Community activities

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Training of Parents

There are many misperceptions about children and adolescents' mental health. In fact, many children with behavioral problems or learning difficulties are labeled "disobedient" or "not smart", where in truth they may have certain mental health conditions that mothers and fathers are not aware of and do not know how to deal with. Sometimes, special behavioral and psychological techniques are needed to manage these problems more effectively. In response to this fact, IDRAAC, with the support of the Canadian Fund for Social Development and OXFAM (Quebec), and in association with the Lebanese Ministries of Social Affairs and Public Health, has initiated a training of social and health workers in the underprivileged suburbs of Beirut, Sidon, Tyre and Nabatiyeh, who will, themselves, train the mothers and fathers of children with behavioral problems in using appropriate interventions. This will ensure continuity of these services, as workers from each community will have the skills to teach more families with children who are at risk of developing behavioral problems. 

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Mental Health Screening

Improving awareness about mental health in the community is of absolute importance and is part of the mission of IDRAAC. One of the effective ways to disseminate information to the general public about mental health is through Health Fairs that take place in public settings. In addition to screening for medical conditions such as Hypertension, Diabetes and Breast Cancer among others, participants in a Health Fair can also get screened for their Temperament, as well as for common mental health conditions such as Depression, Panic Disorder, Attention Deficit Hyperactivity Disorder and Alcohol and Drug Use. IDRAAC has participated in many Health Fairs and has offered screenings to hundreds of adults, children and adolescents.

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Our specialists have a long and well established experience in evaluating and treating mental health problems arising from disasters.

Our experience extends beyond the borders of Lebanon and has encompassed other countries such as Iraq.

We have led several projects assessing PTSD and acute stress disorder, depression, impulse control, mass psychogenic illness etc. These projects occurred in a variety of settings: airplane crashes, war related trauma (in Lebanon and Iraq), exposure to toxic material etc.

Our projects include:
-     Medico legal assessment
-     Field research
-     Clinical evaluation and treatment

Our multidisciplinary team has made it possible for us to cover children and adolescents, adults as well as the elderly.

Psychiatrist, psychologists , social workers , epidemiologists as well as biostatisticians has established our center as a leader covering simultaneously the academic, the medico legal and the clinical endeavors in the field of disaster related mental health services.

Our partners have included local, regional and international institutions: WHO, Médecins Sans Frontières, UNICEF, OXFAM, EU, NIMH (USA), ministries of health, legal firms.

More detailed information is available upon request.

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In solidarity with our community which has been deeply affected by the recent war events that started in July 2006, the Department of Psychiatry and Clinical Psychology at the St. George Hospital University Medical Center/Balamand university, Faculty of Medicine in association with IDRAAC has concentrated its efforts to help out on several fronts by offering free mental health consultations to individuals affected by these events and offering expert opinion through media. At the request of the government, the Department and IDRAAC have prepared a proposal for a National Mental Health Action Plan.

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For further information, contact : 01-583583 or 03-642281

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This national plan provides an integrated vision which foresees different scenarios and develops contingency plans allowing for continuity and  long term sustainability of  the intervention efforts. It plans training of professionals and paraprofessionals to deliver services to individuals of all age groups, allocates human resources, creates treatment protocols and develops networks among collaborating agencies. The main principles guiding this national plan are the following:

1. Reaching the largest possible number of individuals exposed to trauma: while most of those exposed  to war trauma are probably displaced, yet many are still in their regions. Among displaced families, most  are located at schools or refugee centers, but there are many  who have sought shelter at other relatives' and friends' homes, and thus need to be reached there as well. Special groups with high exposure to scenes of horror and atrocities including health and rescue workers, among others are also targeted. This plan will specify various tools to be used such as television, radio and printed material (handouts, brochures) in order to reach individuals and families where appropriate.
2. Reaching all geographic areas in Lebanon: this plan takes into consideration the wide geographic distribution of families in need, and incorporates a model where workers in all regions will receive basic mental health training. 
3. Prioritizing interventions and tasks in step wise stages with immediate, intermediate  and long term phases of intervention for the entire community which follows a temporal progression  based on successful achievement of tasks.
4. Empowerment and training of workers and agents in related fields and who are in contact with  survivors of the war events to delegate therapeutic tasks to them. These workers and agents will be identified by various NGOs and agencies to be regionally, locally and geographically representative. Professionals targeted for basic training include  social workers, teachers, nurses, allied health professionals and  bachelor level students in psychology, education  and social work. All the workers will receive basic training in  delivering psychological first aid and teaching  behavioral strategies to parents of children and adolescents as well as in screening for and identifying psychiatric disorders for referrals to specialized services. Advanced training in  trauma management will target professionals with previous mental health  experience in treatment of psychiatric disorders.
5. Early identification of cases that need immediate referral to psychiatric care by setting up a network of regional psychiatric treatment centers. These treatment centers consist of teams of trained professionals and paraprofessionals  that serve the purpose of not only  providing care  to acutely ill individuals, but are also  regional focal  and resource points for training of field workers within their region. A hierarchy of networking of these centers implementing this plan is proposed starting with a central planning, coordinating and training  team providing leadership and branching  to regional and subregional local centers and teams.
6. Use of quantitative and qualitative validated tools for data collection: it is imperative  to be able to collect data systematically in a uniform fashion across all sites participating in this national  program. The use of questionnaires and screening tools will be mainstreamed to facilitate  analysis of outcome measures and provide feedback on the effectiveness of the interventions delivered.
7. Promotion of functional and adaptive  attitudes during and post-war: building resilience among citizens through specific strategies. This helps avoid "pathologizing" people suffering from psychological symptoms commonly encountered in post war settings.
8. Addressing continuity of services and long term sustainability: an intrinsic aspect of this plan is the ongoing training and supervision of trainers and field workers such that the skills they acquire will continue to be useful to them in their direct contact with families in the long run. Additionally, the plan and training of field workers allows for continuity of service delivery even after population shifts have taken place. Once displaced families return to their hometowns and villages, they will be out of contact with the regional team that provided services to them initially. A mechanism is set up such that a family returning to its previous home or to a new one can be hooked up to the mental health team closest to it in its new location. Similarly, once the school year gets under way, many families may relocate from schools where they are taking shelter now, and services to them will continue uninterrupted in the new areas where they seek shelter.

