Clinical psychologists, Dr Sandra Mattar and Dr Nina Thomas, discuss the long-term psychological effects of war and armed conflict on children’s mental health.
The American Psychological Association (APA) addressed the United Nations in March 2022 to express concern about the long-term psychological effects of war, particularly on children. They stated, “War and its aftermath have devastating consequences in terms of physical wounds and death, material and economic hardship, deep psychological distress, loss of dignity and freedom, and other violations of human rights.”1
There are currently 27 armed conflicts occurring worldwide.2,3 Millions of children have been killed, injured, orphaned, or displaced due to modern warfare, which heavily impacts civilian populations.4 Consequently, individuals exposed to armed conflict are 3 times as likely to develop post-traumatic stress disorder (PTSD), anxiety disorders, or major depression, and women and children demonstrate increased vulnerability to these outcomes.2
Epidemiological research has indicated that as many as 227 million adult war survivors may experience PTSD, 199 million experience major depression, and 110 million experience both.5,6 Given that approximately 1 in 6 children around the world — over 449 million — live in a conflict zone and 1 in 22 children were injured or killed from armed conflict each day in 2021, these findings have major implications for the long-term mental health outcomes of children who are affected.7
Physical and Psychological Effects of War
Stress process theory suggests that “wars generate unique levels of both ‘eventful’ and ‘ambient’ stressors, each of which may exact long-term damage on physical and mental health.”8 Furthermore, these “insults or traumatic exposures may build on one another, proliferating or creating ‘chains of risk’ as adversity begets subsequent adversities.”
Kovnick and colleagues analyzed the long-term effects of childhood exposure to the Vietnam War among older adults living in northern and central Vietnam using the stress process framework. The investigators assessed wartime stress exposures from 5 distinct categories: loss of family and friends, witnessing death, malevolent living conditions, life threat and personal endangerment, and moral injury. Malevolent living conditions contributed to chronic, persistent stress related to food and water shortages, lack of adequate medical care and resources, constant fear of being killed or injured, uninhabitable living conditions, forced displacement, and lack of community stability. Out of these 5 categories, loss of family and friends, witnessing death, and malevolent living conditions increased the risk for psychological distress most significantly.8
In addition to the psychological effects of war, research has affirmed a strong bidirectional link between physical and mental health, especially PTSD and somatization.9 Dr Sandra Mattar, an assistant professor at the Boston University Chobanian and Avedisian School of Medicine at Boston Medical Center and a clinical psychologist at the Boston Center for Refugee Health and Human Rights, has studied the effects of war trauma and spoke on this interplay.
“When you experience these traumatic events, your body is in full shock. Some kids may become dissociated. Physically, the body is completely dysregulated because there is no food, no water, or access to basic needs. There is a difficulty in calming down the body, which turns into a whole series of mental health problems,” she explained.
Dr Mattar also explained that children who are struggling with trauma often exhibit specific behaviors, including emotional withdrawal and self-imposed isolation. Children may have their anxiety, fear, and elevated stress levels manifest through physical symptoms, like jumping at loud noises and nearby sounds.10 For younger children, chronic bed wetting can be a common sign of disrupted mental health while adolescents often display more aggressive behavior. In more extreme cases, children may turn to self-harm, substance abuse, or even suicide as a means of escaping the reality of their experiences.10
Trauma may also manifest through psychosomatic symptoms, such as chest pain, gastrointestinal distress, headaches, stuttering, dyspnea, temporary paresis of limbs, and amnesia.10 In fact, previous research has established a connection between childhood exposure to traumatic events and poor physical health outcomes in later life.8
Zimmer and colleagues explored both the mental and physical impact of early-life war exposure across the lifetime.11 The researchers found that 3 main categories of early-life war exposures — death and injury, stressful living conditions, and fear of death or injury — significantly correlated to worse mental and physical health in adulthood. Vietnamese adults who had greater childhood exposure to these 3 situations during the Vietnam War demonstrated increased mental distress, PTSD symptoms, somatic symptoms, chronic pain, poorer physical functioning, and an increased number of diagnosed health conditions.
Given the intricate relationship between emotional states and physical health, health care for children exposed to war needs to address both mental and physiological aspects of well-being.
The impact of trauma gets perpetuated through generations, so we cannot think of war as a single event. I see PTSD not just as a singular event, but as a societal event. Collectively experienced trauma can impact how societies and nations handle traumatic events in the future.
Direct vs Indirect Exposure
Dr Nina Thomas, a clinical psychologist, has traveled to multiple countries to help refugees recover from their exposure to armed conflicts and has extensively researched war crimes and truth commissions. Dr Thomas emphasized the situational nature of exposure to violence and traumatic events, stating “An important war-related effect is, first of all, to what degree they experienced the loss of family members and the loss of the community they came from, [including] their circle of families, their social network, their religion, and educational centers.”
Dr Mattar echoed these sentiments, agreeing that proximity to traumatic events is a major factor for longitudinal outcomes. “When September 11 happened, people who were across the river saw the towers fall. Even though they were traumatized by watching that, it’s not the same as someone closer to the towers, where they smelled things, where they saw things, where they heard things, and where they experienced the debris and dust that came down,” she commented. “That kind of [direct] trauma gets registered in the body in a different way than those who [indirectly witness events] from a distance… and the trauma becomes cumulative, combining each situation that is experienced.”
For example, researchers conducted a study evaluating the effect of physical proximity to armed conflict on mental health in which adolescents in the Donetsk region in Ukraine completed questionnaires about their wartime exposures from the Russian armed conflict in the region in 2014 and their current mental states between September 2016 to January 2017.12 Questionnaire results from the Donetsk adolescents were compared to those from adolescents living in the peaceful city of Kirovograd in Ukraine. Around 60% of the adolescents in the Donetsk region witnessed armed attacks, close to 14% were victims of direct violence, and almost 28% were forced to evacuate their homes.
