Review: Understanding the challenges of administering a structured a pschiatric diagnositc interview to war-exposed children in a humanitarian setting

Background

Structured diagnostic interviews to assess mental health have advantages but are challenging to use in humanitarian settings.

Lebanon currently hosts over 1.5 million Syrian refugees, many living in informal tented settlements across the Beqaa Valley. These families endure daily hardship, such as economic insecurity, overcrowding, and limited access to education or healthcare. For children, such conditions come in addition to the trauma of war and displacement, placing them at heightened risk of mental health difficulties such as anxiety, depression, and post-traumatic stress.

Despite growing demand for psychological support, most diagnostic and assessment tools used internationally were developed in Western settings and often fail to reflect local idioms of distress, cultural values, or lived realities. This can lead to inaccurate diagnoses or misinterpretations of children’s symptoms.

The present study explored how one such tool – the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) – could be used effectively and sensitively among Syrian refugee children and adolescents in Lebanon.

What were the aims of this study?

Exploring how to make structured diagnostic interviews meaningful in a refugee context

Researchers aimed to examine the cultural and contextual challenges of conducting structured diagnostic interviews with Syrian refugee children and adolescents living in Lebanon. The study sought to understand how the MINI Kid could be implemented in a way that was both clinically valid and culturally appropriate. This included identifying key barriers, adaptations, and ethical considerations that would support more accurate and meaningful mental health assessments in humanitarian settings.

How was this study carried out?

A combination of structured interviews and reflective supervision revealed key challenges and adaptations

The study included 119 Syrian refugee children and adolescents (aged 8 to 17 years), all of whom completed structured diagnostic interviews using the MINI Kid 6.0, widely used tool based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria.

Assessments were conducted by a team of Lebanese clinical psychologists and trained case managers who were fluent in Arabic and experienced in working with displaced populations. Each interviewer received comprehensive training in diagnostic interviewing and was supervised weekly by senior clinical psychologists. Symptom severity was rated using the Clinical Global Impression (CGI) scale to provide an overall measure of impairment.

To explore the process of assessment, researchers analysed detailed supervision notes and field observations using thematic content analysis approach. This allowed them to identify recurring practical, ethical, and cultural challenges during interviews, as well as adaptations that improved communication and validity.

What were the key findings?

Cultural meanings, family dynamics, and environmental context shaped how distress was expressed and understood

Five themes emerged from thematic analysis:

1. Practical and logistical challenges. Many families lived in unstable conditions, making it difficult to arrange private or consistent interview settings. Interruptions and lack of privacy sometimes limited children’s ability to speak openly.
2. Response validity and trust. Stigma, fear of judgment, and concerns about aid eligibility occasionally led participants to underreport or exaggerate symptoms. Building trust was therefore crucial for obtaining reliable information.
3. Cultural meaning of symptoms. Certain phrases or expressions carried different connotations in Arabic. For instance, the phrase “I wish I were dead” was often an idiom for frustration rather than a true indication of suicidal intent. Likewise, the term for “madness” (Junoon) was considered highly stigmatising and was replaced with softer alternatives.
4. Contextual norms and social realities. Some behaviours classified as disordered in Western diagnostic systems were understood locally as adaptive responses to adversity. For example, aggression could reflect self-defence in unsafe environments rather than conduct problems.
5. Comorbidity and formulation. Over half the children met criteria for multiple disorders. The researchers argued for a broader clinical formulation that considers trauma, social stressors, and coping strategies rather than relying solely on diagnostic categories.

Taken together, these findings reveal that mental health assessments in humanitarian settings must move beyond symptom checklists. Diagnostic interviews can provide valuable structure, but they require cultural translation, contextual understanding, and ongoing supervision to ensure findings are both valid and meaningful.

What are the implications of this research?

Culturally grounded assessment is vital for ethical and responsive mental health care in humanitarian settings

This study provides clear guidance for researchers and practitioners working in global mental health. It demonstrates that structured diagnostic tools, such as the MINI Kid, can be used successfully in humanitarian contexts but only when adapted with cultural and contextual sensitivity.

Assessments must be flexible and accessible

Rigid appointment-based models often fail in displacement settings, where families face mobility constraints and unpredictable schedules. Practitioners should be prepared to conduct interviews in safe community spaces or homes and to adapt procedures to each family’s circumstances.

Training and supervision are essential

Interviewers must be supported to recognise local idioms of distress, distinguish between clinical symptoms and adaptive responses, and engage with children sensitively. Ongoing reflective supervision helps ensure that diagnostic decisions remain ethically and culturally grounded.

Assessments should not isolate psychological symptoms from broader social conditions

Many expressions of distress among refugee children reflect ongoing insecurity, poverty, or family stress rather than clinical disorder alone. Integrating psychological care with education, social protection, and livelihood support is therefore critical.

A digestible formulation should be produced

Rather than ending assessments by feeding back a list of diagnoses, it is better to produce a digestible formulation – a narrative that considers the whole picture and links stressors in the child’s environment to their symptoms. This can help to normalise the child and family’s experience, validate their distress, and avoid the stigma of psychiatric diagnostic labels. It should also provide a rationale for and inform treatment.

Local expertise and collaboration are a necessity

Lebanese and Syrian professionals brought invaluable insight into language, norms, and community dynamics, shaping a more accurate and respectful assessment process. Their work demonstrates that effective global mental health practice depends not only on technical skill but also on cultural humility and shared understanding.

About the study team

Our multidisciplinary research team comprises experts in psychology including, Vanessa Kyrillos, Patricia Moghames, Nicolas Chehade, Stephanie Saad, and Diana Abdule Rahman (Medecins du Monde, Lebanon); Tania Bosqui (American University of Beirut); Elie Karam and Georges Karam (IDRAAC, Balamand University), Dahlia Saab (IDRAAC); Micahel Pluess (Queen Mary University of London, University of Surrey) and Fiona S. McEwen (Queen Mary University of London, King’s College London).