**7.1 Principles of assessment**

202 Post Traumatic Stress Disorders in a Global Context

The children of Uganda are at high risk for emotional problems yet there is limited information about children's mental health in the country. This is especially true of very young children (8 years of age and younger) for which information is scarce. Our study was an exploratory mental health needs assessment that could facilitate the development of mental health programs in northern Uganda. The study focused on the children in the community at large and not one targeted group of children. It included a representative sample of all children between 4 and 17 years of age who were willing and able to participate in a semi-structured interview. The study took place at a time when the region of Gulu was secure, and without war related violence or ongoing abductions. In a secure environment selected by children's parents, guardians or caretakers in the comfort of their homes, we obtained a different assessment of mental health problems and needs of children than that obtained from research conducted at a time of political upheaval, warfare and unrest despite the documented long-term effects of war (Jones, 1987); in this way much of our results do not include cases of acute stress disorder among children related to war and organized community violence though some of our study participants appeared to live under the threat of aggression in their homes, school or community almost on daily basis. Our study gathered information that might be useful in guiding mental health interventions for children and adolescents. It is necessary to understand the types of emotional difficulty children experience, as well as the degree to which they are affected, in order to provide appropriate treatment interventions and resources that might prevent further psychological damage. By sampling a broad spectrum of children from several communities, by not limiting our research to one specialized group and by using qualitative measures we believe we had the opportunity to obtain information about the children that will be contextually and culturally rich and provide information about strengths as well as difficulties. We also hoped that the information would complement the data obtained from previous studies and hopefully provide important information in guiding future research, intervention and prevention. The research information can then be used to develop mental health services for children and adolescents (these services are currently rudimentary and inadequate in northern Uganda) and to seek resources to properly address the emotional needs of these children. Our findings from this exploratory research indicate that the children of Gulu district experience significant levels of not only post-traumatic stress disorder but also other mental health problems including anxiety disorders, depression and suicidal behavior in response to a variety of traumatic stressors some of which might be regarded by families as normal manifestations of growing up in this rural district of northern Uganda. Our results suggest that the mental health problems of the children and adolescents resulted from the experiences of loss due to death or separation of parents, domestic violence, lack of food and or school fees, or disputes in the youngsters' relationships at school and in the community. The presentation of depressive disorder with sadness, "many thoughts" and worrying is typical for both adults and children and adolescents. It is also noteworthy that adult caregivers were able to recognise the signs of emotional problems in their children albeit the lack of access to appropriate mental health services in rural areas . Though we did not specifically screen for alcohol and substance use disorders, this appears to be a major potential mental health issue for the children and adolescents in Gulu district. Our findings suggest that children in this resource-poor setting used a variety of psycho-social, traditional and complementary healing approaches to manage their own experiences of distress as reported by Akello et al (2007) and Akello, Richters and Ovuga (2011). As a result of the

**6. Comment** 

Most individuals who suffer from PTSD will a) present with symptoms that will not suggest the condition b) come to the health unit late and or c) present to health facilities with physical complications of traumatic experiences. Typically patients will present with multiple somatic and vegetative or psychotic symptoms, behavioural problems (children and adolescents), or symptoms of alcohol or other drug abuse. An adequate assessment of PTSD is made on suspicion of the presence of the condition at all times and progresses through three related stages. Firstly the process and type of assessment is thus influenced by the patient's residential address; circumstances in which the individual lives; and history, timing and type of trauma. There are various types of traumatic events but these can be categorised as either individual (e.g. car-accident, rape, etc) or group (e.g. landslides, floods, war-trauma, volcanic eruptions, plane crashes, rebel attacks, etc). It also depends on the severity of injuries sustained, some of which may be life threatening or at other times minor, e.g. slaps. Secondly assessment aims to determine the nature of traumatic event, and as to when the trauma occurred. PTSD can be acute (including Acute Stress Disorder, PTSD), chronic or delayed. Complex PTSD involves the exposure of the individual to multiple and complex patterns of trauma that are often repeated and or prolonged leading to changes in the victim's personality and general behaviour. Acute PTSD (including acute stress disorder) calls for immediate treatment and sometimes rescue operations e.g. in volcanic eruption, in war or terrorist attacks. Thirdly, assessment aims to determine the need for immediate intervention.