In addition, the frame of application of these general principles will be as follows:

1. Collaboration and division of labor by various NGOs: this far reaching national plan cannot be carried out by one NGO or group of professionals alone. It assumes a national collaborative effort where tasks are divided by specialty or by geographic availability.
2. Use of evidence-based practices: this plan incorporates psychological interventions that are supported by scientific evidence of efficacy. There are many theoretical and practical approaches that have been proposed to use during war time and  post disasters but unfortunately, many have proven to be either ineffective, have not been tested scientifically, or  have the potential to cause more harm than good. This plan selects safe and effective interventions supported and endorsed by international scientific organizations specialized in mental health work  and in post disaster management guided by local research findings and previous field experience in wars in Lebanon.
3. Culturally sensitive planning and delivery of interventions: one of the most common pitfalls of mental health relief plans is the blind application of techniques developed in a context vastly different from the one they are being applied in. This plan examines the specific cultural parameters of various groups in Lebanon and adapts interventions to make them culturally acceptable.
4. Developmentally appropriate interventions: since children and adolescents are targeted in this plan, interventions have to be developmentally based; eg  interventions for preschoolers are different than those for school-aged children; those for younger adolescents are different than ones for older adolescents.
5. Facilitation of collaboration among various agencies and governmental organizations involved in the relief effort: availability and delivery of  psychiatric medications  and psychiatric hospitalization may be carried out by other agencies (eg Ministry of Public Health) and close coordination is needed. Collaboration with the Ministry of Education and school administrators will be needed as plans for the new academic school year gets under way  and school based mental health interventions delivered by trained teachers can be implemented.

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This national plan  will be implemented in 3 phases that follow successively: an immediate phase, a short term phase, and a mid to long-term phase.

Immediate Phase (2-4 weeks):

In this phase, the immediate tasks are to set up the network of regional mental health teams, disseminate basic information, refer emergency cases of already identified psychiatric patients and prepare the series of training workshops for the next phase. The goals for this phase will be achieved as follows:

A. Set up the central coordinating, planning and training team consisting of mental health professionals who will train and supervise  regional supervisors and trainers.
B. Identify regional  mental health professionals who will serve as focal treatment  points and training teams for local field workers.
C. Identify local field workers  from NGOs and rescue organizations by region and subregion who will receive  training in implementing interventions.
D. Ask local field workers to identify and refer to the regional centers patients already identified with psychiatric disorders in urgent need of services for medication management and/or hospitalization as well as children and adolescents with developmental or severe behavioral disorders in need of the same.
E. Train regional supervisors in conducting systematic focus groups with  local field workers/rescue workers to process with them their own reactions to traumatic events, their own perceptions and beliefs about what constitutes mental health relief services as well as   collect information  from them on   their perceived needs gathered from their field experience. This is a crucial step in the process in order to gather information from the field about the needs which vary from one place to another, and to help identify local field workers who will be able to carry out the required tasks and  to function as team players.
F. Plan for a series of workshops following the above focus groups to take place at set intervals (eg every 10-14 days) to complete basic training in mental health for local field workers. This basic mental health training will give workers skills in delivering psychological first aid,  teaching  behavioral strategies to parents of children and adolescents and in screening for and identifying psychiatric disorders for referrals to specialized services.
G. Disseminate basic information on normal or expected psychological reactions after war as they pertain to children, adolescents and adults. This dissemination effort will include media messages to reach the largest number of people possible, as well as simple handouts that can be given to parents and workers in the field. The media will play a very important role in alerting displaced families at relatives' and friends' homes to the availability of the regional mental health teams closest to them.
H. Begin  implementing structured play activities with children and age-appropriate activities with adolescents and adults at displacement centers.

Intermediate  Phase (from 1-3 months):

During this phase, field workers will complete their training and will begin mental health interventions and screening. The goals of this phase will be met as follows:

