The Psychological Impact of Child Soldiering
Elisabeth Schauer and Thomas Elbert
Abstract With almost 80% of the ﬁghting forces composed of child soldiers, this
is one characterization of the ‘new wars,’ which constitute the dominant form of
violent conﬂict that has emerged only over the last few decades. The development
of light weapons, such as automatic guns suitable for children, was an obvious pre-
requisite for the involvement of children in modern conﬂicts that typically involve
irregular forces, that target mostly civilians, and that are justiﬁed by identities,
although the economic interests of foreign countries and exiled communities are
usually the driving force.
Motivations for child recruitment include children’s limited ability to assess
risks, feelings of invulnerability, and shortsightedness. Child soldiers are more often
killed or injured than adult soldiers on the front line. They are less costly for the
respective group or organization than adult recruits, because they receive fewer
resources, including less and smaller weapons and equipment. From a different per-
spective, becoming a ﬁghter may seem an attractive possibility for children and
adolescents who are facing poverty, starvation, unemployment, and ethnic or polit-
ical persecution. In our interviews, former child soldiers and commanders alike
reported that children are more malleable and adaptable. Thus, they are easier to
indoctrinate, as their moral development is not yet completed and they tend to listen
to authorities without questioning them.
Child soldiers are raised in an environment of severe violence, experience it, and
subsequently often commit cruelties and atrocities of the worst kind. This repeated
exposure to chronic and traumatic stress during development leaves the children
with mental and related physical ill-health, notably PTSD and severe personality
E. Schauer (B)
Department of Psychology, University of Konstanz, Konstanz, Germany;
vivo International, Konstanz, Germany
Statements quoted in the text originate from the authors’ own work with formerly abducted
children and former child soldiers during diagnostic interviews or therapeutic work in Northern
Uganda and the Democratic Republic of Congo in the framework of project interventions of the
NGO vivo. All clients have personally given written informed consent for publication of their
experiences. Some have in fact urged us to tell the world what happened using their own words.
E. Martz (ed.), Trauma Rehabilitation After War and Conﬂict,
DOI 10.1007/978-1-4419-5722-1_14, C
Springer Science+Business Media, LLC 2010
312 E. Schauer and T. Elbert
changes. Such exposure also deprives the child from a normal and healthy develop-
ment and impairs their integration into society as a fully functioning member. This
chapter presents in detail the cascade of changes that prove to be non-adaptive in
a peaceful society. Further, ex-combatants experience social isolation arising from
a number of factors, which include host communities’ negative attitudes towards
ex-combatants and their psychological problems causing difﬁculties in social inter-
action. The risk of re-recruitment is high when ex-combatants fail to reintegrate
economically and socially into their civil host communities, which may cause sub-
stantial economic development issues, and a new turn in the cycle of violence
becomes inevitable. We therefore conclude that the provision of extensive mental-
health services needs to be an essential part of demobilization and rehabilitation
programs. This will improve the individual’s functioning, it will build capacity
within the affected community, and it may be designed to break the cycle of
In this chapter, we include formerly abducted children’s description of selected
experiences of child soldiering. The reader might be faced with emotional reac-
tions, due to the detailed ﬁrst-person reports. All narratives originate from either
clinical diagnostic interviews or testimony established during psychotherapy with
NET (Narrative Exposure Therapy). All children, who are voicing their life expe-
riences, have been part of an already completed or on-going mental-health project,
implemented to psychologically rehabilitate the beneﬁciaries by the NGO vivo.
Child Soldiers Characterize ‘New Wars’
In 2004, political scientists counted more than 42 wars and armed conﬂicts world-
wide, almost all of them in developing countries (Schreiber, 2005). Observers
of these current ‘new wars’ (Kaldor, 1999) or ‘complex political emergencies’
(Ramsbotham & Woodhouse, 1999) have noted that the main target of the war-
ring parties is the civilian population, and the systematic atrocities, massacres, and
bombings are often applied as rational strategies within current warfare. Never
before in history have child soldiers played such a prominent role, constituting 80%
of the ﬁghting forces. This is one indication that we are witnessing a qualitative
change in the way wars are waged and in the way organized violence is exerted;
in other words, a transformation in the ‘culture of violence’ cannot be overlooked.
Researchers have noted that the following are new characteristics or trends (Elbert,
Rockstroh, Kolassa, Schauer, & Neuner, 2006; Kaldor, 1999):
•Fighting is dominated by irregular forces, including paramilitary units, rebel
forces, mercenary troops, and foreign armies that intervene in civil wars. As out-
lined below, a clear separation between civilians and soldiers disappears. Forcibly
recruited child soldiers belong to the usual repertoire of most forces in the new
wars. Parties to the conﬂict are frequently led by powerful warlords, with little or
no power of the state.
•Conﬂicts are justiﬁed by identiﬁcation with ethnic groups, cultures, or religions,
while actually the conﬂicts are driven by economic factors: warring parties get
14 The Psychological Impact of Child Soldiering 313
resources from supporting foreign countries and exiled communities, in order to
control local resources, like minerals, oil, or drugs.
