Impact of the economic crisis and COVID-19.

Parents described negative changes in their children’s behaviours and MH since the COVID-19 pandemic, often attributing them to lockdown measures and resulting social isolation. However, this was exacerbated by the impact of the economic crisis that accompanied the pandemic, reducing the wages and earning potential of all parents interviewed. In some cases, parents were no longer able to provide for basic needs. The strained economic situation meant that some parents could not secure funds to pay for MH services and, even when services were free, they struggled to secure money for transport.

Shame and stigma related to MH.

The shame and stigma associated with MH problems acted as barriers to seeking services for children. While some parents said that that traditional stigma was now less because so many people were affected by the many crises facing Lebanon, thereby serving to normalise seeking help, other parents felt that there is still a long way to go. One Lebanese mother reported: “Now we are no longer the same. It is not like this [MH] is forbidden” (CA8). A Lebanese father described taking care about whom he spoke to, given the persistent stigma. He said “You can’t make the decision on your own [to seek MH care], and you can’t talk about this with anyone, unless they’re professional and specialist, because this can be a topic of shame if you talked to the wrong person” (CA1). Some parents reported concealing their actions in seeking care from unsupportive partners, family members and friends. One Lebanese mother said: “I think his [her husband’s] family have some regressive thinking about this topic. They consider the people who receive MH services as sick and not good. As for his friends, I don’t think he shares this topic with them. I don’t think he shares the idea of going to therapy with anyone. He didn’t even start it. He just accepted the idea of getting help.” (CA4)

Some parents reported feelings of defensiveness if an NGO required their attendance in family therapy sessions. A Lebanese mother explained: “They [NGO] asked that they wanted to see us together as a family. My husband and children argued against a little at first, but my husband then realised that by doing this step, there is nothing personal against him” (CA4). Misconceptions and fear about conditions in psychiatric hospitals made parents reluctant to agree to their children being admitted. One Syrian father described how: “My wife went with us because she wanted to make sure this wasn’t a crazy people hospital, because if it were, she wouldn’t let me admit him [their son]” (CA10).

In contrast, some parents welcomed growing discussion of MH in schools and communities, which they saw as minimising stigma and encouraging them to talk about their children’s MH problems and seek care for them. One Syrian mother explained how: “I say yes, the community is accepting the idea of psychotherapy” (CA3). Some parents also described how their greater awareness of their unhealthy or harmful parenting behaviours and their impact on their children’s MH from feedback from their extended family. This encouraged them to seek help.

Parents also recognised how sharing their own experiences and knowledge about MH with others could help combat stigma while spreading knowledge and encouraging others to seek support when needed.

MH care suggested by child protection or health care professionals.

Most parents reported that the decision to seek MH services was prompted by health professionals and child protection personnel. However, they had to overcome concerns about losing their children to court custody – one Lebanese father explained how “I was just concerned if they wanted to take my daughter away from me” (CA1). Parents found being approached by child protection organisations and juvenile courts to be a positive factor, as they provided solutions for parenting challenges and child MH issues. One Lebanese mother said: “This was a beneficial thing to my life. I got to know great people at [NGO]. I was relieved from most of the stress and anger that I had” (CA2). Another Lebanese mother explained: “The social worker at [NGO] tried to convince my husband of this step. She convinced him, because he used to always blame others, mainly me. This is his character. She explained that by initiating this step, he would feel better. I felt he accepted this” (CA4).

Parents who received advice from health professionals reported fewer concerns about the services on offer and the risk that their children might be taken away from them. All parents described how the willingness of health professionals to address their concerns encouraged them to seeking care for their children.

Impact of family dynamics and parenting style on children’s MH.

Many parents were aware of the impact of parenting styles on their children’s MH. For instance, a Lebanese father reported how his spouse’s parenting style negatively impacted his daughter’s MH: “These actions [distressed behaviour by his daughter] are coming from the mother because she is always afraid for her daughter. This has caused our daughter to feel anxious and depressed.” (CA1). Yet some parents also described how they or their spouses used physical punishment or adopted angry and aggressive reactions when their children misbehave, with consequences for their MH.

The role of family dynamics was also recognised. One Lebanese mother described how her heavy workload and tensions with her husband affected her children: “I fight a lot with my husband. Probably my long working hours are affecting the house, as the father is more present in the house” (CA4). In other cases, some parents reported that their relationships with their children impact their child’s behaviour, as a Lebanese mother mentioned: “She [her daughter] doesn’t set limits [for herself]. She is rebellious, and doesn’t want me to know where she goes” (CA5).