A. Local field workers, under the supervision of regional mental health teams, will start providing psychological first aid measures to children, adolescents and adults. They will hold group meetings at their local centers to educate parents and children and adolescents about healthy means of coping and normalization of activities.
B. Local field workers will deliver training sessions to parents in behavioral techniques that they can use with children. Evidence based behavioral strategies will be taught to parents to prevent development of dysfunctional and disruptive behaviors in the children and to improve communication. These parenting skills  also diminish the magnitude of externalizing  and internalizing symptoms among children with these disorders, improve parent-child relationships and decrease the severity of parent-child conflicts that are likely to arise during this period, thus  decreasing the need for immediate referral to more specialized services. These strategies are preventive in nature and serve to prevent the progression  of war-related psychological distress into severe and persisting disorders.  These parental training sessions are manual based with specific step by step instructions and  "exercises" to perform in between sessions. Ongoing supervision of workers will take place by the regional  teams who in turn are supervised by the central team .
C.  Once they complete their training, local field workers will start systematic screening efforts to detect undeclared cases of Anxiety and Depressive Disorders, Post Traumatic Stress Disorder (PTSD), traumatic grief reactions, hyperactivity, and conduct disorders. This screening process will use quantitative questionnaires and rating scales  filled by parents as well as by children/adolescents themselves. This case detection relies not only on rating scales and objective measures, but also on the capacity to describe symptoms and identify children at risk based on tools the workers acquired in their training  workshops.
D. The process of referrals to the regional mental health teams will continue as more and more cases are identified through mental health screening at the local level.
E. Families not at schools or refugee centers but residing with other family and friends will learn about these efforts through the media and will be directed to contact the regional teams who will assign them to the proper local intervention team closest to them.
F. Individuals with high risk behaviors eg  suicidality, aggression, psychosis, extreme risk-taking or substance use will be referred to more specialized services immediately upon identification.

Long-term Phase (3-12 months):

In this phase, consolidation of the activities planned in the two earlier phases continues. Local workers continue to gain more skills and expertise in  identifying and working with psychological conditions. Mainstreaming of referrals to regional and the central team takes place. Advanced training  of mental health professionals in trauma management allows a greater number of individuals to be reached  on a local level. This phase also offers the opportunity to conduct a nationwide study to follow up on a nationally representative sample of Lebanese.The goals of this phase will be accomplished as follows:

A. As the local field workers continue to build their skills and deliver their interventions under supervision, these skills will be fine tuned and workers can improve their ability to deliver services further. Workers who were not able to  reach a group of families at a local center may now reach them, or assign them to other workers in other regions in coordination with the regional teams if families relocate.
B. Advanced training in more specialized psychological techniques will be offered to mental health professionals  with experience in treating mental disorders. This advanced training enables more professionals to deliver either individual or group services to adults, children or adolescents locally without having to refer them to the regional teams. This includes the efforts to reduce the severity of existing problems to prevent these difficulties from assuming a chronic course.
C. Cases with delayed onset disorders or  those with persistent  psychological distress despite receiving psychological first aid and group interventions locally will need to be referred to the regional  and central teams for more specialized services.
D. This phase offers a unique opportunity  for research that feeds into policy planning for Lebanon. IDRAAC has recently conducted the first national epidemiological study of psychiatric disorders in a nationally representative sample¹⁵. The first results of this study were published in the Lancet in March 2006 and other publications are on the way. The study was conducted  in association with Harvard University  and the World Health Organization (WHO), Geneva^16,17. Early results revealed that psychiatric disorders in Lebanon are very common but there's a huge unmet need for treatment among affected individuals. Additionally there was a relationship between exposure to previous war events and current disorders. With this unfortunate war in Lebanon, large segments of the population have been re-exposed to war events, and this presents a chance to conduct a naturalistic  prospective study of the mental health of the Lebanese population by re-interviewing a convenience sub-sample of those originally interviewed before this war.

References

1- Cross-National Collaborative Group. The changing rate of major depression: Cross-national comparisons. JAMA, 1992; 268:3098-3105.
2- Karam EG. Post Traumatic Stress Disorder. The Lebanon Wars. United Nations Development Programme / Department of Humanitarian Affairs,1994. UNDP/DHA Disaster Management Training Programme.
3- Weissman M, Bland R, Canino G, Faravelli C, Greenwald S, Hwu HG, Joyce P, Karam EG, Lee CK, Lellouch J, Lépine JP, Newman S, Rubio-Stipec M, Wells JE, Wickramaratne P, Wittchen HU,  and Eng-Dung Y. Facing Depression:  Women's increased Vulnerability to Major Depression: Cross-National Perspectives. World Psychiatric Association Press, WPAP,  1994; 2 (4):1-3.
4- Karam EG,  Noujeim J, Saliba S, Chami A, Abi-Rached S. PTSD : How Frequently Should the Symptoms Occur? The Effect on Epidemiologic Research. Journal of Traumatic Stress, 1996; 9(4):899-905.
5- Karam EG, Karam A, Mansour C, Melhem N, Saliba S, Yabroudi P, and Zbouni V . The Lebanon Wars Studies: The Grapes of Wrath Chapter. Phase I. The Final Report.  UNICEF, 1996; Beirut, Lebanon.
6- Karam EG, Al-Atrash R, Saliba S, Melhem N, Howard D. The War Events Questionnaire. Social Psychiatry & Psychiatric Epidemiology, 1999; 34 (5): 265-274.
7- Karam A, Karam EG, Zebouni V, Yabroudi P, Cordahi Tabet C, Fayyad J .  Traumatismes de Guerres. Prévention Psychologique à Large Echelle en Milieu Scolaire. Stress et Trauma, 2002 ; 2(3) : 169-177.
8- Fayyad J, Karam EG, Karam A, Cordahi Tabet C, Mneimneh Z and Bou Ghosn M. PTSD in Children And Adolescents Following War. In Raul R. Silva (Ed.), Posttraumatic Stress Disorders in Children And Adolescents. Handbook. W.W. Norton and Company: 2003; 306 –352.New York.
9- Fayyad J, Karam EG, Karam A, Cordahi Tabet C, Melhem N, Mneimneh Z, Zebouni V, Kayali G, Yabroudi P, Rashidi N and Dimasi H (October 2002). "Community Group Therapy in Children and Adolescents Exposed to War". Research presentation at the 49th Annual Meeting of the AACAP (American Academy of Child and Adolescent Psychiatry), San Francisco, USA.
10- Cordahi Tabet C, Karam EG, Nehme G, Fayyad J, Melhem N, Bou Ghosn M, and Kabbara H. (October 2002)."Orphans of War: A Four Year Prospective Longitudinal Study". Research presentation at the 49th Annual Meeting of the AACAP (American Academy of Child and Adolescent Psychiatry), San Francisco, USA.
11- Cordahi Tabet C, Karam EG, Nehmé G, Fayyad J, Melhem N, Rashidi N. Les Orphelins De La Guerre Experience Libanaise et Méthodologie D'un Suivi Prospectif. Stress et Trauma, 2002 ; 2(4) : 227-235.
12- Fayyad J, Jahshan C, and Karam EG. Systems Development of Child Mental Health Services in Developing Countries, In Myron Belfer (Ed), Cultural and Societal Influences in Child and Adolescent Psychiatry, Child and Adolescent Psychiatric Clinics of North America, 2001;10(4): 745-762. W.B. Saunders Company. Philadelphia, Pennsylvania.
13- Karam EG, Cordahi Tabet C, Fayyad J, and Karam A (May, 2003). "War Trauma" and "Mental Health Sequelae of the Lebanon Wars"  . Research Presentation at the 156th American Psychiatric Association (APA) Annual Meeting, San Francisco, USA.
14- Karam EG (December, 2004). "War Sequelae and Mental Health: A research from Lebanon". Research Presentation at the International Congress of Ministers of Health for Mental Health and Post-Conflict Recovery, Project 1 Billion, Rome, Italy.
15- Karam EG, Mneimneh Z, Karam A, Fayyad J, Nasser S, Chatterji S, Kessler R. Prevalence and treatment of mental disorders in Lebanon: A national epidemiological survey. The Lancet, 2006; 367 (9515): 1000-1006.
16- Kessler RC, Ustun TB. The World Mental Health (WMH) survey initiative version of the WHO-CIDI. International Journal of Methods in Psychiatric Research 2004; 13:95-121.
17- The WHO World Mental Health Survey Consortium. Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization World Mental Health Surveys. JAMA, 2004;291:2581-2590.