•Warfare strategies include systematic atrocities, like massacres and mass rapes, to
frighten civilians and to make regions uninhabitable for the group to be expelled.
Another reason for the prevalence of atrocities in current wars is the assumption
that they help to unite the group committing the atrocities. Easily available small
weapons are sufﬁcient for this type of warfare.
Children have increasingly become victims and perpetrators of warfare (Redress,
2006). Crimes against humanity, like hunting humans, mutilations, and mass rape,
are not an exception, but may be a characteristic of adolescent gangs that have gotten
out of society’s control. Some have argued that the ability to be cruel is a way to exert
negotiating power in this context, which may explain why there is little intervention
of the ruling groups to prevent atrocities. Internationally agreed upon, undesirable,
and prohibited war outcomes, which in fact are a hallmark of today’s conﬂicts, have
been deﬁned (Hicks & Spagat, 2008) and the phenomenon of child soldiering is one
The proportion of civilian casualties in armed conﬂicts has increased continu-
ously during the twentieth century and is now estimated at more than 90%. About
half of the victims are children (UNICEF, 2002). More than 2 million children have
died as a direct result of armed conﬂict over the last decade. More than three times
that number – at least 6 million children – have been seriously injured. Between
8,000 and 10,000 children are killed or maimed by landmines every year (Pearn,
2003; UNICEF, 2005). Of the ten countries with the highest rates of deaths of those
under the age of 5 years, seven are affected by armed conﬂict (UNICEF, 2005). The
World Bank reports additionally that the average mortality rate of children under the
age of 5 years increased signiﬁcantly as a consequence of war (Collier, 2003).
War-related injury means wounds in the body and the mind. Traumatic stress can
also occur from painful and frightening medical treatments and living with disabil-
ity, especially in resource-poor countries. It is estimated that 4 million children have
acquired disabilities after they were wounded in conﬂict over the last decade. For
example, 75% of the injuries incurred from landmines in rural Somalia are to chil-
dren between the ages of 5 and 15 years (ICRC, 1994). All of these samples include
formerly abducted children and child soldiers. The lack of appropriate and timely
1According to Hicks & Spagat, 2008, others are high mortality to civilians versus combatants;
increased injuries to civilians versus combatants; torture of civilians or combatants; rape or sexual
humiliation of civilians or combatants; sexual humiliation of civilians or combatants; mutilations
of civilians or combatants; kidnapping and hostage taking; disappearances; summary execution
of captured prisoners; terrorist attacks; assassination of civilian leaders; attacks on religious and
medical personnel and on medical units; use of particularly undesirable or prohibited weapons
(e.g., landmines and booby traps); suicide bombers disguised as civilians; child death or injury;
female civilian mortality or injury; elderly civilian mortality or injury; violence to non-combatant
indigenous groups; use of human shields; initiating weapon ﬁre from among civilians; locating
headquarters or weapons storage among civilians; combatants taking civilian appearance during
military operations (e.g., not wearing uniforms); combatants disguised as humanitarian, peace-
keeping, or medical workers; leaving landmines or unexploded ordnance; destroying infrastructure
essential for civilian survival (e.g., food, water sources, hospitals).
314 E. Schauer and T. Elbert
medical assistance during child soldiering is an additional serious humanitarian
Among a number of at-risk populations, children of war and child soldiers are
a particularly vulnerable group and often suffer from devastating long-term conse-
quences of experienced or witnessed acts of violence. Child war survivors have
to cope with repeated and thus cumulative effects of traumatic stress, exposure
to combat, shelling and other life-threatening events, acts of abuse, such as tor-
ture or rape, violent death of a parent or friend, witnessing family members being
tortured or injured, separation from family, being abducted or held in detention,
insufﬁcient adult care, lack of safe drinking water and food, inadequate shelter,
explosive devices and dangerous building ruins in the proximity, marching or being
transported in crowded vehicles over long distances, and spending months in transit
camps (Barath, 2002; Boothby, 1994; Elbert et al., 2009; Karunakara et al., 2004;
Mollica, Poole, Son, Murray, & Tor, 1997; Schaal & Elbert, 2006; UNICEF, 2005;
Yule, 2002). These experiences can hamper children’s healthy development and
their ability to function fully, even once the violence has ceased.
Furthermore, destruction brought by war is likely to mean that children of war
and child soldiers are deprived of key services, such as education and health care.
A child’s education can be disrupted by armed conﬂict, due to abduction, displace-
ment, absence of teachers, long and dangerous walks to school (e.g. landmines,
snipers), and parental poverty (e.g. inability to provide school fees and uniforms
and the necessity for children to contribute to household income). Schools can be
caught up in conﬂict as part of the ﬁghting between government forces and rebel
groups or can be used as centers for propaganda and recruitment. Attacks on and
abductions of teachers and students are a frequent phenomenon of global warfare.
