Acute Responses to War Trauma in Children and Adolescents: The Lebanon Wars

E. Karam, N. Melhem, A. N.-Karam, P. Yabroudi, V. Zbouni, C. Mansour and S. Saliba

The Lebanon Wars, which started in 1975, died out in 1990; peace has settled since on all of Lebanon except the Southern and Western areas (W. Bekaa), which have been regularly the arena of military operations. The largest such operation, the "Grapes of Wrath," was launched by Israel in April 1996. The Institute for Development, Research and Applied Care (IDRAC) based in Beirut, mobilized its resources upon the invitation and support of UNICEF, and in partnership with the Lebanese Government, Ministry of Education (MOE), and the support of the Lebanese National Council for Scientific Research, developed a three-fold plan of action to be launched in the South and West Bekaa as soon as a cease-fire was reached Upon conclusion of the cease fire in May 1996, the following plan was implemented: (1) First-line immediate mental health treatment for children and adolescents in the most heavily war ravaged villages (Phase I); (2) assessment of the efficacy of this treatment in a prospective design (Phase II); and (3) assessment of the acute and long term mental health sequelae of the Grapes of Wrath operation on all children and adolescents living in the South and West Bekaa (Phases I&II). The target populations was all six- to 17-year-old children and adolescents enrolled in schools.

First-line immediate treatment. All students of six public schools (N = 2,500) in the villages identified by MOE to be the most exposed were offered a classroom based treatment through their teachers (N = 68). The teachers had received an intensive training from the IDRAC team. The training was preceded by a long debriefing session for the teachers themselves to talk about their own experiences during current and previous episodes of the wars, and by an educational briefing on major psychiatric disorders that follow human-made disasters (depression, anxiety disorders, post traumatic stress disorder).

These were followed by the treatment training, through which we attempted to minimize the impact of traumatic events on children and adolescents, work on natural and expected aftermath symptoms, facilitate the return to a normal life, and prevent the escalation of symptoms toward more exacerbated and severe disorders. Over a period of 12 consecutive school days, teachers held one-hour sessionsto help students express their feelings, correct the wrong assumptions and misconceptions that follow a traumatic event (cognitive restructuring), acknowledge the extent to which students were disturbed, encourage class cohesion in solving specific problems and help students develop coping skills and proper help seeking behavior from the teachers. Group discussions, drawings, role playing and posters were some of the techniques used. Parents were also involved in the treatment through specific home work (about, for example, possible actions to follow in a specific war situation). Teachers were asked to fill a daily "booklet" report prepared by IDRAC that included a detailed description of the sessions and of the students responses and behavior during these sessions. IDRAC's mental health training team supervised the delivery of this first line treatment through 4 long visits with the teachers (each school alone) reviewing their "booklet" reports, discussing the contents with each teacher and recommending the next course of action. Before the start of this treatment, 116 students were randomly selected from the total of 2,500 students and were interviewed (pre-tested) in order to evaluate the effectiveness of the treatment in Phase II (initiated one year later in May 1997).

This treatment was welcomed by teachers and students alike. We were positively surprised to hear the students telling us that this was the first time they had entered into a personal communication with their teachers and indeed felt closer to them. The teachers themselves felt that they had now a "holistic" role and were not "helpless" victims and witnesses of the wars and thus had acquired skills to be more "real" educators. Many told us about a ripple effect in their schools: for the first time in many years, students felt close to each other and helped actively in the daily chores of the school. A detailed analysis of the booklets is underway, in addition to the prospective efficacy of this first line treatment as outlined above.

Assessment of the mental health sequelae of the Grapes of Wrath. The Revised Diagnostic Interview for Children and Adolescents (DICA-R), adapted to Arabic by IDRAC, was administered to a sample (N = 386) representing the total population of children and adolescents students (45,000). The parental version of the DICA-R was also administered to the mothers of the selected students. The interviewers (health counselors from MOE) had received a four-day training program on the Arabic DICA-R along with other instruments, such as the War Events Questionnaire (WEQ). The latter was developed by IDRAC and used in its previous research on the Lebanon Wars and mental health. The WEQ is used to assess the individual level of exposure to specific war events (including the witnessing effect).

This three-fold plan of action was initiated three weeks after the cease-fire. and the Phase I field work was completed in another three weeks.

About 39 percent of the assessed children and adolescents were found to have one or more of the following disorders: depression (12.2%), separation anxiety (15.0%), PTSD (18.1%) and overanxious disorder (19.2%). Diagnosis of these disorders was based on DSM-IIIR criteria. No gender difference was found for the four disorders. Depression, PTSD and overanxious disorder were found to increase with age. Separation anxiety was most prevalent in the 10­12 year age group.

April 1997, one year after the Grapes of Wrath operation, was the date for the initiation of Phase II of the program which evaluated the effectiveness of the First Line Immediate Treatment. The data has been collected and is undergoing analysis.

IDRAC can be reached at fax: 961-1-582560 or e-mail: [email protected]. Its home page (idrac.org.lb) will be operative in January 1998. *