Assessing adolescent mental health in war-affected societies: the significance of symptoms

OBJECTIVE: To compare the use of self-report symptom checklists with qualitative methods for assessing adolescent psychological well-being in a war-affected society. METHOD: A school-based sample of three hundred and thirty seven 13- to 15-year-olds from two communities on opposite sides of the Bosnian conflict (183 from Gorazde, 154 from Foca) completed the Hopkins Symptoms Checklist and the Harvard Trauma Questionnaire. A gender balanced sub-sample of 40 adolescents was selected on the basis of their combined checklist scores, including equal numbers of high and low scorers from each side. Over the following 6 months this sub-sample was assessed (blind to checklist scores) with qualitative methods that included narrative interviews of child and parent, and participant observation. School marks were taken as a measure of social function. RESULTS: QUALITATIVE: Some children identified as "less well" by qualitative methods denied having symptoms. Some children identified as "well" had symptoms with no pathological significance for them. The lifeline revealed that feeling "less well" could be more related to post-war circumstances than war events. QUANTITATIVE: The two symptom checklist items have shown good internal consistency and discriminant validity. However, comparison with the overall well being revealed that still in 9/40 of cases the reported presence or absence of symptoms did not correspond to the well being of the child. Items of the two questionnaires did not discriminate reliably between children identified as "well" and "less well" by other means. CONCLUSIONS: Self-report checklists may be useful as a public health measure to assess the prevalence of psychological distress in war affected areas, but they are not an adequate means of clinical screening. Checklists used in combination with other qualitative approaches make it possible to identify those in need and avoid unnecessary pathologizing.