The same can be observed for hospitals, doctors, and nursing staff. Health centers
often become a direct target, the medical supply is cut off during intense periods
of ﬁghting, and health personnels are frequently kept from accessing the sick and
injured as a political strategy (Cairns, 1996; Sivayokan, 2006; UNICEF, 2005).
The social consequences of growing up in shattered, war-torn environments
include effects like alcoholism, drug abuse, and early unprotected sexual activity
(sex for food and security), which can result in teenage pregnancy and the contrac-
tion of HIV/AIDS (Kessler, 2000; Yule, 2002). The increased likelihood of HIV
transmission in conﬂict zones is mostly due to the breakdown of family, school,
and health systems, with their regulatory safeguards that could counter these risks
During 1990 and 2005, an estimated 30 million children were forced by conﬂict
and human right violations to escape their homes and are currently living as refugees
in neighbouring countries or as internally displaced within their own national bor-
ders. During ﬂight, families may become separated. More than 2.5 million children
have been orphaned or separated from their families because of war in the past
decade (Pearn, 2003; Southall & Abbasi, 1998; UNICEF, 2005). The poor living
conditions, in which ﬂeeing families ﬁnd themselves, increase children’s vulnera-
bility to malnutrition, diarrheal diseases, and infections (Toole & Waldman, 1993).
In Africa, crude mortality rates have been as high as 80 times baseline rates among
refugees and internally displaced populations (IDP) (Toole & Waldman, 1997).
14 The Psychological Impact of Child Soldiering 315
Often the period of exile runs into years and decades, and in such cases, children
may spend their whole childhood in camps and displacement. Nowadays, there are
entire generations of children who have never lived at home in Africa and Asia
The Use of Child Soldiers in Armed Conﬂicts
Prevalence and Phenomenon
A child soldier is any person under the age of 18 who is a member of or attached to govern-
ment armed forces or any other regular or irregular armed force or armed political group,
whether or not an armed conﬂict exists. Child soldiers perform a range of tasks including
participation in combat, laying mines and explosives; scouting, spying, acting as decoys,
couriers or guards; training, drill or other preparations; logistics and support functions, por-
tering, cooking and domestic labour; and sexual slavery or other recruitment for sexual
purposes (Coalition to Stop the Use of Child Soldiers, 2007).
Hundreds of thousands of children are conscripted, kidnapped, or pressured into
joining armed groups. The proliferation of lightweight weapons has made it possi-
ble for children under the age of 10 years to become effective soldiers. Compared to
earlier weapons, which required strong physical force to be an effective ﬁghter, this
is a notable change in technology that has allowed recruiting children as a new class
of ﬁghters, which is a deﬁning characteristic of the ‘new wars.’ The trend in using
children in armed conﬂict as soldiers is not diminishing. An estimated 300,000 child
soldiers – boys and girls under the age of 18 – are involved currently in more than
30 conﬂicts worldwide (Child Soldier, 2001; Jayawardena, 2001). Some 40% or
120,000 child soldiers are girls, whose plight is often unrecognized because inter-
national attention has largely focused on boy soldiers. In general, when people speak
of ‘child soldiers,’ the popular image is that of boys, rather than the thousands of
girls who comprise the less visible, ‘shadow armies’ in conﬂicts around the world
(McKay & Mazurana, 2004).2While the use of child soldiers as combatants is a
2According to the United Nations and Save the Children, key conﬂict areas where the problem of
boy and girl soldiers has been and remains acute today include Colombia, East Timor, Pakistan,
Uganda, the Philippines, Sri Lanka, the Democratic Republic of the Congo (DRC), and west-
ern and northern Africa. Moreover, in Afghanistan, Chechnya, the West Balkans, Haiti, Liberia,
Peru, Rwanda, and Sierra Leone, recruitment and abuse of child soldiers have occurred. Like the
boys, typically the majority of girl soldiers are abducted or forcibly recruited into regular and
irregular armed groups, ranging from government-backed paramilitaries, militias, and self-defense
forces to antigovernment opposition and factional groups, which are often based on ideological,
partisan, and ethnic or religious afﬁnity. Children are recruited and used in armed conﬂict in at
least 15 countries and territories at present which are Afghanistan, Burma (Myanmar), Central
African Republic, Chad, Colombia, Democratic Republic of Congo (DRC), India, Iraq, Occupied
Palestinian Territories, Philippines, Somalia, Sri Lanka, Sudan, Thailand, and Uganda. Countries
especially named for sexual exploitation of child soldiers – this includes boys as well as girls –
are Afghanistan, Angola, Burundi, Congo, Honduras, Cambodia, Canada, Columbia, Liberia,
Mozambique, Myanmar/Burma, Peru, Rwanda, Sierra Leone, Uganda, United Kingdom, and USA
(Alfredson, 2001; Human Rights Watch, 2009).
