**5. Results**

194 Post Traumatic Stress Disorders in a Global Context

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

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

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

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

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

peers. The interview took approximately 30 minutes to complete. 2. *Interview of Children and Adolescents (Ages 9 years to 17 years)* 

more personal. Each interview took approximately one hour. 3. *Interview with Young Children (Ages 8 Years and Younger)* 

accuracy.

1. *Questions for Caregivers* 

approximately 30 minutes.

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

Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective 197

or things. Some of the people or things the children feared were "strangers who chop off children's heads for human sacrifice" (witchcraft), thieves, snakes, cats, mad people, darkness, elephants, dogs, rats, kidnappers, and other children who beat them. Twentyeight of 47 children (59%) reported that they feared getting ill. Many feared an illness that they had in the past; some children feared they would die or never get well. Fifteen of 47 children (almost 32%) feared going to sleep. The reasons for fearing going to sleep were fear of darkness; fear that someone such as a thief, someone to cut off their heads and other scary people would come to them. Some feared animals such as snakes, hyenas or rats would come and harm them while asleep. Two children reported being bitten by a rat in the past;

Sleep disturbance was common with nightmares being the most prevalent problem. Many nightmares were triggered by actual experiences. Sixty-seven out of 98 youngsters (68%) reported a sleep disturbance. For the younger children the sleep disturbances were: difficulty falling to sleep; fear of falling asleep, and bad dreams. For the older children sleep disturbances were: worrying at night; trouble falling asleep; waking up at night; and nightmares. Fifty-two out of 98 children (54%) reported having bad dreams. The content of the dreams varied some between the younger and older groups as well as between villages. However, the most common themes of the nightmares of the younger group of children were; death, or being harmed or chased by animals or bad people. The most common themes in the nightmares of the older children were: death, fighting, being attacked or abducted. In the first rural community, the predominant themes of the nightmares of younger children were death and being chased by ghosts. The content of the bad dreams of the older group of children was primarily of fighting, or being chased or attacked. In the second rural community, the themes of nightmares of younger children were: abandonment, being in a life-threatening situation, and being harmed and or killed by bad people. In regard to the older children almost 86% reported nightmares. For the older children, in general the nightmares were traumatic, with the predominant themes of death or life threatening experiences. In 66% of the older children who reported nightmares they described someone dying in their dream. Some nightmares were recurrent and some were reported as occurring every night. In the third (urban) community, the themes of the bad dreams reported by younger children were that of bad animals coming to harm them or the death of someone close. Almost 79% of the older children in this community reported nightmares. The content of the nightmares were significant. The themes were of death and dying, killing and fighting and abduction by the LRA. In the fourth (urban) community, the prominent sleep disturbance of the younger children was bad dreams. The themes of the nightmares were; animals or a kidnapper coming to harm them, a collision of motor vehicles, and falling in a lake. Of the older children only 2 reported nightmares and the theme was of death – one of them being killed by a witch; the other was of the deceased

one child reported that a snake bit his younger brother.

father coming to him (child) to take him away to die.

**5.5 Emotional problems: sadness/ isolation/ anger/ worries** 

Boxes 1 and 2 below illustrate various reasons that study participants gave for children feeling sad, angry or worried. Twenty-two of the younger children reported that there were times when they were sad; 39 of the older children reported episodes of sadness/ isolation and/or anger. A total of 61 youngsters out of 98 (62%) reported feelings in the spectrum of

**5.4 Sleep disturbance** 

#### **5.1 Significant stress related to the families' inability to pay school fees with resulting lack of education or inconsistent education for the children**

Fifty-eight caregivers (59%) expressed concerns that lack of school fees was a source of stress for them or their children. Many of the children expressed feeling worried about being able to pay fees as well as sadness when "chased from school" because of an inability to pay. Though education is free in government-aided primary and secondary schools in Uganda, many parents in rural areas are sometimes unable to meet small amounts of fees levied by schools to meet the welfare needs of their children; the experience of a child being chased away from school is therefore traumatic for affected children. For some children the stress was very severe with one youngster reporting that when his family failed to pay his school fees he felt that he would never be happy again; another teen reported that when school fees are not paid she thinks of committing suicide.

#### **5.2 Aggression/violence**

Children and caregivers reported that much aggression occurred in the children's lives. The aggression was experienced directly by many children and many also witnessed it. The aggression occurred in the home, in the community, at school and with peers. At times children were victims and at times they participated in the aggression.