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Questions and Answers about War and Mental Health
In this section, answers are based on data from mental health research conducted in Lebanon in the past 20 years by IDRAAC.  For more information about war related studies published by IDRAAC, please click here.

Q1: Is all exposure to war the same? 
"War" comprises many successive events, some more horrific than others. A child or adult who witnesses the destruction of his/her home or the death or mutilation of a close person sustains higher levels of exposure than one who stays in an underground safe shelter with his / her family. In studies of children exposed to war it is clear that just "being there" or "experiencing" the war is insufficient by itself to traumatize a particular child. Studies (including our own at IDRAAC in adults and children) have clearly demonstrated that there is a dose effect: the more frequently a child or adult is exposed to war events and / or the more serious the exposure is, the more likely the child or adult will develop a psychiatric (mental health) disorder.

More specifically, our research on war in Lebanon has shown that the effects of war on mental health varies with:
a) The degree of witnessing of the war event (i.e. how close?)
b) The degree of emotional closeness to the actual victim (if the person him/herself is not the victim)
c) Severity of exposure (superficial injury, almost fatal, destruction of  house, or just sniper bullets)
d) Frequency of events
e) Type of event

The common war traumatic war events include:
a) House damage (self/very close person)
b) Physical Injury (self/ very close person)
c) Kidnapping/imprisonment (self/ very close person)
d) Displacement
e) Business loss

The less common war traumatic events that could be specific to individual wars include:
a) Rape
b) Torture
c) Deportation
d) Ethnic cleansing

Q2: What are some of the "effects of War on mental health" of adults?
As part of its agenda for improving the mental health situation of the Lebanese (in particular) and the Arab (in general), the Institute for Development, Research, Advocacy and Applied Care (IDRAAC) conducted several studies including the mental health consequences of war in Lebanon. The various studies that IDRAAC has conducted are characterized by their strong design since they are all follow-up studies on subjects representative of the community and who were exposed to extreme war trauma. These studies used internationally recognized scientifically sound instruments devised by groups which collaborated from all over the world. IDRAAC's war studies investigated two populations, adults and children.

Adults and War:
 
IDRAAC conducted several studies on adults over three different phases: 1989 (Phase I), 1991 (Phase II), and 1994 (Phase III) (i.e. subjects were followed for 6 years) in four different Lebanese communities exposed to different levels of war trauma, to study the effect of war on the mental health of the Lebanese. These studies were done with the support of National Institute of Health, and the Lebanese National Council for Scientific Research. The sample consisted of household units from which adults between the ages of 18-65 were selected. Six hundred fifty eight subjects were interviewed in Phase I, and a sub-sample was followed to Phases II and III. Information was collected on demographics, war exposure, Depression, Post Traumatic Stress Disorder (PTSD), alcohol and drug use and various other disorders. 
 
High rates of Depression (around 30%) were found in Phase I and  Phase II. These rates however seemed to drop down in Phase III, after the war. The one- year prevalence of PTSD after the war, in Phase I and in Phase II was 11.1% and 10.3% respectively.

