Table 1.
Case examples, by theme.
| Theme and Sub-theme | |
|---|---|
| 1. Practical and logistical challenges | Case example details |
| 1.1 Scheduling assessments | A family was contacted by phone and an interview was scheduled, but on the day of the assessment the family was nowhere to be found, and neither the Community Leader / شاويش, nor the neighbors, knew anything about them. |
| 2. Validity in interviewing | |
| 2.1: Assessing risk in non-private settings | A 12-year-old girl presenting with anxiety met criteria for a diagnosis of Generalized Anxiety Disorder, although the criteria were met based on parent report only. The child said no to all questions, but appeared to be bothered by siblings coming in and out of the room. The assessor felt that the child did not have sufficient privacy to disclose any possible difficulties, and needed to be followed up at another time or in the clinic. |
| 2.2: Fear of deportation | A nine-year-old girl, presenting with depression, anxiety, and behavioral difficulties, met criteria for a diagnosis of Major Depressive Disorder, Separation Anxiety Disorder, and Oppositional Defiant Disorder. The mother of the child was afraid to disclose private information because she thought she would be reported to the UNHCR, who would deport her from Lebanon. Her papers had not been renewed. In order to gain the trust of the family, the assessor carefully explained in detail the purpose of the visit, how the data will be used, and anonymity. |
| 2.3: Perceived assessor judgment | An 11-year-old boy presenting with anxiety met the criteria for a diagnosis of Separation Anxiety Disorder. The mother told the assessor that the Lebanese see the Syrians as inferior, and that she was therefore afraid of being judged by her background and financial situation. The assessor explained her role and her non-judgmental approach, but also adapted her physical appearance to reduce the perception of difference in future assessments, such as not wearing jewelry, wearing baggy clothes, and tying her hair back. |
| 2.4: Establishing the time frame of symptoms | A 14-year-old male presenting with suicidality, anxiety, trauma, and behavioral symptoms met criteria for a diagnosis of Separation Anxiety Disorder, Post-traumatic Stress Disorder, Conduct Disorder, Oppositional Defiant Disorder, and Generalized Anxiety Disorder. The child was unable to identify when their suicidal thoughts began. Describing time frames in weeks and months was unhelpful, but once recent events were offered as markers, the child was able to identify that the symptoms started just before Ramadan (several weeks before the assessment). |
| 2.5: Managing risk when parents decline mental health care | A 14-year-old boy presented with anxiety, severe behavioral disturbance, suicidality, and psychosis symptoms. He met criteria for Separation Anxiety Disorder, Conduct Disorder, PTSD related to witnessing killings in the war, and Generalized Anxiety Disorder. He also reported symptoms of psychosis and scored highly on suicidality, due to multiple past attempts to end his life and current self-harm, by cutting himself and drinking alcohol. He reported imminent plans to run away, and that his father beats him with sticks and shoes. He also heard voices, characterized by commands to do things, telling him he is worthless, or that he needs to run away. He reported he had stabbed someone and frequently broke others’ belongings. Two years ago he had an exorcism, and the parents reported that he is now well. Attempts to refer the child immediately to mental health care were declined. As well as concerns about risks of psychosis and suicide, the team were also concerned about his safety due to his father's beatings and the risk of running away. As the family consented to the assessment and the limits of confidentiality, the child could be referred to mental health and child protection services, so that the case could be followed up. However, the limited scope of child protection in the ITS and lacking services for Syrians meant that there was unlikely to be any change, and the parents fundamentally disagreed with accessing mental health care. It was therefore vital to conduct a thorough and collaborative safety plan with both the child and parents, in the moment, and to follow up regularly to monitor the child's safety and maintain the open option to access care. |
| 2.6: Assessing mental health when having symptoms is seen as the ‘right’ answer | A 10-year-old boy met criteria for Major Depressive Disorder, Obsessive Compulsive Disorder, Separation Anxiety Disorder, Agoraphobia, and PTSD. However, when the case was picked up by the treatment team, the counsellor could not find any evidence of any current symptoms, even over several meetings. They found some evidence for past symptoms. Initially, it was thought that the child and parent had not understood the time frame for reporting, but the assessor had been very clear to delineate past and current, as required by the MINI Kid, and the child and parent had consistently identified past and current symptoms. It was felt by the assessor and the counsellor that the family had over-reported current symptoms in the belief that it would lead to additional support and access to services. |
| 3. Sensitivity to cultural norms and meaning | |
| 3.1: Assessing suicidality | A 17-year-old boy presented with anxiety and trauma symptoms, meeting the DSM-5 criteria for a diagnosis of Specific Phobia and PTSD. The trauma symptoms were war-related: he witnessed missiles, explosions, and Daesh shootings. He also had symptoms of separation anxiety disorder related to his situation. His father and brother left to look for work in Beirut, while he remained with his mother in the ITS. He was concerned about her safety, following her around, sleeping near her, and feeling responsible for her safety and protection. On the MINI Kid suicidality screening, he met the criteria for low suicidality. However, further questioning made it clear that this was not a risk of self-harm or a desire to die, but desperation and distress at the family's situation, expressed passively as ‘wishing to be dead.’ |
| 3.2: Assessing substance use | An 11-year-old boy with depression, anxiety, trauma, and challenging behaviors met criteria for diagnoses of Major Depressive Disorder, Separation Anxiety Disorder, Specific Phobia, Agoraphobia, PTSD, and Conduct Disorder. When answering the substance use disorder questions, the child answered ‘no’ to all questions, but when the questions were asked to the mother separately, she disclosed that she knew that her son was drinking alcohol and caffeinated energy drinks with a group of friends in the ITS, and that he was smoking cigarettes. She was very worried that the Community Leader / شاويش would find out because it would lead to the family being evicted from the ITS. |
