“Being united as a small community will deliver our services countrywide”

The Bosnian war may be over, but its effects on mental health permeate into the next generation. War-affected parents transfer their emotions and behaviour to their children, putting a strain on the small network of child and adolescent psychiatrists (CAP) within the country. The number of children and adolescents seeking specialised mental health care in Bosnia and Herzegovina is rising but can the system cope? The Bosnia and Herzegovina association, now a member of ESCAP, is striving for the Ministries of Health to acknowledge a specialised CAP training, they aim to relieve the stigmas associated with psychiatry and children, and ultimately to provide the much-needed care these children need throughout the whole country.

Professor Nermina Kravic, the general secretary for the association for child and adolescent psychiatry in Bosnia and Herzegovina (ACAP BiH) was asked to give the ESCAP community insight into the challenges and visions of ACAP BiH. Not wanting to dwell on the Bosnian war but highlighting its significance on the mental health of a nation, she describes here how ACAP BiH have their own expertise but are looking forward to exchanging knowledge within the ESCAP community. We teach, we learn, we enrich our knowledge.

Diagnosing post-traumatic stress disorder after the Bosnian war 
International help was critical for Bosnia and Herzegovina (B&H) during the Bosnian war (1992-1995). It provided aid for the struggling health system and developed psychosocial projects to support and care for refugee woman and children affected by war. This support continued after the war, providing vital knowledge about new systems on how to deal with mental health within a ‘divided’ nation. Around the same time, post-traumatic stress disorder (PTSD) was given its specific ICD diagnoses. “In B&H, we firstly diagnosed our patients with PTSD, then we learned about it from these experts from abroad. They gave us specialised lectures and taught us how we should treat and deal with the vast amount of people suffering from it. I should emphasize the great contribution from professor Syed Husain Arshad of the CAP department in Columbia University, Missouri, USA. He and his team came during the worst wartime to provide us with very good training courses on PTSD in children” says professor Nermina Kravic.
Post-war generation: the transferal of emotions 
“We are in a specific situation, the post-war generation. This generation of adolescents was born after the war. They do not remember it, but their parents are very traumatised by the war, and that is how parents transfer, mostly emotionally, on to their children. These parents are sometimes having unrecognised PTSD symptoms, or they have a hyper-aroused reaction to a situation, they cannot stand when a child is shouting, yelling, playing, so the parent reacts with anger, and then the child feels bad about the situation. This is transferring from one generation to another. It is the post-war effect.” 
Stigmatisation is losing valuable time for these vulnerable children 
With the political, healthcare, and mental health care systems still in a transformation period, accessibility to specialised care is difficult. With a population close to 3.7 million people, there are only 150 psychiatrists in B&H and 12, soon to be 14, are trained child and adolescent psychiatrist (CAP). In general, they are working in large city centres, thus small towns have limited access to specialised care.  “Stigmatisation of the psychiatric patient is very present in B&H, especially among children and adolescents. Very often you have the impression that parents feel bad to take a child to see a psychiatrist, they feel guilty and not successful as a parent. You never have one patient you have 2 or 3, the whole family perhaps. It is very important for them to get a warm and open approach, which will alleviate the stigma associated with psychiatry and their children. Many of them are trying to avoid psychiatrists, and going to other specialists, if they go to a psychiatrist it has this sense of being ‘serious’. Unfortunately, by doing this, they are losing valuable time when the child is suffering and should be getting treatment”.  
“We are so few we cannot see so many children in a day. They must wait for weeks for an appointment to see a CAP; this makes the system approach difficult. We are trying to open CAP centres within mental health centres close to primary medical practices and have consultants in paediatric units, so psychiatrists are easily accessible and approachable, and to ultimately relieve this stigma surrounding visiting a CAP with your child”. 
“In fact, there are many non-governmental patient family associations appearing that are putting a huge positive pressure on the system to change and changing societies view on mental health in children”.
Introducing a specialisation in child and adolescent psychiatry
Currently, a CAP specialisation does not exist in the whole country. In the Federation of B&H, you should first finish specialisation in general psychiatry, and then after, complete a sub specialisation in CAP, while in Republic Srpska since last year, there is a divided specialisation in CAP. The ACAP BiH aims to convince the Ministries of Health, in all regions of B&H to adopt and recognise this specialisation. ESCAP has shown its support by writing to the Ministry of Health in B&H stressing the importance of this course. “There are doubts among doctors, what is best, psychiatry or CAP? Many institutions believe it is more profitable to have a trained psychiatrist and then educate them to be a CAP as well, putting a huge strain on them to be specialised in adult, and child psychiatry. We [CAP] are still fighting for our identity, even within the psychiatry profession, to be separate, to have our own strength, education and specialisation”.