Given this level of awareness, parents appreciated when MH service providers included their own behaviour and family dynamics in treatment plans, going beyond a narrow focus on the child. For example, a Lebanese mother highlighted the work her family is doing to improve the family environment to reduce their children’s MH issues: “…We are working together to create the appropriate environment that would help our children. All of us are collaborating to achieve that” (CA4).

Parent’s MH impacting children.

Parents shared insights into the intricate relationship between their own MH and their children’s wellbeing. Several parents described experiencing MH issues themselves, often exacerbated by the ongoing crises, which in turn impacted their children’s MH. For example, the first thought a Syrian father expressed during his interview was about his own MH suffering before describing MH issues his child was facing (CA6). A Lebanese father also highlighted the need for MH support for his wife, emphasising that addressing the MH needs of parents is integral to the overall well-being of the family: “My wife should receive the help before my daughter“(CA1).

Parents also highlighted how parental MH impacted family dynamics. As a Lebanese father said: “You should first address the parents’ [MH], then begin with the child” (CA1).

Children reaching ‘crisis’ point before parents’ seeking care.

Parents faced difficulties deciding when to seek care, often delaying until symptoms were severe, for example when there were suicide attempts or psychosis. One Syrian mother described how severe symptoms were the catalyst for deciding to seek help for her daughter “I sensed that there is something wrong with my daughter, based on her behaviour. For example, she attempted suicide. She threw herself from the balcony, she cut herself. All these were signs to know that my daughter is not fine.” (CA9) A Syrian mother shared: “My daughter cut herself around 3 times. She prefers to sit alone for long periods of time and doesn’t respond when people call her. She is not the same person she was in Syria. That’s why I thought of doing something for her. That’s when we attended the [MH] sessions and thankfully, we, all of us, benefitted from them a lot.” (CA7).

Children asking for parents’ help.

Highlighting the importance of children’s awareness of MH, one Lebanese mother realised the need for seeking help when her child herself asked for support: “Maybe she hurt herself to get our attention. And she used to act in a weird way at home. I used to ask her, but I wasn’t in a good place to see what’s wrong, but thankfully she asked to get help. I think the reason she asked because she felt the need to be heard, and I wasn’t listening to her, and her father didn’t as well. Maybe this was a statement that ‘I exist’” (CA4).

Parents navigate multiple and ad hoc pathways to access MH services for their children.

Parents reported multiple, and often ad-hoc, pathways through which they enabled their children to access MH services, ranging from use of acquaintances to children’s recreational activities, to NGOs and PHCs, and via the UNHCR for Syrian refugees. Several parents also described the difficulty finding and navigating MH services caused by their lack of knowledge about where and how to find them. A Lebanese father noted: “As a matter of fact I wanted to seek help before, …but I didn’t know where to go” (CA1). One Lebanese mother mentioned an element of chance that led her to getting helpful information from an NGO: “coincidentally, I met someone from [NGO], and they gave me a number to contact, and I did” (CA4).

Some parents reported paying for treatment at private psychiatric clinics as the waiting lists were so long at the NGO centres. Others were unaware of free or low-cost MH services being provided by NGOs and PHCs. A Lebanese mother who was informed of these services by a client at her shop, but only after she had paid for services in private clinics explained: “the customer told me there was an organisation that helps in such things. She gave me the number, and I called them” (CA5).

A Syrian mother described how children’s recreational activities could serve as an entry point for parents navigating services, with children receiving information on MH agencies’ hotlines: “The primary healthcare centre told me he needed psychological help, so I saw this paper [at a recreational activity centre] and I called. It is a coincidence. Of course, I would’ve reached this place eventually, as I would have asked around” (CA3).

Syrian refugee parents seeking inpatient care for their children shared similar experiences of being able to get referrals and financial coverage from the UNHCR, which refers cases to NGOs. However, not all Syrian refugee parents were aware that the UNHCR would make these referrals, as revealed by a Syrian father who initially tried to seek care via a private facility: “When I went to the [private] rehab facility and they asked me for too much money, I called the United Nations, and told them about my situation. They told me they would refer my case to other organizations. I then received several calls from different organizations” (CA10).

Parents supported by case management or social workers during their therapeutic journey reported a more efficient and pleasant experience than parents who navigated services independently. Child protection organisations often provided a holistic approach, offering family guidance and parenting sessions in addition to MH services, as a Lebanese father reported: “They told me they would work with the mother and the daughter in order to ameliorate the situation. Because the daughter is depressed.” (CA1). Parents also reported the benefit of services considering parents’ own MH in addition to their children’s, for instance a Lebanese mother said: “They [NGO] guided us to the right direction and referred us to another organization that can help me, because I was suffering” (CA4).

