Globally, over 13% of children and adolescents are affected by mental disorders, yet relatively little scholarship addresses how risk factors, symptoms, and nosology vary by culture and context, especially in young children living in post-conflict and low-resource settings. To address this gap, we conducted a qualitative study to identify and describe the most salient mental health problems facing children aged 6 to 10 years in Sierra Leone, as well as the thoughts, feelings, and behaviors related to these problems. Free list interviews (N = 200) and semi-structured interviews (N = 66) were conducted among caregivers, children, and other relevant key informants to explore risk factors and locally meaningful concepts of distress. Our findings indicate that children are faced with a variety of challenges in their social environments that contribute to distress, including hunger, unmet material needs, and excessive work. Our research identifies five contextually defined mental health problems faced by young children: gbos gbos (angry, destructive behavior), poil at (sad, disruptive behavior), diskoraj (sad, withdrawn), wondri (excessive worry), and fred fred (abnormal fear). The manifestations of these distress concepts are described in detail and contextualized according to Sierra Leone’s history of war and current backdrop of poverty and insecurity. Implications are discussed for locally relevant diagnosis and treatment as well as for the wider literature on global child mental health.
AlonsoJ.ChattersiS.HeY. (Eds.). (2013). The burdens of mental disorders: Global perspectives from the WHO World Mental Health surveys. Cambridge University Press.
AsareJ.JonesL. (2005). Tackling mental health in Sierra Leone. BMJ, 331(7519), 720.
4.
AtilolaO. (2014a). Where lies the risk? An ecological approach to understanding child mental health risk and vulnerabilities in sub-Saharan Africa. Psychiatry Journal, 2014, Article 698348. https://doi.org/10.1155/2014/698348
5.
AtilolaO. (2014b). Child mental-health policy development in sub-Saharan Africa: broadening the perspectives using Bronfenbrenner’s ecological model. Health Promotion International, 32(2), 380–391.
6.
BehrendtA. (2008). Psychosocial needs of children without caregiver support in a post-conflict area: A cross section study in the district of Kailahun in Sierra Leone. AWARE HIV/AIDS, USAID, FHI, Plan International.
7.
BelferM. L. (2008). Child and adolescent mental disorders: The magnitude of the problem across the globe. Journal of Child Psychology and Psychiatry, 49, 226–236.
8.
BentonA.DionneK. Y. (2015). International political economy and the 2014 West African Ebola outbreak. African Studies Review, 58(1), 223–236.
9.
BerghsM. (2011). Embodiment and emotion in Sierra Leone. Third World Quarterly, 32(8), 1399–1417.
10.
BetancourtT. S.Agnew-BlaisJ.GilmanS. E.WilliamsD. R.EllisB. H. (2010). Past horrors, present struggles: The role of stigma in association between war experiences and psychosocial adjustment among former child soldiers in Sierra Leone. Social Science & Medicine, 70(1), 17–26.
11.
BetancourtT. S.BoltonP. (2005). Using qualitative methods to develop a locally-derived measure of psychosocial problems in Acholi war-affected children (Report). World Vision Uganda.
12.
BetancourtT. S.BorisovaI. I.SoudièreM.WilliamsonJ. (2011). Sierra Leone’s child soldiers: War exposures and mental health problems by gender. Journal of Adolescent Health, 49(1), 21–28.
13.
BetancourtT. S.BrennanR. T.Rubin-SmithJ.FitzmauriceG. M.GilmanS. E. (2010). Sierra Leone’s former child soldiers: A longitudinal study of risk, protective factors, and mental health. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 606–615.
14.
BetancourtT. S.BrennanR. T.VinckP.VanderWeeleT. JSpencer-WaltersD.JeongJ., … PhamP. (2016). Associations between mental health and Ebola-related health behaviors: A regionally representative cross-sectional survey in post-conflict Sierra Leone.PLoS Medicine, 13(8), e1002073.
15.
BetancourtT. S.GilmanS. E.BrennaR. T.ZahnI.VanderWeeleT. J. (2015). Identifying priorities for mental health interventions in war-affected youth: A longitudinal study. Journal of Pediatrics, 136(2), e344–e350.
16.
BetancourtT. S.KahnK. T. (2008). The mental health of children affected by armed conflict: protective processes and pathways to resilience. International Review of Psychiatry, 20(3), 317–328.
17.
BetancourtT. S.McBainR.NewnhamE. A.BrennanR. T. (2012). Trajectories of internalizing problems in war- affected Sierra Leonean youth: Examining conflict and post conflict factors. Child Development, 84(2), 455–470.
18.
