were assessed. In 2007, 1 year after baseline, the retention rate was 64% (n = 115 boys, 119 girls, 234 adults) with no evidence of selection bias. Self- and caregiver-rated child mental health (Strengths and Difficulties Questionnaire), depressive (Depression Self-Rating Scale), and posttraumatic stress (Child Revised Impact of Events Scale) symptoms and caregiver mental health (Self-Report Questionnaire) were assessed. Lifetime trauma and past-year traumatic, stressful, and protective experiences were assessed. Results With the exception of posttraumatic stress, one-year trajectories for all mental health outcomes showed significant improvement (p < .001). Family violence had a striking impact on the Strengths and Difficulties Questionnaire data, raising caregiver-rated scores by 3.14 points (confidence interval [CI] 2.21–4.08) or half a standard deviation, and self-rated scores by 1.26 points (CI 0.50–2.03); past-year traumatic beatings independently raised self-rated scores by 1.85 points (CI 0.03–3.66). A major family conflict raised depression scores by 2.75 points (CI 0.89–4.61), two thirds of a standard deviation, whereas improved family life had protective effects. Posttraumatic stress symptom scores, however, were solely contingent on lifetime trauma, with more than three events raising scores by 5.38 points (CI 1.76–9.00). Conclusions Family violence predicted changes in mental health problems other than posttraumatic stress symptoms in a cohort that showed resilience to substantial socioeconomic and war-related stressors. The importance of prospectively identifying impacts of specific types of childhood adversities on mental health outcomes is highlighted to strengthen evidence on key modifiable factors for intervention in war-affected populations.

Editorial Commentary: Resilience in child development - interconnected pathways to wellbeing

Resilience offers the promise of a paradigm shift in many fields of research, clinical practice, and policy. A lens on resilience shifts the focus of attention - from concerted efforts to appraise risk or vulnerability, towards concerted efforts to enhance strength or capability. It also shifts the focus of analysis - from asking relatively limited questions regarding health outcomes, such as what are the linkages between risk exposures and functional deficits, to asking more complex questions regarding wellbeing, such as when, how, why and for whom do resources truly matter. Thus we might ask when interventions are most effective, within the time frame of human development and evolutionary life history; and how do we best measure pathways of human experience, to uncover ways in which individuals and communities withstand adversity. To many, resilience is an intuitive, albeit opaque, concept - akin to fortitude in the face of adversity. We may have an intuitive grasp of what resilience means, but fall short of measuring it comprehensively and meaningfully (the same is true of risk). This Annual Research Review issue features ten articles from leaders in the field on how resilience can transform the field of child development. Each articulates important lessons on resilience some of which we editors wish to summarize at the outset. First, resilience is best understood as a process that unfolds over the course of development; consequently, we seek to understand human experience of adversity as pathways of risk and resilience. Second, research on resilience focuses attention on the biological and social trade-offs in human experience: issues of timing, process, and context to understand change or adaptability. Language: en

Social stressors, mental health, and physiological stress in an urban elite of young Afghans in Kabul.

Afghanistan provides a unique setting in which to appraise psychosocial stress, given the context of persistent insecurity and widening economic inequality. In Kabul, people experience widespread frustrations, hinging on restricted opportunities for social advancement, education, and employment. We appraised social aspirations, every‐day stressors, psychosocial distress, and mental health problems for a random sample of 161 male and female students at Kabul University. The survey featured both existing and newly‐developed instruments (Self‐Reported Questionnaire SRQ‐20; Afghan Symptom Checklist; Afghan Daily Stressor Scale; and Social Aspirations and Frustrations), implementing both internationally‐used and culturally‐grounded measures of mental health assessment. We also included indicators of physical health (blood pressure, immune responses to Epstein‐Barr virus (EBV), C‐reactive protein, and body mass index), to map physiological function with reported psychosocial distress. This young, urban elite expressed major feelings of frustrations, related to physical, economic, social, and political stressors of day‐to‐day life in Kabul. There were striking gender differences for psychosocial and physiological markers of wellbeing; specifically, women showed poorer mental health (SRQ‐20, P = 0.01) and elevated EBV antibody titers (P = 0.003). Both diastolic blood pressure (P = 0.018) and EBV (P = 0.038) were associated with a subscale of family stressors among women, but not among men, consistent with womens social vulnerabilities to stressful family dynamics. This is the first study to integrate approaches from anthropology, cross‐cultural psychiatry, and human biology to document social stressors, psychosocial distress, and physiological wellbeing in the challenging setting of present‐day Afghanistan. Am. J.Hum. Biol., 2008.

Research priorities for mental health and psychosocial support in humanitarian settings.

Wietse Tol and colleagues lay out a a consensus-based research agenda for mental health and psychosocial support in humanitarian settings.