I attended the Peace Caucus Lecture on War and Public Health and was absolutely delighted to see that this issue is taking a bigger stage in the arena of Public Health. Below are some of my notes from the lecture. The notes do not do the lecture justice, as the documentary presentations and conversation that followed the lecture were both stimulating and thought-provoking. And please keep in mind these are notes that I typed very rapidly and without a lot of editing:) Without further delay: War and Public Health
Introductory Remarks
An Assessment of the Extent of Projected Global Famine Resulting From Limited, Regional Nuclear War: Climate and Health Effects of Regional Nuclear War: How sudden global cooling could produce a ‘nuclear famine’ – I. Helfand, MD
• International Physicians for the Prevention of Nuclear War (Physicians for Social Responsibility)
• The fall of temperature due to nuclear war would have a dramatic effect on health, agriculture, etc.
• Indonesia large volcanic eruption – only about half the destruction we expect from regional nuclear war
o prolonged cooling,
o extensive crop failure,
o drought,
o severe famine
• Effects may last as long as a decade (536-554 AD – this is what happened from prolonged cooling)
• But with Nuclear Regional War
o Disruption of the ozone layer
o Diversion of agriculture for industrial use (ethanol)
o Contamination by radioactive material
• We are extremely unprepared to deal with this sort of catastrophe
• Price of grain worldwide would increase exponentially
• Most people (1 billion) will die – this is a realistic figure
• The arsenals of all the nuclear powers are a threat
• Threat of the large scale war between the U.S. and Russia
o Would have even more consequences because of the large nuclear warheads that each country possesses
o Everything that we depend on for survival would be completely destroy
o The climate destruction would be catastrophic for the entire world (would drop temperature 4 degrees centigrade)
• We have come within minutes of being engaged in nuclear war several times
o The latest episode was in January 5, 1995
o These are the only instances that we know about
Health Impacts of War in the Middle East – A.F. Meyers, MD, MPH; A. Rothchild, MD
• Gaza Community Mental Health Programme
• 2008 Emergency Appeals Around the World
• Office for the Coordination of Humanitarian Office
• www. chaopt.org
• West Bank
o travel restrictions on West Bank roads
• Access to work, health services, etc.
o The government of Israel is working to build a physical barrier (separation wall, Apartheid Wall)
• Cuts off Palestinian farmers from arable land
• Most Palestinians are living between the barrier and the green line
o No improvement in Palestinian movement after AMA: Agreement on Movement and Access (2005)
o The government has failed to implement is obligations
o What was once justified on the short term has now been made permanent
o Settler attacks
• Gaza: despite the withdrawal of Israelis, conditions have continued to deteriorate
o 1.5 million people
o 6 nautical mile fishing limit imposed by Israel
o cease fire has been in effect for over nine months
• Israel said it would allow more imports into Gaza, but no improvements have been made
o Restriction of fuel imports
• Only received 1/3 fuel it needs to operate
• 250 thousand people with a severe lack of water
o Sewage has killed most sea-life due to industrial plant waste
• Holding Health to Ransom – GSS Interrogation and Extortion of Palestinian Patients at Erez Crossing (August 2008)
• Mental health
• 86% report sleeping problems
• 77% deterioration family relationship
• 72% tension among children
• 40% losing land, being uprooted
Creating a World Without War
• Human Consequences of war
o Death and disability
o Destruction of communities and cultures
o Diversion of resources
o Infrastructure disruption
o Etc.
• Why now?
o Climate change
o Nuclear Proliferation
o Global Economic Crisis
• Paradigm shift is needed:
o Creating a culture of peace in which human needs receive high priority and conflicts are settled peacefully and nonviolently
• Banning teaching of hate
• Strengthening international agencies and nongovernmental organizations
• Intervene before conflicts break out
• Former president of Finland – preventing armed conflict from breaking out
• These kinds of efforts need to be systemitized
o Controlling weapons and decreasing military expenditures
• Restrict international arms trade
• Stop illegal arms networks worldwide
• Strengthening international treaties to control chemical, biological, and especially nuclear weapons
• Decreasing military expeditures
o Improving the conditions in which people live in order to reduce the underlying causes of war
• Reduce poverty and socioeconomic and health disparities
• Improving quality, accessibility, and affordability of health care
• Strengthening public health
• Strengthening the social safety net
• Improving education and employment opportunities
• Hosts-Agents-Environment – this is the model they hope to use
• Believe it can be applied to create a world without war
• Developing the Popular and Political Will
o Educating others
o Advocating for policies and programs to prevent war and promote peace
o Strengthening the organization and financial support of institutions
• It is now recognized by the WHO as a health issue
o Interpersonal violence
o Intra personal violence
o Collective Violence
• Establish a U.S. Department of Peace
• Paradigm Shift
o Love rather than fear
o Kindness rather than compulsion
Operation Homecoming: Writing the Wartime Experience – R.E. Robbins
Documentary – veterans from previous wars and this current war in Iraq
Tuesday, October 28, 2008
Saturday, October 25, 2008
Day One of the APHA 2008 Conference in San Diego
Today was a settling-in day for me, a chance to look around and become acquainted with the area and the center. I am very excited about all of the opportunities to learn at this conference. I am also very excited about all of the opportunities to run along the marina :-)
I read an article in the latest Foreign Affairs journal (Vol. 87 No. 6) regarding the world food crisis. It was, perhaps, the best article I have read about this particular subject. "The Politics of Hunger," by Paul Collier, takes a practical look at the way the world is currently growing and supplying food and offers several suggestions on how to make the task more efficient and cost-effective.
Collier warns against the populism that has thus far fueled the global food crisis. He goes on to suggest that the GM/anti-American battle between the U.S. and Europe should end immediately if any gain is to be made on the side of commercial food production.
I will not go into detail about the article here and now, but I hope to come back to the article and the subject at a later time.
I read an article in the latest Foreign Affairs journal (Vol. 87 No. 6) regarding the world food crisis. It was, perhaps, the best article I have read about this particular subject. "The Politics of Hunger," by Paul Collier, takes a practical look at the way the world is currently growing and supplying food and offers several suggestions on how to make the task more efficient and cost-effective.
Collier warns against the populism that has thus far fueled the global food crisis. He goes on to suggest that the GM/anti-American battle between the U.S. and Europe should end immediately if any gain is to be made on the side of commercial food production.
I will not go into detail about the article here and now, but I hope to come back to the article and the subject at a later time.
Wednesday, October 22, 2008
Book Review: What is the What
I was recently asked to post a book review for What is the What, a work of fiction (but based on real events) by a Sudanese refugee who resettles in the United States. From the first words in the Introduction, I could not put this book down for even one minute. The feelings and images are clearly communicated through eloquent, raw, witty, and sometimes humorous telling of this personal fictional biography. I find difficulty in labeling this book a work of fiction because the main character is a real person and his story is true. However, due to the difficulty in retelling such a traumatic story with years of backlog, and the fact that the main character does not choose to write the book himself, it remains a work of fiction.
In the book, the author moves seamlessly from real time situations to memories and flashbacks of the war in the Sudan. What results is a disturbing realization that life as a resettled refugee in the United States has just as many barriers as actually living as a Sudanese refugee in Kenya. Although the nature of the barriers is obviously somewhat dissimilar, the situations in which the main character finds himself are nonetheless disheartening and detrimental to his well-being. As an educational tool for learning about the war and its consequences in Sudan, this book is a must-read. Detailed maps and information regarding the history of the conflict come in handy for those who may not be as familiar with the subject. As a work of fiction, this book pulls at the heartstrings of the reader. End the end, the reader is asked, not to feel ashamed, or calloused, or angry, or amused, but, is asked simply to feel something. The fact that the cathartic decision is in the hands of the reader makes the book a necessary addition for anyone interested in issues of human rights and justice, no matter what their personal convictions might be.
Heartland Film Festival
Over the weekend and first half of this week, I saw several films features at the Heartland Film Festival in Indianapolis. The films I saw are as follows:
Lumumba - A feature film following the rise and fall of Patrice Lumumba, former PM of The Democratic Republic of Congo.
As We Forgive - A documentary following the lives of two Rwandan women and the men who murdered their families as they attempt to reconcile and rebuild their community.
WarChild - A documentary following Emmanuel Jal, a former Sudanese child soldier, as he works to helps his people and faces his past.
Tsotsi - A feature film about a South African gang leader who loses his childhood, only to save a child from a world he has never known.
I cannot go into as much detail as is warranted by these fantastic films, but I will say that I am pleased by the wide variety of African films feature at this year's festival. I was not able to see Pray the Devil Back to Hell, a documentary about the women's movement in Liberia, but along with the films that I was able to see, I am glad that many countries in Africa were represented. Also, I witnessed more positive action and emotions coming from these films than I have at festivals in years past. I am hoping that the individuals who come to see these films will leave with a greater knowledge of at least one African country and will have a hopeful feeling upon leaving the theater. People all over the continent are stepping up to help themselves and each other and I am much pleased that the entire world is being shown these wonderful improvements in such an artistic and creative way. Bravo!
Saturday, October 18, 2008
Saturday, October 11, 2008
Healing Broken Hearts
A Theoretical Analysis Of Interventions For Child Refugees Diagnosed With War-Related Posttraumatic Stress Disorder
Copyright 2008 Jennifer M Kerner, IUSM DEPARTMENT OF PUBLIC HEALTH
Please properly cite this blog if using any material, in whole or in part, found within.
10/11/2008
A Population in Need
An estimated 15 wars have been fought since the turn of the 20th century. That number is conservative taking into account the ill-considered definition of aggression as stated in the United Nations General Assembly Resolution 3314 (XXIX). As a result of these conflicts, there are 11.4 million refugees worldwide under UNHCR mandate. In addition, there are 26 million internally displaced persons (IDPs) as a result of conflict (UNHCR 2008). Almost half (43%) of these refugees and IDPs are under the age of 18 (Onyut 2005). These children must struggle to survive daily life while grieving the loss of loved ones (Ehntholt 2005). Many times, children living in conflict areas witness killings and, sadly, may even be the killers (Bayer 2007). Children who are survivors of war-related traumatic events are of particular concern due to their vulnerable “developmental status” (Veenema 2002). Children up to age 19 go through a tremendous amount of life changes, separate from the external changes they face. With all of these factors adding to the strain of their lives, it is no surprise that “refugee children are at high risk of having mental health problems” (Yule 2000).
The situation is dire. As of the mid-1990s, “serious psychiatric disorder” has been diagnosed in 40-50% of refugee children in the United States alone (Hodes 1998). For refugees worldwide, the most prevalent of these psychiatric disorders is posttraumatic stress disorder (PTSD) (Fazel 2002). According to the DSM IV (Diagnostics and Statistical Manual of Mental Disorders), 6 criteria must be fulfilled in order to accurately diagnose a case of PTSD (Association 1994). These criteria include 1) “experiencing or witnessing a life-threatening” event, and experiencing “feelings of helplessness, fear or horror during that event,” 2) “reliving or re-experiencing” the event through flashbacks or dreams, 3) “avoidance,” 4) “being overly aroused,” 5) at least four weeks of suffering from these symptoms, and 6) “severe problems” in “every day functioning,” (Schauer 2005). Posttraumatic stress disorder “following exposure to global and community violence” affects “more than 3 million children” (Veenema 2002). This number accounts for “more than half of children exposed to war” (Allwood 2002). The effect is worldwide and does not discriminate based on factors such as geography, socioeconomic status, gender, or length of conflict. For example, the prevalence of PTSD among “Cambodian children who had been exposed to war and genocide during the Pol Pot regime” was 50% (Allwood 2002). A striking 93.8% of IDPs under the age of 18 were diagnosed with PTSD following the Bosnian war (Allwood 2002). “Significant mental health and psychosocial problems” abound in the Great Lakes region of Africa, where some 120,000 people have settled into IDP and refugee camps (Bolton 2007).
The needs of this vulnerable population must be addressed immediately, as the effects of traumatic events will likely continue into adulthood. In a study of 59 Cambodian adults, Hubbard et al (1995) found that 24% still showed clear symptoms of PTSD “a decade and a half removed from the horrors of the Pol Pot regime” (Hubbard 1995). Psychiatric disorders such as PTSD are detrimental to the normal development of children into young adults. But perhaps more concerning is the deterioration of reconciliation and peace-fostering among war-affected communities due to the prolonged prevalence of PTSD. According to Veenema et al (2002), several common reactions to trauma include “aggressive behavior” (for children ages 6-11 years), “reckless, risk-taking behavior,” and “wish for revenge” (for children ages 12-18) (Veenema 2002). A 2004 study by Pham et al revealed that a diagnosis of PTSD following war-related trauma was associated with limited support for reconciliation (Pham 2004). These findings suggest an immediate concern for treatment of PTSD symptoms in children who are living as refugees and IDPs. These children require effective and long-term treatment programs that will rebuild individual lives and foster peace in communities. For all of these reasons, public health interventions for refugee and IDP children diagnosed with PTSD due to war-related trauma must include elements of self-efficacy, self-determination, social support, cultural accommodation, sustainability, and should have the capacity for follow-up over time.
Designing Interventions: Two Suggested Theories
Before designing public health interventions, one must identify the causes and risk factors associated with the targeted health issue. For PTSD, the causes and risk factors can be confusing and confounded. In a letter responding to a study conducted by Bolton et al (2007), Dr. Metin Basoglu cautions researchers to focus treatment programs on the root of posttraumatic stress disorder. “Anxiety/fear,” maintains Basoglu, is the “causal process” behind PTSD (Basoglu 2007). This anxiety and fear could create a barrier to overcome at the very beginning stages of any intervention. Due to the common geographic and socioeconomic factors of most refugee populations, some of the confounding causes of psychiatric disorders among refugee children may also include “malnutrition,” “infectious disease,” “physical trauma,” “neglect,” “racism,” “harassment,” “identity conflicts,” and “failure to acculturate,” (Westermeyer 1991). These issues could further complicate intervention programming by causing relapse in treatment procedures. For example, the intervention design must address the basic needs of the patient (health, adequate food and shelter) before addressing underlying causes of PTSD (anxiety and fear due to ongoing racial and ethnic hatred, child abuse and neglect). Only after all of these factors have been resolved to a manageable measure, can the intervention focus on the actual issue of PTSD. Risk factors unique to children suffering from psychiatric disorders related to trauma and crisis “must be considered in order to design interventions likely to promote long-term mental health for different populations, at various times” (such as developmental stages (Veenema 2002)) “in the life cycle, and for groups with specific needs” (such as unaccompanied minors, resettled refugee children, and former child soldiers), (Willinsky 2002). In the following section, two theories of health behavior intervention are presented. Each theory offers distinct constructs that are beneficial to the long-term treatment of refugee children diagnosed with PTSD.
Social Cognitive Theory (SCT)
Social Cognitive Theory (SCT) takes into consideration multiple levels of intervention effectiveness. Specifically, the constructs of reciprocal determinism and environment/situation are helpful in designing appropriate intervention programs for this particular population. Refugee children do not fit one particular mold and their needs are very different depending on their country of origin, nature of traumatic experience(s), and their personal stage in human development. By taking into account aspects of their environment (both of origin and current situation, if different) health professionals are better equipped to affect behavior change. Culture and environment, as well as the particular experience of the patient, provides models for behavior that can be utilized for intervention purposes. SCT also focuses on self-efficacy, self-controlled performance, and managing emotional arousal. All three of these constructs are of tremendous importance to this at risk population. PTSD is a disorder of heightened emotional reactions. It is also a disorder that negatively affects feelings of self-efficacy and self-worth. These children must understand that their lives are not defined by the atrocities they have witness, nor are they a product of a “failed society.” Rather, after choosing to be a part of and to complete a treatment program, these children will have the opportunity to build a better life for themselves, their family, and their community. Social Cognitive Theory (SCT) stresses that, “while the environment largely determines or causes behavior, the person in turn can act in ways to change the environment” (Elder 1994). Changing their environment, to the extent they are able, may be the most effective way to promote continued and sustainable behavior change and treatment programs.
Theory of Reasoned Action/Theory of Planned Behavior
The first construct of Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB) involves instilling positive beliefs and outlooks in the attitudes of individuals. Refugee children, first and foremost, are looking for some reassurance that they will be “O.K.” and that their world has not been shattered forever. The second construct, subjective norms, focuses on social and peer group education. More often than not, refugee children are unaccompanied minors that have banded together, either as child-soldiers, asylum-seekers, in refugee camp youth groups, or resettlement programs. Willinsky et al (2002) offers several strategies for mental health promotion that follow the TRA/TRB models, including public policy changes, advocacy, “creating supportive environments,” promoting self-efficacy, and “strengthening community action,” (Willinsky 2002). Third, TPB addresses perceived behavioral control whereby intervention administrators can help to alleviate any structural or resource barriers the participant believes will hinder their ability to make behavior changes. When working with young children diagnosed with PTSD, one perceived barrier will be time. Administrators should not expect immediate changes and children should be given adequate time for the development of behavior modification. For indigenous interventions, barriers will include lack of resources, safe environments for the intervention and treatment program, and cultural issues, such as religion and language. Children who have survived “ethnic cleansing,” for example, will identify a perceived barrier if asked to work with a member of a different tribe or race. Fourth, behavioral intention is modified to instigate actual behavior. Administrators must not expect behavior change without establishing a clear understanding of what the change means and why the change is necessary. Children, especially, must have the desire and intent to change if they are to sustain the behavior change over their lifetime. Both TRA/TPB and SCT bring positive constructs to behavior change interventions. The following section will analyze the use of TRA/TPB and SCT in several recent case studies.
