Studies Draw Attention to Ways That War Affects Children's Mental Health

Marlene Busko

August 01, 2007

August 1, 2007 — In its August 1 theme issue on violence and human rights, the Journal of the American Medical Association examines the psychological outcomes of war, including the effects on children. Two studies report on mental-health issues of former child soldiers and teen war survivors in Africa, and 1 study discusses abuse among children of deployed US soldiers.

Revenge vs Reconciliation

Among 169 Ugandan and Congolese adolescents, with a mean age of 15 years, who were former soldiers, those with the greatest number of posttraumatic stress symptoms also had the strongest feelings of revenge, as opposed to reconciliation, according to a study by Christophe Pierre Bayer, from the University Clinic Hamburg, in Germany, and colleagues.

The group explains that it is estimated that there are currently 250,000 child soldiers worldwide, many of them in Uganda and the Congo. "These children carry the special burden of being the recipient and the perpetrator of violence," they write, adding that despite the large number of children involved, research into the mental health of these children has been minimal.

This study sought to enroll every second former child soldier of the 296 living in rehabilitation centers in Gulu, Uganda, and in Goma and Bukavu, Democratic Republic of the Congo. A total of 169 children (mean age, 15.3; range, 11 – 18 years) participated and replied to a questionnaire designed to assess symptoms of posttraumatic stress disorder (PTSD) as well as openness to reconciliation and feelings of revenge. The children were mainly boys (84.3%) who had been (violently) recruited by the armed forces at an average age of 12.1 years, had served a mean of 38.3 months, and had been demobilized a mean of 2.3 months before participating in the survey.

The children had experienced a mean of 11.1 potentially traumatic events; most commonly they had witnessed a shooting (92.9%) or witnessed someone being wounded (89.9%). A total of 59 (34.9%) of these former child soldiers had a PTSD symptom score higher than 35, indicating clinically important PTSD symptoms. The children with more PTSD symptoms had significantly less openness to reconciliation and more feelings of revenge. These feelings "could impose barriers to sustainable and long-term peace building," the group writes, adding that their study supports the need to promote psychological recovery for war-affected children.

Female Teen War Survivors Benefit From Depression Therapy

Among adolescent survivors of war in northern Uganda, group interpersonal psychotherapy was effective for treating depressive symptoms in girls but not boys, according to a study by Paul Bolton, from the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland, and colleagues.

The group explains that more than 1.8 million Ugandans, mainly ethnic Acholi, have been displaced by 20 years of conflict between the Ugandan government and the Lord's Resistance Army. Previous studies of mental-health problems in this population looked at adults.

The researchers performed a randomized controlled trial of 314 Acholi teens, aged 14 to 17 years, who were living in 2 camps for displaced persons near Gulu in Northern Uganda and who met study criteria for depression. The teens (57% girls) were randomized to receive 16 weekly 1.5- to 2-hour sessions of either creative play (n = 105) or group interpersonal psychotherapy (n = 105), or they were placed in a control group to receive treatment at the study end (n = 104).

Those who received interpersonal group psychotherapy had fewer depressive symptoms than those in the control group, but the reduction was only statistically significant in girls, possibly because boys are less willing to talk about emotional problems in a group format, the authors suggest. Creative play was not linked to improved depressive symptoms, possibly because this intervention was originally designed for younger children (15 or younger). Neither intervention resulted in statistical improvement in anxiety or conduct problems.

The failure of either intervention to assist boys suggests that they might require a different type of intervention, possibly individual therapy, the group writes.

Editorial: War Trauma and Implications for Peace

In an accompanying editorial, Robert J. Ursano, MD, from Uniformed Services University, in Bethesda, Maryland, and Jon A. Shaw, MD, from the University of Miami, in Florida, write that the researchers "bring much-needed attention to the violence of war and the resulting mental-health problems."

They note that the study by Bayer et al revealed that the child soldiers had a high exposure to war-related trauma and, not surprisingly, the prevalence of PTSD symptoms was high (34.9%). They add that the most novel aspects of these studies are their implications for peacemaking; the more PTSD symptoms the children experienced, the less likely they were to be willing to reconcile and the more they harbored feelings of revenge.

Children who are still learning to regulate mood and aggression are even more vulnerable than adults to the life-changing traumatic events of war, they add.

Better understanding of the issues surrounding the impact of war on mental health "may contribute to the development of interventions to address the barriers to recovery not only from disease and illness but from lost futures and visions of like," they conclude.

Child Abuse by Mothers Rises When Dads Are Deployed

Among families of US enlisted soldiers in which child mistreatment has been reproted, the rates of maltreatment were greater when the soldiers were deployed, as reported in a study Deborah Gibbs, from RTI International, in Research Triangle Park, North Carolina, and colleagues.

The authors explain that parental stress is believed to play a critical role in child maltreatment (neglect, and physical, emotional, and sexual abuse) and, in military families, combat-related deployment is often stressful.

The researchers sought to investigate child maltreatment in enlisted families during combat-related deployments. They analyzed data from 1771 families of enlisted (noncommissioned) US Army soldiers who experienced at least 1 deployment during the 40-month study period and who also had records of child maltreatment by a parent.

The rate of child maltreatment was 42% greater during deployments than during times when the soldiers were not deployed, largely because of a 3-fold higher rate of child maltreatment by civilian female spouses during deployment than during nondeployment. The rate of child neglect was almost 4 times greater.

The authors urge caution in generalizing their findings, because of study limitations, and they also note that the army does provide services for families during deployments. "Nevertheless, the greater rate of child maltreatment associated with deployments suggests the need for enhanced support for civilian parents," they conclude.

The authors report no relevant financial relationships.

JAMA. 2007;298:555-559 Abstract , 519-527 Abstract , 567-568 Abstract , and 528-535. Abstract


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