Violence, suffering, and mental health in Afghanistan: a school-based survey

Abstract

Background: Studies in Afghanistan have shown substantial mental health problems in adults. We did a survey of young people (11-16 years old) in the country to assess mental health, traumatic experiences, and social functioning. Methods: In 2006, we interviewed 1011 children, 1011 caregivers, and 358 teachers, who were randomly sampled in 25 government-operated schools within three purposively chosen areas (Kabul, Bamyan, and Mazar-e-Sharif municipalities). We assessed probable psychiatric disorder and social functioning in students with the Strength and Difficulties Questionnaire multi-informant (child, parent, teacher) ratings. We also used the Depression Self-Rating Scale and an Impact of Events Scale. We assessed caregiver mental health with both international and culturally-specific screening instruments (Self-Reported Questionnaire and Afghan Symptom Checklist). We implemented a checklist of traumatic events to examine the exposure to, and nature of, traumatic experiences. We analysed risk factors for mental health and reports of traumatic experiences. Findings: Trauma exposure and caregiver mental health were predictive across all child outcomes. Probable psychiatric ratings were associated with female gender (odds ratio [OR] 2·47, 95% CI 1·65-3·68), five or more traumatic events (2·58, 1·36-4·90), caregiver mental health (1·11, 1·08-1·14), and residence areas (0·29, 0·17-0·51 for Bamyan and 0·37, 0·23-0·57 for Mazar-e-Sharif vs Kabul). The same variables predicted symptoms of depression. Two thirds of children reported traumatic experiences. Symptoms of post-traumatic stress were associated with five or more traumatic events (3·07, 1·78-5·30), caregiver mental health (1·06, 1·02-1·09), and child age (1·19, 1·04-1·36). Children's most distressing traumatic experiences included accidents, medical treatment, domestic and community violence, and war-related events. Interpretation: Young Afghans experience violence that is persistent and not confined to acts of war. Our study emphasises the value of school-based initiatives to address child mental health, and the importance of understanding trauma in the context of everyday forms of suffering, violence, and adversity. Funding: Wellcome Trust. © 2009 Elsevier Ltd. All rights reserved.