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Psychosocial Concepts in Humanitarian Work with Children: A Review of the Concepts and Related Literature

INTRODUCTION

In recent years, many humanitarian agencies have come to address psychological and social factors in their programmatic responses to conflict, natural disasters, and displacement. These programs have been termed “psychosocial” programs. At the same time, there has been very little consensus as to how the term should be defined and what elements are essential in a psychosocial program.

The evolution of psychosocial programs reflects trends in psychology toward acknowledging the social aspects of experiences and the movement away from such terms as “mental health.” In essence, the term “psychosocial” implies a very close relationship between psychological and social factors. Psychological factors include emotions and cognitive development— the capacity to learn, perceive, and remember. Social factors are concerned with the capacity to form relationships with other people and to learn and follow culturally appropriate social codes. Human development hinges on social relationships. Forming relationships is a human capacity and is also a need. This becomes especially relevant in humanitarian work, in which the natural social structures that support child development have been torn and disrupted.

According to the Oxford English Dictionary, the term pertains to “the influence of social factors on an individual’s mind or behaviour, and to the interrelation of behavioural and social factors; also, more widely, pertaining



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Psychosocial Concepts in Humanitarian Work with Children: A Review of the Concepts and Related Literature INTRODUCTION In recent years, many humanitarian agencies have come to address psychological and social factors in their programmatic responses to conflict, natural disasters, and displacement. These programs have been termed “psychosocial” programs. At the same time, there has been very little consensus as to how the term should be defined and what elements are essential in a psychosocial program. The evolution of psychosocial programs reflects trends in psychology toward acknowledging the social aspects of experiences and the movement away from such terms as “mental health.” In essence, the term “psychosocial” implies a very close relationship between psychological and social factors. Psychological factors include emotions and cognitive development— the capacity to learn, perceive, and remember. Social factors are concerned with the capacity to form relationships with other people and to learn and follow culturally appropriate social codes. Human development hinges on social relationships. Forming relationships is a human capacity and is also a need. This becomes especially relevant in humanitarian work, in which the natural social structures that support child development have been torn and disrupted. According to the Oxford English Dictionary, the term pertains to “the influence of social factors on an individual’s mind or behaviour, and to the interrelation of behavioural and social factors; also, more widely, pertaining

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to the interrelation of mind and society in human development.” Clearly in this definition the emphasis is on the influence that social factors have on human thoughts and behavior and, in turn, the influence of thoughts and behaviors on people’s social world. The interrelationship of the two sets of factors is central in the definition. Psychosocial interventions seek to positively influence human development by addressing the negative impact of social factors on people’s thoughts and behavior. They also seek to ameliorate the effects of negative thoughts and behavior on the social environment through facilitating activities that encourage positive interaction among thought, behavior, and the social world. In humanitarian assistance, there has been little consensus with regard to what constitutes psychosocial work. This lack of consensus has arisen because of the disagreements around the psychological consequences of conflict and displacement. These consequences are frequently conceptualized as trauma, post-traumatic stress disorder, stress, and mental illness and are based on the assumption that conflict and displacement have negative effects on the mental health of refugees. The diverse expressions of psychosocial work among humanitarian workers and their agencies have resulted in the term’s eliciting diverse interpretations as well as common expectations that psychosocial programs are concerned with counseling, psychiatric symptoms, and therapy. This report is concerned with reviewing psychosocial concepts in research related to humanitarian work, with particular emphasis on research related to children affected by prolonged violence and armed conflict. PSYCHOSOCIAL FACTORS AND MENTAL HEALTH Children The influence of psychosocial factors on mental health in childhood, not a new concept in psychological studies, has focused on several key themes. Over the past 50 years, a vast body of work has studied psychosocial adversity and childhood psychopathology. In the late 1940s, mental hygiene movements in the United States and Britain focused on the interplay between children’s interpersonal relationships at home and at school and how these shaped children’s behavior, both normal and abnormal. Psychoanalysis, while seemingly about intrapsychic mental processes, also focused on children’s relationships and patterns of nurturance as they

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moved through early psychosexual phases. Developmental studies, some of them experimental and longitudinal in nature, have investigated the influence of the environment on children’s development. The landmark World Health Organization monograph of Bowlby (1951), on the effects of maternal deprivation, has had a major influence on the thinking about children and separation. In the monograph, Bowlby contends that motherly love is vital for mental health. He goes on to assert that the absence of the mother can cause lasting damaging effects, even if the absence has been a brief one. Bowlby’s study led to a rethinking of approaches to parenting and the nature of institutional care for children. The 1960s and 1970s saw a broadening of the range of psychosocial risk factors (Rutter, 1999). As early as 1962, Lois Murphy, a scholar on children’s coping efforts, lamented that a vast “problem literature” focused on difficulties, failures, and blocked potential had prevented sufficient attention to be paid in psychological science to adequacy and the positive endeavours of humans (Murphy, 1962). She went onto contribute to the understanding of the efforts made by children to cope with their own problems (Murphy and Moriarty, 1976). Her work heralded an important transition to focusing on children’s health, their coping, adaptation, and resilience rather than their problems. Refugees An overview of research of the psychological adjustment of refugees by Ager (2001) reports a study conducted in 1939 on the adjustment of refugees from Nazi Germany to the United States. Kraus (1939) suggests the psychosocial sources of such characteristics as overaggressiveness are the result of the strain of dealing with everyday ways of life in a new environment. Ager goes on to examine research since the World War II, noting that the research immediately after the war focused on the psychopathology of individual refugees and the comparison of refugee groups and the receiving populations. The research that developed out of the Vietnam War focused less on psychopathology and more on the psychological and social functioning of individuals and communities. Only since the late 1980s does research address the needs of populations of refugees from a psychosocial perspective. At a 1981 conference on the psychosocial problems of refugees, Rack (1981:1) summarized the discussions:

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Most refugees are likely to need food, shelter; be physically and emotionally exhausted on arrival; be wary of strangers; have private sorrows; experience fluctuation of mood; feel helpless and sometimes dehumanised and incompetent; and be in some sense “bereaved” and need to go through the process of mourning. He stated that each refugee group had many variations, and to generalize any further could be perilous. While wide-reaching in reference to different cultural groups, Rack does not refer to refugee children as a distinct group to be considered. He also focuses on refugees in host countries, which at the time were more likely to also become resettlement countries, rather than developing countries, which were receiving a vast influx of the world’s refugees. Rack spoke of the challenges of working with trauma and displacement and cultural differences, and it is evident that the mental health professionals at the conference were struggling with the issue of how best to meet the refugees’ problems and needs. Refugee Children More recently attention has focused on the mental health and psychological and emotional well-being of children affected by armed conflict. In 1986, at a meeting of the UNICEF executive board and nongovernmental organizations, the agenda reflected concern for the psychosocial effects on children in war and natural disasters. One participant at the meeting called for a need to “wake up and do something about the psycho-social development of children” (Radda Barnen, 1986). In 1989 the Convention on the Rights of the Child was adopted by the United Nations General Assembly, providing a framework for considering the needs and best interests of children. The ratification of this convention by 191 countries has had a major impact on work with children in all spheres, not only in the psychological field. Article 39 specifically refers to children in armed conflicts and requires states to take all appropriate measures to promote physical and psychological recovery of children who have been victims of “any form or neglect, exploitation, or abuse; torture or any other form of cruel, inhuman or degrading treatment or punishment; or armed conflicts. Such recovery and reintegration shall take place in an environment which fosters the health, self-respect and dignity of the child.” This imperative has helped to ensure that in recent times psychosocial work

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has gone beyond addressing the individual needs of children and adults to enhance the environment and the social setting of the affected population. DEVELOPMENT OF THE FIELD We explore below the development of research and theories in psychology more systematically in order to show how thinking in the field has developed, as well as the origins of the dominant theories in the field. World War II Much of what is known about the psychological and social effects of wars on children arose out of research and therapy conducted around the time of World War II. The events of this war led to many children being displaced from their homes and frequently separated from parents out of fear for their security or the death of a parent. Every country in the war had large numbers of separated children. In England, for example, over 750,000 schoolchildren were evacuated from their family homes within four days of the war’s being declared (Ressler, Boothby, and Steinbock, 1988). What were the effects, if any, of these separations? In a review of studies investigating psychological deprivation in childhood—that is, social settings that can have negative consequences for child development—Langmeier and Matejcek (1975) looked at studies of the effects of the war. These studies contained disturbing accounts of deserted and suffering children. The majority, conducted during and immediately after the war, focused on children without families, resettled children, and children in concentration camps. They estimated that World War II disrupted approximately 30 million families (Langmeier and Matejcek, 1975). Some of these studies focused on the children who had been separated from their families and evacuated to the countryside as a safety precaution. From these studies, Langmeier and Matejcek (1975) concluded that evacuation appeared to have more severely affected children’s mental health than if they had stayed and witnessed the bombing and its effects. In general, they found that the incidence of disorder and maladjustment among evacuated children was lower than expected. They reported that the nature of the children’s relationships with their parents seemed to influence their tolerance for being evacuated. A positive parental relationship appeared to ease the experience of evacuation. The quality of the parental relationship with

