When I was asked to write about the research gaps in paediatric mental health research in conflict settings my first reaction was to shout about the unmet need in mental health services for children and adolescents. I often hear my health peers in the UK saying, “this child needs help but, with services as they are, they won’t meet the criteria.” Now imagine yourself in a low or middle income country, where it is estimated that between 76% and 85% of people with severe mental disorders receive no treatment. This is staggering. Now, once again, transfer yourself in your imagination to the situation of children in a conflict zone, where there is fear, violence, displacement, and uncertainty, and think about the scale of their unmet mental health needs.
Provision of services to these children is hampered by our lack of knowledge. What are the vulnerability factors for mental health problems? What are the factors that promote resilience? What kind of problems do children and adolescents present with? How do we efficiently identify children and adolescents in need of mental health support? How do we encourage children, adolescents, or their families to access support services? Why do some children access care and not others? How do we keep patients engaged in a therapeutic intervention? How do we measure success? These are all questions that have yet to be answered.
So we have two options: to either ignore these children, paralysed by the dearth of knowledge, or to respond to their needs, and through service-based operational research, develop, adapt, and improve as we respond to their needs.
At the start of November this year we published a description of children and adolescents presenting to Médecins Sans Frontières supported mental health facilities in three areas affected by conflict: The Democratic Republic of Congo, occupied Palestinian territory, and Iraq. The article illustrates many points about child mental health needs in conflict settings, but I would like to highlight three observations.
The first is that when children are not targeted by mental health interventions they are significantly under-represented. Overall, children under 15 years old represented just 7.1% of the 17,655 individuals attending for counselling. This proportion increased to 36.5% in the occupied Palestinian territory, where children were targeted through outreach activities, illustrating how programme design may be important in improving uptake of services.
Secondly, many precipitating events, as identified by the patient or parent, were directly related to the conflict setting: direct physical, sexual, or psychological violence; incarceration and detention; and witnessing abuse, injury, and death. But in addition to these, 34.7% of precipitating events were domestic violence, neglect, and non-violence related, suggesting that services must consider wider triggers for mental health presentations than the direct effects of a conflict.
Thirdly, the most common presenting symptoms in children and adolescents were anxiety-related complaints, including stress, worry, and fear. Other important presentations were physical complaints, for example, enuresis and sleep disturbance, and complaints related to mood, such as anhedonia, guilt, feeling worthless, and suicidal thoughts. What is notable about this list is that these are familiar presentations seen in children and adolescents all over the world, and that there are evidence based interventions to treat them.
The impact of mental health trauma can reverberate throughout a lifetime and it is our duty to protect the mental health of children in these most fragile of regions. There must be a paradigm shift, so that mental health needs in children and adolescents receive the provision and academic energy they deserve. Survival alone is not enough.
Tejshri Shah is a paediatric trainee based in London. Previously, Tejshri worked for Médecins Sans Frontières from 1999 to 2010 as a doctor, health advisor, and head of the MSF UK Manson Unit.