Analysis of SCT and TRA/TPB in Current Treatment Interventions
Cognitive-Behavioral Therapy (CBT)
Cognitive-behavioral therapy (CBT) is the most popular method of treatment for child refugees diagnosed with PTSD. However, the way in which CBT is administered as a public health intervention varies considerably across case studies. Cognitive behavioral treatments for PTSD due to war-related trauma have included “play, art, music therapy, and story telling” (Fazel 2002). Play-therapy follows the constructs of TRA/TPB by fostering positive beliefs in the patients prior to conducting sessions that delve deep into the psychiatric hardships of the patient. In addition, this form of intervention is often applied in a group atmosphere, providing peer and social support for behavior change. Finally, play-therapy includes the constructs of TRA/TPB that promote self-efficacy and intention modification. This attribute of play-therapy is crucial for this population of young people. Rather than hope or guess as to the sustainability of behavior modification, TRA/TPB constructs work to predict actual behavior change, making the promise of individual and community reconstruction a reality.
Exposure Therapy (ET) and Narrative Exposure Therapy (NET)
Exposure therapy, according to some studies, is the most effective form of CBT for the treatment of trauma survivors (Veenema 2002). KIDNET is a short-term, kid-friendly exposure therapy treatment for individual children diagnosed with PTSD (Onyut 2005). Before the intervention begins, a baseline is acquired by assessing patients for symptoms of PTSD. During the intervention, patients are asked to illustrate their life story using a rope (representing time), rocks (representing negative experiences), and flowers (representing positive experiences). Once the child has completed this task, he or she then proceeds to give an oral biography of their lives. The administrator writes down the story verbatim. In subsequent sessions, the administrator has the child read (or reads to the child) the biography from the session prior. If necessary, the child then makes any changes to the biography. At the final session, the child reads or hears their final draft of their biography and is asked to once again illustrate their life story. Any changes between the first and last session are made and the child is assessed for symptoms of PTSD. The case study conducted by Onyut et al in 2005 showed immediate improvements that were sustained at a nine-month follow-up. The success of this intervention can be attributed to the application of several SCT constructs. First, reinforcement, both from the administrator and from the child as he or she edits his or her biography, motivates behavior change in the participant. The intervention also uses self-efficacy to foster confidence in the participant’s ability to recall and retell their life story. Self-controlled performance and managing emotional arousal by confronting stressors and triggers affects behavior change as well. Although a study conducted in 2001 by Paunovic and Ost found no difference in treatment outcomes between exposure therapy (confrontation of “trauma-related images”) and cognitive-behavioral therapy (a “combination of exposure, cognitive therapy and controlled breathing”) (Paunovic 2001), KIDNET is clearly a viable intervention option that makes appropriate use of SCT constructs.
The Equilibrium and Developmental-Ecological Models
An early intervention model, The Equilibrium Model, focuses on stabilizing the affected individual before applying any sort of treatment. The goal is to assist the person in regaining enough psychological “equilibrium” to agree that life is worth living (James 2008). Thus, subsequent treatment measures will be better received. This is important when developing an intervention based on the TRA/TPB. One must “assess the effect of interventions on the beliefs targeted and on other components of the model” so as not to “negate the effect of the targeted belief,” (Montano 2002). The Developmental-Ecological Model acknowledges the developmental stage of the individual alongside environmental factors relating to the crisis situation (James 2008). This model is closely related to the SCT concept of reciprocal determinism.
Manual-Based Interventions
In a 2005 study of a school-based Cognitive-Behavioral Therapy (CBT) group intervention, Ehntholt, et al (2005) utilized the ‘Children and War: Teaching Recovery Techniques’ manual (Smith 2000). The study applied certain constructs of the TRA/TPB in an attempt to design an intervention for refugee children who had been resettled in the United Kingdom. The intervention addressed the participants’ attitudes toward the behaviors they were asked to adopt, but in an indirect way. For instance, children were asked to discuss war-related photos and images, thoughts, and dreams, but were not confronted about their beliefs regarding their future or future actions. Although the intervention was group-based, participants were not asked to discuss normative beliefs, or fears and anxieties about what other individuals in the group would think about their behavior. Because these children have experienced many of the same traumatic events, a change in behavior, even a positive change, may seem like a betrayal to the rest of the group. The redeeming quality of the case-study intervention was the application of the TRA/TPB construct of behavioral intention. At the end of the intervention program, participants were asked to discuss and write about the importance of enjoying one’s activities, and to draw pictures of ambitions and hopes for the future. By ending the intervention with the construct of behavioral intention, the children are more likely to actually perform the behavioral change. Unfortunately, because the other constructs of the TRA/TPB were lacking, the positive effects of the intervention program were not sustained after a two-month period (Ehntholt 2005).
Implications for Intervention
The treatment of refugee children diagnosed with war-related PTSD has gained world-wide attention in the past few years. More and more studies are examining the way in which interventions are conducted with respect to the unique needs of this population. Some studies advise immediate intervention, while others promote waiting until “a few months” after the traumatic event to administer treatment (Karam, Fayyad et al. 2008). Other studies focus on educating the children “about the symptoms of PTSD” rather than simply treating the symptoms without providing additional knowledge to the patient (Smith 2000). Several studies were successful in treating depression symptoms, but unsuccessful “in improving anxiety, conduct problems, or functioning” (Bolton 2007). This imbalance in outcomes may stem from a failure to apply enough constructs of either SCT or TRA/TPB to affect positive and lasting change in behavior. The imbalance may also be caused by an oversight regarding the root of PTSD in this particular population. Several rounds of interventions based on either SCT or TRA/TPB may be needed before the fundamental symptoms of PTSD can be treated. It is also beneficial to note that group-based interventions (Ehntholt 2005; Bolton 2007) were less effective over time than individually-based interventions (Paunovic 2001; Onyut 2005). This phenomenon may be due to the “herd mentality” of child refugees and their fear of straying from the group. Rather than risk being noticed for a change in behavior, these children may opt for a more camouflaged approach to survival, even if it means continuing to possess destructive behavior.
Self-efficacy, self-determination, and intention of behavior change are the three most important constructs in the development of effective interventions for this population. This global health issue is concerned, not simply with the treating of PTSD symptoms, but with healing the broken hearts of children orphaned and abused by situations of circumstance. No one, no matter how young or old, no matter where they are from, no matter creed, gender, or race should ever have to witness the atrocities these children have witnessed. It is the duty of the world’s public health professionals to find and test theories of behavioral intervention in order to give hope and a promise of a better life to these innocent, brave children.
Allwood, M., Bell-Dolan, D., Arshad Husain, S. (2002). "Children's Trauma and Adjustment Reactions to Violent and Nonviolent War Experiences." J Am Acad Child Adolesc Psychiatry 41(4): 450-457.
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Basoglu, M. (2007). "Treatment for Depression Symptoms in Ugandan Adolescent Survivors of War and Displacement." JAMA 298(18): 2138.
Bayer, C. P., Klasen, F., Adam, H. (2007). "Association of Trauma and PTSD Symptoms With Openness to Reconciliation and Feelings of Revenge Among Former Ugandan and Congolese Child Soldiers." JAMA 298(5): 555-559.
Bolton, P., Bass, J., Betancourt, T., et al. (2007). "Interventions for Depression Symptoms Among Adolescent Survivors of War and Displacement in Northern Uganda: A Randomized Controlled Trial." JAMA 298(5): 519-527.
Ehntholt, K. A., Smith, P.A., Yule, W. (2005). "School-based Cognitive-Behavioural Therapy Group Intervention for Refugee Children who have Experienced War-related Trauma." Clinical Child Psychology and Psychiatry 10(2): 235-250.
Elder, J. P., et al (1994). Motivating Health Behavior. Albany, Delmar Publishers Inc.
Fazel, M., Stein, A. (2002). "The mental health of refugee children." Arch Dis Child 87: 366-370.
Hodes, M. (1998). "Refugee Children: May need a lot of psychiatric help." BMJ 316: 793-794.