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the child prior to evacuation, the parents’ explanation for the evacuation, and the quality of communication between the parents and children all appeared to contribute to an easing of the experience. When reviewing the studies on child refugees and children released from concentration camps, Langmeier and Matejcek (1975) commented that there was a surprisingly “high potential for re-adaptation and relatively quick recovery in a healthy environment” (p.153). This did not mean that the children had no problems compared with the evacuated children. The children from concentration camps were seen as being more severely psychologically damaged but, in a relatively short time after leaving the camps, about 60 percent were reported as showing no symptoms of mental disorder. Langmeier and Matejcek (1975) further comment that while individual differences in the extent of children’s readjustment are clearly important, with subsequent good care most children who survived appeared to have a good prognosis. They also noted that multiple factors contributed to the psychological development of children exposed to social catastrophes such as war, and that all these factors need to be taken into account when investigating the psychological consequences of war. One of the classic studies of children under wartime stress in Britain in World War II is that of Freud and Burlingham (1943) titled War and Children. They reported that, in spite of the popular expectation that children directly experiencing war would be traumatized by air raids and would go on to develop war-related neuroses, the children they examined did not show these signs of traumatic shock. Among the children studied, they noted that if the children were young and in the care of their own mothers or a substitute, they did not seem to be psychologically negatively affected by the bombing. “War acquires comparatively little significance for children so long as it only threatens their lives, disturbs their material comfort, or cuts their food rations. It becomes enormously significant the moment it breaks up family life and uproots the first emotional attachments of the child within the family group” (p. 37). Freud and Burlingham have clearly identified the importance to children of family life or their relationship with a significant caregiver in situations of conflict and displacement. We now also know that material and physical well-being has a substantial influence on children’s psychosocial well-being in such settings. These World War II studies clearly highlight that children can experience war with few lasting effects. The type of experiences of war and the social supports available to the children during and after the events influence how well they are able to cope with their experiences.

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Recent Psychological Studies on War and Displacement Recent approaches to psychosocial work with refugee children have focused on the well-being, coping, and resilience of the children in spite of their experiences. These approaches have developed out of research on children at risk and children in stressful settings. These settings have been varied and include war settings and situations of armed conflict. It was the observation that many children, despite experiencing extremely distressing and sometimes horrifying events, grow up to be healthy adults that led Garmezy and Rutter (1983) to undertake a landmark review of earlier studies that had focused on childhood stress, coping, and resilience. The studies they reviewed focused on a wide range of events and experiences associated with psychopathology in childhood, such as divorce, chronic physical disability, having a parent who suffered from psychopathology, and natural disasters. At the end of their review, they highlighted the importance of individual differences in susceptibility to developing future psychopathology, regardless of the events they had witnessed or experienced. They also drew attention to the lack of knowledge surrounding the factors associated with the ability of children to meet and conquer adversity. In addition, they noted that negative experiences in childhood played contrasting roles. In a number of the studies they found that negative experiences could either be “steeling” or “sensitizing” in their effects, the former helping children to learn how to cope with adversity and the latter making children more susceptible to negative effects. Most of these early studies focused on patterns of maladaptation and incompetence, placing a lot of emphasis on symptoms of various psychopathological states. Less attention was given to the concept of resilience, neglecting the fact that some children appeared to rebound after stressful events. In this comprehensive review, Garmezy (1983) examined studies of children affected by war. War in these studies was characterized as an adverse event of extraordinary intensity, leading to family disruption, suffering, and mental change. Like Langmeier and Matejcek (1975), he observed that the studies of children evacuated during World War II revealed that those who were able to handle evacuation best enjoyed positive relationships with their families. When he reviewed the studies of refugee children and children who had been imprisoned in concentration camps, he expressed surprised that many of them adapted reasonably well after a relatively short time, with the majority showing no symptoms of mental disorder. Garmezy did, however, point to a sensitizing effect, noting from

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Langmeier and Matejcek (1975) that such children shared an increased vulnerability and susceptibility to breakdown in the face of minor changes in their life situations after liberation. In a subsequent review of children and war studies, Garmezy and Masten (1990) wrote that short-term observations of the children liberated from concentration camps consistently showed that developmental delays in hygiene and social interaction were common. In addition, these children were observed to display destructive behavior marked by aggression, and older children were found to be overly suspicious of adults. Many of the children sought to avoid discussing the trauma they had experienced. However, these were short-term reactions and were replaced with signs of rapid adjustment to new environments, with the children’s moral and social behavior improving rapidly. When trying to explain what might have contributed to the children’s adjustment, they draw attention to the work of Moskovitz (1983, cited in Garmezy and Masten, 1990), who posits four possible factors that may have played a positive role in facilitating the children’s growth to adulthood after the concentration camps of the Holocaust: the power of religious belief, which in this case was a sense of historic continuity with Judaism; a sense of strength derived from caregivers and community; identification with their parents; and a sense of public responsibility derived from service to country and community. In putting forward these factors for consideration, Garmezy and Masten (1990) highlight that Moskovitz had shifted the focus for studying the effects of war on children, from studies of predisposing factors that could be related to the origins of psychopathological states in children, to an emphasis on “protective factors,” that is, factors that provided children with a resistance to risk. Of further significance to Garmezy in his review of the earlier studies was the critical factor of individual variation in response to stress, which led to studies of the protective factors in children’s lives as well as their patterns of adaptation under extreme circumstances. Garmezy identified three categories of protective factors: (1) positive personality dispositions, (2) a supportive family milieu, and (3) an external societal agency that functions as a support system for strengthening and reinforcing a child’s coping efforts