The benefits that parents reported from receiving more holistic care provided by NGOs included greater wellness and provision of housing, supplies, and other basic needs. As a Lebanese mother noted: “[NGO] even helped me get nutritional goods. They also handed stationary at some point. They also organise activities for the kids. I register the kids there because we can’t afford someplace else. We are poor, but thankfully we are healthy” (CA2).

Financial factors affecting seeking children’s MH care.

All parents identified the high cost of MH services as a barrier to care, especially since the economic crisis. Some Lebanese parents who used private services previously reported being unable to keep up with soaring costs, instead seeking low-cost or free services at PHCs and NGO centres even though they often have long waiting lists: “I didn’t seek help at first because it’s costly. If it was cheaper, I would’ve gone through it. It would cost a lot if you wanted to do this on your own [through a private clinic].” (CA1). With PHCs and NGOs under strain and offering limited services, they sometimes ask parents to pay for tests at private clinics and laboratories for their children, which are often not possible due to the high cost: “They [NGO] also ordered me to do some tests for her, as she has some growth issues [in addition to MH issues]. I managed to do most of the tests, except one that costs around $400 USD, so I stopped this process” (CA1).

In contrast, Syrian refugee parents reported full financial coverage of inpatient MH services for their children from UNHCR: “The UN covers 75%, and this organization covers 15%. And there is another organization covers 10%. So, everything is covered” (CA10). However, Syrian parents reported facing long waiting lists for inpatient care, sometimes taking up to 6 weeks to get admitted in one case (CA10).

The financial barriers exacerbated by the economic crises in Lebanon were seen as a cause of shame amongst parents, acting as a barrier to care, and to their ability to visit children in hospital. Syrian parents, in particular, described the shame of being unable to meet their children’s basic needs or recreation. A father said: “I can’t afford to send my kids to football events and trainings. I can’t afford to make my kids happy.” (CA6)

The high cost of fuel and transport was another barrier facing Lebanese and Syrian parents whose children had repeated visits to MH services. While parents receive some transportation costs from NGOs and PHCs once they reach them, some parents described their inability to find the money up front. As a Syrian father explained: “I was close to missing this interview, because I don’t have money. I then called someone and they lent me money.” (CA6). Another Syrian father reported not having enough money to take transport to visit his child in a hospital, even though the hospital would have reimbursed the transport cost: “I still have an A/C [air conditioner] I am trying to sell, so I can go and see my son. I told the one in the hospital that I may not be able to come because I couldn’t afford it. She told me they would cover the transportation when you come here. I told her I know you would, but I don’t have any money to reach you” (CA10).

Accessibility of MH services.

Parents reported several barriers to accessing services, including long waiting lists, geographical inaccessibility, as well as inflexible opening times of facilities. Parents reported long waiting lists at PHCs, NGO facilities, and hospitals. For example, one Syrian father reported waiting for more than a month to receive follow up calls from organisations providing child MH care: “I started contacting them, and they told me the doctor is abroad, and he should be the one to admit him. There was a month between the first time I called, and when they contacted me again” (CA10). In turn, some parents reported being forced to keep trying to get their children seen in private clinics, sometimes calling for support from religious leaders.

Parents who contacted child protection organisations through hotlines reported facing many weeks of inter-agency referrals before being able to get their children the services they needed: “They just listened at first, and hung up. I called them a few more times, around 2 or 3 times, until they gave me an appointment. They told me they would give me an appointment and they will call me back. I called them every 2 weeks as I remember, I just ignored it, and then when my daughter did something wrong, I called them again. And since then, I’ve been coming here for 2 years now” (CA5).

Opening hours of facilities often clashed with parent’s working hours, forcing them to make difficult choices to attend the sessions and lose their daily wage or miss appointments. One Syrian father described how: “They used to contact me to have some [parenting] sessions, but I can’t because every day I am absent, I lose money. And I am a daily worker, so each day I’m not at work, I lose the ability to bring food to the house” (CA6). Other parents reported prioritising their children’s sessions over work, though this comes at a cost to their daily wages. A Lebanese mother said: “Sometimes it’s paid, sometimes it’s not. I get one day off, in addition to Sunday. Sometimes I am able to have it on Tuesday, but sometimes I can’t, so I take it as a day off at my expense. But I don’t want to skip any session with [NGO]. I work for my family. It’s ok to lose something for my family” (CA4)

Although remote services online or by phone were reported as being more accessible, parents reported a preference for face-to-face services: “Face to face is more important. From my experience… Having online sessions or over the phone is the only solution, as some people don’t have a car. But the result is not the same” (CA4). Other parents refused remote MH consultations and demanded a face-to-face consultation, as one mother explained: “The last psychiatrist who told me he would charge 600,000LL [approximately $6.50 USD] and he would conduct the session over the phone, because of COVID, and COVID was nearly over, and we should transfer him the money. I didn’t accept that, and demanded that he sees [my daughter] face-to-face.”