War exposure was measured by using a specific questionnaire (War Event Questionnaire) developed by our group: we found that exposure to war was related strongly to the increase in these health disorders. Previously existing mental health problems (that is problems present before exposure to war) increase the risk of having Depression, PTSD, and other mental health disorders upon exposure to war. While it is known that people develop Depression because of their genetics or previous personal experiences, and that Depression tends to be recurrent problem for many individuals, it is therefore not surprising to see a rise in Depression cases after a stressor of an extreme nature such as war.

Q3: Does exposure to WAR affect levels of substance use among adults?
In our review of the scientific literature, we found that substance abuse may increase during wartime. For example: In one study, cigarette consumption was found to be more common among Dutch World War II veterans who suffered from chronic PTSD (more than 40 years after the war) than among those veterans who did not.
War-like incidents like the September 11 events in the US may also be related to increases in substance use: Manhattan residents who where interviewed one month after 9/11 reported an overall increase of 28.8% in their use of cigarettes, alcohol or marijuana (compared to their use one week before September 11). PTSD and Depression were risk factors for this increase.
Our studies in Lebanon did not show an increase in rates of substance use. We are currently looking again at a larger set of data to be able to answer this question and hope to come with a more solid answer.

Q4: What are some long term mental health consequences of war on adults?
War has long-term psychological consequences; some mental health disorders are commonly found to be recurrent or chronic.  A study in Denmark has found that a sub-sample of World War II veterans still had PTSD 50 years after the end of the war. Further, chronic PTSD has been found to be treatment-resistant. Another study on Rwandan adults showed that 15.5% still had Depression five years after the genocide. Very recently, and for the first time, our L.E.B.A.N.O.N. Study (Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation) conducted on a national level, indicates that mood, anxiety, and impulse control disorders were strongly associated with two or more war-related traumatic events, resulting in substantially higher proportions of moderate and severe mental health disorders in respondents exposed to multiple war-related traumata and that for several years after exposure.
The reasons for long-term consequences are not only due directly to war traumata but also to the many other losses that occur in the aftermath of war such as economic hardship and disruption of family relationships.

Q5: What are some of the "effects of War" on mental health of children?
Children & War Studies:
IDRAAC investigated the mental health of children and adolescents in 1996, in an effort to help them during and following the Israeli operation, "The Grapes of Wrath". Several programs were launched in 1996 to support the displaced families and help those who stayed in the bombarded areas. One of these programs was the one initiated by IDRAAC (with the support of Hariri Foundation, Dutch Foreign Ministry, and the Lebanese National Council for Scientific Research), which aimed at assessing the mental health and relieving the distress of the traumatized children. This program consisted of three main components:
 
First component:
Its goal was to assess the mental health consequences of the trauma directly after exposure (Phase I -1996) and the persistence of mental health disorders one year later (Phase II-1997). A sample representative of 45,000 students who attended schools located in the exposed villages was selected in Phase I. A sub-group was selected for follow-up in Phase II. School children had very high rates of depression, PTSD, Separation Anxiety Disorder (SAD), and Overanxious Disorder (OAD). These mental health problems are normally quite low (below 5 %) in times of peace. However, in our sample of Lebanese children and adolescents the prevalence of each of these disorders fell between 17.9% and 24.9%. By one year later the prevalence of disorders had significantly dropped.

Second Component:
Its goal was to measure the effectiveness of a school-based group treatment for 2500 students in the most affected villages. Thus 116 students were selected in Phase I to test their mental health status directly after trauma and before the treatment was delivered, then in Phase II, they were assessed again. In this study we could not  show that group community treatment after war trauma was effective. However the effectiveness of individual therapy was consistently established in our studies targeting orphans.

Third component:
Its goal was to assess the psychological, medical and social needs of war orphans who lost one or two parents during the bombarding of a U.N shelter at Qana. Since then these children have been followed yearly in a "Child Care Program".  They were treated "in the field" in South Lebanon as well as by IDRAAC team members.

The Qana orphans who had lost one or two parents in Qana continued to have high rates of depression, PTSD, SAD, Attention Deficit Hyperactivity Disorder (ADHD) & Conduct disorder one year later after the trauma (death of parent(s)-1997), whereas, their counterparts (children who were exposed to the same war but had not lost their parents) had gone down to normal rates of these mental health disorders.
Two years later (1998), the rates in the orphan sample where still high for depression, PTSD, SAD, ADHD & Conduct disorder.
Three (1999) & four (2000) years later, the rates in Qana orphans who were under intensive treatment by our group in conjunction with the Hariri foundation finally started going down; some disorders (Conduct & ADHD) however continued to be elevated and they are at present the focus of careful research by our group.   
Thus it is very important to note here that whereas the rates of disorders in school children dropped due to the effect of time, social support of the community and family members, the orphans had over and above been intensively treated by a multidisciplinary group of psychiatrists, psychologists, social workers….

In addition to the studies of IDRAAC in Lebanon on Children and War, Palestinian children exposed to war in the Palestinian Intifada were also studied by other researchers (Thabet A.M., 2000). These children have been exposed to witnessing of the beating/killing/torture of close friends/relatives, gas inhalation and witnessing house destruction. Similar to what we found in Lebanese Children, there were moderately high levels of PTSD immediately after exposure to traumatic events and this was directly related to the degree of exposure: the more events the children experienced, the more likely they were to develop PTSD. In addition, and as we found in our Lebanese sample of children and adolescents, most of the Palestinian children who had mental health disorders improved one year later.

Q6: What are some mental health reactions that could appear upon losing someone close during war?
Individuals who lose a very close person are at high risk to develop psychological problems, as they are exposed to a two-fold trauma: violent death and war. In addition to the closeness of the individual to the deceased, the nature of the death itself is also important: the more violent the death is (especially if it includes body mutilation), the more traumatic the event will be. These traumatized individuals may develop Post Traumatic Stress Disorder, Depression, and Anxiety Disorders.
  
Post Traumatic Stress Disorder is a psychological state where the individual is so overwhelmed by the trauma that he feels sort of obsessed with the event and its possible re-occurrence. S/he dreams of it at night, images and thoughts related to it come to his / her mind intrusively despite him / herself, causing much distress. S/he tries hard to avoid it actively or unconsciously, to the point of sometimes detaching from reality and feeling numb. The traumatized individual could also feel changes in body reactions such as excessive startling, sleep problems, fast heart rate.

When depression occurs, it affects heavily the person's mood, sleep, energy, appetite, interests, and concentration, coloring their world in black, lasting for several days or weeks in a row.

Anxiety Disorder causes the individual to experience overwhelming fears and or worries, including fears of separation and staying alone with associated physical signs such as sweating, palpitations and trouble sleeping.
It is assumed that when a person loses someone close, the resulting Depression is "normal". Our studies on adults who were bereaved during war revealed that if Depression occurred for the first time after the death of a close person, it tended to recur in the future similar to spontaneously occurring Depression not caused by grief or bereavement. Depression is known to be a recurrent disorder which may return in the future even after completely recovering from it. Our research showed that once Depression occurs, whether after bereavement or not, it carries the same risk for recurrence in the future.

Q7: What are some mental health reactions that could appear upon witnessing a physical injury of a loved one during war? 
Our research at IDRAAC has shown that persons have a marked increase in the risk of having Depression or other mental health disorders. For example, children who reported witnessing physical injury of a loved one in our study of "Children and War" were 6 times more likely to develop Depression and Separation Anxiety Disorder.

Q8: What are some mental health reactions that people would have upon witnessing house damage during war?
Similarly, our research has shown that students who reported witnessing house damage were 4.5 times more likely to develop lifetime depression (compared to those who did not witness any house damage).

Q9: What are some long term mental health consequences of war on children?
While many children and adolescents have been examined during wars and in their aftermath, there is relatively little research about the long-term outcome of children exposed to war.
  
Only a few studies examined this issue scientifically and followed children for more than one year after the cessation of war events. These studies show that most of the children who appeared to have suffered emotional symptoms of mental health disorders after war no longer show these symptoms later. However, they seem to develop symptoms of Impulse Control Disorders. Of course, and as our research has shown in our studies on Qana orphans (1996), exceptions exist, and these children and others who continue to have disorders more than one year after war are those who witnessed unusually high levels of trauma which personally affected them. In fact, we found that among those children who had lost one or two parents in Qana, 56.9% still had at least one disorder one year later, and 28.6% even two years later.

Our same prospective study (or clinical follow up) on the Lebanese Qana orphans of war, revealed that even three or four year later, when anxious and depressed feelings subsided, other behavioral symptoms appeared. Children and adolescents became much more disruptive and difficult to discipline. They had problems organizing themselves, following directions, and had trouble in situations that required a sustained level of mental effort. 

Other risk factors that were found in studies related to this issue include maternal factors such as the mother's level of anxiety: as one would expect the higher the level of maternal anxiety or the poorer maternal adjustment, the more the likelihood that the child would suffer long term mental health sequelae; we don't know if this is purely modeling or in addition carries a genetic predisposition with it.

It should also be noted that traumatic experiences, in children and adolescents, may have long term important socio-emotional developmental consequences, including identity problems, and personality changes.

Q10: Do the mental health reactions experienced by Arabs differ from those experienced by their Western counterparts?We think that the reactions to war in different countries are basically the same but what may change from one country to the other is the availability of social support. For example, when Vietnam soldiers went back to the US, they were received as perpetrators of atrocities, and not as heroes, whereas in our study of children in war we have been repeatedly impressed by the attitudes of 9 or 10 year olds saying they wanted to be heroes and they were.
When war reactions do differ among countries, it is rather due to differences in the context of different wars, rather than to cultural differences.  A recent study by De Jong et al. (2001) compared the reactions of four communities that have been exposed to war or war-like conditions: Palestinians, Ethiopians, Cambodians, and Algerians. Specific risk factors from each country depended specifically on the setting and the circumstances of war rather than on the nationalities of the populations under study.

Q11: What are some known risk and protective factors of mental health outcomes during war, in adults?  
Among adults, the immediate early reactions to the traumatic events have been found to be the most significant predictor of PTSD after exposure to trauma. 
Other factors that may play a role in the reactions specific to war trauma include previous exposures to other  types of trauma (being mugged, beaten, and other types of peace time trauma) and the psychiatric history of the individual prior to the trauma. Depression, PTSD, and substance use themselves increase the risk of mental health outcomes after exposure to war.

More recently, a new interesting factor has been found to possibly affect the reaction to war; maybe what pushes people to become more exposed to war is the size and shape of the Hippocampus, which is the structure deep in our brain that is heavily involved in memory and emotions. These however are early results that still need to be studied.
Being a refugee is an especially high risk factor due to exposure to the stress of migration and exile in addition to the war stressors. Social support in general is found to be a very important factor in many studies in preventing negative outcomes and has been shown to be quite important especially among refugees.