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(Garmezy, 1983). When he returned to the earlier studies of children in war, he found that the prime factor that explained how they responded to the situation was to a large extent the behavior of the significant adults in their lives. He noted that his proposed triad of protective factors was evident in these earlier studies. In a study of children in five war zones around the world, Garbarino, Kostelny, and Dubrow (1991) explored the roles of “ameliorating factors” that they had identified from earlier research on children in difficult life circumstances. These factors included actively trying to cope with stress, cognitive competence, experience of self-efficacy, a stable emotional relationship, an open, supportive educational climate, and social support from persons outside the family. They were identified as important when the stresses involved were in the normal range. The researchers also saw that these factors were a way into explaining why some children managed to cope in war situations and others did not. Childhood Stress and Protective Factors Having posited a relationship between childhood stress and protective factors in situations such as war, it was then necessary to explore the nature of this relationship. Early on, Garmezy, Masten, and Tellegen (1984) had identified three generic models for exploring the relationship between stress and competency. In the first, the compensatory model, stress factors and personality attributes were believed to combine additively. Thus when stress was a constant, its impact could be compensated for by personal attributes of strength. In the second model, the challenge model, stress was viewed as a potential enhancer of competence. In the third model, immunity versus vulnerability, there was a dynamic interaction between stress and personal attributes. They conceded that the three models were not mutually exclusive of each other. This work clearly demonstrates that stress could play a different role in different individuals’ experiences. A significant body of research related to stress focused on risk research. Horowitz (1989, cited in Luthar and Zigler, 1991) delineated five types of risk research: life events research, research on small events or hassles, specific life stresses, socioeconomic status, and multiple measures of stress. However, when Luthar and Zigler (1991) reviewed this literature, they found the definitions of stress and stressors differed across the studies. They noted that, on the whole, studies on the effects of war were included under studies of specific stressful life experiences. They also commented on the

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shift in focus from measures of maladjustment (or its absence) to outcome measures of competence. When discussing the problems arising when comparing studies in risk research, Luthar and Zigler remarked on the difficulties in defining risk, stress, and stressors. They also noted that any one variable could at different times, to different individuals, be either a risk factor or a protective factor. They drew several conclusions. First, it is necessary to consider multiple indices of risk to develop a comprehensive understanding of the relationship between stress and protective factors and the resilience of some children. Second, a number of personality dispositions seem to have protective functions, could possibly moderate stress, and contribute to an understanding of resilience: level of distractibility, stimulation threshold, approach to novel stimuli, intellectual ability, sense of humor, effective social problem-solving skills and coping strategies, and an internal locus of control (the latter is a belief that positive consequences result from one’s own behavior and are not the product of external agents). Third, they highlighted the importance of familial factors in coping with stress and Garmezy’s (1983) idea of the usefulness of an external social support, giving frequent examples of such external supports, such as youth networks, teachers, and clergy, in protecting high-risk children, The earlier work of Garmezy and Rutter (1983) delineated five categories of stressors: loss, chronically disturbed relationships, events that redefine the family composition, events that require social adaptation, and acute events, such as physical trauma or illness. Subsequent research noted that these categories were not exhaustive. The definition of stress in these stress studies typically includes a stimulus event that was capable of modifying an individual’s physiological and psychological equilibrium; a resulting state of disequilibrium with increased levels of arousal that had neurophysiological, cognitive, and emotional consequences for the individual; and a significant disruption in the individual’s adaptation (Garmezy and Masten, 1990). Of particular interest in this review was their inclusion of studies of children in situations of war. Chronic stressors such as war were observed to include a number of specific stressors, such as separation, deprivation, and physical harm. In most of the stress studies, how individuals responded to

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stress was termed “coping.” In the process of coping, individuals appraised the stimulus event confronting them, assessing whether they have the resources to deal with it or not (Lazarus and Folkman, 1984). If the stimulus event was appraised to be beyond the individual’s capacity, the consequences were often disruptive. Several factors appeared to influence the way children coped, and these factors could be divided into two categories: factors that were intrinsic to the child, such as temperament, gender, age, and competence, and those that were extrinsic, such as the child’s environment, economic setting, and quality of family support. In addition, how the child viewed the stress appeared to be significant. The link between stress and the onset of psychiatric disorders was thought to be much stronger if the stress was perceived by the individual to be uncontrollable (Paykel, 1974, cited in Trad and Greenblatt, 1990). If the stressor was perceived as manageable or had been experienced earlier, this was also thought to influence the child’s response. In comparison with randomly selected children from the general population, some individual children were thought to be more at risk of experiencing long-term negative consequences as a result of experiences of stress (Garmezy and Rutter, 1983). Factors that appeared to increase the chances of a negative consequence were biological, personal, familial, and environmental. The personal factors included socioeconomic status, gender, level of education, age, and previous life experiences. In 1987, Rutter (1987) proposed that it was not the quality of the protective or risk factors that was significant but the nature of their interaction with the stressors. He asserted that the focus of research should shift from factors to the exploration of risk and protective mechanisms or processes. Such a focus would emphasize the underlying dynamic relationship between the stressful events and the individual. This research found that when the balance between the stress event and the risk was appraised as manageable by the individual, then it was possible to cope with the stressor. When the stressful events were perceived to be unmanageable, even a resilient child was seen to develop problems (Werner, 1989). Psychopathology tended to be an outcome of stressful events for only a minority of children. A quality of resilience, or the capacity to bounce back in adverse settings, appeared to be characteristic for most individuals (Garmezy and Masten, 1990). Importantly, children’s vulnerability to stressors was perceived to be dynamic, since their maturity and experience are constantly changing. In the findings of these stress studies, protective factors were seen as

