A 15-year-old male came to clinic for his well child examination. He and his immediate family had been in a refugee camp for a period of time after fleeing armed conflict in central Africa. They had moved to Europe and had been in the United States for 2 years. He was doing well in school and was playing on the junior varsity high school soccer team and the track teams. The family had received support services from several sources including a local religious organization and he had had mental health services for the first year after immigration. He usually slept well and denied major intrusive thoughts. He said that sometimes he had flashbacks to their flight from their home country and time in the refugee camp but usually would think about them for a while and then thinks about other things. He said that sometimes loud noises would bother him but he realized why he would jump and then think about what he was doing before the noise. Occasionally he would worry about his own or his families’ personal safety. He said that he talked with his parents about these issues which his mother verified. “I think we all are doing pretty well. He has good friends now and is doing well in school. I don’t think he’s too worried or scared. We all are going to think about things that happened or be scared at times. That’s normal, but I don’t think any of us are having any real problems,” his mother stated.
The pertinent physical exam showed a healthy tall male with normal growth parameters. He had some well-healed scars on his arms. The diagnosis of a healthy male who was a survivor of armed conflict was made. The physician offered to assist the family with any needs particularly for mental health issues as they arose. A review of his medical records showed that the scars were from a knife fight in the refugee camp. He was also fully immunized, but the dates were at minimum intervals as the camp health care providers would immunize everyone in the camp when they made their regular scheduled visits.
It is estimated that more than 1 billion children live in countries with armed conflicts and wars (war). The people most affected by war are children and women. A visual global conflict tracker to see active conflicts can be seen here.
War events that a child might be exposed to include:
- Victim of violent acts
- Physical violence such as rape, torture or physical injury, imprisonment, drugs, sex-trafficking
- Mental – threats of violence to self or family member, verbal and emotional abuse
- Child soldier – often forced to kill or wound others
- Suicide bomber
- Witness to violent acts
- Combat or similar event exposure (i.e. explosions, gunshots)
- Loss of loved ones
- Family separation
- Child separated from the family
- Job-related such as separation from parents who are in the military
- Loss of basic human needs – water, food, clothing, shelter, medicine
- Loss of basic protections – security, legal status
- Hostility from other groups of people
Risk factors for long term dysfunction include:
- Dose affect is the main predictor of the degree of distress and long-term function. Children experiencing more events and more severe events generally experience more distress and are more likely to have continued problems
- Age – older children or adolescents are at higher risk, probably because they are more likely to be directly involved and also comprehend the situation more
- Gender – but depends on specific circumstances and events the child is exposed to
In addition to the obvious physical needs and problems these events can cause, the mental health problems are enormous including increased immediate and long-term anxiety, depression and potentially post-traumatic stress disorder. Long term studies of childhood survivors of war have found that they have overall poorer health (particularly an increase in cardiac problems) and mental health outcomes seen even when they are elderly.
Interventions that are needed immediately for children and families affected by war include meeting basic needs of clean water, food, shelter, sanitation and clothing and providing security. Longer term needs include economic opportunities for the families and educational activities for the children. School helps provide routine and academic skills for the child, child care for parents, and potentially acts as a venue for mental health services. Treatment intervention studies for children exposed to war are not as numerous, but some have found that pre-exposure training to violent episodes may have some improved outcomes, as well as group mental health services provided afterward.
The terminology describing persons who flee because of war can sometimes be confusing, but the number of people affected is staggering. The United Nations High Commissioner for Refugees uses the following characterizations:
- Are persons fleeing armed conflict or persecution or who are forcibly displaced and who cross an international border
- They are officially recognized according to international and national laws and receive protection and assistance under those laws
- The basic principle is that refugees cannot return to their home country without their life and/or freedom being threatened
- 19.5 million worldwide in 2014
- Are persons choosing to cross an international border often to improve their life by improved education, work, reunification with family or other reasons, that do not meet the definition of a refugee
- They are recognized by national laws through immigration laws
- Migrants can return to their home country and be protected by the laws of their home country
- Internally Displaced Persons (IDPs)
- Are fleeing armed conflict, persecution or forcible displacement but who move within their own country and do not cross an international border
- As IDPs have not crossed an international border legal protections for them are mainly national laws. It can therefore be more difficult for IDPs to receive appropriate protection and assistance
- 38 million people in 2014. It was almost 30,000/day new people affected in 2014.
- Asylum Seekers
- Are people who claim to be a refugee but the claim has not been definitively evaluated by the national asylum systems
- The national asylum systems can evaluate the claims individually or by entire groups of people such as with mass movements usually secondary to obvious violence within an area
- 1.2 million people in 2014
- Stateless People
- Are people not considered a national by any country often because of discrimination, change in international borders or problems with nationality laws
- United Nations conventions are the primary legal protection of stateless persons
- 10 million people
Although war events are truly tragic, recovery and resilience are the norm for survivors after these severe events. This does not mean that children and families do not have ongoing issues even years later, but humans are resilient and can integrate these experiences in ways that still allows them to be functional, creative and hopeful people. Qualities which seem to have a protective, promotive or mitigating effect on the effects of war that allows a person to have good developmental and mental health outcomes despite the adversity is termed resilience.
Factors that improve resilience to exposure to war include:
- Internal locus of control
- Defense mechanism use – altruism or use of humor
- Strong belief that the world and life has meaning – having faith and hope
- Coping or having emotional regulation
- Strong caregiver and child bond – parent support appears to be one of the most important
“Remaining with parents in a war zone may serve to protect a child more than evacuation without the parents.”
- Family cohesion
- Better maternal mental health
- Additional caregiver availability
- Higher socioeconomic status
- Language skills
- Strong caregiver and child bond – parent support appears to be one of the most important
- Social supports from other members of the community who have experienced same/similar events such as teachers and peers
- Shared community values
- Acceptance by the community – particularly important for former child soldiers
- Religious belief
- Responsibility for welfare and protection of others
- Positive school experience after event
Research on survivors of other severe life events, particularly natural disasters, have found similar, but not exactly the same results for resilience factors.
Questions for Further Discussion
1. What are ACEs (adverse childhood events)?
2. How would children in foster care be similar to children who have survived war?
3. What are the criteria for post traumatic stress disorder?
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Know your Numbers.
Masten AS, Narayan AJ. Child development in the context of disaster, war, and terrorism: pathways of risk and resilience. Annu Rev Psychol. 2012;63:227-57.
Werner EE. Children and war: risk, resilience, and recovery. Dev Psychopathol. 2012 May;24(2):553-8.
Drury J, Williams R. Children and young people who are refugees, internally displaced persons or survivors or perpetrators of war, mass violence and terrorism. Curr Opin Psychiatry. 2012 Jul;25(4):277-84.
Tol WA, Song S, Jordans MJ. Annual Research Review: Resilience and mental health in children and adolescents living in areas of armed conflict–a systematic review of findings in low- and middle-income countries. J Child Psychol Psychiatry. 2013 Apr;54(4):445-60.
United Nations High Commissioner on Refugees. Know your Numbers. Available from the Internet at http://www.unhcr.org/pages/49c3646c11.html (rev. 2001-2015, cited 9/28/15).
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital