1. Trauma History and Psychopathology in War- Affected children and Adolescents: A comparison of survey and Psycho-trauma Centers-based data in northern Uganda James Okello PCAF conference 21-23 rd July, 2014 Lake View Hotel, Mbarara Uganda drokellojames@gmail.com

2. Affiliations Gulu University,Faculty of Medicine Peter C. Alderman Foundation Children for Tomorrow Uganda, Gulu Regional Referral Mental health unit MUCHS, Department of Psychiatry Ghent University Collaborations:Okello J, Nakimuli-Mpungu E, Klasen Fionna, AldermanS, Alderman J, Pavia A, Nakku J, Adaku A,Musisi S,Derluyn I.

3. Background There is an increasing need to deliver effective mental health services to young persons in post-war settings in Africa. Public-Private Partnerships (PPP) plays an active role in the assessment and treatment of war-affected adolescents Children and adolescents contribute >40% referrals to the psychotrauma clinics( Nakimuli et al., 2013 ) Studies of war-affected youth consistently report high levels of exposure to both war-related trauma and intrafamilial childhood adversities. High rates of psychological distress have been reported for war affected youth from Sub-Saharan Africa ( Okello et al., 2007, Mels et al., 2010,Macmullen et al.,2012). More recently there is a trend towards clinical syndromes and their persistence post-war, most commonly post traumatic stress disorder(PTSD) depression and anxiety

4. Background Complex nature and repeated exposure to interpersonal trauma maybe better explained by emerging concept of Developmental trauma disorder(DTD, Klassen et al.,2013 ) Focus on explanatory mechanisms, vulnerability and protective factors is limited( Okello et al.,2013,2014 ) Increasing need to deliver effective mental health services to war-affected children post-war Evidence base needed to guide the design and delivery of services is sparse. Some work on influence of medications, exposure, individual and group approaches on symptoms and function( Nakimuli et al.,2013 )

5. Background The limited utilization of mental health services due to barriers such as cultural attitudes and stigma For those who access services, little is known regarding their clinical profiles that might help to prioritize services, training, and research to better address their needs. Such data can guide development,implementation, and evaluation of community mental health treatment, while also informing the work of mental health practitioners, funding agencies, and policymakers.

6. Aim & Methods We investigated the trauma history profiles, psychopathology, and associated behavioral and functional indicators among war-affected children presenting for psychological treatment and among a school-going sample of adolescents Clinics: Peter C Alderman & Children for Tomorrow Uganda ’s 2011 data set. 425 war-affected children and adolescents aged 10-21 years old were identified (56.24% males, mean age = 13.5 years, SD = 4.13). Cf WAR 2010 Survey: 551 school-going adolescents in 7 Gulu schools aged 13-21 years. Protocol approved and observed with additional Institutional waiver for clinic data

7. Clinic data Five psycho-trauma centers in districts Tororo (2006- 2011), Gulu (2008), Kitgum (2009) Arua( 2010) and Soroti (2011). Based at district hospitals, each PCAF trauma clinic employs a supervising psychiatrist, a psychiatric clinical officer, a psychiatric nurse, a social worker and a trauma counselor/psychologist, all of whom received initial training at the Butabika National Referral Hospital. Furthermore, each clinic runs two outreach centers located within a radius of 50 – 80km.

8. Tools: clinic data Basic sociodemographic data War Trauma events checklist Harvard Trauma Questionnaire(HTQ) Self Reporting questionnaire(SRQ) Functional assessment Standardised clinical interview

9. Tools: survey data Sociodemographics Adverse childhood experiences Stressful war events Hopkins symptoms check-list 37 adolescents( HSCL- 37A ) Impact of Events Revised( IESR ) Sexual risk behaviour survey

10. Results: Vulnerability

11. Results: Clinical diagnosis

12. Clinic rates of psychopathology Clinical assessments indicated high rates of probable depression (53.88%) and PTSD (57.18%), with PTSD higher among boys and depression higher among girls. Alcohol use and epilepsy higher among boys whereas suicidality higher among girls.

13. Survey-based data Girls report more childhood adversities, stressful war events, AND Less PTSD, depression and anxiety symptoms and multiple risk behaviours among boys (Okello et al.,2013 ) 43.7% PTSD, 18.1%Depression and 27.8% anxiety symptoms higher among girls ( Okello et al., in preparation ) Rule breaking higher among boys whereas aggression and suicidal behaviour was higher among girls, but no gender differences in substance use( Okello et al.,2013 ).

14. Results: Psychotherapeutic interventions

15. Overall improvement in outcomes

16. Discussion Despite the non-random nature of our clinic data and lack of controls, Monitoring & Evaluation to track clinical outcomes help demonstrate impact. Opportunities to adapt and develop local screening questionnaires with clinical relevance Consistent with previous data post-conflict, clinic data is comparable to survey-based data and indicate that depression and PTSD are the commonest, with depression and suicidality consistently higher among girls. Substantial mental, neurological and substance use disorders as well as HIV, confirm need for integrated management of mental disorders & integrating HIV care into mental health services in post-conflict settings

17. Discussion Gender differences between survey and clinic based data suggest need for culturally sensitive gender specific interventions. Combining western evidence-based therapies with traditional, culturally-specific structures for reconciliation and reintegration in northern Uganda (such as matu oput, a cleansing ritual for returning child soldiers) result in better outcomes.

18. Conclusions These findings highlight the complex trauma profiles, conditions, and functional problems that are important to consider in providing mental health interventions for post- war children and adolescents Future work should compare survey and clinic based data as well as transferability across settings.

19. Selected Publications: 1.Okello, J., Onen, T.S. & Musisi, S. (2007). Psychiatric disorders among war abducted and non- abducted adolescents in Gulu district, Uganda: A comparative study. African Journal of Psychiatry; 10, 225-231. 2.Klasen, F., Gherke, J., Metzner, F., Okello, J.(2013). Complex Trauma Symptoms in Former Ugandan Child Soldiers. Journal of Aggression, Maltreatment, and Trauma 22, 698-713. 3.Nakimuli-Mpungu E, Alderman, S, Kinyanda E, Allden K, Pavia A, Betancourt T, Okello J,Nakku J, Adaku A, Musisi S.A (2013) Implementation and Scale-Up of Psycho-Trauma Centers in a Post- Conflict Area: A Case Study of a Private–Public Partnership in Northern Uganda. PLoS Med 10(4): e1001427. doi:10.1371/journal.pmed.1001427 4. Etheldreda Nakimuli-Mpungu, James Okello, Eugene Kinyanda, Stephen Alderman, Juliet Nakku, Jeffrey S. Alderman, Alison Pavia, Alex Adaku, Kathleen Allden, Seggane Musisi( in press). The impact of group counseling on depression, post-traumatic stress and function outcomes: A prospective comparison study in the Peter C. Alderman trauma clinics in northern Uganda, Available online 17 June 2013 Journal of Affective Disorders 5.Okello J, Nakimuli-Mpungu E, Musisi S, Broekaert E & Derluyn I.(2013). War-related trauma exposure and multiple risk behaviors among school-going adolescents in northern Uganda: The mediating role of depression symptoms. Journal of Affective Disorders, 151, 715-721. 6.Musisi S, Akena D, Nakimuli-Mpungu E, Abbo C, Okello J(2013).Neuropsychiatric perspectives on nodding syndrome in northern Uganda: a case series study and a review of the literature.African Health sciences 13(2): 205 - 218 7.Okello J, Nakimuli-Mpungu E, Musisi S, Broekaert E & Derluyn I.(2014). The Association between Attachment and Mental Health Symptoms among School-going Adolescents in Northern Uganda: the Moderating Role of War-related Trauma. Plos One 9(3):e88494