**4. Mental health problems of children in Northern Uganda**

#### **Methods of data collection**

192 Post Traumatic Stress Disorders in a Global Context

develop and break down a set of the child's self-injurious behavior pattern from the most complex to the smallest units for purposes of drawing up a behavior modification strategy based on appropriate rewards if the child refrained from self-injurious behavior and the withholding of attention or reward if the child engaged in any form of behavior considered by the surrogate mothers or other nurses as unacceptable. Each time the child's behavior was considered positive he was praised and occasionally presented with a personal toy, but each time his behavior was unacceptable this was indicated to him in a clear simple language promptly. The rules of the therapy were typed out and pinned on the notice boards on the children's ward for all nurses to follow in support of the two surrogate mothers. Though the author (EO) was from another culture, the behavior modification strategy was planned carefully with the nurses, written out in simple language and explained before its implementation. As part of the therapy, the bandages were removed from the child's hands as the initial reward for non-injurious behavior. All medications were also withdrawn and the child was left free to do whatever he wanted within the provisions of the behavior modification strategy. Using this strategy, the child's self-injurious behavior progressively and eventually resolved completely within two weeks. The child's clinging behavior on either of the surrogate mothers stopped; he became social and interacted freely

When the parents eventually came to take him home after six months, the mother narrated the history of the child's mental health problem as follows. The child was the first-born in the family and received the full attention of his mother. When he was two-and-half years old, a sibling came in between him and his mother. The child reacted with intense rivalry with his infant sibling who the child attempted repeatedly to push off from their mother's lap. When he failed in his efforts to push the infant from the mother's lap, he became more and more vicious in his attacks on the infant sibling. In a final effort to stop the child's hatred toward the infant sibling his mother confessed hitting the boy so hard that he stopped pushing the infant from her lap. In reaction the child turned his hatred toward himself and started to slap and scratch himself. As observed in the hospital whenever he got tired he would come to the mother and beckon her to slap him in the face as she had done. A full explanation was made to the mother as to the probable origin of his self-injurious behavior, which the parents accepted, and the mother believed the explanation would help

with all nursing staffs on the ward and began to play with other children.

in her future relations with the little boy, who we shall call Sipho in this chapter.

post-traumatic stress disorder co-morbid with obsessive-compulsive disorder.

It is possible that this child suffered from two episodes of traumatic stress; first his loss of his first love object, the mother, and secondly the physical attack on his physical integrity by the mother. Though young, the child apparently drew the correct relationship between his hateful feelings toward his sibling and the punishment that he received from the mother. In order to protect himself and his infant sibling, the child took a middle option; selfpunishment that in adult term would have led him to suicidal behavior, which is a common occurrence in post-traumatic stress disorder. One might interpret his never-ending urge for punishment as an obsession, and the self-injurious behavior as a compulsive disorder. It is therefore not surprising that a program of response prevention that aimed to modify his behavior into a healthy lifestyle in the face of unavoidable challenge in life worked for him. The child's mental health problem that we might refer to basically as an obsessivecompulsive disorder probably qualifies to be intrusions and attempts to re-experience his traumatic experience in the hands of his mother. Further his behavior interfered significantly with his social functioning to the extent that it interrupted his normal relations with his parents and sibling resulting in hospitalization. Given the history this was a case of In this section we summarize the findings of our research on the patterns of mental health problems of children in northern Uganda. The findings highlight the diverse nature of traumatic experiences and their associated psychological distress symptoms the children aged 4-17 in the region experience. We conducted a cross-sectional survey of children in Gulu district using both qualitative and quantitative research methods. We used stratified cluster sampling strategy to select two urban and two rural villages in Gulu District. We randomly selected the participating villages from 2 sub-counties (one rural and one urban) in Gulu District. We estimated that 100-150 children would participate in the study. The parent or caretaker of each child or adolescent selected was also requested to participate in the study.

Participant selection involved community leaders in each village who helped the research team to discuss the research in general terms with the identified children and their caregivers and gave them the opportunity to ask questions and to think about possible participation. We explained the research project; and gave the participating children and their caregivers the opportunity to ask questions. A simple consent/assent form was explained to each potential participating child and caregiver. If they still wished to participate we asked that they sign the consent/assent form or place a thumbprint in the case of those who could not write. (In some of the studies referred to above only verbal consent was obtained). Throughout the interviews participants were asked if they were okay in participating and given the opportunity to stop if they chose to. At the end of each interview participants were asked how they felt about having participated and if they had any questions about the project at the end. Each caregiver was given a phone number to call or a person they could contact (they may not have access to a phone) who could contact one of our team members (EO or CL) if any concerns or questions should arise in the future about the research interview.

Using a semi-structured interview we collected demographic information, descriptions given by the children of their personal experiences and their reactions to events in their lives. We covered areas of strengths as well as difficulties. A principal investigator (CL) or a trained assistant conducted the interviews. When indicated, an interpreter asked the questions in Luo (the primary language spoken in Gulu district) and translated the answers for the primary interviewer who spoke English. The primary interviewer clarified answers with the research subjects through the assistance of the interpreter. The primary interviewer wrote down answers to the questions on each questionnaire. We also used a semi-structured interview with parents/caregivers of the children to determine how well the children functioned emotionally and behaviorally. The investigators of this research project constructed the questions for the interview with the assistance of community members in order to be sure that the concept of how an individual functioned in daily life was consistent with cultural expectations. We examined the child's ability to function in 3 domains: 1) the home 2) in peer relationships and 3) at school, job (such as farming), or age appropriate activity.

In order to gather the information required we developed three questionnaires to obtain information about the emotional well being of children in northern Uganda. In order to be culturally and linguistically accurate each questionnaire was developed with input from professionals and community members in the region. The questionnaires were first written

Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective 195

children (or caregivers) who were of serious concern to us, e.g. severely depressed, suicidal etc. we attempted to help them utilizing any resources that might be available such as Hospital. In addition, CL who is child psychiatrist provided supervision for mental health

Pre-coded numerical data from the semi-structured questionnaires were entered and analyzed with SPSS version 10.0. Chi-squared test was used to determine statistical significance levels between groups. One-way ANOVA multivariate and logistic regression analyses were used to determine factors associated with emotional disorders and impaired social functioning among the participants. Significance levels were set at 0.05 and 95% Confidence Intervals. Prose accounts from the questionnaires were analyzed manually according to emerging themes emotional disorders and psychosocial functioning of participants. In this chapter we provide only qualitative material to present the nature of post-traumatic stress disorder among children aged 4-17 years in Gulu district, northern Uganda. We conducted our interviews in a private room or outdoor space chosen by the caregivers of every subject in the comfort of their own homes. In general, the adolescent participants were interviewed alone without an adult caregiver present; children, especially those younger than 9 years, were interviewed in the presence of their caregiver. However, children and adolescents were given the opportunity to determine whether they wished to have an adult caregiver present or not during the interview. We received ethical clearance for the study from the Institutional Review Committee of Gulu University and the Uganda

We analyzed the interviews to determine themes and patterns that were expressed by each child. We then worked with selected community members and faculty members of the school of medicine to determine how certain themes and patterns such as somatic complaints, visitation by spirits, feelings of abandonment, etc. might compare with western constructs of such disorders as PTSD, depression and anxiety. We hoped that the analyzed information would give us a percentage of the children in each village who were experiencing significant emotional difficulty and those who were not functioning adequately. We also hoped that we would have qualitative and descriptive data, which would give us information that would take into consideration the culture and context of the

Ninety-eight families from four separate randomly selected villages in Gulu district in northern Uganda participated in a Fulbright-supported qualitative study to determine the mental health needs of one child per family in January to March in 2010. The study related to the mental health of the children and the children's functioning, their general concerns, attitudes and coping strategies of each child who was aged between four and seventeen years. This review highlights the complex situation of children in northern Uganda where they not only cope with the day-to-day problems of poverty, the aftermath of war and conflict but also troubled relationships within their own families. We summarize our findings under seven themes; namely: stress related to difficulties paying school fees, aggression/violence, fear, sleep disturbance, emotional problems, spirit possession, and coping strategies. Coping strategies are particularly significant as they relate to the resilience described by Betancourt and Khan (2008), Betancourt et al (2010), and Akello et al 2010, 2011). For purposes of clarity we group the children in this study as younger children aged

workers referring them to the mental health unit at Gulu Regional Referral Hospital.

National Council for Science and Technology.

participating children and their caregivers.

between 4 and 8 years, and older children aged from 9-17 years.

**5. Results** 

in American English and converted into Ugandan English to assure accuracy in communication. The questionnaires were then translated from Ugandan English to Luo. In order to be sure that the original meaning of each questionnaire was not lost in translation the questionnaires were translated from Luo back to American English to check for accuracy.