ESCAP board accepted the BiH ACAP as a member at the General Assembly meeting in May 2018“In 2001/2002, the medical school at the University of Sarajevo collaborated with the University of Umea, Sweden to deliver a master’s degree in child and adolescent psychiatry and psychology. In total, 30 students enrolled onto the course, 18 psychiatrists and 12 psychologists. Unfortunately, the course didn’t continue, but 10 of these students have now achieved their PhD in this field. They will be the driving force for organising specialised courses within universities and transfer this knowledge to the younger generation. This can be achieved with the help of professors from other European countries and world specialists who could provide additional lectures. It’s important about how we enrich our knowledge, bringing one person to the country to give a specialised lecture can influence so many individuals rather than individuals having to seek knowledge themselves by going to other countries”.
Restricted medication results in more behavioural techniques
In B&H, psychiatrists are seeing a wide range of pathologies in the children and adolescents they treat. As mentioned previously, due to home situations, emotional and behavioural disturbances are often seen. “Attention-deficit hyperactivity disorder (ADHD) is on the rise, and we have the major obstacle that ADHD drugs are not permitted in B&H. We recognise that prescribing drugs to any patient who displays ADHD signs is not good practice, but for those cases on the upper extreme we cannot provide them with the specific medicine to alleviate their symptoms or we give non-specific medication which does not relieve the disturbances as much. Instead, we are using all the other possible treatments through behavioural techniques to improve the state of these patients”.
“Another challenge we face here in B&H is the lack of inpatient hospitals for children and adolescents. For individuals displaying early psychotic disturbances, depression, and suicidal attempts we are forced to put these adolescents in an adult unit, which is not optimal, or in a psychiatric ward that is at a distance from their home, making it difficult for parents to visit and be involved in the treatment process. We are trying to establish new wards of CAP, to provide inpatient access to more children throughout the country”.
Network of specialists
“CAP is a part of psychiatry that is very connected with other mental health care disciplines; special educators, speech therapists, psychologists, and through this transdisciplinary approach we are all connected within schools working with pedagogues. We have to work as a team, the CAP holds the coordinator role, and many of these specialists ask us for advice and help. Thus, it is important to have a very strong, reliable and well-structured CAP system in place to work together and cooperate and communicate for the better mental health state of our children. These specialists are always keen and welcome to attend our workshops and seminars. Providing knowledge to these specialists and using social media can ensure parents and teachers are aware and react quickly and so the child can be provided with early interventions. Early intervention will hence prevent later stage development of mental health issues”.
Visions and aims: we have our expertise
“It was always a big effort for us within a divided country to join together as CAP and rise above our inner doubts and bad feelings to make an association for CAP. Our primary goal is to improve child and adolescent mental health throughout the whole country. We realise that only as a unique organisation and association can we do it in the best way. We are a small community, and if we are divided in this community, then the association will not exist at all. This is how we have organised ourselves, and it is important that we are a part of the ESCAP community which will give us even more strength.
Another goal is to make this education CAP program for the whole of B&H as unique as it can be. Politically, we have two Ministries of Health, one for the Federation, one for the Republic Srpska, we aim not to have this specialisation divided too much between these two Ministries of Health. Association for the whole country and similar principles of CAP education is how we plan to strengthen our knowledge in the country”.
“It is important to make contacts with other associations in Europe and the world, to learn from their wealth of knowledge and experience, for example, we have not much experience with genetics, we don’t have the laboratories to screen the genetic components of disorders. So, getting advice from others would be essential for us.
With the principle of ‘exchange of knowledge,’ B&H will not just take, but we can provide to the ESCAP community. We are very skilled in PTSD, therefore now with the refugee crisis and the European migration crisis, we can share our experiences of the war with professionals in the countries who have seen an influx of refugees, help and advise how to deal and how to face with such a crisis and critical situation. It is also important for these professionals to understand the cultural background of these young refugees who are coming into their country, and we, as a multicultural and multi-religious country could contribute to that. These refugees have lost everything, their way of life, belongings and of course loved ones. We are aware of what this is like, so we can relate to them. We can provide these essential experiences to many CAP specialists in other countries who are accepting so many refugees”.
Professor Izet Pajevic, president of BiH ACAP“We are already very proud of what we have achieved, and this year in Tuzla we will hold our first international symposium from 6-7th July*. We intend to have a union of B&H specialists with international attendance. We aim to present our work, to show to the CAP community we can put a strong and interesting program together and make it visible to others that we are progressing and what we’re doing in our country. In attendance, will be professor Klaus Schmeck and doctor Susanne Schlüter Müller, two psychiatrists based in Basel, Switzerland. We are very grateful for their support. They have already, over the last 3 years, delivered specialised lectures in B&H. They are the ‘goodwill missionaries’ in the CAP field and provide B&H with fresh and new information due to their wealth of knowledge and experience. Many of us have lots of practical questions for them about specific cases and situation. They have had a great influence on us”.
Joining the ESCAP community is very important for ACAP BiH, they are looking forward to generating more international connections.
*Since the interview the symposium has taken place.