316 E. Schauer and T. Elbert
contemporary development, children have continuously served throughout history
as servants, messengers, porters, cooks, and to provide sexual services. Some are
forcibly recruited or abducted; others are driven to join by poverty, abuse, and dis-
crimination, or to seek revenge for violence enacted against themselves and their
families. When children are recruited into combat and servitude, they experience
sexual violence and exploitation and are exposed to explosives, combat situations,
and the experience and witnessing of killings (Pearn, 2003). Reports abound from
conﬂict zones of girls and boys being abducted and forced into sexual slavery by
militias or rebel groups (Southall & Abbasi, 1998; UNHCR, 2003; UNICEF, 2005).
Reasons for Recruitment of Children
The development of light weapons and small arms made it possible, for the ﬁrst
time in history, to recruit children as ﬁghters. Blattman (2007) summarized several
reasons why children and young adolescents have become the focus of recruitment,
because this possibility arose in the late twentieth century. The following arguments
should be interpreted as complementary facets of motivations for child recruitment.
First, the current demographic shift in poor countries (in part due to HIV/AIDS)
led to the largest population of children and adolescents ever, making this age
group most available for recruitment and abduction. Second, commanders (espe-
cially African) emphasize stamina, survival, and stealth of child soldiers, as well as
their fearlessness and will to ﬁght (International Labor Organization [ILO], 2003).
This may be due to children’s limited ability to assess risks, feelings of invulnera-
bility, and short-sightedness (Brett & Specht, 2004). It is a fact that child soldiers
are more often killed or injured than adult soldiers, which can be explained by their
being deployed at the front line, e.g. to lay or clear mines, or as suicide bombers
because they provoke less suspicion (Coalition to Stop the Use of Child Soldiers,
2008). Third, child soldiers are cheaper for the respective group or organization
than adult ones, because they receive fewer resources, including fewer and smaller
weapons and equipment.
From a different perspective, becoming a ﬁghter may be an attractive possibility
for children and adolescents facing poverty, starvation, unemployment, and eth-
nic or political persecution (International Labor Organization [ILO], 2003). Facing
these problems, children are ‘soft targets’ as recruits into armed groups and may
be more willing to ﬁght for honour or duty, for revenge, or for protection from
violence (Brett & Specht, 2004; Redress, 2006). Fourth, children are also easier to
retain in the group. In our interviews (see below), child soldiers and child com-
manders argue that children are more malleable and adaptable, and hence easier to
indoctrinate. They stick more to authorities without questioning them. Moral and
personality development is not yet completed in children, reducing their inhibition
against performing crimes against humanity. Interviews with rebel leaders of the
Ugandan Lord’s Resistance Army (LRA) revealed that adults have been the most
skilled ﬁghters, but also those who were most likely to desert. Despite being weak
14 The Psychological Impact of Child Soldiering 317
ﬁghters, young children have been most likely to stay, because they were easiest to
indoctrinate, while at the same time, it is more difﬁcult for them to plot escape strate-
gies. Adolescents seemed to offer the best ﬁt between malleability or likelihood
to stay and effectiveness as ﬁghters (Blattman, 2007). In addition, Somasundaram
(2002) stated that military leaders in Sri Lanka prefer younger children because
of their suggestibility and fearlessness or weaker ability to estimate dimensions of
Enlistment and Recruitment
Pertinent Laws of War anonymously state that the enlistment, recruitment, use,
and/or deployment of child soldiers under the age of 15 are actions that are war
crimes according to the 1989 Convention on the Rights of the Child, and the 1998
Rome Statue of the International Criminal Court.
These two guiding, international instruments have even been advanced by the
Convention of the Rights of the Child, which states a ‘straight 18’ approach to
recruitment in the 2002 Optional Protocol to the Convention on the Rights of the
Child. The 1990 African Charter on the Rights and Welfare of the Child supports
the age of 18 as a minimum entry age of soldiering (more information on related
topics can be sought in Redress, 2006). There are hardly any systematic investiga-
tions of child soldiers, exploring their views, motives, and identities. We therefore
have performed semi-structured interviews in several regions of East Africa.
Forced or Voluntary Recruitment and Remaining?
A cautionary note to the reader: the following pages contain interviews with children, some
of whom report events that were exceedingly graphic or violent. These children have experi-
enced or observed these horriﬁc events in environments of conﬂicts or wars, and thus, their
ﬁrst-person accounts, while shocking, are needed to illustrate the nature and depth of the
issues. The editor.