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James, R. (2008). Crisis Intervention Strategies. Belmont, CA, Thomson Brooks/Cole.
Karam, E. G., J. Fayyad, et al. (2008). "Effectiveness and specificity of a classroom-based group intervention in children and adolescents exposed to war in Lebanon." World Psychiatry 7(2): 103-9.
Montano, D., Kasprzyk, D. (2002). The Theory of Reasoned Action and the Theory of Planned Behavior. Health Behavior and Health Education. K. Glanz, et al. San Francisco, Jossey-Bass: 583.
Onyut, L. P., Neuner, F., Schauer, E., Ertl, V., Odenwald, M., Schauer, M., Elbert, T. (2005). "Narrative Exposure Therapy as a treatment for child war survivors with posttraumatic stress disorder: Two case reports and a pilot study in an African refugee settlement." BMC Psychiatry 5(7).
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Schauer, M., Neuner, F., Elbert, T. (2005). Narrative Exposure Therapy: A Short-Term Intervention for Traumatic Stress Disorders after War, Terror, or Torture. Cambridge, Hogrefe & Huber Publishers.
Smith, P., Dyregrov, A., Yule, W., Perrin, S., Gjestad, R., Gupta, L. (2000). Children and War: Teaching recovery techniques. Bergen, Norway, Foundation for Children and War.
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Willinsky, C., Pape, B. (2002). Mental Health Promotion. Transforming Health Promotion. L. E. Young, Hayes, V. Philadelphia, F. A. Davis Company: 162-173.
Yule, W. (2000). "Emanuel Miller Lecture From Pogroms to "Ethnic Cleansing": Meeting the Needs of War Affected Children." J Child Psychol Psychiatry 41(6): 695-702.
Copyright 2008 Jennifer M Kerner, IUSM DEPARTMENT OF PUBLIC HEALTH
Please properly cite this blog if using any material, in whole or in part, found within.
10/11/2008
A Population in Need
An estimated 15 wars have been fought since the turn of the 20th century. That number is conservative taking into account the ill-considered definition of aggression as stated in the United Nations General Assembly Resolution 3314 (XXIX). As a result of these conflicts, there are 11.4 million refugees worldwide under UNHCR mandate. In addition, there are 26 million internally displaced persons (IDPs) as a result of conflict (UNHCR 2008). Almost half (43%) of these refugees and IDPs are under the age of 18 (Onyut 2005). These children must struggle to survive daily life while grieving the loss of loved ones (Ehntholt 2005). Many times, children living in conflict areas witness killings and, sadly, may even be the killers (Bayer 2007). Children who are survivors of war-related traumatic events are of particular concern due to their vulnerable “developmental status” (Veenema 2002). Children up to age 19 go through a tremendous amount of life changes, separate from the external changes they face. With all of these factors adding to the strain of their lives, it is no surprise that “refugee children are at high risk of having mental health problems” (Yule 2000).
The situation is dire. As of the mid-1990s, “serious psychiatric disorder” has been diagnosed in 40-50% of refugee children in the United States alone (Hodes 1998). For refugees worldwide, the most prevalent of these psychiatric disorders is posttraumatic stress disorder (PTSD) (Fazel 2002). According to the DSM IV (Diagnostics and Statistical Manual of Mental Disorders), 6 criteria must be fulfilled in order to accurately diagnose a case of PTSD (Association 1994). These criteria include 1) “experiencing or witnessing a life-threatening” event, and experiencing “feelings of helplessness, fear or horror during that event,” 2) “reliving or re-experiencing” the event through flashbacks or dreams, 3) “avoidance,” 4) “being overly aroused,” 5) at least four weeks of suffering from these symptoms, and 6) “severe problems” in “every day functioning,” (Schauer 2005). Posttraumatic stress disorder “following exposure to global and community violence” affects “more than 3 million children” (Veenema 2002). This number accounts for “more than half of children exposed to war” (Allwood 2002). The effect is worldwide and does not discriminate based on factors such as geography, socioeconomic status, gender, or length of conflict. For example, the prevalence of PTSD among “Cambodian children who had been exposed to war and genocide during the Pol Pot regime” was 50% (Allwood 2002). A striking 93.8% of IDPs under the age of 18 were diagnosed with PTSD following the Bosnian war (Allwood 2002). “Significant mental health and psychosocial problems” abound in the Great Lakes region of Africa, where some 120,000 people have settled into IDP and refugee camps (Bolton 2007).
The needs of this vulnerable population must be addressed immediately, as the effects of traumatic events will likely continue into adulthood. In a study of 59 Cambodian adults, Hubbard et al (1995) found that 24% still showed clear symptoms of PTSD “a decade and a half removed from the horrors of the Pol Pot regime” (Hubbard 1995). Psychiatric disorders such as PTSD are detrimental to the normal development of children into young adults. But perhaps more concerning is the deterioration of reconciliation and peace-fostering among war-affected communities due to the prolonged prevalence of PTSD. According to Veenema et al (2002), several common reactions to trauma include “aggressive behavior” (for children ages 6-11 years), “reckless, risk-taking behavior,” and “wish for revenge” (for children ages 12-18) (Veenema 2002). A 2004 study by Pham et al revealed that a diagnosis of PTSD following war-related trauma was associated with limited support for reconciliation (Pham 2004). These findings suggest an immediate concern for treatment of PTSD symptoms in children who are living as refugees and IDPs. These children require effective and long-term treatment programs that will rebuild individual lives and foster peace in communities. For all of these reasons, public health interventions for refugee and IDP children diagnosed with PTSD due to war-related trauma must include elements of self-efficacy, self-determination, social support, cultural accommodation, sustainability, and should have the capacity for follow-up over time.
Designing Interventions: Two Suggested Theories
Before designing public health interventions, one must identify the causes and risk factors associated with the targeted health issue. For PTSD, the causes and risk factors can be confusing and confounded. In a letter responding to a study conducted by Bolton et al (2007), Dr. Metin Basoglu cautions researchers to focus treatment programs on the root of posttraumatic stress disorder. “Anxiety/fear,” maintains Basoglu, is the “causal process” behind PTSD (Basoglu 2007). This anxiety and fear could create a barrier to overcome at the very beginning stages of any intervention. Due to the common geographic and socioeconomic factors of most refugee populations, some of the confounding causes of psychiatric disorders among refugee children may also include “malnutrition,” “infectious disease,” “physical trauma,” “neglect,” “racism,” “harassment,” “identity conflicts,” and “failure to acculturate,” (Westermeyer 1991). These issues could further complicate intervention programming by causing relapse in treatment procedures. For example, the intervention design must address the basic needs of the patient (health, adequate food and shelter) before addressing underlying causes of PTSD (anxiety and fear due to ongoing racial and ethnic hatred, child abuse and neglect). Only after all of these factors have been resolved to a manageable measure, can the intervention focus on the actual issue of PTSD. Risk factors unique to children suffering from psychiatric disorders related to trauma and crisis “must be considered in order to design interventions likely to promote long-term mental health for different populations, at various times” (such as developmental stages (Veenema 2002)) “in the life cycle, and for groups with specific needs” (such as unaccompanied minors, resettled refugee children, and former child soldiers), (Willinsky 2002). In the following section, two theories of health behavior intervention are presented. Each theory offers distinct constructs that are beneficial to the long-term treatment of refugee children diagnosed with PTSD.
Social Cognitive Theory (SCT)
Social Cognitive Theory (SCT) takes into consideration multiple levels of intervention effectiveness. Specifically, the constructs of reciprocal determinism and environment/situation are helpful in designing appropriate intervention programs for this particular population. Refugee children do not fit one particular mold and their needs are very different depending on their country of origin, nature of traumatic experience(s), and their personal stage in human development. By taking into account aspects of their environment (both of origin and current situation, if different) health professionals are better equipped to affect behavior change. Culture and environment, as well as the particular experience of the patient, provides models for behavior that can be utilized for intervention purposes. SCT also focuses on self-efficacy, self-controlled performance, and managing emotional arousal. All three of these constructs are of tremendous importance to this at risk population. PTSD is a disorder of heightened emotional reactions. It is also a disorder that negatively affects feelings of self-efficacy and self-worth. These children must understand that their lives are not defined by the atrocities they have witness, nor are they a product of a “failed society.” Rather, after choosing to be a part of and to complete a treatment program, these children will have the opportunity to build a better life for themselves, their family, and their community. Social Cognitive Theory (SCT) stresses that, “while the environment largely determines or causes behavior, the person in turn can act in ways to change the environment” (Elder 1994). Changing their environment, to the extent they are able, may be the most effective way to promote continued and sustainable behavior change and treatment programs.
