Healing the scars of war
When Jan was 10 he started at Hallfield junior school in Paddington, west London. Unable to make friends, he lashed out at children who approached him, interpreting their interest as hostile. Unsettled in class, he couldn't concentrate. He dared not discuss the nightmares he was having.
Jan was a refugee, originally from Kurdistan in northern Iraq. As a toddler he had lived through the Gulf War and witnessed the kind of state-sponsored violence most of us would rather not think about. He was terrified by police sirens and was unable to play at home for more than 10 minutes without checking for his parents. His schoolwork suffered - despite having good verbal skills, he had difficulties reading and writing.
In many schools such children sink or swim, depending on the skills of their teachers. But thanks to a pioneering project at Hallfield, Jan was referred to a child psychiatrist who treats troubled refugee children and their families on school premises.
Jan's early childhood had been traumatic. His house had been searched, his father arrested, and his cousin and her six children gassed in prison, victims of Iraqi leader Saddam Hussein's brutal war against Kurdish separatists. When he had ventured out, he saw police shooting people in the streets.
When he was five, his parents fled with him and his older sister to Israel, where they spent four years. As Muslims, they were harassed and Jan was bullied in school. In 1997, they sought asylum in England.
When they arrived in England, Jan's father was held for seven months in a refugee camp. The rest of the family lived in a single hotel room, with the threat of deportation hanging over them while their asylum application was processed.
It was at this time that Jan became a pupil at Hallfield in the London borough of Westminster and began to see child psychiatrist Bridget O'Shea. She says: "He had post-traumatic stress disorder. One of the signs is hypervigilance - he was wary, always scared something was going to happen to him. He was preoccupied with memories of trauma, which prevented him concentrating."
Ms O'Shea helped Jan and his parents to face their past. "In the debriefing, the family talked for the first time about what had happened to them and how it made them feel, rather than each being isolated with their inner experience.
"Jan drew pictures of a happy and an unhappy time. He drew a cheerful picture of his father, who was a car dealer, getting a new car to sell. His unhappy picture showed helicopters dropping bombs, his family escaping in lorries and the army shooting people. He continued to draw at home, which opened up discussions with his parents about what they'd been through. A key symptom of post-traumatic stress is avoidance, and an important element of treatment is exposure."
Jan improved during six months of weekly one-hoursessions. "As his condition improved, his aggression towards his peers diminished," says Ms O'Shea. When Jan transferred to secondary school, his treatment continued through the local child and adolescent mental health service and his nightmares disappeared.
Bridget O'Shea describes how children are assessed. "We talk to the teacher, the child and the carers and find out as much as we can about how they feel.
"The teacher completes a strengths and difficulties questionnaire, which gives a clear idea of the problems and acts as a benchmark. After some therapy, we repeat it and refer to the original score to see if things have improved."
The maximum questionnaire score, denoting extreme problems, is 40. Jan started high, with 31, but by the time he left Hallfield he was at 13, just two points above normal.
John Bramley, Hallfield's then headteacher (he retired last autumn), conceived the refugee scheme four years ago. Thirty per cent of the school's 360 pupils are refugees, English is a second language to 72 per cent of the children and 39 mother tongues are spoken. Pupil mobility is high - about 65 join and leave each year.
Mr Bramley believes school-based treatment is essential for refugee children with mental health problems. "Teachers are well placed to identify those who need therapy," he says. But sending children to external clinics had proved unsuccessful.
Parallel to John Bramley's vision, mental health professionals were becoming increasingly aware of the needs of the rising numbers of young refugees in the UK. Britain has at least 250,000 refugees, most of them in inner London, and 40 per cent of them are under 18. Their experiences of violence and loss often defy belief, leaving 25 per cent with serious psychiatric problems.
Matthew Hodes, consultant at the department of child and adolescent psychiatry at St Mary's Hospital, and senior lecturer at Imperial College, London, recognised that the mental health needs of refugee children were receiving scant attention. This led to a collaboration between Hallfield and Matthew Hodes's team, which included Bridget O'Shea.
Mr Hodes says offering help in schools made sense. "Attendance is simpler and less stigmatising than going to a clinic. With funding from the charity Action for Peoples in Conflict, we allocated a therapist to Hallfield. The school provides interpreters, and by collaborating with teachers we help people who wouldn't readily use mental health services.
"The project builds on trust between child, family and school, which encourages attendance. Drop-out rates are lower than in many child mental health clinics and Hallfield families allow feedback from therapist to teacher."
Judith Grigg, acting head at Hallfield, says the service is a reassuring presence for teachers and a vital extension of what the school can offer. "Even if teachers have counselling skills, we don't have the time. In the classroom or playground, we deal with academic, emotional and behavioural problems as they crop up, but they can only really be unravelled through therapy. The impact on social skills and learning is immense."
Bridget O'Shea believes in the benefits of close liaison that come from being on site. "We can help teachers understand what happens in child psychiatry," she says. "On one occasion, a teacher was worried that a boy would be distressed by a visit to the Imperial War Museum in London, particularly its exhibition on the Blitz Experience. We discussed the possibility that he would benefit from going if his worries were sensitively handled, and he did. We can also feed into discussion about helping other, non-refugee, children."
Jan Beard, teacher and primary co-ordinator of the Refugee Education Project in Haringey, another London borough with a large refugee population, is impressed by the scheme's potential. She says: "Separation and loss are huge issues for many, and children can become withdrawn or develop behavioural problems. Giving them the opportunity to talk can be helpful, and the classroom becomes a nicer, more productive place."
Ms Beard and her colleagues are working with the Medical Foundation Caring for Victims of Torture to increase teacher awareness.A report on the Hallfield project was recently presented to the Royal College of Psychiatrists. It is to be used as a model by Westminster education action zone.Refugee awareness training is available at the Haringey Professional Development Centre, tel: 020 8489 5020
Be realistic and patient. You cannot change children's experiences They need time to adjust and may have lost loved ones.
Treat refugee children normal- y, while acknowledging extraordi- ary pasts.
Simple words or gestures may trigger extreme eactions. Male and female teach- ers can be viewed differently. Sta- )ility - talking daily to the same :eacher - is invaluable. Refugee communities may have people who can volunteer in schools.
What teachers can do
Be fair. Demand consistent behaviour. Make clear the differ- ence between bad behaviour and being a bad person. Children may see their traumatic experiences as punishment, and be hypersen- sitive to injustice. Keep parents or carers informed of problems.
Deal firmly with bullying or racism.
Provide a supportive atmos- phere - a comprehensive list of approaches is found in the Child Psychotherapy Trust booklet (see below). Develop a refugee policy.
Recognise when specialist help is needed. Some children may not be registered with GPs, so teach- ers may be best placed to refer to mental health services.
If therapy starts, teacher input is invaluable.
Schools that want to provide on- site help should contact their loca child mental health service or refugee organisations.