K.G., a 16-year-old boy at the time of the interview (South Kivu, Democratic
Republic of Congo [DRC], March 2009), was an active recruit for 3 years, i.e. he
joined at age 13:
I think I joined freely. All my friends were already part of this group, even my uncle and
many of my cousins. The Mai-Mai had long been around us; in fact they had built shelters
next to our community in the forest. One day a friend of mine told me to come to the
football grounds for a game. There we saw the Mai-Mai and they were telling us that today
would be their pay-day, that a government ofﬁcial of the Congolese army would come and
give them their monthly wages and if we joined, we could all get a share of that money. It
didn’t take me long to decide. In those days I was frightened, since our home was attacked
almost every night by bandits and other rebel groups as well, what did I have to lose? Also
my parents were too poor to send me to school anymore. My mind was made up fast, I
joined my friends and from that day I never went home to my parent’s house again. I know
you think, how can I not think of home, but I never did. I was totally there in the forest
318 E. Schauer and T. Elbert
with the rebels, I only thought of today and the drugs we got there. One time my parents
tried to ﬁnd me and buy me out with a goat, but I didn’t even look at them. Home did not
exist anymore you know, I was always under drugs from that day onwards. Also we had a
purpose. You know North Kivu is very rich, many people come and want to rule us, they
come and want our riches and we need to ﬁght that, we need to ﬁght for our freedom and to
ﬁght for our village. Our commander used to talk to us about this every morning when we
met for morning assembly.
O.B. received therapeutic treatment for trauma-related mental health when he
was an 18-year-old (May 2006). He had served for nearly 5 years after being
abducted by the Lord’s Resistance Army (LRA) in Northern Uganda at age 14:
After two days, an assembly took place. Everybody was gathered. They talked about us
newly abducted children and they said: “you look like people who plan to escape and we
are going to make you rebels now.” They told us to lie down. Now we were surrounded by
40 rebels. They said: “do not raise your head or we will kill all of you.” We had to stretch
our hands forward and put our foreheads to the ground. They started beating my back. 350
strokes were given on my back and buttocks. After a while the pain was so big that I felt
that it would be better if I was dead. It was just too much to bear. Coldness started creeping
into my body. And the trembling started. And then it happened again. I looked at my body
from outside. I knew I would die. I saw death. It was in me. Death takes people’s soul. My
soul was already outside my body. I could feel pain, deep pain, but it was not from my
back, from the strokes, it was everywhere inside me now. Death was trying to take my soul.
Pain was everywhere in me. I could see death. You can see it when you are going to die.
I couldn’t hear anything. I also didn’t realise when it was that they had stopped beating me.
But then I heard a loud voice: “Get up.” I tried, but I couldn’t sit. I kneeled for almost one
hour. It felt like a very long time. I realised that all other children around me had died in the
beating. I could see them lying still and not breathing. They were lying all around me. Their
bodies were swollen and full of blood all over. The rebels dragged their bodies and dumped
them into the nearby river.
K.K.G., male, 16 years old at time of diagnostic interview (March 2009), spent
3 years as an active recruit, joining Mai-Mai, in North Kivu, DRC at age 13:
When you would not follow the commander’s rule, he could get very angry. People would
get beaten terribly for disobedience or if they were trying to escape. When their wounds
were open and bleeding, salt was rubbed inside their wound. In that the commander was
merciless. You had to follow the rules or you would lose the ‘protection’. When people did
something really wrong, they got killed as a punishment...I have seen 5 people being killed
for severe disobedience during my time with the group. They were cruciﬁed in the forest.
The commander would order them being nailed to trees at their hands and feet higher up
on tall trees. The nails were thick ones, like those you would use to nail big logs for the
roof of a house. You would ﬁrst nail through the palms of the hand and later through the
feet, just below the ankle and then turn the nail around so as to ﬁx the foot to the tree stem.
Sometimes the commander then ordered for people to be burnt with hot plastic again and
again until they had real holes in their bodies.
Even if it might appear so to the individual child, from a psychological and social
point of view, children’s choices to join and remain in armed groups cannot be
considered ‘voluntary’. In summary we propose the following reasons:
14 The Psychological Impact of Child Soldiering 319
•Children have no or limited access to information concerning the consequences of
their choice; they neither control nor fully comprehend the structures and forces
that they are dealing with.
•Children have little knowledge and understanding of the mid- and long-term
consequences of their actions.
•Children might be told and believe that they have to ‘stand up’ against an enemy,
who would otherwise kill them or hurt their families; they tend to trust and obey
caretakers’ and families’ or key community leaders’ judgement on this.
•Children might believe that they have to take the place of a family member, who
would otherwise be enlisted, or to avenge a family member, who has been killed
by the ‘enemy,’ which might constitute a emotionally perceived life-threat for the
•Conditions of civil war and armed conﬂict undermine the ability of families and
communities to protect the young of both sexes (Druba, 2002); parents might
then be driven to give in to the powerful inﬂuence of militia leaders of their own
ethnic group. Enlistment on the part of the parents or caretakers can never be
considered ‘voluntary’ on part of the child.
•A large number of child victims of social chaos and violence become orphans,
refugees, or are only partly protected by adult care, as a result being left alone
in their struggle to survive social, emotional, and economic hardship, a poten-
tial push factor into recruitment. Interestingly, it is extremely rare for wealthier
children from urban areas to be recruited.