#### 1. *Questions for Caregivers*

Parents, guardians or other caregivers of children participating in the study were asked questions about the children in the study. One interview took place using a semi-structured format to determine how the children functioned at home, school or work, and with their peers. The interview took approximately 30 minutes to complete.

2. *Interview of Children and Adolescents (Ages 9 years to 17 years)* 

This semi-structured questionnaire was administered to children and adolescents aged 9 years to 17 years of age. It was administered in 2 parts. Part one was administered during a first meeting in order to establish rapport. Part two was administered during a separate meeting during which time questions related to feelings; reactions and functioning were more personal. Each interview took approximately one hour.

3. *Interview with Young Children (Ages 8 Years and Younger)* 

To date studies related to the mental health of children in Uganda have focused on older children, primarily adolescents. There is little information about children 8 years of age and younger. This semi-structured questionnaire was designed to engage younger children by using puppets and giving stories about the puppets. After hearing about the puppets the children were asked questions about themselves in a qualitative approach using a semistructured interview. The questionnaire was administered in two parts on two separate occasions. Part one was administered during a first meeting in order to establish rapport. Part two was administered during a separate meeting during which time questions related to feelings, reactions, and functioning were more personal. Each interview took approximately 30 minutes.

To participate in the study we included a) children or adolescents who participated in the study were aged between 4 and 17 years and were willing and able to answer our questions and b) those that agreed to be in the study and an adult responsible for the child (parent/caregiver/guardian) also willingly consented to the child's, and their own participation in the study. We excluded from the study a) children who could not speak English and there was no appropriate interpreter to interpret for the subject related to the study and b) children that were unable to communicate due to a medical or severe psychological problem such as mutism, catatonia, and severe mental retardation. Children under 18 years of age, who were able to answer our questions, as well as their guardians / caregivers, were interviewed. We took special care to be sure the children and their caregivers knew that participation was voluntary; that there would be no negative consequences for not participating, and that any benefits they might receive from the community, university or hospital would not change if they decided not to participate. We received informed consent from the caregivers and assent from the children in the study. Because our study did not offer specific interventions and because mental health resources are limited in rural areas of the region we interviewed the children in a non-direct manner asking about their life – what they enjoyed, what annoyed them, what they routinely ate and or how they slept, what they would like to see be different, etc. Such an approach allowed the children to disclose information while not putting them in a position of forcing them to talk about things that are emotionally very upsetting for them. If we were to notice some children (or caregivers) who were of serious concern to us, e.g. severely depressed, suicidal etc. we attempted to help them utilizing any resources that might be available such as Hospital. In addition, CL who is child psychiatrist provided supervision for mental health workers referring them to the mental health unit at Gulu Regional Referral Hospital.

Pre-coded numerical data from the semi-structured questionnaires were entered and analyzed with SPSS version 10.0. Chi-squared test was used to determine statistical significance levels between groups. One-way ANOVA multivariate and logistic regression analyses were used to determine factors associated with emotional disorders and impaired social functioning among the participants. Significance levels were set at 0.05 and 95% Confidence Intervals. Prose accounts from the questionnaires were analyzed manually according to emerging themes emotional disorders and psychosocial functioning of participants. In this chapter we provide only qualitative material to present the nature of post-traumatic stress disorder among children aged 4-17 years in Gulu district, northern Uganda. We conducted our interviews in a private room or outdoor space chosen by the caregivers of every subject in the comfort of their own homes. In general, the adolescent participants were interviewed alone without an adult caregiver present; children, especially those younger than 9 years, were interviewed in the presence of their caregiver. However, children and adolescents were given the opportunity to determine whether they wished to have an adult caregiver present or not during the interview. We received ethical clearance for the study from the Institutional Review Committee of Gulu University and the Uganda National Council for Science and Technology.

We analyzed the interviews to determine themes and patterns that were expressed by each child. We then worked with selected community members and faculty members of the school of medicine to determine how certain themes and patterns such as somatic complaints, visitation by spirits, feelings of abandonment, etc. might compare with western constructs of such disorders as PTSD, depression and anxiety. We hoped that the analyzed information would give us a percentage of the children in each village who were experiencing significant emotional difficulty and those who were not functioning adequately. We also hoped that we would have qualitative and descriptive data, which would give us information that would take into consideration the culture and context of the participating children and their caregivers.
