It is always the most vulnerable that fare the worst in crises. It is true in times of war and conflict, and it is true now, in the global crisis due to the rapid spread of the COVID-19 virus. One vulnerability attracts another that attracts the third, fourth, the fifth, and on it goes. Child protection specialists sometimes call this the ‘Velcro-effect’.
El-Khodary and Samara demonstrate in a Palestinian sample of 1029 children and adolescents aged 11–17 years that two thirds were exposed to violence at home, half to violence in the neighbourhood, and three quarters to violence at school . So, it should not come as a surprise that the prevalence of post-traumatic stress disorder (PTSD) diagnosis was high at 53.5%. There was also a dose–response effect, such that exposure to violence in multiple contexts predicted higher levels of PTSD, social and emotional problems and depression. This supports previous findings that victimization across multiple domains of a child’s life has particularly damaging effects . The cruelty of this finding is that, as a child or young person, where else do you have to go? If you are exposed to violence at school, your neighbourhood and at home, there is no safe haven, no one to trust, and nowhere to hide. If you develop a mental health problem due to such exposures, your chances of getting better decrease for lack of stability and supporting relationships. You will be more prone to bullying or to bully, academic failure, and sexual victimization [3, 4]: the Velcro-effect takes charge.
In recent years, there has been an explosion of our understanding on the adverse effects of poverty, neglect and violence exposure on the developing brain. Premature connectivity between the amygdala and prefrontal cortex is a repeated finding following early traumatisation, across species . The finding is, in very simple terms, interpreted as the individual’s increased focus on survival, at the cost of learning. Functional MRI studies on PTSD indicate that abnormalities in fear learning play an important role in the development of PTSD , but we do not quite know what is the chicken and the egg in that equation. Thus, when societies do not manage to protect their youth from violence exposure, especially in multiple contexts, they are in effect messing with society’s future brain power. Add poverty into the mix  and the effects on the development, mental health, and productivity of a whole generation is jeopardized.
So what do we make of this? Measures addressing social determinants, such as child poverty, insecure housing and employment, and inadequate education have great potential to promote better (mental) health in vulnerable groups, but combining such policies with effective interventions requires the initiation and development of a cross-sectoral approach, which takes time . The fact that such a large proportion in this sample of Palestinian children has PTSD calls for immediate action.
Community-based mental health interventions offer a way to reach lots of people when there is a high level of need. A growing number of studies concerning cognitive behavioral therapy (CBT)-based PTSD treatments using trained lay counselors [9, 10] indicate feasibility and short-term effectiveness. Thus, there are alternatives to the traditional, intensive individual therapies for PTSD.
Teaching Recovery Techniques is an example, which has also been trialed in Palestine . It is a five-session programme based on trauma-focused CBT and includes psychoeducation, affect modulation, relaxation, imaginary techniques, desensitization, and reprocessing techniques (‘knee-tapping’) and guided exposure. Our group has trialed Teaching Recovery Techniques in Sweden on unaccompanied refugee minors  and we are currently conducting larger scale trials on both accompanied and unaccompanied minors . The response from the children has been overwhelmingly positive, with a direct quote serving as the title for this piece. Personnel in schools offering Teaching Recovery Techniques increasingly understand the intimate relationship between mental health, especially PTSD, and learning: “Working with these issues creates a basis for learning. You simply can’t build a second floor of a house if you don’t have the first floor in place”, says a principal.
Of course, not all children with PTSD symptoms will improve from a relatively light-touch intervention and complex trauma likely requires specialist treatment, which is scarce and costly. But not having enough specialist resources should not be accepted as an excuse for inaction. If a society fails to protect its most vulnerable, there will be a need for more costly clean-up operations across the lifetime.
Right now, we are in the middle of a new crisis that will, undoubtedly, create its own mess to be cleaned up. In the midst of our own anxieties, we need to remind ourselves that the most vulnerable will once again suffer the most. Overcrowding is a particularly pertinent ‘Velcro’ in the era of COVID-19. Not only does it limit possibilities to minimize the spread of infectious diseases, it is a known risk factor for domestic violence and antisocial behavior [14, 15].
What are we doing to protect vulnerable children and youth in this crisis? There are a number of inspiring initiatives spanning across sectors in many countries. As researchers, we can offer adequate documentation and certain evaluation of efforts as well as elementary psychoeducation about the nature of children’s reactions to crises and ways to provide support. For our ongoing trial of Teaching Recovery Techniques, we are quickly exploring ways to deliver the sessions online and document the feasibility of full digital delivery. Maybe we can learn something about scalability we would not otherwise have learnt?
Finally, as private individuals, we can always be an important adult in a vulnerable child’s life, even if it’s just online for now. Because when you can talk about what’s hurting you in a safe environment, “something in your heart becomes lighter”.
El-Khodary B, Samara M (2019) The relationship between multiple exposures to violence and war trauma, and mental health and behavioural problems among Palestinian children and adolescents. Eur Child Adolesc Psychiatry. https://doi.org/10.1007/s00787-019-01376-8
Turner HA, Shattuck A, Finkelhor D et al (2016) Polyvictimization and youth violence exposure across contexts. J Adolescent Health 58:208–214. https://doi.org/10.1016/j.jadohealth.2015.09.021
Lucas S, Jernbro C, Tindberg Y et al (2016) Bully, bullied and abused. Associations between violence at home and bullying in childhood. Scand J Public Health 44:27–35. https://doi.org/10.1177/1403494815610238
Fry D, Fang XM, Elliott S et al (2018) The relationships between violence in childhood and educational outcomes: a global systematic review and meta-analysis. Child Abuse Neglect 75:6–28. https://doi.org/10.1016/j.chiabu.2017.06.021
Callaghan BL, Sullivan RM, Howell B et al (2014) The international society for developmental psychobiology Sackler symposium: early adversity and the maturation of emotion circuits—a cross-species analysis. Dev Psychobiol 56:1635–1650. https://doi.org/10.1002/dev.21260
Kunimatsu A, Yasaka K, Akai H et al (2019) MRI findings in posttraumatic stress disorder. J Magn Reson Imaging. https://doi.org/10.1002/jmri.26929
Noble KG, Houston SM, Brito NH et al (2015) Family income, parental education and brain structure in children and adolescents. Nat Neurosci 18:773–778. https://doi.org/10.1038/nn.3983
Wahlbeck K, Cresswell-Smith J, Haaramo P et al (2017) Interventions to mitigate the effects of poverty and inequality on mental health. Soc Psych Psych Epid 52:505–514. https://doi.org/10.1007/s00127-017-1370-4
Weiss WM, Murray LK, Zangana GA et al (2015) Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial. BMC Psychiatry 15:249. https://doi.org/10.1186/s12888-015-0622-7
Neuner F, Onyut PL, Ertl V et al (2008) Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a randomized controlled trial. J Consult Clin Psychol 76:686–694. https://doi.org/10.1037/0022-006x.76.4.686
Qouta SR, Palosaari E, Diab M et al (2012) Intervention effectiveness among war-affected children: a cluster randomized controlled trial on improving mental health. J Trauma Stress 25:288–298. https://doi.org/10.1002/jts.21707
Sarkadi A, Adahl K, Stenvall E et al (2017) Teaching recovery techniques: evaluation of a group intervention for unaccompanied refugee minors with symptoms of PTSD in Sweden. Eur Child Adolesc Psychiatry 27:467–479. https://doi.org/10.1007/s00787-017-1093-9
Sarkadi A, Warner G, Salari R et al (2020) Evaluation of the teaching recovery techniques community-based intervention for unaccompanied refugee youth experiencing post-traumatic stress symptoms (Swedish UnaccomPanied yOuth Refugee Trial; SUPpORT): study protocol for a randomised controlled trial. Trials 21:63. https://doi.org/10.1186/s13063-019-3814-5
Marshy M (1999) Social and psychological effects of overcrowding in Palestinian refugee camps in the West Bank and Gaza-Literature review and preliminary assessment of the problem. International Development Research Centre, 8
Makinde O, Bjorkqvist K, Osterman K (2016) Overcrowding as a risk factor for domestic violence and antisocial behaviour among adolescents in Ejigbo, Lagos, Nigeria. Glob Ment Health 3:e16
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Sarkadi, A., Warner, G. “When you talk about it, something in your heart becomes lighter”. Eur Child Adolesc Psychiatry 29, 573–574 (2020). https://doi.org/10.1007/s00787-020-01538-z