Exposure to these traumatic events and daily stress significantly increased the likelihood of psychological distress among the adolescents from the Donetsk region as they demonstrated significantly higher rates of PTSD (odds ratio [OR] 4.11; 95% CI, 2.37-7.13), severe anxiety (OR, 3.10; 95% CI, 1.83-5.27), and moderately severe to severe depression (OR, 2.65; 95% CI, 1.79-3.92) compared to adolescents from Kirovograd.12
A similar study was conducted among 515 school-aged children in Egypt who were indirectly exposed to the intense political violence around Tahrir Square. These children demonstrated higher rates of depression (62%), PTSD (70%), and symptoms associated with anxiety, such as heart palpitations (53.1%), fear of staying at home alone (61.2%), fear of being attacked or killed in their own home (73%), and fear of being kidnapped (either oneself or family members) (81%). Further, girls and children who knew someone directly exposed to trauma were at higher risk of developing mental health conditions.13
“To be so helpless in these conditions dramatically alters a child’s belief in the security of any future,” Dr Thomas commented.
The Refugee Experience
For children displaced from their homes and communities, the refugee experience introduces an entirely new set of stressors and trauma.14
Dr Thomas explained that refugees encounter a wide variety of obstacles — adapting to their host country, applying for work visas, finding jobs to pay for food and shelter, and potentially facing prejudice and stigma. She mentioned that refugees and asylum-seekers in other countries often live with an ever-present fear of deportation back to a conflict zone. In this process, children may become separated from their parents, and this policy of separating families adds to the child’s cumulative trauma, instability, lack of safety, and mistrust.
Dr Thomas also explained that adolescents may suddenly have to “act as adults” depending on the situation. She stated, “Once these adolescents escape from their war-torn countries and begin adjusting to a new culture, it may evoke a lot of violence, especially when they experience the difference between their living conditions and the conditions of the native people” in the country to which they fled.
In a policy editorial written in response to the war in Ukraine, Bürgin and colleagues stressed that asylum countries should establish post-migration infrastructures “enabling and supporting parents in the care for their children, as well as…social environments [and professional services] that foster mental health.”14 Authors suggested that services should focus on continuously providing for the mental health needs of children affected by armed conflict and must extend beyond just the period of resettlement, given that mental health disorders can manifest even 5 years after resettlement.14
The APA has also emphasized that it is critical for the international community to collaborate on this issue to provide evidence-based psychological services aimed at mitigating the lifelong and even generational consequences of war and armed conflict, especially for children.1
Dr Mattar stressed that time is of the essence when providing these services, stating, “When there is a disaster or acute event in a war, there is a window of opportunity to intervene that can really save years and years of PTSD and trauma.”
Interventions That Build Resilience
Although children may develop mental health disorders after exposure to the dehumanizing conditions associated with war, they also demonstrate an enormous capacity for resilience which allows them to adapt, heal, and grow into fully functional adults. Protective mechanisms may include coping strategies, belief systems, and building healthy family relationships and friendships. However, factors such as poverty, discrimination, social isolation, and domestic violence, may confound resilience and therefore must be effectively addressed.15
To build resilience against mental health problems after exposure to violence and trauma, Dr Thomas noted that the re-establishment of routines within a stable and safe community is critical to recovery.
Dr Mattar emphasized that interventions promoting restorative sleep and mindfulness connected with physical activity, such as yoga, help to build resilience and develop healthy coping mechanisms. “Once my patients start sleeping better and their nightmares decrease significantly…they have more hope, they are more regulated in their bodies, they start smiling, and they have more energy to work,” she said.
Dr Mattar also underscored the tremendous value in healthcare providers building a connection with their patients by asking about and understanding the patient’s belief system from their unique cultural perspectives.
“Establishing trust is another factor that cannot be taken for granted. Individuals who’ve experienced trauma are coming from a place of fear. They often want to quickly blurt out their trauma stories, but I teach them to pace themselves,” Dr Mattar noted. “If they tell their stories too fast, they perpetuate this dysregulation within their bodies, but if they go slow, they have a better chance to effectively process what has happened to them,” she said.
Ending the Cycle of Violence Through Healing
The multidimensional nature of armed conflict and trauma has far-reaching and profound effects — even after the conflict has ended.
Dr Mattar expanded on these ramifications, stating, “The impact of trauma gets perpetuated through generations, so we cannot think of war as a single event. I see PTSD not just as a singular event, but as a societal event. Collectively experienced trauma can impact how societies and nations handle traumatic events in the future.”
Dr Thomas also pointed out how current political climates incite and perpetuate “fear of and hatred toward migrant people,” further complicating the refugee experience for these parents and children and exacerbating these traumatic events.
Given the heavily documented adverse health outcomes associated with childhood exposure to war and armed conflict, the international community needs to establish stability and safety to effectively safeguard the mental health of children. In the words of Dame Graça Machel, human rights activist and former first lady of Mozambique and South Africa, “Children are both our reason to eliminate the worst aspects of armed conflict and our best hope of succeeding in that charge.”14
This article originally appeared on Psychiatry Advisor
Maria Arini Lopez,
Maria Arini Lopez, PT, DPT, is a freelance medical writer and editor from Maryland. She has expertise in the therapeutic areas of orthopedics, neurology, chronic pain, gastrointestinal dysfunction, and rare diseases, especially Ehlers-Danlos syndrome.