•With systematic indoctrination and acculturation, a commander can, over time,
replace the position of a caretaker/parent and serve as an adult role model, which
children will naturally accept, and in fact, need to attach to for mentorship, guid-
ance, and survival; fellow child combatants can take the place of siblings and/or
replace the community peer group; this ‘surrogate family’ phenomenon does not
imply a voluntary choice by the child, but a forced adaptation and might, in fact,
be a sign of healthy development in the absence of other choices.
•Children might feel that they have to protect themselves, if the ofﬁcial state struc-
ture, community, or family cannot; by perceiving to have no choice, they might
try to escape the violence and abuse around them – and enlisting might become
a perceived means of survival.
•Girls might think that joining an army might protect them from being raped or
harmed by free-roaming ‘militia groups’.
•During the initial period, children who have joined armed groups, whether vol-
untary or forced, are almost always subjected to harsh, life-threatening initiation
procedures, such as severe beatings, forced killings, magic-spiritual rituals (e.g.
tattooing, scarring, spraying with blood or ‘holy’ water), and forced drug intake,
in order to make them ‘proper soldiers’ and fear the repercussions of escape; such
practices tend to be forced on the new recruit and put children’s lives in danger.
•Rarely do demobilized children share with their parents or communities the emo-
tional context of what they have experienced or how they were treated; as a result
of the lack of emotional communication, reintegration into local communities is
hampered by perceptions of the community’s view of the particular armed group
320 E. Schauer and T. Elbert
with which the child was associated. The individual needs and unique case of the
returning child are rarely considered. Stigmatization levels are high at the time
of re-entry into the community of origin and constitute a potential push factor for
Risk Factors for Recruitment
Known risk factors for becoming a child soldier are poverty, less or no access to
education, living in a war-torn region, displacement, and separation from one’s
family, with orphans and refugees being particularly vulnerable (Beth, 2001).
Somasundaram (2002) lists the following factors as catalysts for children to become
Liberation Tigers of Tamil Eelam (LTTE) child soldiers in North-Eastern Sri Lanka:
death of one or both parents or relatives, family separation, destruction of home or
belongings, displacement, lack of food, ill health, economic difﬁculties, poverty,
lack of access to education, no avenues for future employment, social and polit-
ical oppression, harassment from government soldiers, abductions, and detention.
He also describes an emerging pattern of youth violence in the general population
after two decades of war in the affected communities. After growing up in a war
environment, male youth in displaced camps seemed to drift into anti-social groups
and activities when a natural disaster hit the coastal regions. Unemployed and left
out of school-based programs, some left to join militant groups, while other started
abusing alcohol and formed into violent groups and criminal gangs. Having grown
up immersed in an atmosphere of extreme war violence, many had witnessed hor-
rifying deaths of relatives, the destruction of their homes and social institutions,
experienced bombings, shelling, and extrajudicial killings (Somasundaram, 2007).
A similar pattern of ‘saturation’ can be assumed in children who grow up
in conﬂict-stricken communities, which later become recruitment targets of rebel
movements. This could constitute a pull factor for joining the movement. Further
reasons might be hearing false promises or relatives taking part in the movement.
As P.A.N., who was male, 29 years at time of diagnostic interview (March 2009),
served 1 year as an active recruit, and joined Mai-Mai in North Kivu, DRC at the
age of 15 years, described:
The whole village was overtaken by Hutu’s and even our houses and shambas (ﬁelds) were
occupied by them. The population of the villagers was living in displacement. My whole
family and all my relatives and friends were displaced. So we decided to protect ourselves
and our ‘earth’ and to ﬁght. All young men were in this, family members, friends, the whole
community. You see our parents could not support us, there were no more school fees and
no more home. When I was 16 years old, I joined the Mai-Mai. We fought to eliminate the
Hutus, and there were two groups of them, the old Hutus who had come earlier and those
who came during the genocide of Rwanda in 1994. So I joined to help create a resistance
movement and to protect our home. During my time in the group, things changed of course
and later I stayed on also because I was afraid to be killed if I ﬂed. But there was also the
other voice in me, which wanted to stay and learn as best I could to be a good combatant
and especially learn how to have enough inner discipline to be strong for the rest of my life,
so as to never be helpless again.
14 The Psychological Impact of Child Soldiering 321
The Consequences for Children Who Have Been Combatants
Exposure to Traumatic Stress
Severe and traumatic stress and its deteriorating effects for mental health, such as
the development of post-traumatic stress disorder (PTSD), a debilitating psychiatric
condition, gain more and more importance in the description of societies affected
by the new wars’ human rights violations. Our research has highlighted the role of
a ‘building block effect’: traumatic experiences build upon each other and cumula-
tively increase the chance of developing PTSD and depression (Karunakara et al.,
2004; Kolassa & Elbert, 2007; Kolassa et al., in press; Onyut et al., 2009; Schaal
& Elbert, 2006; Schauer & Elbert, 2010; Schauer, Neuner, & Elbert, 2005; Schauer
et al., 2003). PTSD patients have developed a ‘fear network,’ composed of intercon-
nected, trauma-related memories, in which even only peripherally related trauma
stimuli can cause a cascading fear response with ﬂash-back properties. Therefore,
the cumulative exposure to traumatic stress constitutes a predictor of endemic
mental-health issues. We begin our discussion about traumatic stress with an
exemplary outline of the type and frequency of traumatic stressors in crisis regions:
V.A., a 20-year-old woman who, at time of therapy (May 2006), had spent
10 years in abduction with the LRA, Northern Uganda, reported:
I remember my life from around the time when I was 5 years old. I lived with my parents
in the hills around Gulu and we had a good time. When I was 7 years old, my mother got
poisoned and died. From then on, my step-mother took over the household and I suffered
a lot, she used to beat me badly. When I was 9 years old, a boy raped me while I was on
the way to the well to fetch water. When I was 10 years old, I got abducted by the LRA.
