War and Children

Over one billion children worldwide inhabit countries or territories torn apart by armed conflict, war, or terrorism (1), principally in lower- and middle-income countries where 90% of the world’s children and adolescents live (2). Armed conflict can last throughout an entire childhood, such as in Liberia where civil war caused widespread trauma from 1989 to 2004 (3). The effects of war extend beyond isolated areas of crisis: in 2016, the United Nations High Commission on Refugees reported that 59.5 million people worldwide were forcibly displaced, and over half of these were children under the age of 18 (4).

The present review provides an overview of research on the psychological impact of war and conflict on children, including the types of mental disorders that arise following war trauma; differences in the type of exposure, individual traits, and environmental characteristics that increase risk for mental disorders; and interventions to minimize psychological harm following exposure to war and conflict.

Prevalence of Mental Disorders Following Conflict

Children exposed to war manifest a higher rate of mental disorders compared with children in the general population (5), although prevalence data are inconsistent and likely depend on the nature of the trauma, the duration of exposure, diagnostic criteria used, and cultural discrepancies (6). The distress of a child following trauma may be overlooked due to children’s difficulties communicating or articulating their experiences (7). Adults tend to underestimate the posttraumatic stress reactions of their children, and their initial response to the effects of trauma on their children may be denial (8). While it was previously believed that children did not understand or remember traumatic occurrences, there is now increasing awareness that children are very vulnerable to the stresses of war and terrorism.

Childhood Adverse Experiences

The negative long-term effects of childhood trauma or adverse childhood experiences on physical and mental health are well established in the literature (4). Childhood adversity, commonly experienced as child abuse, neglect, and/or household dysfunction has been linked to increased risk for various long-term chronic illnesses. It increases the risk for depression 4.5-fold and suicide attempts 12.2-fold (7). Childhood adversity may increase impulsive behaviors, reward orientation, and unhealthy lifestyle choices (4). Epigenetic changes, posttranslational modification, and an unregulated inflammatory response may accompany the behavioral and cognitive response to childhood trauma (4). Exposure to war or terrorism increases a child’s risk for both medical and psychiatric disorders in adult life.

Psychiatric Disorders Following Trauma

The past two decades have marked increasing interest in the psychological impact of war on children (9). The relationship between exposure to war trauma and development of acute stress disorder and posttraumatic stress disorder (PTSD) is well documented in the literature (1, 3, 6, 9, 10). Children may experience acute PTSD, with hyperarousal, re-experiencing, and sleep disruption, or chronic PTSD, characterized by dissociation, restricted affect, sadness, and detachment (6). Exposure to trauma increases both internalizing and externalizing reactions in children. Internalizing reactions, such as depression, suicidal thoughts, worry, and anxiety were prevalent among Liberian youths exposed to armed conflict (3) and in a study of 300 Syrian refugee children in Turkey (1). These Syrian refugee children who had been exposed to war commonly exhibited anxiety and excessive fears, manifested by dependent behavior, clinging to parents, and fear of being left alone or sleeping in the dark (1). After 9/11, 15% of New York City school children surveyed had developed symptoms of agoraphobia, 12% developed separation anxiety, 10% developed generalized anxiety, and 9% developed panic attacks (8). Externalizing behaviors, such as delinquency, bullying, and drug and alcohol use, also appear to increase after trauma (7).

Risk and Protective Factors Mediating Trauma

Characteristics of the Trauma

Traumatic exposure can be direct or indirect. Direct exposure occurs when a child has personal experience with a traumatic incident, such as living in a conflict zone or experiencing the death of a parent. Conversely, indirect exposure occurs through television, the Internet, or hearing others talk about a traumatic event. Indirect exposure through media can also produce significant distress. Following the 9/11 attacks and the Oklahoma City bombing, children who watched more television coverage of the traumatic events experienced more posttraumatic stress symptoms (8, 11). War and conflict are often accompanied by changes to a child’s environment; for example, a child may experience the closing of his or her school after destruction of infrastructure or financial hardship after loss of family members (12).

When children are exposed to war and conflict directly, the number of conflict-related traumatic events (11), the duration of the threat (13), and the severity and nature of the threat mediate psychological outcomes and distress. Severe reactions occur when there is threat to the child’s life and/or physical harm (1, 13), as well as in cases of death of a parent or loss of social support (14).

Children’s Individual Risk and Protective Factors

Many children demonstrate incredible resilience, and recovery is the expected outcome of acute stress responses for most children (13). However, when traumatic exposure has lasting effects on a child, individual differences mediate these effects. A child’s developmental stage affects his or her reaction to trauma, and reactions range from regressive behaviors in younger children (15) to problems at school, nightmares, and substance use in older children and adolescents (1, 14).

Individual genetic vulnerabilities also play a role in response to trauma. Maternal anxiety and depression levels are correlated with the child’s levels (11), and severity of PTSD in fathers has been linked to that in children (6). Protective factors include religion (correlated with fewer PTSD symptoms) (11), emotional regulation, self-control, problem-solving skills, and a close relationship with caregivers (1).

Characteristics of the Environment

Conflict and war may damage a child’s environment and subsequently impair a child’s ability to recover from a traumatic event. For example, the 1989–2004 Liberian civil war damaged infrastructure such as schools and health services, which impaired Liberia’s ability to treat injuries or address concerns (3). Children who have access to more resources (e.g., higher socioeconomic status and quality education) tend to fare better after trauma (1).

Conflict and terrorism may have devastating effects on individual families, through the loss of family members or disruption in household routines (1). Moreover, children may lose parental support, parenting styles may change, and negative parental expressions increase levels of distress in children (8). Following a traumatic event, parenting style can mediate a child’s reaction to stress; punitive parenting styles are associated with less resilient attitudes in children (11), while a parent who provides emotional support, encourages self-esteem, and answers questions directly may minimize the effects of trauma (6, 8).

Interventions

The devastating effects of war and terrorism call for a “multilayered” approach to supporting communities, families, and individuals. Following a traumatic event such as 9/11, the first interventions should target communities to promote safety, self- and community efficacy, connectedness, and hope (1). Priority should be given to reunite families (12) and restore infrastructure. Schools should have emergency plans. First responders, such as police, firefighters, medical personnel, and teachers, should be trained regarding the effects of trauma on children and effective communication regarding traumatic events (13).

The literature supports using community-wide screening to identify children and families at high risk for trauma-related psychological distress. Children whose lives are personally disrupted by trauma, such as those who have witnessed family members killed and/or had their homes demolished and/or have become orphaned or live in distressed families, are particularly vulnerable (10). Because adults often have difficulty recognizing children in distress, children with the greatest need may go unrecognized, making screening essential (16). Screening and aid may be delivered in clinic or school settings; schools are readily accessible, may help normalize the experience, and reduce stigma about mental health care (16).

Finally, children and families who manifest psychiatric symptoms will benefit from mental health care. While research supports the use of psychotherapy, there is limited information on specific pharmacologic interventions for psychiatric disorders related to war trauma. Trauma-focused cognitive-behavioral therapy, in combination with resilience-based and symptom-based techniques that can take advantage of the child’s social network, may be particularly helpful (10).

Conclusions

The literature examining the effects of war and terror on children shows significant levels of psychological distress and psychiatric problems following exposure to conflict. Internalizing disorders such as PTSD, depression, and anxiety, as well as externalizing behaviors, are prevalent following exposure to war and terrorism. Future research should investigate interventions to reduce a child’s distress and improve resiliency in the setting of war and terrorism.

Key Points/Clinical Pearls