Of the 98 youngsters in the study 66 (65%) experienced physical aggression that was directed towards them. Almost 31% of the children experienced physical aggression toward them at school by teachers and or other students; almost 29% of the children experienced physical aggression at home by caregivers and or siblings and almost 28% of the children experienced physical aggression in the community.

The percentage of children who reported that they experienced physical aggression in the home was much higher in the rural communities as compared to the urban communities. In the two rural communities: 11 out of 24 youngsters from one community and 11 out 25 youngsters from the second community, for a total of 22 out of 49 children (almost 45% from both rural communities) experienced aggression at home. In the urban communities 3 out 25 youngsters from the first community and 2 out 24 from the second community, or a total of 6 out of 49 (12%) from both urban communities experienced aggression at home. Five of the 98 children reported experiencing physical aggression in all three places; i.e.: home, school and community. Three of the five were from the same rural village, and there was one child from each of the two urban villages.

Fifteen of the 98 children were reported to be aggressive. Out of the 15, eight children came from the rural village in which 3 children experienced physical aggression in all three sites examined. The children in the study were more vocal about the aggression they experienced than any other topic. They reported fear, sadness and anger related to the behaviour directed toward them.

#### **5.3 Fear**

Many of the younger children expressed that they were fearful. While it is not uncommon for young children to express fear the content and extent of the fear was troubling as it suggested significant stress and at times trauma. 36 out of 47 children from the younger age group (76%) reported that they had experienced fears from at least one f the three categories; 1) some one or something 2) illness and 3) going to sleep. Eight out of 47 children (17%) feared something from all 3 categories; 15 children (almost 32%) feared something from 2 categories and 13 (almost 27%) from one category. Twenty-five children (53%) feared people or things. Some of the people or things the children feared were "strangers who chop off children's heads for human sacrifice" (witchcraft), thieves, snakes, cats, mad people, darkness, elephants, dogs, rats, kidnappers, and other children who beat them. Twentyeight of 47 children (59%) reported that they feared getting ill. Many feared an illness that they had in the past; some children feared they would die or never get well. Fifteen of 47 children (almost 32%) feared going to sleep. The reasons for fearing going to sleep were fear of darkness; fear that someone such as a thief, someone to cut off their heads and other scary people would come to them. Some feared animals such as snakes, hyenas or rats would come and harm them while asleep. Two children reported being bitten by a rat in the past; one child reported that a snake bit his younger brother.

#### **5.4 Sleep disturbance**

196 Post Traumatic Stress Disorders in a Global Context

**5.1 Significant stress related to the families' inability to pay school fees with resulting** 

Fifty-eight caregivers (59%) expressed concerns that lack of school fees was a source of stress for them or their children. Many of the children expressed feeling worried about being able to pay fees as well as sadness when "chased from school" because of an inability to pay. Though education is free in government-aided primary and secondary schools in Uganda, many parents in rural areas are sometimes unable to meet small amounts of fees levied by schools to meet the welfare needs of their children; the experience of a child being chased away from school is therefore traumatic for affected children. For some children the stress was very severe with one youngster reporting that when his family failed to pay his school fees he felt that he would never be happy again; another teen reported that when school fees

Children and caregivers reported that much aggression occurred in the children's lives. The aggression was experienced directly by many children and many also witnessed it. The aggression occurred in the home, in the community, at school and with peers. At times

Of the 98 youngsters in the study 66 (65%) experienced physical aggression that was directed towards them. Almost 31% of the children experienced physical aggression toward them at school by teachers and or other students; almost 29% of the children experienced physical aggression at home by caregivers and or siblings and almost 28% of the children

The percentage of children who reported that they experienced physical aggression in the home was much higher in the rural communities as compared to the urban communities. In the two rural communities: 11 out of 24 youngsters from one community and 11 out 25 youngsters from the second community, for a total of 22 out of 49 children (almost 45% from both rural communities) experienced aggression at home. In the urban communities 3 out 25 youngsters from the first community and 2 out 24 from the second community, or a total of 6 out of 49 (12%) from both urban communities experienced aggression at home. Five of the 98 children reported experiencing physical aggression in all three places; i.e.: home, school and community. Three of the five were from the same rural village, and there was one child