I witnessed how many other children got abducted and we were made to walk towards
Sudan. On the way, I saw how he beat many people to death, probably those who could not
keep up with the walking and the heavy loads. When we arrived at Kony’s place in Sudan,
I witnessed the torture and killing of a wizard. I was given to one of the elder women of a
commander as a helper. She was nice, but she died soon and from then on I was mistreated
by the co-wives. At age 11, I remember the commander coming home to the house early and
I had not cleaned-up yet; he beat me severely for that. From that day onwards he would do
it regularly. Sometimes so much that I had to go to hospital, but the rebels always took me
out again forcefully and brought me back before my wounds were healed. One day when
I was 12 years old, we saw how children in a school were forced to eat their own teacher
by the LRA; apparently the man had resisted giving food to the rebels. At age 14 years,
the commander started raping me and told me that I am now his wife. A few months later
I had my ﬁrst baby. It was a beautiful child, but I did not know how to look after him, so
he died soon. In the same year, there was a ﬁerce battle with the UPDF [Uganda People’s
Defense Force], an air attack, where many of our people in the settlement died. At age 16,
I gave birth to another baby. The next morning when I woke up, also he had died. He had
been tiny and weak and he probably died from the cold night air, since I had nothing to
cover him. One day soon after this we saw how the Lutugu people got hold of enemies and
poured boiling water over their bodies until they died. At age 18, I had to take part in a raid
on Lira IDP camp. We were trying to get new abductees and food, but people resisted, so 18
of them were killed by our group. At age 20, I gave birth to George in the bush. He is weak,
but he is still alive, I so much hope that he will grow up. That same year during an attack
by government soldiers, the rebels, including my husband, left me behind. I guess I was a
burden to them, since we women with small children were not able to run fast. He never
322 E. Schauer and T. Elbert
explained to me what he was thinking, he just left me behind and the soldiers brought me
to this reception center. In the future I hope to do small business. I am a bit worried, since
I can’t read and write. They want me to go back to my relatives’ place, but it is insecure and
rebel attacks are frequent. If I could choose, I would choose a safe place to live.
F.O., a 13-year-old boy at time of therapy (April 2006), who had spent 3 years in
abduction with the LRA in Northern Uganda, described his experiences:
I was born in 1994 in a small village in Uganda. My mother used to cook beans so well
for me and my father. When I was 6 years old, my parents had a ﬁght and my mother got
wounded by my father with a knife. He would always start acting in a funny way when he
was drunk, he would act as if he was still a soldier in the bush. At age 7, I ﬁnally started
going to school, that was a good day. At age 11, I was abducted and that same day they
made me kill 3 of my uncles. A few days later, they ‘initiated’ me to be a soldier and gave
me 100 strokes of beating. One year later, I was forced to cut off both hands of a hunter with
a hapanga. In the same year, we fought a big battle with the UPDF, where my friend was
killed. When I started crying, the commander forced me to lie in his blood. Many battles
followed that one in the same year, also air attacks. We were often starving, since there was
no time to ﬁnd food. Once we had to ambush a bus with civilians on the road towards Atiok
to get hold of food; many people died and got burnt. Two days later we were asked to attack
a camp. We were told to bring food and girls; we found three, but I was forced to kill two
since they couldn’t manage to carry the heavy loads and keep up. It wasn’t long after that
incident in the same year that I got a chance to escape during a battle with the UPDF. I was
13 when I reached this center.