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experiencing. This shift in emphasis made the study of children in war more relevant than ever and has assisted in addressing what it was that facilitated the evacuated children and the children of the Holocaust to “recover” from their experiences, or as Garmezy (1983) puts it, to “rebound or recoil,” reflecting the capacity of humans to be resilient and to recover and adapt from a stressful events. A significant collection of research on children in modern wars and community violence is titled Minefields in Their Hearts: The Mental Health of Children in War and Communal Violence. In it, Apfel and Simon (1996) enunciated factors, gleaned from relevant child development research, that contributed to an understanding of children’s resiliency in war. From these factors, they defined appropriate interventions for children in war. This work incorporated earlier research on children in situations of stress and high risk as well as research examining protective mechanisms and processes and childhood resilience. What was known about resilience was reviewed for the Emmanuel Miller Memorial Lecture in 1992 (Fonagy et al., 1994). The reviewers listed the following attributes of resilient children gleaned from risk studies: higher socioeconomic status, female gender if prepubescent, male gender after that, the absence of organic deficits, easy temperament, younger age at the time of trauma, and absence of early separation and losses. They listed specific features of a child’s immediate circumstances: competent parenting, a good relationship with one of the primary caregivers, availability in adulthood of social support, better networks of informal relationships, better educational experience, and involvement with organized religious activity. In addition, they noted the following characteristics of the resilient child’s psychological functioning: high IQ, superior coping styles, task-related self-efficacy, internal locus of control, a high sense of self-worth, empathy, capacity to plan, and a sense of humor. In other words, a child who has a good relationship with a primary caregiver, strong social support networks, as well as a cluster of personal helpful characteristics is more likely to be resilient when faced with certain experiences. They concluded that resilience could develop normally under difficult conditions. In a subsequent review of stress research in the late 1980s and

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early 1990s, Rutter (1996) acknowledged the accomplishments of stress research but also emphasized the challenges ahead. Examining the evidence on risk in childhood, he acknowledged the evidence that negative events and experiences are associated with psychopathology in childhood. Significant risks such as bereavement, divorce, chronic physical disorders, and disasters appeared to threaten psychological health. Importantly, though, he stressed that the research findings indicated that focusing solely on isolated life events was not the most appropriate way to view these stressors. Rather, he saw, along with other researchers that it was the “aggregated accumulation of events over time that contributes to the emergence of psychological resilience or vulnerability in individual cases” (Rutter, 1996:356). Rutter described the factors that seemed to characterize resilient children more as a set of psychosocial processes than a list of attributes. Overall, vulnerability and resilience did not seem to have a single source. What makes some individuals struggle to manage a traumatic experience and makes others appear to survive unscathed is the result of many interacting factors (Basic Behavioural Science Task Force of the National Advisory Mental Health Council, 1996). Among those concerned about the effects on children of war, some emphasize the stresses that children are exposed to in war, and some the resilience such children display. Too much emphasis on resilience could detract from the incidents of psychological distress that occurred in the context of political violence and war (Dawes, Tredoux, and Feinstein, 1989). There is a concern that little attention would be paid to children who were living in situations of ongoing war and violence. Cross-Cultural Studies As part of the research on resilience, a number of researchers started to look at the experiences of different groups of children. Werner (1990), exploring methodological issues in the study of resilience, commented on the importance of these studies in examining the cross-cultural universality of protective factors and questioned the cross-cultural universality of the types of protective factors that appeared to be consistently being suggested in studies. Two other significant researchers on children in conflict, Cairns in Northern Ireland and Dawes in South Africa, have had similar observations (Dawes and Cairns, 1998).

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Gender Weist and colleagues (Weist et al., 1995) explored the impact of stress and intervening influence on urban youth in the United States and found a different pattern for boys and girls. Family cohesion served as a protective factor for boys, but not for girls. And problem-focused coping strategies were protective for girls but not for boys. Age In addition, the age of the child was found to be relevant, with different factors having varying degrees of significance depending on the age of the individual. Overall, children were thought to be more vulnerable than adults to the vicissitudes of life and greatly influenced by the adults in their lives (Turkel and Eth, 1990). The differences among children of different age groups was accounted for by developmental variables (Arnold, 1990), such as emotional maturity and cognitive and psychomotor abilities. For infants and young children, biological factors were seen to be more significant, whereas for adolescents, interpersonal factors seemed to play a major role (Kimchi and Schaffner, 1990). Adolescence The research literature on adolescents acknowledges that, unlike younger children, adolescents rely more heavily on peers than family, and in situations of stress the support of peers may not be as strong or as present. Adolescents were also found to be more likely to be exposed to a variety of situations, and some of these may be appraised as stressful. However, the stability and support provided by the family is a significant factor in determining adjustment (Hendren, 1990) and facilitating the coping of the adolescent. Adolescents who were experiencing environmental stresses, such as family breakdown or the absence of family, were found to be at increased risk of mental illnesses such as depression and anxiety. Interaction with social, cultural, and political values is another important factor in adolescents’ lives. Current Research Issues It is clear from this body of resilience literature that there is direction for those concerned about redressing the effects of political violence and