| 4. Contextual norms | |
| 4.1: Assessing Conduct Disorder in context | A 10-year-old girl presented with depression, anxiety, and trauma. Her trauma symptoms related to seeing missiles drop in Syria, and witnessing her dad and brother being forcibly taken from their tent by the ISF in Lebanon. She met diagnostic criteria on the MINI Kid for Major Depressive Disorder, Agoraphobia, Separation Anxiety, Specific Phobia, PTSD, Obsessive Compulsive Disorder, and Conduct Disorder. The criteria for Conduct Disorder were met because the child had started fights, threatened someone, used a weapon, and physically hurt someone, within the last six months, causing disturbance to her family. When examples of these behaviors were explored, they all related to severe bullying by other children, directed at her and her brother. Her brother was severely traumatized during the war and was not able to function, including having lost the ability to walk. In the context of the ITS and the targeted bullying, the aggressive and violent behavior was clearly in self-defense and in defense of her family. Whilst the bullying and fighting were concerning, for her safety and others, it was not substantially different from other children in the same context. Conduct Disorder, a serious behavioral disorder characterized by violating social norms, was therefore not assigned. |
| 4.2: Assessing anxiety in context | An 11-year-old girl presented with depression and anxiety. She met criteria for Major Depressive Disorder, Separation Anxiety Disorder, Agoraphobia, and Specific Phobia. The family lived in particularly stressful conditions, because they were staying with the father's brother while the father was sick in Syria. They had no papers to stay legally in Lebanon, and UNHCR had ceased financial support after they visited Syria. They also lived near to the ITS where a child died after a fire. The agoraphobic and phobic symptoms related to a fear of fire, and had generalized to any object or situation where there may be a fire, such as electric wires, or cooking. Whilst the symptoms were understandable in the context of the child's experience and the instability of the family's situation, the impact of the fear on functioning was above and beyond other children in the same ITS, and the diagnoses were assigned. |
| 4.3: Assessing severity | An 11-year-old boy presented with anxiety, trauma, and behavioral problems. He met DSM-5 criteria for Agoraphobia, Separation Anxiety Disorder, PTSD, and Conduct Disorder. He also had psychotic, obsessive compulsive, and generalized anxiety symptoms, but these were better explained by trauma and separation anxiety respectively. The child had witnessed Daesh killing people, including his own family members. He reported that he sometimes sees blood that others cannot see. Although this was reported under psychotic features, the content and fear was clearly characteristic of an intrusion linked to his PTSD. In addition, the content of the obsessions picked up under Obsessive Compulsive Disorder and the worry picked up under generalized anxiety was related to the safety of his family, and better explained by separation anxiety. Despite his symptoms, the child was able to complete chores to support his family and was attending school regularly. On this basis he was initially given a score of 3 on the CGI-s (clearly established symptoms but minimal or no distress or difficultly in functioning). However, given the distress he described due to the constant anxiety about his family's safety, his frightening trauma intrusions, and the impact of his externalizing behaviors on his family, the CGI-s score was amended to 4 (overt symptoms causing noticeable, but modest functional impairment or distress) in supervision. |
| 5. Co-morbidity and formulation | |
| 5.1: Trauma-induced psychosis-like symptoms | A 13-year-old girl presented with low mood, panic, and hallucinations, and met criteria for Panic Disorder and Major Depressive Disorder. A close family member drowned while trying to escape to another country. The child was not attending school as the family could not afford it, and was isolated at home. The child experienced hearing screaming, seeing shadows, and frequent nightmares. The auditory and visual hallucinations were often linked to panic symptoms and high arousal, and the onset was directly after the death of her family member. They were therefore better understood within a broader formulation of traumatic grief and the precariousness of the family's situation, than a prodromal psychosis. |
| 5.2: At risk of psychosis | An 11-year-old boy presented with depression, anxiety, trauma, and attenuated psychosis symptoms. He met criteria for Major Depressive Disorder with psychotic features, Separation Anxiety Disorder, Social Anxiety Disorder, Specific Phobia, and PTSD. He has also scored highly on suicidality, prompting a safety assessment and emergency plan. The child and parents reported that he had witnessed multiple killings by Daesh in Syria, including beheadings and hangings. In the ITS in Lebanon, he was isolated from others, and excluded by peers because he was seen as weird. His psychotic features were characterized by believing that people are out to hurt him, which the mother confirmed was untrue. He also displayed delusions of reference by conversing and arguing with people on the television. The child's low mood, anxiety about losing his parents, dislike of being with others who call him weird, and phobia of darkness can all be understood as interconnected and reactive to his current situation and past exposure to extreme violence. His dysregulated affect and elevated arousal, combined with traumatic intrusions, are likely to have fueled a sense of current danger and interpersonal mistrust. The beliefs may then be exacerbated by the continuing vulnerability and instability of the ITS. Whilst his psychotic features, particularly believing that others are out to get him, are also understandable in this broader formulation of his difficulties, they are concerning in content and intensity and warrant further assessment and preventative intervention. |
CGI-s Clinical Global Impression severity, DSM Diagnostic and Statistical Manual of Mental Disorders, ITS Informal Tented Settlement, MINI Kid Mini International Neuropsychiatric Interview for Children and Adolescents, PTSD Post-Traumatic Stress Disorder, UNHCR United Nations High Commissioner for Refugees.