War and Children

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.

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.

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).

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).

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.