AAP Releases Policy on Effects of Armed Conflict on Children

Fran Lowry

November 12, 2018

ORLANDO, Florida — Coordinated efforts from child health professionals around the world are needed to advocate for the safety of children exposed to armed conflict, either as direct targets or as "collateral damage," and to promote measures to mitigate the harm such trauma causes.

To that end, the American Academy of Pediatrics (AAP) released its first policy statement on the effects of armed conflict on children here at the AAP 2018 National Conference (Pediatrics. Published online November 5, 2018).

Jeffrey Goldhagen

Hundreds of millions of children around the world are affected by violence, and one in 10 children lives in a conflict zone, said senior author Jeffrey Goldhagen, MD, from the University of Florida College of Medicine–Jacksonville.

In addition to physical injuries, these children suffer high rates of post-traumatic stress disorder, depression, anxiety, and other mental health problems. One of the hoped-for outcomes of this report "is to ensure that pediatricians and the community in general understand the prevalence and the profound impact that armed conflict is having on children," said Goldhagen.

Anywhere there is an organized dispute that involves the use of weapon violence or force is a conflict zone, he explained. This includes gang-related violence related to drugs or race, so it is not just children in low-income countries who are affected. Children here in the United States are affected as well, he said.

In areas traditionally considered conflict zones and in new areas of urban violence, psychological trauma and post-traumatic stress disorders are pervasive in children, said Goldhagen, who spent his early years as a pediatrician working in Cambodia, during the era of the Khmer Rouge killing fields, and then in Ethiopia, and has seen the effects of armed conflict on children first hand.

"I can tell you from experience that the issues related to the impact of armed conflict in children are far worse today than they were 40 years ago," he said.

An estimated 646 million children live in areas affected by conflict. Forced displacement is at a record high, with more than 68.5 million people, 28 million of whom are children, currently living as refugees, asylum seekers, stateless people, or internally displaced people.

Separation From Parents Devastating for Children

One of the impacts of conflict is the separation of children from parents. In 2015, 98,400 unaccompanied children around the world applied for asylum. Because they do not have any documentation or papers with them, they are often put in detention, with limited or no access to healthcare, social services, or education.

Julie Linton

The language used to describe people who are seeking asylum in the United States, such as invaders, rapists, drug smugglers, and gang members, is dehumanizing, said Julie Linton, MD, from University of South Carolina School of Medicine–Greenville and the Children's Hospital of Greenville Health System, who is cochair of the AAP immigrant health special interest group.

"When we talk about people who are fleeing violence and seeking safety, we need to be acknowledge that children and families are not willingly placing themselves at risk," she told Medscape Medical News. These people are "escaping armed conflict or other forms of threats."

"During their journey, they may be exposed to conditions that threaten their short- and long-term health," said Linton, who takes care of immigrant children who have been released from detention after being processed by the American court system.

Linton has made three trips to the southern border of the United States — in August and November of 2016 and, most recently, this past June.

She related the story of a family she met during her last visit. "The father decided to flee because his young daughter had been threatened with rape and murder if she did not date a man from a gang who was terrorizing the village. They felt they had no other choice."

And Linton has personally witnessed young children having to go to immigration court hearings by themselves, with no adult guardian or legal representation. "I've had children as young as toddlers who have not had representation in court."

On one particular day in June at the Texas border, a teenager was asked by the judge whether he would want to go back to his home country. "He looked at her and, with the voice of a traumatized child, said very clearly, 'I never want to go back'."

"To hear that voice of a child, clearly fearing for his life, was very powerful," Linton said.

The right education, medical services, and mental health services can help these children overcome the traumatic events they have experienced.

All Children Are Resilient

"Not only do children have the capacity for resilience in the face of seemingly debilitating circumstances, they are the engines of peace in their own right," Goldhagen said. "This is the distillation of this report."

The AAP says that children should be enabled to use their voices to advocate on their own behalf.

Children are able to overcome the terrible traumas they have endured with the right interventions, so "doctors and any other health professionals who come in contact with these children can do a lot to help," said Goldhagen.

"The policy statement identifies a large number of interventions that can occur in the context of the clinical work that pediatricians do," he said.

All of us who are concerned about children's health and wellbeing must mobilize to address this global issue.

These include getting trained in the culturally sensitive delivery of trauma-based care, being prepared to diagnose and provide the initial management of mental health issues, and getting involved with local refugee-resettlement organizations and other public- and private-sector organizations, such as schools, health systems, and social services, to help the children and their families integrate into their new communities.

"We have a voice and we must continue to use it," Linton said. When asked if she finds it difficult to be a pediatrician these days, she replied: "It's an honor."

"All of us who are concerned about children's health and wellbeing must mobilize to address this global issue," Goldhagen added.

"All children have the capacity for resilience. What we need to do is provide the environment that allows them to heal, and we know a lot about what it takes to provide that."

Goldhagen and Linton have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2018 National Conference. Presented November 5, 2018.

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