Fifteen of the 98 children were reported to be aggressive. Out of the 15, eight children came from the rural village in which 3 children experienced physical aggression in all three sites examined. The children in the study were more vocal about the aggression they experienced than any other topic. They reported fear, sadness and anger related to the behaviour

Many of the younger children expressed that they were fearful. While it is not uncommon for young children to express fear the content and extent of the fear was troubling as it suggested significant stress and at times trauma. 36 out of 47 children from the younger age group (76%) reported that they had experienced fears from at least one f the three categories; 1) some one or something 2) illness and 3) going to sleep. Eight out of 47 children (17%) feared something from all 3 categories; 15 children (almost 32%) feared something from 2 categories and 13 (almost 27%) from one category. Twenty-five children (53%) feared people

**lack of education or inconsistent education for the children** 

children were victims and at times they participated in the aggression.

are not paid she thinks of committing suicide.

experienced physical aggression in the community.

from each of the two urban villages.

directed toward them.

**5.3 Fear** 

**5.2 Aggression/violence** 

Sleep disturbance was common with nightmares being the most prevalent problem. Many nightmares were triggered by actual experiences. Sixty-seven out of 98 youngsters (68%) reported a sleep disturbance. For the younger children the sleep disturbances were: difficulty falling to sleep; fear of falling asleep, and bad dreams. For the older children sleep disturbances were: worrying at night; trouble falling asleep; waking up at night; and nightmares. Fifty-two out of 98 children (54%) reported having bad dreams. The content of the dreams varied some between the younger and older groups as well as between villages. However, the most common themes of the nightmares of the younger group of children were; death, or being harmed or chased by animals or bad people. The most common themes in the nightmares of the older children were: death, fighting, being attacked or abducted. In the first rural community, the predominant themes of the nightmares of younger children were death and being chased by ghosts. The content of the bad dreams of the older group of children was primarily of fighting, or being chased or attacked. In the second rural community, the themes of nightmares of younger children were: abandonment, being in a life-threatening situation, and being harmed and or killed by bad people. In regard to the older children almost 86% reported nightmares. For the older children, in general the nightmares were traumatic, with the predominant themes of death or life threatening experiences. In 66% of the older children who reported nightmares they described someone dying in their dream. Some nightmares were recurrent and some were reported as occurring every night. In the third (urban) community, the themes of the bad dreams reported by younger children were that of bad animals coming to harm them or the death of someone close. Almost 79% of the older children in this community reported nightmares. The content of the nightmares were significant. The themes were of death and dying, killing and fighting and abduction by the LRA. In the fourth (urban) community, the prominent sleep disturbance of the younger children was bad dreams. The themes of the nightmares were; animals or a kidnapper coming to harm them, a collision of motor vehicles, and falling in a lake. Of the older children only 2 reported nightmares and the theme was of death – one of them being killed by a witch; the other was of the deceased father coming to him (child) to take him away to die.

#### **5.5 Emotional problems: sadness/ isolation/ anger/ worries**

Boxes 1 and 2 below illustrate various reasons that study participants gave for children feeling sad, angry or worried. Twenty-two of the younger children reported that there were times when they were sad; 39 of the older children reported episodes of sadness/ isolation and/or anger. A total of 61 youngsters out of 98 (62%) reported feelings in the spectrum of

Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective 199

sadness and anger. Sixty-two caregivers (63%) reported that their child had periods of being sad, lonely, isolative and/or angry. Reasons youngsters gave for being sad or angry were: physical abuse by caregivers, teachers or peers; death or illness of parent or parents with child being neglected or being deprived of food or school because of no money; being overworked; illness; relationship issues with peers and missing someone. Nineteen of the younger children and 26 of the older children, a total of 45 out of 98 (45%) reported that they worried. Fifty-five caregivers (56%) reported that their youngsters worried. Children reported that they worried about the following things: a sick parent or sibling who they fear will die or who would transmit disease to them; physical abuse by teachers, caregiver or peers; well being of family members when they travelled or went to school; being turned away from school because of no fees or not passing grades; fear of nightmares; fear of abandonment; lack of food; poor living conditions; becoming burned when starting a fire;

**Children's reasons for being worried Caregivers' reasons for their** 

**children being worried** 

Thinking about father's death

 When hungry; when friends steal her books or pens; when

Lack of fees; being beaten by

friends fight over toys

Lack of school fees

 No food; friends fight him When friends or children at school try to take her

belongings Lack of school fees

last year

teachers

and alcohol problems of caregiver.