BetancourtT. S.McBainR.NewnhamE. A.BrennanR. T. (2014). Context matters: Community characteristics and mental health among war-affected youth in Sierra Leone. Journal of Child Psychology and Psychiatry, 55(3), 217–226.
19.
BetancourtT. S.McBainR. K.NewnhamE. A.BrennanR. T. (2015). The intergenerational impact of war: Longitudinal relationships between caregiver and child mental health in post conflict Sierra Leone. Journal of Child Psychology and Psychiatry, 56(10), 1101–1107.
20.
BetancourtT. S.Rubin-SmithJ. E.BeardsleeW. R.StulacS. N.FayidaI.SafrenS. (2011). Understanding locally, culturally, and contextually relevant mental health problems among Rwandan children and adolescents affected by HIV/AIDS,AIDS Care, 23(4), 401–412.
21.
BetancourtT. S.SpeelmanL.OnyangoG.BoltonP. (2009). A qualitative study of psychosocial problems of war-affected youth in northern Uganda.Journal of Transcultural Psychiatry, 46(2), 238–256.
22.
BirdH. R. (1996). Epidemiology of childhood disorders in a cross-cultural context. Journal of Child Psychology and Psychiatry, 37(1), 35–49.
23.
BoltonP. (2001). Local perceptions of the mental health effects of the Rwandan genocide. Journal of Nervous and Mental Disease, 189(4), 243–248.
24.
BoltonP.BassJ.BetancourtT.SpeelmanL.OnyangoG.CloughertyK. F., … VerdeliH. (2007). Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: A randomized controlled trial. The Journal of the American Medical Association, 298(5), 519–527.
25.
BoltonP.TangA. M. (2002). An alternative approach to cross-cultural function assessment. Social Psychiatry and Psychiatric Epidemiology, 37(11), 537–543.
26.
BronfenbrennerU. (1979). The ecology of human development: experiments in nature and design. Harvard University Press.
27.
BronfenbrennerU. (1995). Development ecology through space and time: A future perspective. In MoenP.ElderG. H.LuscherK. (Eds.), Examining lives in context: Perspectives on the ecology of human development (pp. 619–647). American Psychological Association.
28.
BronfenbrennerU.CeciS. J. (1994). Nature-nurture reconceptualized in developmental perspective: A bioecological model. Psychological Review, 101(4), 568–586.
29.
BurkeyM. D.GhimireL.AdhikariR. P.WissowL. S.JordansM. J. D.KohrtB. A. (2016). The ecocultural context and child behavior problems: A qualitative analysis in rural Nepal. Social Science & Medicine, 159, 73–82.
30.
CamposR.RaffaelliM.UdeW.GrecoM.RuffA.RolfJ., … GrecoD. (1994). Social networks and daily activities of street youth in Belo Horizonte, Brazil: Street youth study group.Child Development, 65, 319–330.
31.
CannizzoJ. (1979). Alikali devils of Sierra Leone. African Arts, 12(4), 64–70.
32.
CortinaM. A.SodhaA.FazelM.RamchandaniP. G. (2012). Prevalence of child mental health problems in sub-Saharan Africa: A systematic review. Archives of Pediatric & Adolescent Medicine, 166(3), 276–281.
33.
DavisV. A. (2002). War, poverty and growth in Africa: Lessons from Sierra Leone. Paper presented at the Centre for the Study of African Economies (CSAE) 5th Annual Conference “Understanding Poverty and Growth in Africa”, Oxford, United Kingdom.
34.
de JongK.vd KamS.FrommS.van GalenR.KemmereT.van der WeerdH.… HayesL. (2006). Kashmir: Violence and health. A quantitative assessment on violence, the psychosocial and general health status of the Indian Kashmiri population. Medicins sans Frontieres.
35.
FanthorpeR.MaconachieR. (2010). Beyond the “crisis of youth”? Mining, farming and civil society in post-war Sierra Leone.African Affairs, 109, 251–272.
36.
GoodmanA.Fleitlich-BilykB.PatelV.GoodmanR. (2007). Child, family, school and community risk factors for poor mental health in Brazilian school children. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 448–456.
37.
HenryD. (2006). Violence and the body: Somatic expressions of trauma and vulnerability during war. Medical Anthropology Quarterly, 20(3), 379–398.
38.
HintonD. E.GoodB. J. (2015). Culture and PTSD: Trauma in global and historical perspective. University of Pennsylvania Press.
39.
HintonD. E.PichV.MarquesL.NickersonA.PollackM. H. (2010). Khyâl attacks: A key idiom of distress among traumatized Cambodia refugees. Culture, Medicine, and Psychiatry, 34(2), 244–278.