Q12: What are some known risk and protective factors of mental health disorders during war, in children and adolescents?
The study conducted by IDRAAC in the South of Lebanon on children exposed to war has shown that the profile of the subject at risk for psychopathology one year following war is that of a child or adolescent who directly witnessed a traumatic war event, who had psychiatric disorders before the war or who had associated psychosocial stressors. These stressors which are unrelated to war and occur in the lives of children everywhere included the fear of someone beating the child (within the home or outside of it), having family quarrels at home, having financial problems and having a chronic physical illness. The presence of any of those stressors independently raised the risk for development of mental health disorder.
Protective factors would naturally include: living in a peaceful home, feelings of security among all family members, minimal financial problems, good social support (by extension from other studies); we found that children that were healthy before the war (not only mentally, but also physically) were at a lower risk of suffering during war.

Q13: Are there effective community interventions for children  or adults exposed to war?
Most large-scale studies on this issue, in addition to our own, have been conducted on children. While there are many models for interventions in the community for children and adolescents who were exposed to traumatic events (e.g. natural disasters), no studies have examined this issue in children exposed to war.

Our group IDRAAC not only conducted but also carefully evaluated a treatment that we have put together for 2500 children exposed to war. It is unclear at this stage whether mass interventions for all children are effective. It looks to us that it is more advisable to first do a large scale screening in order to pick up the children who are adversely affected by the trauma and only then provide them with help, as a group or as an individual.

There are no studies to our knowledge that have studied large scale interventions on adults; there have been a few on specific subgroups like Cambodian refugees.

Q14: Is it alright for children to watch war footage?
It is preferable to limit the amount of news coverage and war footage that children view. Parents should supervise and choose the programming that children watch.
Watching news footage repeatedly and extensively may be more anxiety provoking than watching a war movie because there is no closure.
Parents have to remember that in watching day to day coverage of war, there is no closure, until the end of war: there is no definitive ending to the sequel they are watching (until obviously the war is over), which means that children and adults (alike), may go on spending endless hours watching the news, in fact awaiting "surprises" or "new" news.

Q15: To what extent do children realize that what they're seeing on TV is "real life" and not "fiction"?
Knowledge from childhood development studies indicate that children as young as three can distinguish fantasy from reality. That is why young children who watch violent images may feel themselves personally threatened: they perceive it as a "real" threat, that is they don't realize this is happening very very far, in a far away place.

Q16: What kind of impact (short/long-term) could war footage have on children?
Pictures of casualties and other vividly graphic footage of violent content not only is frightening but is potentially traumatizing to children.

The immediate effects after exposure to such footage may include:  constantly saying that s/he is afraid, sleeplessness, crying, and sometimes bedwetting. More long-term reactions may occur in children who are traumatized by these images. Such reactions could include among other things Depression, Post Traumatic Stress Disorder (PTSD) and Separation Anxiety Disorder (SAD)... These are mental health conditions that may require specialized treatment especially if they impact the child's emotional well being and his/her capacity to function.

Q17: How can war footage on TV, newspapers… affect people who have been previously exposed to war?
War has kept in most individuals a large amount of painful and overwhelming memories related to traumatic experiences such as destruction, losses, separation, horror, irreversible damage, humiliation, torture, shame and rage....
These emotions are the most difficult to manage and interfere dramatically in one's life at all levels: cognitive, emotional and behavioral. They alter the way people organize themselves towards the meaning of life, such as their sense of security, integrity, the way they relate to others and construct a vision directing their hopes, ambitions, spirituality and the multiple functions they possess as active and meaningful component of the world. Being exposed to viewing or reading about the horrors of war is considered to be a vivid exposure prone to re-actualize old memories, remaining sequelae and unresolved pain.....
These observations are shown by several research studies retracing the path of emotions in the brain, showing how the experience of fear or other very intense feelings are encapsulated in the affective memory (Hippocampus) and are ready to emerge at any time they are stimulated and solicited...

So what we could observe is the following: 
Traumatic events are re-experienced as if they are occurring now in the current and immediate life of the individual. This re-experiencing can be expressed as intrusive and distressing recollections of images, negative thoughts, negative view of one's life and one's future. This creates depressive and anxious ideations, and a tendency to generalize this way of thinking to all areas of life, thus ultimately generating a negative way of processing all kinds of information and distorting it according to the negative mode that is now in action....

This state of mind perpetuates and maintains a negative affectivity altering one's energy by decreasing sleeping and eating patterns (insomnia, nightmares or hypersomnia, decrease or uncontrollable increase in appetite, decrease in concentration and motivation, an overwhelming sense of insecurity, a feeling that nothing is anymore predictable or controllable, avoidant behavior (such as not being able to put up with one's habitual and usual responsibilities and activities), feeling helpless and hopeless.... Being on the edge, keyed up, irritable, sad and angry.

This alteration in one's mood, thinking and behavior will in return affect the way a person is likely to relate to his family, work and social surrounding, creating some kind of impairment and dysfunction in the previously established equilibrium. A feeling of extreme vulnerability is experienced, resulting in a rupture or a lowering in the sense of resilience against adversities.

Q18: Who are the children most vulnerable to the negative effects of war footage?
In general, younger children are more vulnerable to the effects of violent images on TV than older children.  
Other risk factors particular to an individual child can also determine which child becomes affected. For example, children who are already prone to worrying and anxiety, or those who have been through other traumatic experiences may be more affected than those who are not. Our extensive research at IDRAAC on the effects of war on children in Lebanon revealed that children who have stressors within their home are at greater risk to develop mental health disorders following war exposure. Similarly our extensive research showed that younger children were for example more likely to develop symptoms of Separation Anxiety Disorder (SAD) which manifests itself as fears of separation from family (and/or  care givers) and worries that serious harm may befall them.