conditions of his mother

school fees for the brother

has alcohol problems

sacrifice

**5.6 Spirit possession** 

slap her and say bad things to her

 9 year old male worries and will not eat at school because he fears the teacher will beat him 17 year old male worries about the living

 16 year female worries when her brother is delayed that he might be in an accident; worries when boys

 15 year old female worries when her brother lacks school fees; sometimes she goes out digging to earn

 16 year old female worries about getting bad dreams about a man slashing her throat for human

16 year old male worries that his aunt (caregiver)

 16 year old female whose parents are deceased worries about her brother when he has no money

Box 2. Reasons children and caregivers gave for children being worried

No caregiver from urban villages reported their child as having experienced spirit possession currently or any time in the past. However three caregivers from rural villages felt that their youngster might have spirit possession. In one case the caregiver thought this because the child would awaken from sleep 2 to 3 times per month shouting, "something is coming to hurt me". Another caregiver reported that a teenager experienced spirit possession at the beginning of each month. Rebels abducted the child when he was very young. He has had episodes of spirit possession since returning from the bush. A third caregiver felt that her child experienced possession during the previous year. The nine-yearold girl reported that she is sad most of time and has repetitive dreams of her deceased


Box 1. Reasons why children felt sad, angry or isolative

**Caregivers' reasons for their children feeling sad, angry or isolative** 

 Lonely; wants to see her dad/ wants to go to school Fears other children will fight

Lonely; friends like beating

 Thinking about mother; parents are dead Stomach pain; "many thoughts"; does not like father because he beats the

Sad one time per week;

caregiver does not know why Sees other children going to school and cannot go because

 "Many thoughts"; not going to school because of fees; isolates when being refused something asked for He has "many thoughts " 2 or 3 times per month and is sad because of the death of his

 He is sad and lonely for reasons unknown to caregiver; "many thoughts" about how he will make a

 She is sad and lonely when she thinks about her deceased parents; sad and has "many thoughts" when she is chased from school because she lacks

 He is sad but caregiver does not know the reason 9 year old male is sad;

caregiver does not know why

him

him

mother

of fees

father

living

fees

**Children's reasons for feeling sad, angry or isolative** 

 13 year old female fees sad when she is lacking food and when she asks for something and is denied; she is angry when school asks for fees and there is no money; she thinks about and plans suicide when

money for school fees and when there is no food in the house about twice a week; she often thinks of committing suicide by collecting pills and

overdosing; she feels suicidal because of failure to

 17 year old female reports that she is sad when she lacks school fees or when she is sick; she is sad when she thinks about her deceased father and he is not here; she is angry when relatives disturb her because her father is dead; she is angry when she is

 14 year old female says she is angry when she is delayed by being asked to do something at school and because of the delay she is denied food at home

11 year old female is lonely because she likes to

 16 year old female is sad after she refuses to do something for her parents; she isolates when

16 year old male feels that he will never be happy

 16 year old female whose both parents are deceased is lonely and sad when friends are not around

Box 1. Reasons why children felt sad, angry or isolative

again because of a lack of school fees

stay away from boy neighbors; she feels bad when

relatives compare her to her late father 14 year old female is sad often when there is no

 9 year old female feels sad when she arrives at school; she fears being caned by the teacher 10 year old male feels very sad when he is sick; he feels he will not get better; he feels very angry when friends beat and hurt him one time per week 13 year old female reports that she is lonely, sad and likes isolating because friends gossip; she is angry with herself after quarrelling at home 15 year old male is sad when he quarrels with

friends

pay school fees

all alone

and gets no lunch

friends say she is stupid

someone gossips about her

sadness and anger. Sixty-two caregivers (63%) reported that their child had periods of being sad, lonely, isolative and/or angry. Reasons youngsters gave for being sad or angry were: physical abuse by caregivers, teachers or peers; death or illness of parent or parents with child being neglected or being deprived of food or school because of no money; being overworked; illness; relationship issues with peers and missing someone. Nineteen of the younger children and 26 of the older children, a total of 45 out of 98 (45%) reported that they worried. Fifty-five caregivers (56%) reported that their youngsters worried. Children reported that they worried about the following things: a sick parent or sibling who they fear will die or who would transmit disease to them; physical abuse by teachers, caregiver or peers; well being of family members when they travelled or went to school; being turned away from school because of no fees or not passing grades; fear of nightmares; fear of abandonment; lack of food; poor living conditions; becoming burned when starting a fire; and alcohol problems of caregiver.