Theory of Reasoned Action/Theory of Planned Behavior
The first construct of Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB) involves instilling positive beliefs and outlooks in the attitudes of individuals. Refugee children, first and foremost, are looking for some reassurance that they will be “O.K.” and that their world has not been shattered forever. The second construct, subjective norms, focuses on social and peer group education. More often than not, refugee children are unaccompanied minors that have banded together, either as child-soldiers, asylum-seekers, in refugee camp youth groups, or resettlement programs. Willinsky et al (2002) offers several strategies for mental health promotion that follow the TRA/TRB models, including public policy changes, advocacy, “creating supportive environments,” promoting self-efficacy, and “strengthening community action,” (Willinsky 2002). Third, TPB addresses perceived behavioral control whereby intervention administrators can help to alleviate any structural or resource barriers the participant believes will hinder their ability to make behavior changes. When working with young children diagnosed with PTSD, one perceived barrier will be time. Administrators should not expect immediate changes and children should be given adequate time for the development of behavior modification. For indigenous interventions, barriers will include lack of resources, safe environments for the intervention and treatment program, and cultural issues, such as religion and language. Children who have survived “ethnic cleansing,” for example, will identify a perceived barrier if asked to work with a member of a different tribe or race. Fourth, behavioral intention is modified to instigate actual behavior. Administrators must not expect behavior change without establishing a clear understanding of what the change means and why the change is necessary. Children, especially, must have the desire and intent to change if they are to sustain the behavior change over their lifetime. Both TRA/TPB and SCT bring positive constructs to behavior change interventions. The following section will analyze the use of TRA/TPB and SCT in several recent case studies.
Analysis of SCT and TRA/TPB in Current Treatment Interventions
Cognitive-Behavioral Therapy (CBT)
Cognitive-behavioral therapy (CBT) is the most popular method of treatment for child refugees diagnosed with PTSD. However, the way in which CBT is administered as a public health intervention varies considerably across case studies. Cognitive behavioral treatments for PTSD due to war-related trauma have included “play, art, music therapy, and story telling” (Fazel 2002). Play-therapy follows the constructs of TRA/TPB by fostering positive beliefs in the patients prior to conducting sessions that delve deep into the psychiatric hardships of the patient. In addition, this form of intervention is often applied in a group atmosphere, providing peer and social support for behavior change. Finally, play-therapy includes the constructs of TRA/TPB that promote self-efficacy and intention modification. This attribute of play-therapy is crucial for this population of young people. Rather than hope or guess as to the sustainability of behavior modification, TRA/TPB constructs work to predict actual behavior change, making the promise of individual and community reconstruction a reality.
Exposure Therapy (ET) and Narrative Exposure Therapy (NET)
Exposure therapy, according to some studies, is the most effective form of CBT for the treatment of trauma survivors (Veenema 2002). KIDNET is a short-term, kid-friendly exposure therapy treatment for individual children diagnosed with PTSD (Onyut 2005). Before the intervention begins, a baseline is acquired by assessing patients for symptoms of PTSD. During the intervention, patients are asked to illustrate their life story using a rope (representing time), rocks (representing negative experiences), and flowers (representing positive experiences). Once the child has completed this task, he or she then proceeds to give an oral biography of their lives. The administrator writes down the story verbatim. In subsequent sessions, the administrator has the child read (or reads to the child) the biography from the session prior. If necessary, the child then makes any changes to the biography. At the final session, the child reads or hears their final draft of their biography and is asked to once again illustrate their life story. Any changes between the first and last session are made and the child is assessed for symptoms of PTSD. The case study conducted by Onyut et al in 2005 showed immediate improvements that were sustained at a nine-month follow-up. The success of this intervention can be attributed to the application of several SCT constructs. First, reinforcement, both from the administrator and from the child as he or she edits his or her biography, motivates behavior change in the participant. The intervention also uses self-efficacy to foster confidence in the participant’s ability to recall and retell their life story. Self-controlled performance and managing emotional arousal by confronting stressors and triggers affects behavior change as well. Although a study conducted in 2001 by Paunovic and Ost found no difference in treatment outcomes between exposure therapy (confrontation of “trauma-related images”) and cognitive-behavioral therapy (a “combination of exposure, cognitive therapy and controlled breathing”) (Paunovic 2001), KIDNET is clearly a viable intervention option that makes appropriate use of SCT constructs.
The Equilibrium and Developmental-Ecological Models
An early intervention model, The Equilibrium Model, focuses on stabilizing the affected individual before applying any sort of treatment. The goal is to assist the person in regaining enough psychological “equilibrium” to agree that life is worth living (James 2008). Thus, subsequent treatment measures will be better received. This is important when developing an intervention based on the TRA/TPB. One must “assess the effect of interventions on the beliefs targeted and on other components of the model” so as not to “negate the effect of the targeted belief,” (Montano 2002). The Developmental-Ecological Model acknowledges the developmental stage of the individual alongside environmental factors relating to the crisis situation (James 2008). This model is closely related to the SCT concept of reciprocal determinism.
Manual-Based Interventions
In a 2005 study of a school-based Cognitive-Behavioral Therapy (CBT) group intervention, Ehntholt, et al (2005) utilized the ‘Children and War: Teaching Recovery Techniques’ manual (Smith 2000). The study applied certain constructs of the TRA/TPB in an attempt to design an intervention for refugee children who had been resettled in the United Kingdom. The intervention addressed the participants’ attitudes toward the behaviors they were asked to adopt, but in an indirect way. For instance, children were asked to discuss war-related photos and images, thoughts, and dreams, but were not confronted about their beliefs regarding their future or future actions. Although the intervention was group-based, participants were not asked to discuss normative beliefs, or fears and anxieties about what other individuals in the group would think about their behavior. Because these children have experienced many of the same traumatic events, a change in behavior, even a positive change, may seem like a betrayal to the rest of the group. The redeeming quality of the case-study intervention was the application of the TRA/TPB construct of behavioral intention. At the end of the intervention program, participants were asked to discuss and write about the importance of enjoying one’s activities, and to draw pictures of ambitions and hopes for the future. By ending the intervention with the construct of behavioral intention, the children are more likely to actually perform the behavioral change. Unfortunately, because the other constructs of the TRA/TPB were lacking, the positive effects of the intervention program were not sustained after a two-month period (Ehntholt 2005).
Implications for Intervention
The treatment of refugee children diagnosed with war-related PTSD has gained world-wide attention in the past few years. More and more studies are examining the way in which interventions are conducted with respect to the unique needs of this population. Some studies advise immediate intervention, while others promote waiting until “a few months” after the traumatic event to administer treatment (Karam, Fayyad et al. 2008). Other studies focus on educating the children “about the symptoms of PTSD” rather than simply treating the symptoms without providing additional knowledge to the patient (Smith 2000). Several studies were successful in treating depression symptoms, but unsuccessful “in improving anxiety, conduct problems, or functioning” (Bolton 2007). This imbalance in outcomes may stem from a failure to apply enough constructs of either SCT or TRA/TPB to affect positive and lasting change in behavior. The imbalance may also be caused by an oversight regarding the root of PTSD in this particular population. Several rounds of interventions based on either SCT or TRA/TPB may be needed before the fundamental symptoms of PTSD can be treated. It is also beneficial to note that group-based interventions (Ehntholt 2005; Bolton 2007) were less effective over time than individually-based interventions (Paunovic 2001; Onyut 2005). This phenomenon may be due to the “herd mentality” of child refugees and their fear of straying from the group. Rather than risk being noticed for a change in behavior, these children may opt for a more camouflaged approach to survival, even if it means continuing to possess destructive behavior.
Self-efficacy, self-determination, and intention of behavior change are the three most important constructs in the development of effective interventions for this population. This global health issue is concerned, not simply with the treating of PTSD symptoms, but with healing the broken hearts of children orphaned and abused by situations of circumstance. No one, no matter how young or old, no matter where they are from, no matter creed, gender, or race should ever have to witness the atrocities these children have witnessed. It is the duty of the world’s public health professionals to find and test theories of behavioral intervention in order to give hope and a promise of a better life to these innocent, brave children.
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Basoglu, M. (2007). "Treatment for Depression Symptoms in Ugandan Adolescent Survivors of War and Displacement." JAMA 298(18): 2138.
Bayer, C. P., Klasen, F., Adam, H. (2007). "Association of Trauma and PTSD Symptoms With Openness to Reconciliation and Feelings of Revenge Among Former Ugandan and Congolese Child Soldiers." JAMA 298(5): 555-559.
Bolton, P., Bass, J., Betancourt, T., et al. (2007). "Interventions for Depression Symptoms Among Adolescent Survivors of War and Displacement in Northern Uganda: A Randomized Controlled Trial." JAMA 298(5): 519-527.