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war on children. However, there are very real methodological constraints that researchers face in studying displaced and war-affected children. While it is recognized that research knowledge is necessary to guide interventions designed to address the effects of war and violence on children, a scientific perspective is often difficult to maintain in the midst of conflict (Jensen, 1996). Researchers struggle to design good prospective research, and longitudinal studies are almost nonexistent. The very settings of conflict and displacement can be difficult to access, and there are many limitations on the nature of the studies that are possible. These include the much needed intervention studies that can provide information on what constitutes efficacious psychosocial interventions. In addition, there is a growing concern around the ethical issues surrounding research with refugees and war-affected populations. Many of these concerns arise from the tension between the need to develop emergency measures and the need to protect vulnerable populations from exploitation (Leaning, 2001). Such issues as informed consent with children can be very problematic in an unstable setting in which such consent is unfamiliar and requires significant cultural sensitivity (Felsman et al., 1990). This is particularly problematic when researching separated children. Some of these concerns have resulted in published research on children and armed conflict being dominated by research exploring causal links between the experience of war and increased psychopathology using screening tools designed to measure large numbers of children. Consultants to nongovernmental agencies and some United Nations agencies have conducted much of this research in an attempt to quantify children’s experience of war (Dyregov et al., 2000; Yule, 2001). Few of these studies have focused on the resilience of children, and even fewer on the factors that facilitate their protection in spite of exposure to high-risk settings such as war. Apfel and Simon, after reviewing the resilience literature, pointed to the need to develop psychologically informed and resiliency-promoting interventions for children in situations of war (Apfel and Simon, 1996). They also cautioned about the ethical strains that were “inevitable for anyone working with children in contested situations” (Apfel and Simon, 1996:18). In the same publication, Straker (Apfel and Simon, 1996) explored six ethical principles that she considered to be particularly significant when working with children in war: fidelity, nonmaleficence, beneficence, justice, self-interest, and autonomy. She saw these ethical principles as central to the formulation of policy regarding interventions for children in situations of

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war. The issues raised by Apfel and Simon and Straker were given further prominence in a publication by the International Save the Children Alliance (International Save the Children Alliance, 1996). Drawing on the Alliance’s most experienced staff, the organization published a working paper outlining the core principles and approaches to psychosocial work with children in situations of war. The stated purpose of this paper was to clarify some of the key issues that should inform all assistance programs with children. This working paper remains a significant resource on psychosocial work with children. Trauma Another literature that has come to influence psychosocial work in humanitarian work is the research arising out of the trauma discourse. In 1980 the term post-traumatic stress disorder (PTSD) was introduced in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). The disorder gained recognition when it was observed in soldiers returning from the Vietnam War. The major symptom is the reexperiencing of a traumatic event after exposure to traumatic or catastrophic experiences. The reexperiencing can be in the form of nightmares of the event, painful memories, and flashbacks. The disorder is characterized by such behaviors as avoidance of settings that evoke the traumatic event, inattentiveness, and startle responses. The reexperiencing can persist for months or years. Previous experience and temperament are also thought to influence the specific expression of PTSD. Not until 1987, in the revised edition, the DSM-IIIR, was there any reference to children and PTSD. The diagnosis PTSD opened a new framework from which to explain the behavior of both adults and children after exposure to stressful events experienced in events of disaster and war. In the early 1980s, researchers sought to investigate the prevalence of PTSD among refugee populations, most noticeably in Indochina (Kinzie et al., 1984). Questionnaires, such as the Harvard Trauma Questionnaire (Mollica et al., 1992), were developed so that large populations of refugees could be assessed for signs and symptoms of the disorder. It could be said that the advent of PTSD resulted in a return to “pathologizing” refugee populations, with an emphasis away from protective factors and resilience and back to psychopathology and clinical intervention. Yule (1992), for example, has argued that, after major disasters, as many

