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Abstract
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Description of the condition
It is estimated that one in 10 children (approximately 230 million children) currently live in a war or conflict-affected society and will be exposed to daily violence in their communities (UNICEF, 2016). Some may be forced into violent combat, and many more will experience familial, social and cultural losses (Betancourt, McBain, Newnham & Brennan, 2013; Betancourt, Meyers-Ohki, Charrow & Tol, 2013; IASC, 2014; Santa Barbara, 2006). It is generally accepted that children and young people exposed to violence in areas of conflict are at an increased risk of harmful effects, including injury, sexual abuse, disability, illness and long-term mental health issues or psychological problems.
The harmful psychological effects of living through war or conflict include depression and anxiety disorders and post-traumatic stress symptoms (PTSS) such as flashbacks, nightmares or intrusive thoughts about the trauma, avoidance of people, places or activities related to the trauma, disturbed sleep, disturbed play in young children and somatic symptoms (Attanayake et al., 2009; Dimitry, 2012; Fasfous, Peralta-Ramírez & Pérez-García, 2013; Jordans, Tol, Komproe & de Jong, 2009; Slone & Mann, 2016; Yule et al., 2000). While most people will experience some post-traumatic stress symptoms following trauma, those whose symptoms persist and interfere with daily life may be diagnosed with post-traumatic stress disorder (PTSD). A meta-analysis of child and adolescent mental health in conflict affected settings estimated that prevalence rates were elevated for PTSD (47%, 17 studies, 95% CI: 35-60%), depression (43%, four studies, 95% CI: 31-55%) and anxiety (27% three studies, 95% CI: 21-33%) (Attanayake et al., 2009). This is compared to much lower lifetime prevalence estimates in the general population of, for example, American adolescents of 5% PTSD, 12% depressive disorder, 2.2% generalized anxiety disorder (Merikangas et al., 2010). A systematic review of the effect of war or conflict related violence on young children (age 0-6) found that prevalence of either PTSD or PTSS ranged from 8% to 45% (Slone & Mann, 2016). PTSD is the most common mental-health condition associated with exposure to war, conflict or political violence (Attanayake et al., 2009; Betancourt, Borisova, et al., 2013; Dimitry, 2012; McDermott, Duffy, Percy, Fitzgerald & Cole, 2013; Slone & Mann, 2016).
As with adults, children suffering PTSD present with broad categories of post-traumatic stress symptoms (re-experiencing, avoidance/numbing and increased arousal). Younger children may display more overt aggression and destructiveness and re-experiencing symptoms may take the form of re-enacting the experience, repetitive play or frightening dreams. Subjective experience of the event and peri-trauma factors, such as perceived severity and proximity, have been identified as possible risk factors for developing PTSD after trauma (Trickey, Siddaway, Meiser-Stedman, Serpell & Field, 2012). Post-trauma risk factors include low social support, poor family functioning (Trickey et al., 2012) and higher negative posttraumatic cognitions (Punamäki, Palosaari, Diab, Peltonen & Qouta, 2014). Finally, pre-trauma factors, such as a non-related mental health disorder, age and gender have also been linked to development of PTSD following war and conflict related violence. The exact nature of the relationship between age, gender and PTSD is unclear. There is some evidence suggesting that girls are at greater risk than boys because they may have higher levels of rumination or pre-trauma anxiety (McDermott et al., 2013), girls may be more likely to experience greater subjective exposure than boys, but boys may exhibit more externalizing problems in response to trauma such as increased aggression (Dimitry, 2012). It may be that this different pattern of response in boys and girls reflects socially constructed gendered norms of appropriate behaviour and inequitable distribution of power and agency between boys and girls, but gender inequalities are understudied in the context of war and conflict and trauma more generally (Gilfus, 1999). Concerning age, older children are more likely to have direct exposure to conflict related violence (Dimitry, 2012) but younger children may be more vulnerable to developing PTSD as they lack the cognitive capability to process trauma that older children have developed. Others have argued that younger children may actually be protected by their less developed cognitive capacity as they cannot fully comprehend the meaning and implications of war and conflict (Barenbaum, Ruchkin & Schwab-Stone, 2004).
In recent years there has been a noticeable shift in attention to the influence of mediating variables (e.g., cultural context, family/community support and personal capacity) and the importance of these influences in reducing the impact of war or conflict (Tol, Reis, Susanty & de Jong, 2010; Tol, Song & Jordans, 2013). This understanding has informed preventative psychosocial interventions, which aim to strengthen and improve protective factors for children living in war affected societies in order to inoculate children against the harmful effects of exposure to war, conflict or political violence. Having fundamental (although possibly relative) elements included in a intervention such as promoting community, self-efficacy, a sense of hope, and feeling connected to a place may help reduce the negative effects of war (Betancourt, Borisova, et al., 2013; IASC, 2007).
While PTSD is common in children exposed to war and conflict related violence, it is important to note that not all children exposed to trauma will go on to develop PTSD. Severe distress and fear is a normal reaction to trauma and there is substantial natural recovery in the initial months and years after a traumatic event (Bisson et al., 2010). For example Punamäki et al. (2014) showed that 12% of children aged 10-12 exposed to war in Gaza suffered relatively low amount of post-traumatic stress symptoms in the following year. A further 76% of children had initial high levels of symptoms but recovered within 11 months. A sizeable minority of 12% experienced initial severe levels of post-traumatic stress symptoms which increased over a year. It is important to recognise that immediate intervention may not be necessary, and in the case of critical incident stress debriefing (CISD) may in fact be harmful (NICE, 2013; Rose, Bisson, Churchill & Wessely, 2002). Providing an intervention too early may interfere with the natural recovery process. A Cochrane Review of 11 trials involving adults indicated that CISD should not be routinely implemented with victims of trauma (Rose et al., 2002). The current evidence base for the use of debriefing with children is low quality (Pfefferbaum, Jacobs, Nitiéma & Everly, 2015; Jacobs & Pfefferbaum, 2015; Pfefferbaum et al., 2015) and while there is no current evidence of harm there is little empirical support for its use (Jacobs & Pfefferbaum, 2015; Pfefferbaum et al., 2015).
This raises important questions; when, if at all, should intervention be offered after a potentially traumatising event? How can we decide who does and does not need intervention to reduce the risk that PTSD will develop? Can at-risk children be identified, screened and offered appropriate interventions?
2 DESCRIPTION OF THE INTERVENTION
This review focuses on psychosocial interventions that can be implemented with children following exposure to war and conflict-related violence and will only include early interventions that aim to prevent childhood PTSD. We define psychosocial intervention as any intervention that offers psychological or social support (or both) with a goal of helping to prevent mental disorders developing (in particular PTSD) and improve long-term mental health.
Universal interventions are offered to everyone in a population, regardless of the level of their exposure to war or conflict related violence. Selective interventions are targeted at subpopulations who may be at a higher risk of developing mental disorders, for example, only those directly exposed to war and conflict related violence. Indicated interventions are aimed at those already displaying some symptoms of disorder and who may benefit from intervention to prevent PTSD developing. We intend to include all three levels of intervention in this review...
Language: en |