Ehntholt, K. A., Smith, P.A., Yule, W. (2005). "School-based Cognitive-Behavioural Therapy Group Intervention for Refugee Children who have Experienced War-related Trauma." Clinical Child Psychology and Psychiatry 10(2): 235-250.
Elder, J. P., et al (1994). Motivating Health Behavior. Albany, Delmar Publishers Inc.
Fazel, M., Stein, A. (2002). "The mental health of refugee children." Arch Dis Child 87: 366-370.
Hodes, M. (1998). "Refugee Children: May need a lot of psychiatric help." BMJ 316: 793-794.
Hubbard, J., Realmuto, G., Northwood, A., Masten, A. (1995). "Comorbidity of Psychiatric Diagnoses with Posttraumatic Stress Disorder in Survivors of Childhood Trauma." J Am Acad Child Adolesc Psychiatry 34(9): 1167-1173.
James, R. (2008). Crisis Intervention Strategies. Belmont, CA, Thomson Brooks/Cole.
Karam, E. G., J. Fayyad, et al. (2008). "Effectiveness and specificity of a classroom-based group intervention in children and adolescents exposed to war in Lebanon." World Psychiatry 7(2): 103-9.
Montano, D., Kasprzyk, D. (2002). The Theory of Reasoned Action and the Theory of Planned Behavior. Health Behavior and Health Education. K. Glanz, et al. San Francisco, Jossey-Bass: 583.
Onyut, L. P., Neuner, F., Schauer, E., Ertl, V., Odenwald, M., Schauer, M., Elbert, T. (2005). "Narrative Exposure Therapy as a treatment for child war survivors with posttraumatic stress disorder: Two case reports and a pilot study in an African refugee settlement." BMC Psychiatry 5(7).
Paunovic, N., Ost, L. (2001). "Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees." Behaviour Research and Therapy 39(10): 1183-1197.
Pham, P. N., Weinstein, H.M., Longman, T. (2004). "Trauma and PTSD Symptoms in Rwanda: Implicationsfor Attitudes Toward Justice and Reconciliation." JAMA 292(5): 602-612.
Schauer, M., Neuner, F., Elbert, T. (2005). Narrative Exposure Therapy: A Short-Term Intervention for Traumatic Stress Disorders after War, Terror, or Torture. Cambridge, Hogrefe & Huber Publishers.
Smith, P., Dyregrov, A., Yule, W., Perrin, S., Gjestad, R., Gupta, L. (2000). Children and War: Teaching recovery techniques. Bergen, Norway, Foundation for Children and War.
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Yule, W. (2000). "Emanuel Miller Lecture From Pogroms to "Ethnic Cleansing": Meeting the Needs of War Affected Children." J Child Psychol Psychiatry 41(6): 695-702.
Tuesday, October 7, 2008
First Draft of Letter of Intent, IU PhD in Political Science, Bloomington
On April 9, 2008, Dr. Solomon M. Nkiwane, a former professor at The Colorado College passed away in South Africa after giving a lecture regarding the political scene in Zimbabwe. Dr. Nkiwane was the single most influential person in my decision to pursue a career in academia. He stressed the importance of life-long learning, and using knowledge gained to enrich the lives of others. It was after a conversation with Dr. Nkiwane regarding the importance of honoring human dignity in the study of political science that I made the decision to travel to Nigeria with a medical mission. During the trip, I realized that the success of a community depends on the health of its people and how a government regards the wellbeing of its people.
I am currently a dual concentration Masters of Public Health student at the IU School of Medicine in Indianapolis. I have chosen a dual concentration in Epidemiology and Public Health Policy and Management. The MPH program has allowed me access to invaluable resources and research support from faculty and staff. I will take what I have learned in the Masters program to support my specific interests in the area of Political Science.
During my undergraduate career, I learned advanced research methods and procedures that I continue to utilize in my graduate work. In 2005, I enrolled in the Semester in Washington Foreign Policy Program to learn and put into practice a higher level of research methods, including conducting primary resource interviews and practicing proper confidentiality procedures. I conducted interviews with several high-ranking political officials in both the United States and Zimbabwe. I learned when to take risks and when to be prudent in my research. The culminating project from my experience living and researching in Washington, D.C., reflects my determination and resourcefulness in completing complex research projects.
At the start of my senior year at The Colorado College, I accepted the roll of Senior Research Assistant for Dr. Andrew T. Price-Smith. My duties included organizing and coordinating the efforts of six Junior Research Assistants, acting as mentor and coach to new Research Assistants, and personally assisting Dr. Price-Smith in conducting research for his articles and presentations regarding bio-terrorism and political stressors.
After consulting with Dr. Gregory Steele and Dr. Cynthia Stone of the IU School of Medicine Department of Public Health, plan to enroll in the PhD program in August of 2009 and either suspending my Masters program or applying many of my Masters classes to a PhD minor in Public Health. During my time in the PhD program, I will pursue my interests, including maintaining the well-being of adolescents in rural East and Southern African countries; specifically, refugees, internally displaced persons and former child-soldiers suffering extreme political persecution. The Indiana University – Bloomington campus offers tremendous research and publishing opportunities, as well as one of the best African Studies programs in the nation. I will take full advantage of the resources available to me through the IU Department of Political Science PhD program.
With a PhD in International Relations and a minor in Public Health from the IU Department of Political Science, I will continue to involve myself in progressive research projects, seeking to broaden the information available to those in my field. I will apply for professorship at institutions that have strong foci on scholarship, research and student-faculty relations. I will apply the knowledge of my field to facilitate and encourage in-depth, thought-provoking discussion and student class-work.
I seek to be a scholar-practitioner and leader in the field of political science. In addition, I will be a servant-leader, using my skills and knowledge to assist in the cultivation of young scholars and viable participants in the work force.
I am currently a dual concentration Masters of Public Health student at the IU School of Medicine in Indianapolis. I have chosen a dual concentration in Epidemiology and Public Health Policy and Management. The MPH program has allowed me access to invaluable resources and research support from faculty and staff. I will take what I have learned in the Masters program to support my specific interests in the area of Political Science.
During my undergraduate career, I learned advanced research methods and procedures that I continue to utilize in my graduate work. In 2005, I enrolled in the Semester in Washington Foreign Policy Program to learn and put into practice a higher level of research methods, including conducting primary resource interviews and practicing proper confidentiality procedures. I conducted interviews with several high-ranking political officials in both the United States and Zimbabwe. I learned when to take risks and when to be prudent in my research. The culminating project from my experience living and researching in Washington, D.C., reflects my determination and resourcefulness in completing complex research projects.
At the start of my senior year at The Colorado College, I accepted the roll of Senior Research Assistant for Dr. Andrew T. Price-Smith. My duties included organizing and coordinating the efforts of six Junior Research Assistants, acting as mentor and coach to new Research Assistants, and personally assisting Dr. Price-Smith in conducting research for his articles and presentations regarding bio-terrorism and political stressors.
After consulting with Dr. Gregory Steele and Dr. Cynthia Stone of the IU School of Medicine Department of Public Health, plan to enroll in the PhD program in August of 2009 and either suspending my Masters program or applying many of my Masters classes to a PhD minor in Public Health. During my time in the PhD program, I will pursue my interests, including maintaining the well-being of adolescents in rural East and Southern African countries; specifically, refugees, internally displaced persons and former child-soldiers suffering extreme political persecution. The Indiana University – Bloomington campus offers tremendous research and publishing opportunities, as well as one of the best African Studies programs in the nation. I will take full advantage of the resources available to me through the IU Department of Political Science PhD program.
With a PhD in International Relations and a minor in Public Health from the IU Department of Political Science, I will continue to involve myself in progressive research projects, seeking to broaden the information available to those in my field. I will apply for professorship at institutions that have strong foci on scholarship, research and student-faculty relations. I will apply the knowledge of my field to facilitate and encourage in-depth, thought-provoking discussion and student class-work.
I seek to be a scholar-practitioner and leader in the field of political science. In addition, I will be a servant-leader, using my skills and knowledge to assist in the cultivation of young scholars and viable participants in the work force.
Health and the Juvenile Justice System
Confined Concern:
The Health of Youth in U.S. Juvenile Detention Centers
Copyright 2008 Jennifer M Kerner
Please properly cite this blog if using any material, in whole or in part, found within.
Introduction
The United States possesses a complicated web of institutions that support law enforcement and incarceration of those who do not abide national and state laws. One of those institutions is the juvenile detention program. Over the course of the year, United States law enforcement makes 2.5 million arrests of juveniles (Snyder, 2000). As of 2003, it is estimated that 109,000 youths under the age of 18 are incarcerated in the juvenile detention program each day (Abram, 2003). According to Teplin (2002), two-thirds of males and three-quarters of females possess “one or more psychiatric disorders.” In addition, Abram (2003) believes that many of those psychiatric disorders are “comorbid.” Alcohol, tobacco, and other drug addictions run rampant among incarcerated youth. Add this information to the fact that HIV/AIDS is “prevalent among detained youths” (Teplin, 2003) and one can imagine a formula for disaster within the juvenile detention program.
Even with so many health issues affecting the population of the U.S. juvenile detention program, knowledge and resources for dealing with these problems are scarce. Until a series of inquiries beginning in 2002, few studies had delved into the specific epidemiology of mental and physical health issues affecting juvenile detention detainees (Wasserman, 2003). This paper focuses on three major concerns of the U.S. juvenile detention program. The first is the high prevalence of psychiatric disorders. Detainees display a much higher prevalence of mental disorders than youths of the same age outside of the juvenile justice system. This unique demographic requires special attention by the public health community. Second, although several studies have brought to light the extent of the public health issues in the juvenile justice system, few studies have addressed treatment options for these youths (Parent, 1994). More research regarding interventions and treatment programs must be conducted before effective treatment programs may be applied to juvenile detention centers. Finally, suggested answers to the distinctive problems facing the juvenile justice system are discussed and projections for the future of these youths, both during and after incarceration, are made.
High Prevalence of Psychiatric Disorders
The number of incarcerated youth in the United States is staggering. The number of those youths with diagnosed psychiatric disorders is even more disturbing: About 60 percent of males and 70 percent of females within the juvenile justice system possess some psychiatric disorder (Abram, 2003). However, the most alarming fact regarding the U.S. juvenile justice system is that few options exist for the treatment and recovery of these individuals. The argument of whether these youths were arrested and incarcerated due to the presence of psychiatric disorders is irrelevant to this discussion. Rather, the more poignant case is the failure of the juvenile justice system to care for those who need treatment most. In an evaluative report regarding the conditions of the juvenile justice system, Parent, et. al. (1994) found that only 43 percent of admitted youths were given health screenings within one hour of admittance. The nationally recognized standards for the juvenile justice system require that all admitted youths receive health screenings within that first hour time period. Because of the delay in diagnoses, treatment programs (where they exist) cannot be applied in a timely manner. In addition, untrained staff members screen “one-third of juveniles in detention centers”(Parent, 1994). Training programs and adherence to national standards are imperative to the goal of improving health care within the juvenile justice system. Once clear diagnostic methods are created and maintained, federally funded treatment options can begin to form.
Treatment Options
A number of treatment programs and interventions exist for youths who are “at-risk” for dropping out of school, engaging in criminal activities, and becoming members of the juvenile detention program. The difficulty arises when these youths are not reached before they become incarcerated. Within the juvenile detention program, the effective treatment and intervention programs do not exist and these youth are doomed to repeat their actions as soon as they are released from the system. The cycle continues until these youth are old enough to be tried in adult criminal court. The concern lies, not only with the youth who are seemingly trapped in this cyclical progression of government custody, but also with the tax-payers who must pay for the living expenses, court fees, and other costs for these individuals while they are incarcerated. Those tax dollars would be better spent on school-based programs aimed at treatment and interventions before and during the incarceration period. Because of this connection between the health and wellbeing of youth in the juvenile justice system and the financial and social welfare of the general population, government must make aggressive policy changes aimed at treating these individuals. Wasserman (2003) recommends “systematically” implementing the “specific recommendations” for treatment programs as a “necessary first step toward policy changes that will optimize the standard of care for” incarcerated youth. Treatment and intervention programs based on health behavior theories, such as the Health Belief Model, the Theory of Reasoned Action, and the Transtheoretical Model, would promote tools of wellbeing, such as self-efficacy, among youth in the juvenile justice system.
The Future of the Juvenile Justice System
The unfortunate truth behind understanding the juvenile justice system is that there will always be a need for such an institution. However, what happens to young men and women while they are living in confinement can change the future of those individuals and, indeed, can change the future of our communities. The high prevalence of psychiatric disorders among youth in the juvenile justice system deserves the attention of researchers, health professionals and government bodies. Youth with psychiatric disorders require special treatment programs to alleviate any medically treatable conditions, provide tools for self-efficacy, and support needed to break the cycle of crime and incarceration. Treatment options should include qualified health behavior models to provide sustainable solutions to problems associated with psychiatric disorders in young people.
Although individuals within this particular population have been tried and found guilty for crimes requiring incarceration, their lives and wellbeing should be of upmost importance to our federal and state governments. Federally funded programming should be based on empirical data regarding psychiatric disorders among youth in the juvenile justice system across the United States. Nationally recognized standards for the treatment of incarcerated youths must also be upheld without exception. The juvenile justice system is not a purely punitive measure for youth who choose to engage in criminal activity. The juvenile justice system is meant to be a safe and controlled environment where at-risk youth can receive the special treatment and services they require to become self-relying adults. At its best, the U.S. juvenile justice system provides the tools that allow at-risk youth to make better choices for their lives. However, the health and wellbeing of those youth must be addressed before these goals can be achieved.
Works Cited
Abram, K., Teplin, L, Charles, D., Longworth, S., McClelland, G., Dulcan, M. (2004). “Posttraumatic Stress Disorder and Trauma in Youth in Juvenile Detention.” Arch Gen Psychiatry 61:403-410.
Abram, K., Teplin, L., McClelland, G., Dulcan, M. (2003). “Comorbid Psychiatric Disorders in Youth in Juvenile Detention.” Arch Gen Psychiatry 60:1097-1108.
Aquirre-Molina, M., Gorman, D.M. (1996). “Community-Based Approaches for the Prevention of Alcohol, Tobacco, and Other Drug Use.” Annual Review of Public Health 17:337-358.
Cauffman, E. (2004). “A Statewide Screening of Mental Health Symptoms Among Juvenile Offenders in Detention.” Journal of the American Academy of Child & Adolescent Psychiatry 43(4):430-439.
Hein, K., Cohen, M.I., Litt, I.F., Schonberg, S.K., Meyer, M.R., Marks, A., Sheehy, A. (1980). “Juvenile Detention: Another Boundary Issue for Physicians.” PEDIATRICS 66(2):239-245.
Helitzer, D.L., Soo-Jin, Y. (2002). “Process evaluation of the Adolescent Social Action Program in New Mexico.” In A. Steckler, L. Linnan (Eds.) Process Evaluation for Public Health Interventions and Research. Indianapolis: Jossey Bass, pp83-109.
Parent, D.G., et. al. (1994). “Conditions of Confinement: Juvenile Detention and Corrections Facilities. Research Summary.” Abt Associates, Inc.
Pliszka, S.R., Sherman, J.O., Barrow, M.V., Irick, S. (2000). “Affective Disorder in Juvenile Offenders: A Preliminary Study.” Am J Psychiatry 571(1):130-132.
Snyder, H.N. (2000). Juvenile Arrests 1999. Washington, D.C.: Office of Juvenile Justice and Delinquency Prevention.
Teplin, L., Abram, K., McClelland, G., Dulcan, M., Mericle, A. (2002). “Psychiatric Disorders in Youth in Juvenile Detention.” Arch Gen Psychiatry 59:1133-1143.
Teplin, L., Mericle, A., McClelland, G., Abram, K. (2003). “HIV and AIDS Risk Behaviors in Juvenile Detainees: Implications for Public Health Policy.” American Journal of Public Health 93(6):906-912.
Wasserman, G.A., Jensen, P.S., Ko, S.J., Cocozza, J., Trupin, E., Angold, A., Cauffman, E., Grisso, T. (2003). “Mental Health Assessments in Juvenile Justice: Report on the Consensus Conference.” Journal of the American Academy of Child & Adolescent Psychiatry 42(7):752-761.
The Health of Youth in U.S. Juvenile Detention Centers
Copyright 2008 Jennifer M Kerner
Please properly cite this blog if using any material, in whole or in part, found within.
Introduction
The United States possesses a complicated web of institutions that support law enforcement and incarceration of those who do not abide national and state laws. One of those institutions is the juvenile detention program. Over the course of the year, United States law enforcement makes 2.5 million arrests of juveniles (Snyder, 2000). As of 2003, it is estimated that 109,000 youths under the age of 18 are incarcerated in the juvenile detention program each day (Abram, 2003). According to Teplin (2002), two-thirds of males and three-quarters of females possess “one or more psychiatric disorders.” In addition, Abram (2003) believes that many of those psychiatric disorders are “comorbid.” Alcohol, tobacco, and other drug addictions run rampant among incarcerated youth. Add this information to the fact that HIV/AIDS is “prevalent among detained youths” (Teplin, 2003) and one can imagine a formula for disaster within the juvenile detention program.