KaiserB. N.KohrtB. A.KeysH.KhouryN.BrewsterA.-R. (2013). Strategies for assessing mental health in Haiti: Local instrument development and transcultural translation.Transcultural Psychiatry, 15(4), 532–558. https://doi.org/10.1177/1363461513502697
43.
KaiserB. N.McLeanK. E.KohrtB. A.HagamanA. K.WagenaarB. H.KhouryN. M.KeysH. M. (2014). Reflechi twop – Thinking too much: Description of a cultural syndrome in Haiti’s central plateau. Culture, Medicine and Psychiatry, 38(3), 448–472.
KielingC.Baker-HenninghamH.BelferM.ContiG.ErtemI.OmigbodunO., … RahmanA. (2011). Child and adolescent mental health worldwide: evidence for action. Lancet, 378(9801), 1515–1525.
46.
KirmayerL. J. (2007). Psychotherapy and the cultural concept of the person. Transcultural Psychiatry, 44(2), 232–257.
47.
Kirmayer, L. J., & Ramstead, M. J. D. (2017). Embodiment and enactment in cultural psychiatry. In C. Durt, T. Fuchs, & C. Tewes (Eds.) Embodiment, enaction, and culture: Investigating the constitution of the shared world (pp. 397–422). MIT Press.
48.
Kirmayer, L. J., & Swartz, L. (2013). Culture and global mental health. In V. Patel, M. Prince, A. Cohen, & H. Minas (Eds.) Global mental health: Principles and practice (pp. 44–67). Oxford University Press.
49.
KleinmanA. (1987). Anthropology and psychiatry. The role of culture in cross-cultural research on illness. The British Journal of Psychiatry, 151(4), 447–454.
50.
KohrtB.HruschkaD. J. (2010). Nepali concepts of psychological trauma: The role of idioms of distress, ethnopsychology and ethnophysiology in alleviating suffering and preventing stigma. Culture, Medicine, and Psychiatry, 34(2), 322–352.
51.
KohrtB.JordansM.TolW.LuitelN.MaharjanS.UpadhayaN. (2011). Validation of cross-cultural child mental health and psychosocial research instruments: Adapting the Depression Self-Rating Scale and Child PTSD Symptom Scale in Nepal.BMC Psychiatry, 11, Article 127.
52.
KohrtB. A.JordansM. J.TolW. A.SpeckmanR. A.MaharjanS. M.WorthmanC. M.KomproeI. H. (2008). Comparison of mental health between former child soldiers and children never conscripted by armed groups in Nepal. JAMA, 300, 691–702.
53.
KohrtB. A.RasmussenA.KaiserB. N.HarozE. E.MaharjanS. M.MutambaB. B.de JongJ. T. V. MHintonD. E. (2014). Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology. International Journal of Epidemiology, 43(2), 365–406.
54.
KvasvigA.O’ConnorM.RedmondG.GoldfeldS. (2014). The unknown citizen: Epidemiological challenges in child mental health. Journal of Epidemiology and Community Health, 68(10), 1004–1008.
55.
LettJ. (1990). Emics and etics: Notes on the epistemology of anthropology. In HeadlandT. N.PikeK. L.HarrisM. (Eds.), Emics and etics: The insider/outsider debate (pp. 127–142). SAGE.
56.
McKayS.WessellsM. G. (2004). Post-traumatic stress in former Ugandan child soldiers. Lancet363(9421), 1646.
57.
MillerK. E.OmidianP.RasmussenA.YaqubiA.DaudzaiH. (2008). Daily stressors, war experiences, and mental health in Afghanistan. Transcultural Psychiatry, 45(4), 611–638.
58.
MurrayC. J.VosT.LozanoR.NaghaviM.FlaxmanA. D.MichaudC., … MemishZ. A. (2012). Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380(9859), 2197–223.
59.
NgL. C.KanyanganziF.MunyanahM.MushashiC.BetancourtT. S. (2014). Developing and validating the Youth Conduct Problems Scale-Rwanda: A mixed methods approach. PloS One, 9(6), e100549.
60.
NichterM. (2010). Idioms of distress revisited. Culture, Medicine and Psychiatry, 34(2), 401–416.
61.
Panter-BrickC.GoodmanA.TolW.EggermanM. (2011). Mental health and childhood adversities: A longitudinal study in Kabul, Afghanistan. Journal of the American Academy of Child and Adolescent Psychiatry, 50(4), 349–363.
62.
PatelV.KimY. R. (2007). Contribution of low- and middle-income countries to research published in leading general psychiatry journals, 2002–2004. British Journal of Psychiatry, 190, 77–88.
63.
PatelV.KleinmanA. (2003). Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization, 81(8), 609–615.
64.
PatelV.FlisherA. J.HetrickS.McGorryP. (2007). Mental health of young people: A global public-health challenge.Lancet, 369(9569), 1302–1313.
65.
PatelV.FlisherA. J.NikapotaA.MalhotraS. (2008). Promoting child and adolescent mental health in low and middle income countries. Journal of Child Psychology and Psychiatry, 49(3), 313–334.
66.
PatelV.KielingC.MaulikP. K.DivanG. (2013). Improving access to care for children with mental disorders: A global perspective. Archives of Disease in Childhood, 98(5), 323–327.
67.
PetersK. (2011). War and the crisis of youth in Sierra Leone. Cambridge University Press.
68.
PfeifferJ.ChapmanR. (2010). Anthropological perspectives on structural adjustment and public health. Annual Review of Anthropology, 39, 149–165.
69.
PieterseP.LodgeT. (2015). When free healthcare is not free: Corruption and mistrust in Sierra Leone’s primary healthcare system immediately prior to the Ebola outbreak.International Health, 7, 400–404.
70.
PolanczykG. V.SalumG. A.SugayaL. S.CayeA.RohdeL. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56(3), 345–365.
71.
Schwab-StoneM.RuchkinV.VermeirenR.LeckmanP. (2001). Cultural considerations in the treatment of children and adolescents: Operationalizing the importance of culture in treatment. Child and Adolescent Psychiatric Clinics of North America, 10, 729–743.
72.
ScorzaP.StevensonA.CaninoG.MushashiC.KanyanganziF.MunyanahM.BetancourtT. S. (2013). Validation of the “World Health Organization Disability Assessment Schedule for Children, WHODAS-Child” in Rwanda. PLoS One, 8(3), e57725.
73.
SheplerS. (2014). Childhood deployed: Remaking child soldiers in Sierra Leone. New York University Press.
74.
SmithC. P. (1992). Motivation and personality: Handbook of thematic content analysis. Cambridge University Press.
75.
SongS. J.TolW.de JongJ. (2014). Indero: Intergenerational trauma and resilience between Burundian former child soldiers and their children. Family Process, 53(2), 239–251.
76.
SongS. J.van den BrinkH.de JongJ. (2013). Who cares for former child soldiers? Mental health systems of care in Sierra Leone. Community Mental Health, 49(5), 615–624.
77.
Statistics Sierra Leone (SSL) and ICF International. (2013). Sierra Leone Demographic and Health Survey 2013. Freetown, Sierra Leone and Rockville, Maryland, USA: SSL and ICF International.
78.
SuperC. M.HarknessS. (1986). The developmental niche: A conceptualization at the interface of child and culture. International Journal of Behavioral Development, 9(4), 545–569.
79.
SuperC. M.HarknessS. (2002). Culture structures the environment for development. Human Development, 45(4), 270–274.
80.
UNDP. (2016). Human Development Report 2016: Human Development for Everyone. United Nations Development Programme. http://hdr.undp.org/en/2016-report
81.
U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity -- A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.
82.
van GogJ. G. (2009). Talking about the “Kissy Kresyad”: An ethnographic exploration of the Sierra Leone Psychiatric Hospital [Unpublished master’s thesis]. Maastricht University.
83.
WalkerS. P.WachsT. D.GardnerJ. M.LozoffB.WassermanG. A.PollittE., … International Child Development Steering Group. (2007). Child development: Risk factors for adverse outcomes in developing countries. Lancet, 369(9556), 145–157.
84.
WeaverL. J. (2017). Tension among women in North India: An idiom of distress and a cultural syndrome. Culture, Medicine and Psychiatry, 41(1), 35–55.
85.
WeaverL. J.KaiserB. N. (2014). Developing and testing locally derived mental health scales: Examples from India and Haiti. Field Methods, 27(2), 115–130.
World Health Organization (WHO). (2016). Ebola situation report -- 30 March 2016. Retrieved from http://apps.who.int/ebola/current-situation/ebola-situation-report-30-march-2016.
89.
YoderH. N.TolW. A.ReisR.de JongJ. T. (2016). Child mental health in Sierra Leone: A survey and exploratory qualitative study. International Journal of Mental Health Systems, 10, Article 48.
90.
ZuilkowskiS. S.ThulinE. J.McLeanK. E.McGill RogersT.Akinsulure-SmithA. M.BetancourtT. S. (2019). Culturally contextualized parenting: Understanding and assessing parenting in Sierra Leone [Manuscript submitted for publication].