Parents’ expectations for holistic MH services.

Many parents expressed a preference for holistic care and a reluctance for their children to “get used to medications” (CA5). They described how children, sometimes as young as 10 years old, were given medication rather than attempting alternative approaches such as counselling, with the medicines perceived as achieving minimal or no improvement in their children. Some parents expressed concern that children whose problems were acute, with suicide attempts or self-harm, were repeatedly offered medication without any offer of psychotherapy or other treatments. Most parents rejected this emphasis on medication, opting for alternatives such as improving the family environment and psychotherapy. For instance, a Lebanese mother said, “The psychiatrist said she should get some medication, but I refused, because I thought there was no need for medications, as we were working together to create the appropriate environment that would help our children.” (CA4). They also advocated for counselling and psychotherapy approaches as initial treatment for their children, instead of medication being the primary intervention. For example, a Lebanese mother explained: “The psychiatrist shouldn’t have prescribed medications to individuals as young as my daughter. They should have referred her to a specialist that she just talks to. Here at [NGO], they don’t prescribe medications, they just speak to her, and medications are the last option” (CA5).

Parents preferred face-to-face sessions rather than remote therapy. They also wanted MH services to include life skills and recreational activities as ways to convey practical messages for their children. For instance, a Lebanese mother suggested that such messages and skills would help children to better deal with challenges they would encounter (CA5). Parents, particularly those struggling financially, also emphasised the importance of providing support for basic needs of children alongside MH services.

Parents saw any shift from medical treatment to counselling and psychotherapy services as an improvement. One Lebanese mother expressed her relief when her daughter no longer required medical interventions: “She is being treated by words… I was relieved, because I didn’t want her to get used to medications. She was feeling better by talking alone, so this is very good.” (CA5).

Syrian parents linked their child’s MH issues to the socioeconomic and educational challenges they were facing. These parents expected MH services to be more holistic, and they looked to child protection organisations for help with school enrolment and meeting their children’s basic needs (CA3). Another Syrian parent argued that MH services need to consider the social determinants of poor mental health, including violations of human rights: “I say why bother giving sessions to kids who work, because they are beaten, and the sessions won’t help them. The UN should help and support them” (CA3).

Beyond reduction of ‘symptoms’, some parents also expected treatment and counselling to help their children gain self-confidence and acquire life skills. For instance, a Syrian mother said “I expected that my son gains a bit more self-confidence so he can stand up for himself. And this worked somehow” (CA3).

Trusting and supportive relationship with MH care providers.

Parents and their children reported being encouraged to persist with care where they experienced trust, empathy, respect, and encouragement by service providers. For example, a Lebanese mother described how her interactions with service providers and the guidance they offered alongside the clear treatment plan for her child as inspiring trust: “They gained my trust fast after a few sessions, because I saw the effect of their guidance. Maybe the effect isn’t apparent yet, but the trajectory is apparent. That made me trust them” (CA4). A Lebanese mother further noted: “I felt comfortable here. They [service providers] support you in every aspect, even if they just cheer for you” (CA2).

Another Lebanese mother also noted the importance of her child receiving MH services in a trusted setting such as a primary health clinic (PHC) where her family has been receiving health care for years: “Also because here for us in the area this is the [primary health care] centre where we used to go to since we were little … We used to come to this PHC, and I remember whenever we get sick. This centre has been here for us over the years” (CA8).

Parents were sensitive to perceived slights to their dignity, even when well-intentioned. For example, a Lebanese father perceived a service provider providing a taxi pick up for his child as an act of charity and an affront to his dignity when he was unable to pick them up due to his work schedule: “I skipped [picking up my child] a few times, so she [service provider] thought I was being reckless. But I had work. She told me I can send them [his wife and daughter] by a cab, and they would cover the expenses. I thought of this gesture as charity. And I don’t like that. I don’t like to send them by a cab” (CA1).

Changes in children’s MH influence parents’ motivation to continue to seek care.

Noticing positive changes in their children motivated parents to continue seeking MH services for their children as well as to initiate help-seeking for other family members, (CA1, CA7). One Lebanese mother said: “But I can tell from my husband, as he was against this idea [of their child receiving MH services]. However, when he saw it was beneficial, he was convinced” (CA4).

However, when parents did not notice rapid improvements in their child’s MH, they reported not committing to the prescribed treatment, and their actions ranged between changing service providers to changing treatment approaches.