Effective intervention following war and mass violence can be facilitated by screening and identifying children and adolescents who have persistent trauma-related symptoms. In situations involving mass violence and related threats, the mental health and psychosocial needs of children should be assessed as soon as possible, using validated behavioral and psychosocial assessment instruments, in order to identify populations of children and adolescents who may be at higher risk for developing trauma-related psychopathology, direct resources, and allow for early intervention (Cohen et al., 2000; NIMH, 2002.
Evidence suggests several important factors that should be taken into account whenever conducting post-emergency mental health needs assessments of children and adolescents events (Balaban, in preparation).
1) Necessity of assessing severity and type of trauma.
It is essential that the type, nature, and duration of trauma be assessed in children exposed to disasters and emergencies. There is evidence of relationships between the type and severity of trauma children are exposed to and the outcome in relation to PTSD, anxiety, and depression, i.e. children in war situations may have been exposed to a variety of traumas over long periods of time, while children in the aftermath of a natural disaster may be dealing with a single, relatively circumscribed event.
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A screening should include basic exposure information about where the children were and what happened to them and those around them. This should be followed by specific questions about high-risk experiences for example, direct life-threat, being trapped or injured, witnessing grotesque injury, hearing screams of distress, being separated from family members or caretakers, or, injury or death of family members. Additional exposure screening questions should address the child's subjective appraisal of the event and associated emotional responses.
2) Necessity of assessing multiple disorders
Post-emergency psychological assessment should not be limited to determining the presence of any single psychological disorder. A great deal of the current knowledge of children’s psychological responses to disasters is based on research on PTSD. However, PTSD is only one of a range of possible responses to trauma. Traumatized children can also exhibit trauma-based symptoms including physical symptoms such as headaches or stomachaches, anxiety, depression, and behavioral problems such as aggressive or disruptive behaviors (see Figure 1).
3) Independent Assessment of Children’s Behavior
Whenever possible, assessments of children should include an assessment of the child’s functioning by an adult familiar with the child’s behavior such as a parent, caretaker or teacher. Assessing child mental health often requires input from several informants. Children have generally been found to be able to accurately report their own internal states, but are often not reliable observers of their own behaviors. Adults, in contrast, are
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generally reliable observers of children’s behaviors, but have a tendency to underestimate children’s emotional distress.
4) Assessment of family members, especially mothers
If possible, assessments of children’s mental health should be conducted in conjunction with an assessment of parental mental health. A variety of studies have indicated that parental adjustment, particularly mothers, is an important predictor of children’s mental health outcomes. If a parent is distressed, depressed or highly anxious, he or she may need to get emotional support or counseling in order to be able to better care for and help their children.
5) Functional status
Whenever possible, screening instruments should include questions of social and behavioural functioning such as how children are behaving at home and at school. In the aftermath of emergencies, some children who report trauma symptoms in an assessment might be functioning well enough not to need immediate intervention; while the absence of reported symptoms does not necessarily mean that a child is not distressed and not functioning well.
6) Age and Developmental Differences
Although the impact of age on children’s post-traumatic behavior and functioning are not yet well understood, it is critically important that any assessment instruments used in an assessment be age and developmentally appropriate and presented in language that children can understand. Instruments used in post-emergency assessment of younger
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children must take into account their limited verbal skills and different ways of reacting to stress. For example, younger children may show re-experiencing symptoms of PTSD in the form of play reenactment, rather than flashbacks or intrusive thoughts.
7) Pre-Existing Risk Factors
Good practice in early intervention should take into account the special needs of those who may be vulnerable and less able to cope with unfolding situations. A variety of studies have identified risk factors which influence response to trauma and affect recovery. These include: exposure to previous traumas, pre-existing psychopathology such as depression or anxiety disorders, and social isolation. Other studies of traumatized child populations have also indicated that family displacement and loss of parents can add to the effects of the original trauma itself.
8) Cross-cultural differences
Whenever possible, assessments should be carried out using instruments that have been validated in the culture and population where they are being used, since different ethnic and cultural groups may have different categories of mental health and illness, and different culturally appropriate ways to express grief, pain and loss. Many assessment instruments may not be appropriately sensitive to cultural and ethnic variability; and simply translating an instrument into another language does not necessarily mean that the same symptoms or the same disorders are being assessed across cultures. Even when language is not an issue, original validation studies of an instrument may not be sufficient to establish cutoff scores in a new setting or population i.e. a test validated in a middle class clinical population may need to be re-validated for use in a non-Western context.
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