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as 50 percent of children affected may be distressed a year later. He maintains that inadequate attention has been given to the long-term effects of disasters on children because of overprotection by parents and the underreporting of symptoms by parents and teachers. He argues that much more would be known about the effects of traumatic events on children if it was they who were asked, rather than the adults responsible for them. While conceding that all human beings, including children, are adaptable, Yule maintains that when resources are stretched, this adaptation can become stressful (Yule, 1992). Like researchers of resilience, he has explored why some children adapt well in situations of disaster, and others do not. In his exploration, Yule reviews the work that considers single versus multiple traumas for children and refers to studies focused on the Chernobyl nuclear disaster and situations of war, both situations of chronic stressors. Citing the data collected in the former Yugoslavia by UNICEF (Stuvland, 1994), Yule notes that, in such situations, given the children’s many experiences, it is difficult to disentangle the effects of the many things that happen during war, including ethnic cleansing, family breakups, and forced relocation (Yule, Perrin, and Joseph, 1999). A number of recent studies of the Balkans conflict, the Rwandan genocide, and other conflict settings (Dyregov et al., 2000) have focused on estimating the number of traumatic events that children have been exposed to and the resulting number of traumatized children. These data have been used to inform the public about the harmful affects of war, donors about the need to assist victims of war, and humanitarian agencies about the need for clinical interventions in war and refugee settings. These studies have also attracted heavy criticism. Summerfield (1999) and Bracken (Bracken and Petty, 1998) are writers who have strongly questioned the applicability of the diagnosis PTSD to non-Western populations, questioning whether the assumptions underpinning the diagnosis meet the needs of the people of concern. More significantly, they have questioned the pathologizing of large populations of people who have experienced war and ask whether the pathologizing of suffering serves the affected population or the humanitarian organizations who are looking for justifications and funding for their programs. Anthropological and Cultural Psychology Significant contributions have also been made in recent years by scholars from the disciplines of anthropology and cultural psychology. One of

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the main arguments they have made is that Western models are inadequate for capturing the experiences of distress and suffering of the majority of the world’s population. Medical anthropologists have emphasized the importance of understanding local conceptualizations of distress and suffering, as well as the meaning attached to them, in order to avoid medicalizing or psychologizing experiences of war (Kleinman, Das, and Lock, 1997). Scholars such as Arthur Kleinman and Byron Good argue that imposing Western psychiatric categories, such as trauma, depression, and anxiety, leads to wrong diagnoses and faulty research. Kleinman coined the term “category fallacy”: the ethnocentric imposition of one culture’s diagnostic system, and the tacit beliefs and values it contains, on the illness experiences of another culture, whose indigenous categories, beliefs, and values may be different (Kleinman, 1986). The terms “emic” and “etic” have also been used to describe the different approaches to health and illness: an etic approach examines issues from a position outside a particular social or cultural system, for example, using biomedical lenses through which to view illness; an emic approach emphasizes the world view of the people themselves and studies behavior and illness from within a cultural or social system (Berry et al., 1992). Similarly, some cultural psychologists argue that culture and society fundamentally influence all aspects of human development, behavior, emotion, thought, and well-being, so that conclusions reached by psychologists using Western models and theories cannot be adequately applied to people from other cultures. Psychologists concerned with the alleviation of psychosocial suffering have increasingly started paying attention to research from anthropology and cultural psychology, investigating local understandings of distress and local resources and ways of coping with distress. Nader, Dubrow, and Stamm (1999), for example, have edited a book on the role that cultural issues play in psychosocial work. Wessells and Monteiro (2000) and Honwana (1997) have investigated local rituals and integration ceremonies for returning soldiers in Angola and Mozambique, emphasizing that the communities have their own effective cultural practices that facilitate the reintegration of soldiers and the alleviation of problems they may experience upon return. Reynolds (1996) has investigated the role of indigenous healers in the alleviation of children’s reactions of distress to Zimbabwe’s War of Liberation. While it has become standard to refer to the importance of cultural issues in psychosocial work, more research is necessary on how psychosocial professionals can incorporate these considerations into actual programs.

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Social anthropologists have focused on conceptualizations of childhood and images of children, which are dominant among Western-trained developmental psychologists, pointing out that these are not shared across culture, society, and class (Boyden, 2000). Burman (1994) points out, for example, that images and notions of childhood that scholars and professionals implicitly hold have varied across historical periods and seem to reflect the politically correct ideology of particular times and places inasmuch as they represent the objective findings of scientific research. Current conceptualizations of childhood have presented children as passive, dependent, and vulnerable—in other words, in need of adult protection and nurturance. This has led to particular narrow theories about the needs of children and what the ideal environment for children to grow up in is, based on Western middle-class ideas. Psychologists working with children who are affected by adversity have increasingly questioned the implications of these notions for their work, for example, the idea that the family always provides safety and security to children, and that work is harmful for children who are then robbed of their right to a carefree childhood (Hwang, Lamb, and Sigel, 1996). Instead, they have considered not only the varying ways in which children and their roles and needs are understood in different societies, but also how children themselves understand these issues. This move toward taking children’s needs as well as their rights into account and viewing them as active participants rather than as passive victims is, among other things, a reflection of the children’s rights movement linked to the ratification of the Convention on the Rights of the Child in 1989. Children’s rights to participation and to have their views and opinions heard and taken into account are central to the convention, and psychologists are engaged with how this affects their work with children in adversity (Woodhead, 1996; Dawes and Cairns, 1998). More and more programs adopt a child rights perspective and seek to work with children as equal partners. PROVIDING PSYCHOSOCIAL ASSISTANCE The sheer magnitude of need in humanitarian settings has led to the increased recognition that population-based responses are the most appropriate. It is widely believed that only a small fraction of the affected community will have serious psychological problems requiring specialized care. It is thought that the vast majority of the population will return to normal