Box 2. Reasons children and caregivers gave for children being worried

### **5.6 Spirit possession**

No caregiver from urban villages reported their child as having experienced spirit possession currently or any time in the past. However three caregivers from rural villages felt that their youngster might have spirit possession. In one case the caregiver thought this because the child would awaken from sleep 2 to 3 times per month shouting, "something is coming to hurt me". Another caregiver reported that a teenager experienced spirit possession at the beginning of each month. Rebels abducted the child when he was very young. He has had episodes of spirit possession since returning from the bush. A third caregiver felt that her child experienced possession during the previous year. The nine-yearold girl reported that she is sad most of time and has repetitive dreams of her deceased

Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective 201

people who lived in the urban villages ate or drank items for their wellbeing than did those in the rural villages. Some of the beverages the youngsters drank were juice, which gave energy and strength and improved appetite; tea, especially to reduce shivering: water which "added blood", and soda to relieve headaches. Some of the food items eaten were: peas to relieve headaches, beans, vegetables, rice, *posho* (bread made from maize or corn flour),

Of the 51 older children 35 (69%) reported using specific strategies when sad; 13 specifically reported that they did not do anything when feeling sad; 1 child reported that he did not get sad and for 2 coping strategies are unknown. Of the children who used strategies there were

a. Going to another person such as a friend or relative (mother, brother or sister) to get advice, to play, or to listen to a song or stories. Twenty-two youngsters chose this strategy making it the most popular. Friends were chosen more often than family

b. To participate in an enjoyable activity. Six youngsters chose this approach and went to

c. To engage in a quiet or contemplative activity. One child bathed or relaxed; 1 prayed

e. To correct the reason for sadness. One young lady would go to those who offended her

Thirty-four of 51 youngsters (66%) reported using specific strategies when angry and for most the strategies worked. However, 1 teen coped very poorly. He would cry and then he thought of running in front of a car. One child reported that he did not get angry. Fifteen reported doing nothing when angry. For 1 child the coping approaches were unknown. For

a. Going to another person such as a friend or relative for advice, to talk, to play, to tell stories and laugh or get away and sit with people. Thirteen young people chose this

b. To participate in a useful or enjoyable activity. Three children chose this strategy and

c. To engage in a quiet or contemplative activity. Ten youngsters chose this strategy and

d. To move away from the situation or to isolate. Five young people chose this approach and would move away from home or the situation; stay or sit alone; and isolate to think

f. To wait for the situation causing anger to be corrected – to seek fairness. One child would ask her parents to give her the same things given to her siblings and wait for

g. Self-destruction. One child would cry and think of killing himself by running in front of

h. Some of the youngsters chose more than one strategy to help them overcome feelings of

d. To isolate. Two children reported that they isolated and 1 "moved away".

**5.7.7 Coping when angry (Asked only of the older children ages 9 through 17)** 

the young people who used strategies there were several approaches to coping:

cleaned utensils; ate; and played by concentrating on a game.

e. Aggression. Two youngsters reported that they would fight.

strategy. Twelve went to friends or other people; 1 went to an older sister.

would go and lay down; sat and did nothing; slept; kept quiet; and prayed.

**5.7.6 Coping when sad (Asked only of the older children ages 9 through 17)** 

play; played football; sang or enjoyed music or a movie.

eggs, porridge and fish.

several approaches to coping.

members

and 1 just sat.

of new things.

them to do so.

a vehicle.

anger.

and ask for their apology.

grandmother coming to take her away. She cries because her father was killed by the rebels and there is no one to help her mother care for her. The previous year when her mother was hospitalized, the mother's sister-in-law cared for the child. The child did poorly in school due to the hardships she went through during that period. One day during the same year the child ran away to the bush for just 1 day. Her mother saw her rolling on the ground and her mother heard spirits making sounds over the girl's head and the mother thought the girl was possessed or cursed. Two additional caregivers initially reported that their children did not experience spirit possession. Each caregiver then added that their child does get nightmares and, therefore, they wondered if the child had spirit possession.