Q19: What are some of the signs that children may reveal upon being exposed to war footage?
On the one hand, younger children may show their distress through complaints about various aches and pains in the different parts of the body. Teenagers, on the other hand, may react with irritability, hostility or wanting to be on their own and in some there can even be an increase in openly aggressive and violent behavior.   
Regardless of the age of the child, parents should observe the child's reaction while watching news on television. This provides them with the opportunity to be alert to the child's emotional state in order to process further this experience with their child.

Q20: What should parents do or say when their children view war footage?
Parents must discuss all  TV viewing (in general) with their children, and in the case of exposure to violent images this becomes an absolute necessity!!!

- Parents should be advised to ensure enough time and a quiet place to talk to the child before and after the news if these contain or are expected to contain violent scenes.
- Parents should watch the news with the child and not leave the child alone in front of images of horror.
- Parents should ask the child what s/he has heard and seen, in addition to what questions s/he may have.
- Parents should reassure their child regarding his/her safety in simple words. Discussions with the child should be more oriented towards practical problem solving and finding solutions rather than showing exaggerated expressions of emotions or burdening the child with the parent's own concerns.
- Parents are advised to give honest answers and information as children would usually know if the parent is not being honest.

Q21: How should parents discuss war with their children?
There's no right or wrong way to discuss war with children. However some general guidelines may be helpful. These include:

- Create an open and supportive environment where children know they can ask questions. On the others hand, it's best not to force children to talk about things until they're ready.
- Be prepared to repeat explanations several times; asking the same question over and over again may be away for the same child to seek reassurance.
- Be reassuring but don't make unrealistic promises. Let children know that they are safe in their home or at school but you cannot promise them that no more bombs with fall or that no one will get hurt anymore.
- Help children find ways to express themselves. Some may not want to talk about their fears but may be comfortable drawing pictures or playing with toys instead.
- Avoid stereotyping groups of people by country or religion. Use the opportunity to explain prejudice and discrimination and to teach tolerance.
- Help children establish a predictable routine and schedule. Children are reassured by structure and familiarity. School, sports, birthdays and group activities all take on added importance.
- Don't confront your child's defenses. If your child thinks things are happening "very far away" it is best not to disagree. This is may be the child's way of telling you they need to think this way right how in order to feel safe.
- Some signs might indicate that a child may need professional help like trouble sleeping that might persist several days. Other signs that could indicate a need for professional help include intrusive thoughts  that could interfere with studying or carrying on their regular activities, images or worries or recurring fears about death that are repeatedly disturbing and don't seem to be decreasing in spite of reassurance, persisting new reactions upon any separation from parents, such as when going to school... 
- Help children reach out and communicate with each other, or even with people outside their regular circles. They may also want to write a letter to their teachers, to a newspaper, to some parliament or government official, or even to families who lost loved ones or their home in the world.
- Let children be children: they may not want to think or talk a lot about these events. As you would expect, it is fine if they would rather play, ride their bike or climb trees!

Q22: What can one do to be less affected by war footage on TV?
When intense emotions experienced during wartime (i.e. depressive ideations, irritability, hopelessness…) are maintained for extended periods of time, they can negatively affect individuals psychologically, physically and mentally.
 
Therefore, it may be significantly helpful to:
- Recognize that these are "expected" reactions to legitimately upsetting images.
- Recognize that there is no closure, so unlike a movie or a television show, continuing to watch war footage will not provide an answer or a resolution. There is a considerable number of individuals who continue to watch for extended periods of time, possibly a desire for seeking closure or a desire for information that, in their opinion, will decrease their anxiety. Unfortunately, that does not happen. People watch in anticipation of the next attack or press conference....
- Limit your viewing. With increased exposure there will be sensitization. The more one thinks about a traumatic image, the easier it becomes for other events or cues to trigger memories of it (i.e. the threshold for activating distressing memories becomes lower and lower.)
- Turn it off way before bedtime. Try to do something to help you relax before going to sleep.
- Seek support. If you feel like it, share your thoughts and feelings about your worries and what is tormenting you with people that are close to you such as your friends and family.
- Protect your children from war footage. There isn't any good reason for children to be exposed to such images.  
- Keep the day's events in perspective. When individuals become anxious or fearful, they tend to overestimate the likelihood or probability of the occurrence of a traumatic event, perceive that they are incapable of managing it, as well as magnify the severity of the outcome.
- Watch, but be aware of your initial emotional reaction. Research has shown that our emotions could influence the ways in which we think about events. These initial appraisals help us to respond to events, and they become a filter through which we understand subsequent situations. Feelings of anger typically tailor our thoughts in a way that we become obsessed with retribution and thoughts of how to gain control over the situation. Feelings of anxiety lead to decreased locus of control, that is we don't feel we are able to have any control over the situation and this leads to feelings of uncertainty and pessimism, as well as a desire to withdraw from the threat, all of which could be maladaptive, when they become too intense. 
- Each of us has activities that are pleasurable and relaxing and that provide a sense of mastery or accomplishment. If you are stressed, then that would be a good time to make a list of these activities and engage in one or more of them… Just remember what you were doing when you were not watching or experiencing war.
- During difficult times, it helps to maintain in others a sense of faith, a sense of hope for a more positive outcome, an ability to direct attention away from personal concerns and thoughts towards supporting others, a sense of efficacy and meaning from the experiences....

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