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Knowing what to look for is key to helping children affected by war

WHO seeks to improve awareness and treatment of possible psychiatric disorders resulting from conflict

With schools back in session and tourists returning to revel in the end of Ramadan, daily life seems back to normal in Lebanon, despite this summer's 34-day war with Israel.

However, according to Khalid Saeed, a mental health specialist with the World Health Organization (WHO), this period is a crucial one - not for putting the recent past to rest but rather for coming face-to-face with its current manifestations, which are post-war distress or worse: severe psychiatric disorders stemming from the country's most recent brush with extreme violence.

Originally from Pakistan, Saeed spent nine months working in the country of his birth, tackling mental health issues in the aftermath of last year's horrific earthquake. After Pakistan, he came to Lebanon, again for the purpose of dealing with the period that has followed in the wake of a disaster.

The Lebanese population as a whole, he says, has been affected by the war, whether directly or indirectly, and whether people acknowledge it or not. The issue now, he explains, is to determine to what extent the Lebanese are suffering.

"To begin with, it is important to separate distress from disorder," Saeed says.

"Distress is something all of us experience when we go through something like war, but in most of our cases it does not compromise our ability to continue, and does not create problems for ourselves or other people, and we can generally find an outlet without any expert help, but rather, through normal social channels, such as family, community, religion and schools.

"Disorder, on the other hand, is when it has developed to a point where expert help is necessary to sort it out."

A study published earlier this year in the Lancet medical journal reports that 5 percent of the Lebanese population already suffers from extreme psychiatric disorders. That number would increase to 6 percent, the study suggests, in the event of another war. In addition, if 12 percent of the population already suffers from minor to moderate psychiatric disorders, around 16 percent would be afflicted in a post-war situation such as the one Lebanon finds itself in now.

"People are more susceptible to develop a psychiatric disorder if they have previously experienced emotional or physical trauma," says Saeed. "Or if there is a family history of mental illness. Personal circumstances can contribute as well, such as poor housing, unemployment, single-parent upbringing and difficult relationships. Disorders are more likely to occur in the extremes of age," he adds, "as in the very young and the very old. They tend to be the most vulnerable."

Saeed and the WHO are currently in Lebanon to train teachers, medical workers and community members on how to deal with post-war disorders in general, and the more extreme conditions on the mental health spectrum in particular. According to Saeed, he and his team are taking a "holistic" approach to their work in Lebanon because the problems are so multi-faceted that they cannot be solved by a single methodology.

This holistic approach involves taking overall mental health into consideration rather than targeting individual psychiatric disorders in isolation. The WHO is tailoring services for people who are themselves ill, along with programs and projects for communities and schools at large. The point, says Saeed, is to promote greater mental health awareness on three levels at once - in the immediate community, through the state-wide healthcare system and through education and social welfare networks, whether formal or informal.

"At the level of the community, we are planning on launching a public education campaign where posters and information will be distributed among schools, health institutions and community centers," says Saeed. "It is to inform people of the symptoms they are likely to see with the development of mental illnesses and disorders, and how, as a parent or a family member, they should react to it."

In addition, the WHO - in collaboration with local non-governmental organizations, health agencies and the education and public health ministries - is starting a training program that will be run in conjunction with school healthcare programs so teachers, parents and counselors will learn how to look for signs of developing or persisting mental illnesses, and know how to deal with them, too.

There is a common misconception that psychiatric disorders are linked to crime. In reality, however, studies have long proven that the people suffering are more likely to be victims of abuse than perpetrators of violence. While there may be connections between drug abuse (which can also be related to a psychiatric disorder) and crime, there is no causal relationship between the severe mental illness and criminal behavior.

When it comes to mental health in general, Saeed notes, Lebanon's biggest dilemma is a lack of adequate services and suitably equipped professionals.

"The problem is that in Lebanon there are very few psychiatrists, and very few clinical psychologists, with the majority of them being based in Beirut, and not in the South," he says. "Furthermore, there are only 100 school counselors available at the moment up and down the country.

"In order to overcome this obstacle, we are aiming to sensitize and train those who work in the field of child healthcare to be able to help those dealing with problems, and who are not taking those problems to psychiatrists, either because of the stigma attached to visiting a psychiatrist, or because of lack of access. Therefore our aim is to make alternative services available and accessible."

The WHO's training program is meant to give teachers and counselors the tools they need to answer - and act on - the following questions: Who is at risk of developing a psychiatric disorder? What are the most common disorders that are likely to arise in the post-war period? What is the likelihood that people who have already been treated or who have a past

history of mental illness will suffer a relapse? How can the general well-being of the community or the population be ensured and safeguarded?

Because information, awareness and basic services for mental health are currently so limited, there is an acute danger that parents and teachers will fail to notice the symptoms of psychiatric disorders that children are exhibiting.

In the majority of cases, children express their disorders through their behavior - they disrupt class, they become abusive with other children, they skip school entirely or they become short-tempered. Unless parents and teachers are aware of the symptoms accompanying various disorders, they are likely to conclude that ill-behaved children are simply, to use Saeed's term, ornery.

"What people are not aware of is that this is how children tend to present ... a problem. Either through behavioral problems or [through complaining] about stomach aches or head aches to bring attention to the fact that something is wrong," he says.

"In very few cases are the children going to open up immediately and admit they have a problem. Therefore it is more likely they will receive a slap or a scolding than proper psychiatric help."

It is essential, Saeed adds, that any and all institutions with which children come into contact have a greater awareness of mental health issues - meaning hospitals, local health centers, clinics, schools, day-care centers and more.

Teachers at all levels need to be able to spot symptoms as they appear, in their earliest stages, so they can prevent distress from developing into disorder. Teachers at all levels need to be able to distinguish between a child who is misbehaving and a child who is crying out for help. To do so, teachers need training.

Saeed says teachers must be able to detect certain benchmarks in a child's development - a child has to achieve certain milestones at certain points in his or her young life. If those milestones have not been achieved and the child is acting younger than his or her age, then it's possible the child has developed a mental illness or a psychiatric disorder.

In order for children to overcome the distress of the war and cope with its aftermath, the most important thing for them to have, says Saeed, is routine.

"Children need to regain that feeling of normality, that things are the same," he says. "One of the good things [now] is that they are all going back to school and this provides structure in their lives. What families need to do is establish a routine together - as quickly as possible. Eating meals together, praying together, playing together. The quicker families return to how they used to be, the quicker children will recover."

Beirut 27-10-2006
Nour Samaha
The Daily Star



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