Even with so many health issues affecting the population of the U.S. juvenile detention program, knowledge and resources for dealing with these problems are scarce. Until a series of inquiries beginning in 2002, few studies had delved into the specific epidemiology of mental and physical health issues affecting juvenile detention detainees (Wasserman, 2003). This paper focuses on three major concerns of the U.S. juvenile detention program. The first is the high prevalence of psychiatric disorders. Detainees display a much higher prevalence of mental disorders than youths of the same age outside of the juvenile justice system. This unique demographic requires special attention by the public health community. Second, although several studies have brought to light the extent of the public health issues in the juvenile justice system, few studies have addressed treatment options for these youths (Parent, 1994). More research regarding interventions and treatment programs must be conducted before effective treatment programs may be applied to juvenile detention centers. Finally, suggested answers to the distinctive problems facing the juvenile justice system are discussed and projections for the future of these youths, both during and after incarceration, are made.
High Prevalence of Psychiatric Disorders
The number of incarcerated youth in the United States is staggering. The number of those youths with diagnosed psychiatric disorders is even more disturbing: About 60 percent of males and 70 percent of females within the juvenile justice system possess some psychiatric disorder (Abram, 2003). However, the most alarming fact regarding the U.S. juvenile justice system is that few options exist for the treatment and recovery of these individuals. The argument of whether these youths were arrested and incarcerated due to the presence of psychiatric disorders is irrelevant to this discussion. Rather, the more poignant case is the failure of the juvenile justice system to care for those who need treatment most. In an evaluative report regarding the conditions of the juvenile justice system, Parent, et. al. (1994) found that only 43 percent of admitted youths were given health screenings within one hour of admittance. The nationally recognized standards for the juvenile justice system require that all admitted youths receive health screenings within that first hour time period. Because of the delay in diagnoses, treatment programs (where they exist) cannot be applied in a timely manner. In addition, untrained staff members screen “one-third of juveniles in detention centers”(Parent, 1994). Training programs and adherence to national standards are imperative to the goal of improving health care within the juvenile justice system. Once clear diagnostic methods are created and maintained, federally funded treatment options can begin to form.
Treatment Options
A number of treatment programs and interventions exist for youths who are “at-risk” for dropping out of school, engaging in criminal activities, and becoming members of the juvenile detention program. The difficulty arises when these youths are not reached before they become incarcerated. Within the juvenile detention program, the effective treatment and intervention programs do not exist and these youth are doomed to repeat their actions as soon as they are released from the system. The cycle continues until these youth are old enough to be tried in adult criminal court. The concern lies, not only with the youth who are seemingly trapped in this cyclical progression of government custody, but also with the tax-payers who must pay for the living expenses, court fees, and other costs for these individuals while they are incarcerated. Those tax dollars would be better spent on school-based programs aimed at treatment and interventions before and during the incarceration period. Because of this connection between the health and wellbeing of youth in the juvenile justice system and the financial and social welfare of the general population, government must make aggressive policy changes aimed at treating these individuals. Wasserman (2003) recommends “systematically” implementing the “specific recommendations” for treatment programs as a “necessary first step toward policy changes that will optimize the standard of care for” incarcerated youth. Treatment and intervention programs based on health behavior theories, such as the Health Belief Model, the Theory of Reasoned Action, and the Transtheoretical Model, would promote tools of wellbeing, such as self-efficacy, among youth in the juvenile justice system.
The Future of the Juvenile Justice System
The unfortunate truth behind understanding the juvenile justice system is that there will always be a need for such an institution. However, what happens to young men and women while they are living in confinement can change the future of those individuals and, indeed, can change the future of our communities. The high prevalence of psychiatric disorders among youth in the juvenile justice system deserves the attention of researchers, health professionals and government bodies. Youth with psychiatric disorders require special treatment programs to alleviate any medically treatable conditions, provide tools for self-efficacy, and support needed to break the cycle of crime and incarceration. Treatment options should include qualified health behavior models to provide sustainable solutions to problems associated with psychiatric disorders in young people.
Although individuals within this particular population have been tried and found guilty for crimes requiring incarceration, their lives and wellbeing should be of upmost importance to our federal and state governments. Federally funded programming should be based on empirical data regarding psychiatric disorders among youth in the juvenile justice system across the United States. Nationally recognized standards for the treatment of incarcerated youths must also be upheld without exception. The juvenile justice system is not a purely punitive measure for youth who choose to engage in criminal activity. The juvenile justice system is meant to be a safe and controlled environment where at-risk youth can receive the special treatment and services they require to become self-relying adults. At its best, the U.S. juvenile justice system provides the tools that allow at-risk youth to make better choices for their lives. However, the health and wellbeing of those youth must be addressed before these goals can be achieved.
Works Cited
Abram, K., Teplin, L, Charles, D., Longworth, S., McClelland, G., Dulcan, M. (2004). “Posttraumatic Stress Disorder and Trauma in Youth in Juvenile Detention.” Arch Gen Psychiatry 61:403-410.
Abram, K., Teplin, L., McClelland, G., Dulcan, M. (2003). “Comorbid Psychiatric Disorders in Youth in Juvenile Detention.” Arch Gen Psychiatry 60:1097-1108.
Aquirre-Molina, M., Gorman, D.M. (1996). “Community-Based Approaches for the Prevention of Alcohol, Tobacco, and Other Drug Use.” Annual Review of Public Health 17:337-358.
Cauffman, E. (2004). “A Statewide Screening of Mental Health Symptoms Among Juvenile Offenders in Detention.” Journal of the American Academy of Child & Adolescent Psychiatry 43(4):430-439.
Hein, K., Cohen, M.I., Litt, I.F., Schonberg, S.K., Meyer, M.R., Marks, A., Sheehy, A. (1980). “Juvenile Detention: Another Boundary Issue for Physicians.” PEDIATRICS 66(2):239-245.
Helitzer, D.L., Soo-Jin, Y. (2002). “Process evaluation of the Adolescent Social Action Program in New Mexico.” In A. Steckler, L. Linnan (Eds.) Process Evaluation for Public Health Interventions and Research. Indianapolis: Jossey Bass, pp83-109.
Parent, D.G., et. al. (1994). “Conditions of Confinement: Juvenile Detention and Corrections Facilities. Research Summary.” Abt Associates, Inc.
Pliszka, S.R., Sherman, J.O., Barrow, M.V., Irick, S. (2000). “Affective Disorder in Juvenile Offenders: A Preliminary Study.” Am J Psychiatry 571(1):130-132.
Snyder, H.N. (2000). Juvenile Arrests 1999. Washington, D.C.: Office of Juvenile Justice and Delinquency Prevention.
Teplin, L., Abram, K., McClelland, G., Dulcan, M., Mericle, A. (2002). “Psychiatric Disorders in Youth in Juvenile Detention.” Arch Gen Psychiatry 59:1133-1143.
Teplin, L., Mericle, A., McClelland, G., Abram, K. (2003). “HIV and AIDS Risk Behaviors in Juvenile Detainees: Implications for Public Health Policy.” American Journal of Public Health 93(6):906-912.
Wasserman, G.A., Jensen, P.S., Ko, S.J., Cocozza, J., Trupin, E., Angold, A., Cauffman, E., Grisso, T. (2003). “Mental Health Assessments in Juvenile Justice: Report on the Consensus Conference.” Journal of the American Academy of Child & Adolescent Psychiatry 42(7):752-761.
Friday, October 3, 2008
Wednesday, September 10, 2008
A sneak peek at my latest publication . . .
Katrina, Fay, Gustav, Hanna, Ike . . . They are the names of five terrorists that have no prejudice, no bias, and no capacity to discriminate. Yet, each has wreaked havoc on several countries, including the United States, Haiti, Jamaica, and Cuba. Infrastructure collapses, homes are destroyed, people are killed and more die from injury, starvation and disease. If hurricanes cannot choose their victims, than why do we see a disturbing pattern in the individuals that are affected? Hurricanes, by nature, occur along coastal lines. The demographics of the lower Mississippi and the Caribbean Isles are comprised of mostly poor blacks. This observation is more telling than anyone would like to admit. Although the New Orleans tragedy rocked the nation and brought to light the failure of our government to adequately care for its people, the situation in Haiti following the impact of four massive storms is deplorable.
Link to the final publication soon to come!
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