Theresa Betancourt (center) in northern Uganda
While researchers have been untangling the social, medical, and economic repercussions of such conflicts, they are just beginning to assess the mental health damage done to war-affected children, many of whom are in developing countries with cultural experiences that do not fit neatly into Western-formulated psychiatric tools.
But Theresa Betancourt, assistant professor of child health and human rights in the HSPH Department of Population and International Health, is working to address the gaps. For more than 10 years, she has traveled to meet with children traumatized by armed conflict: Kosovar refugee children in Albania, youth displaced by conflict in Chechnya, Ethiopia, and northern Uganda, and former child soldiers in Sierra Leone.
"Children in adversity and their resiliency are my interests," said Betancourt. "But it's not just about the inherent resiliency some children have to overcome horrific things. I am also interested in what happens at the family, peer, and community levels that helps kids have better health and developmental outcomes. And how we can assess and implement that knowledge."
Betancourt grew up in a small village in Alaska where she witnessed how adversity can affect health, given what she described as the high rates of child abuse, domestic violence, and related deaths that are common in the region. She recognized how cultural identity can be a source of strength for people living in hardship.
"Growing up among the Yup'ik, I also learned about collective conceptions of wellness that differed greatly from the more individualistic view of self and health that are dominant in American culture," she said. These experiences planted a seed that drive her interest in culture, adversity, and mental health today.
She trained originally as an expressive arts therapist and moved to Oregon, where she worked as a school mental health specialist and later for the Multnomah County Department of Community and Family Services. In the summer of 1995, she volunteered for a human rights organization involved with the Fourth World Conference on Women.
"That work exposed me to the world of NGOs, the United Nations, human rights conventions," said Betancourt. "I became very interested in the potential of human rights frameworks, such as the U.N. Convention on the Rights of the Child, to promote better developmental circumstances for kids - to prevent some of the problems we were trying to address in mental health treatment."
She took a leave of absence from her job and interned for the Office of the U.N. High Commissioner for Human Rights. She later worked for the Special Representative of the United Nations Secretary-General for Children and Armed Conflict. The timing was serendipitous. During her tenure, the U.N. unveiled an influential policy study, The Impact of Armed Conflict on Children, led by Graca Machel, the former first lady of Mozambique and current wife of Nelson Mandela.
Betancourt came to HSPH as a student in what was then the Department of Maternal and Child Health. In 1998, she co-founded the Child Rights Working Group at the Harvard Center for Population and Development Studies and earned her doctoral degree in 2003. She joined the faculty at the Boston University School of Public Health, working with Professor Paul Bolton and his team at the Center for International Health and Development. Last year, she became a member of the HSPH faculty and the FXB Center for Health and Human Rights. She has retained an adjunct position at BU.
While working with Bolton, Betancourt was a co-principal investigator on a randomized controlled trial in northern Uganda. The country has experienced more than 20 years of conflict, creating a generation that has known nothing but war. More than 1.8 million people have been internally displaced and have been forced to live in teeming refugee camps. The trial examined two mental health interventions - 'group interpersonal psychotherapy' and 'creative play' - among adolescents living in two camps.
The team purposefully began by asking local people about what they identified as their biggest worries. Of these, the team then focused on the problems that were described related to thinking, feeling, and relationships with others. This provided a launching point for understanding local conceptualizations of mental health problems.
The open-ended, qualitative approach was important, noted Betancourt, because it allowed the participants to identify what they saw - not what the researchers assumed - were the important issues. The approach also helped the research team adapt their diagnostic tools to the culture of the study participants. For example, Betancourt noted that common diagnostic tools for behavioral and emotional problems used in the U.S. can have symptom items that can be misleading or inappropriate in other cultural contexts. She described a tool that includes a question about whether a child lights fires.
"If a child here in the United States starts to light fires, the behavior can be indicative of conduct problems or anger or aggression - destructive intent," said Betancourt. "But in a lot of the refugee camps where I've worked, the child who lights fires is often helping to prepare dinner or doing a very important activity that represents integration and social responsibility. If you were to ask an adult in northern Uganda whether a child lights fires as some kind of psychopathology, they simply would tell you that doesn't make sense."
Instead, a more sensitive warning sign is if children remove themselves from peers and sit quietly, alone, with their cheeks resting in the palms of hands. This posture has a name in northern Uganda - "sitting Kumu" - and it is a clear sign that a child is experiencing a depression-like feeling.
"Once we learned about these local syndromes, such as Kumu, we were also able to ask what people commonly do to help children with these sorts of difficulties," said Betancourt. "That provided us with a lens into what intervention models could be a good fit locally."
With improved measures in hand and ideas about feasible intervention models, the team set out on the quantitative part of the trial. One arm of the study investigated whether group interpersonal psychotherapy, developed by Myrna Weissman and others at Columbia University, could help alleviate depression. The other explored the use of an activity-based intervention called "creative play," which focused on large group activities such as sports, arts, and role plays to foster social interaction and skills. The team found that adapted group interpersonal therapy was more effective compared to controls and to the creative play intervention for treating symptoms of depression, particularly in young women.
"The study in northern Uganda really made me appreciate the importance of mixed methods - qualitative and quantitative - and of sensitivity to other cultures," said Betancourt. "It also demonstrated how some interventions can be useful in low-resource settings without a huge investment in training, equipment, or therapeutic drugs."
Now at the FXB Center for Health and Human Rights at HSPH, Betancourt aims to broaden the mixed-methods approach shown to be successful in northern Uganda to other regions of the world. She hopes to revisit Sierra Leone, where she conducted research in 2002 and again in 2004 for the International Rescue Committee on former child soldiers. She is also working with HSPH Professor Jim Kim and colleagues at Partners in Health to investigate the intersection of HIV/AIDS, children, and mental health in post-genocide Rwanda.
"Mental health issues are so central to our work as public health and human rights professionals," said Betancourt. "These war-affected children are not a lost generation or throwaway kids. Their problems are not untreatable. We need more quantitative and qualitative research to help identify the most pressing mental health issues, the most workable treatments, with an open mind to culture and a clear understanding of history."
Copyright, 2007, President and Fellows of Harvard College