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lives through the assistance of comprehensive programs of assistance. In recent years, such organizations as the United Nations High Commissioner for Refugees (UNHCR) have argued that, in the area of psychosocial assistance, there is a need to end the debate between population versus individual assistance and to accept a twofold approach based on needs (Petevi, 1996). In 1996, Naomi Richman, a practitioner who has dedicated most of her work to this task, described two major approaches that seek to best assist children affected by conflict (Richman, 1996). One approach, the specialist approach, focuses on children most at risk. The second approach has a primary care emphasis and encompasses all children and often their families as well. She observed that in some programs the two approaches sometimes overlap. According to Richman, the specialist approach generally involves foreign psychiatrists, psychologists, and other mental health workers who provide technical knowledge, training, and support. These specialists are predominantly concerned with trauma, symptoms of trauma, and the effects of trauma. Their pursuits reflect the focus in psychology on the onset of psychiatric disorders following exposure to acute life events. In situations of conflict and post-conflict, when a large population is involved, the primary task of these specialists is to identify children with special needs. This is often done through the use of screening instruments or questionnaires. These instruments are designed to elicit the prevalence of symptoms of mental illness or psychopathology. In her manual Richman states that there are a number of problems associated with using such questionnaires. For example: In many settings, the population is illiterate and unfamiliar with pen-and-paper interviews. The questionnaires need to be translated, and this can be problematic if the questions are not culturally familiar. It is difficult to determine the extent of the presence of symptoms because many of them are present in a normal setting. It is also difficult to ensure that all respondents understand the range of possible responses in the same manner. The understanding of the difference between “a little” and “sometimes” can vary enormously within a sample group and between interviewers. Such variations influence cutoff scores, and the resulting decision as to whether children are at risk or not. What is more problematic is what is not asked. The translation of scales used in different cultural settings is helpful for the purpose of com

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parison with samples. It is even more helpful if the questionnaire has good psychometric properties and norms have been established, but what are often missing are questions about particular symptoms that characterize distress in different cultural groups (emic). Failure to include these items in the questionnaire can result in the specialists’ failing to obtain vital information about the children they are screening. A further concern is the lack of information about the relationship between the levels of symptomatology and social functioning. Interviews and observations are sometimes used to replace questionnaires. They can often be more effective if people known to the children, like teachers and parents, are given sufficient information to know what to look for so as to be able to identify children who are distressed or in special need. The primary care perspective is built on the premise that social cohesion can facilitate good psychosocial health and assist all to cope with the adversity they are facing. This approach is seen as attentive to the special needs of individuals and families, but in general it has the community as its primary concern. The primary care approach is described by Richman as one that provides services for all of the community. It aims to prevent secondary stressors affecting the community and it adopts a “horizontal” approach with programs influencing different sectors of assistance (Richman, 1996). In this approach, a psychosocial program may be embedded in other sector programs, such as a health program, an income-generating program, or an education program; within these programs, psychosocial support is given to individuals and families as part of a more extensive program. For children, it is assumed that with sufficient social support the majority of them can cope with the difficulties that are facing. Adults can be part of providing this support, provided they are also being assisted to cope with the daily tasks that they must complete. The primary care model seeks to avoid cultural insensitivity by facilitating the community to respond in its own culturally appropriate ways. The community environment is assumed to meet the needs of children through: a trusting relationship with significant adults, an environment that resembles normalcy with schools and opportunity for play, and

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the opportunity to relate to peers who are also facing the same difficulties. Under these circumstances, those assisting children and their families most are not outside specialists, but rather supports within the community, such as teachers, youth workers, and community leaders. Advocates of this approach include Tolfree (1996) and Segerstrom (1995). One of the major problems with this approach is that it is difficult to identify and evaluate because it permeates the social setting. It can also be problematic if the social fabric of the community has been severely damaged. It will then take much longer to reestablish structures and possibly even the sense of community. The levels of support that a community may require can be identified on four levels. Level 1 consists of the material needs of the entire community. Levels 2, 3, and 4 are related to the particular needs of groups within the community, including individuals and families. Level 4, the top of the pyramid, is a level of assistance that is required by a few families and individuals who need assistance beyond that provided by their community in order to be able to cope with the particular difficulties they are facing. It is not assumed that this assistance will be required for lengthy amounts of time. Other significant authors on psychosocial work with children in conflict have promoted similar and sometimes more elaborated hierarchical models of intervention. Of particular interest is the work of Inger Agger, Elizabeth Jareg, and colleagues (Agger et al., 1999). Psychosocial work with children is a relatively new area in situations of conflict. The models of assistance are still being elaborated, and the nature of appropriate interventions debated. Guidance on what models of assistance may be appropriate is available from the World Health Organization (2003, 1996), UNICEF, the United Nations High Commissioner for Refugees (1994), and nongovernmental organizations that specialize in this area. This monograph includes an annotated bibliography of much of this material. A lot of the literature focuses on emergency work with children and has been selected for annotation because its content reflects the core psychosocial concepts that are outlined above, informing present-day psychosocial assistance with children in humanitarian work.