In a study by our group (Pfeiffer et al., submitted), which was carried out in a
representative selection of IDP camps of Northern Uganda during 2007 and 2008,
it was found that of the interviewed sample of 1114 children and young adults,
43% were formerly abducted children and many of them were recruited temporarily
as child soldiers. The most common traumatic life events of those who had been
abducted were forced to skin, chop, or cook dead bodies (8%), forced to eat human
ﬂesh (8%), forced to loot property and burn houses (48%), forced to abduct other
children (30%), forced to kill someone (36%), forced to beat, injure, or mutilate
someone (38%), caused serious injury or death to somebody else (44%), experi-
enced severe human suffering, such as carrying heavy loads or being deprived of
food (100%), gave birth to a child in captivity (33% of women), were threatened to
be killed (93%), saw people with mutilations and dead bodies (78%), experienced
sexual assault (45%), experienced assault with a weapon (77%), and experienced
physical assault including being kicked, beaten, or burnt (90%). The PTSD rate of
the children, who were never abducted, was found to be 8.4%; of those who had ever
been abducted, 33%, and those who had spent more than 1 month in captivity, the
PTSD rate was measured at 48%. In this large, representative study, the children’s
mental-health impairment had remained chronic, because in a majority of cases,
the interviews had taken place years after they had come back from captivity. One
out of four former child soldiers reported to be still currently disturbed by different
intensities of self-perceived ‘spirit possession,’ which as our data shows is a way to
express and attribute symptoms of trauma-related illness and which in the studied
population correlates well with a PTSD diagnosis.
In another large study by Vinck and colleagues (Vinck, Pham, Stover, &
Weinstein, 2007), again in Northern Uganda, it was found that 82% of formerly
14 The Psychological Impact of Child Soldiering 323
abducted children presented with PTSD symptoms. A follow-up review of Pham
and colleagues (Pham, Vinck, & Stover, 2009) with former abductees showed that
67% met the symptom criteria for PTSD; in those abducted for 6 months or more,
this rate rose to 80%.
In 2007, Bayer and colleagues (Bayer, Klasen, & Adam, 2007) carried out a study
among former child soldiers in Uganda and Congo. The interviewed 169 children
had a mean age of 15 years at the time of being interviewed. All children reported
that they had been violently recruited by armed forces at a mean age of 12 years.
They had served an average of 38 months in captivity. The most commonly reported
traumatic experiences were having witnessed shooting (92.9%), having witnessed
somebody being wounded (89.9%), and having been seriously beaten (84%). A total
of 54% of the children reported having killed someone, and 28% reported that they
were forced to engage in sexual contact. Further, 35% of the interviewed children
had exhibited a fully developed post-traumatic stress disorder.
The 2004 Derluyn et al. (Derluyn, Broekaert, Schuyten, & De Temmerman,
2004) ﬁndings are the highest symptom scores so far reported in formerly abducted
children. The study interviewed 301 former child soldiers who had been abducted.
All children were abducted at a young age (mean 12.9 years) and for a long time
(mean 25 months). Almost all the children experienced several traumatic events (a
mean of six traumatic events): 77% saw someone being killed and 39% had to kill
Amone-P’Olak (2005) examined experiences of war, physical abuse, sexual
abuse, and related psychological disorders in formerly abducted girls in 2005. The
results demonstrated that 98% of girls had been threatened to be killed when dis-
obeying, 98% had thought that they would be killed, 99% only narrowly escaped
from death, 72% had been sexually abused by the rebels (in most cases forcefully
‘being given as a wife’ from the age of 13 years), 65% witnessed people being killed,
44% of the girls witnessed people being mutilated, 18% of the girls participated in
killings, and 7% were forced to participate in killing own relatives. On average, the
girls experienced 24 traumatic events during captivity.
The large ‘Survey of War Affected Youth – SWAY’ study (Annan & Blattman,
2006) found very similar rates and types of traumatic experiences as all of the above
mentioned. As an additional item, this study found that 23% of the children had
been forced to abuse dead bodies (see Coalition to Stop the Use of Child Soldiers,
2004, 2008 for a more comprehensive description of child soldiers’ experiences).
Post-traumatic Stress Disorder
K.K.G., male, 16 years, who, at time of diagnostic interview (March 2009), had
spent 3 years as an active recruit and had joined the Mai-Mai, in North Kivu, DRC
at age 13 years, reported:
When I was out in the forest, I was feeling nothing, I was drugged all the time. But after
I had come out and now since I stay in this transit center, I get these terrible nightmares.
324 E. Schauer and T. Elbert
They are always about the children we killed, especially their crashed skulls and I hear the
voice of my commander telling me to do things. I wake up and get so frightened. My heart
is beating strong these days and something in my head is so wrong. On one hand, I have
a new life and I have left the forest behind and also all the hardship of those days, on the
other, I think of the times and especially the drugs we had. Sometimes at night I walk out
of the building, especially when I get the dreams and stare at the sky. I would just wish that
my head gets normal again.
According to the Diagnostic and Statistical Manual of Mental Disorders
(American Psychiatric Association, 2000), a PTSD diagnosis is restricted to indi-
viduals who have experienced or witnessed at least one traumatic event in their life,
i.e. a stressor that involved actual or threatened death or serious injury, or a threat to
the physical integrity of self or other, and the subjective perception of intense fear,
helplessness, and/or horror. Victims, as well as eyewitnesses, can enter a psycholog-
ical alarm state during the traumatic event and a cascade of responses in the body
and mind is triggered which can damage both the mind and the body (Schauer et al.,
During life-threat, the defense cascade is activated as a coherent sequence of fear
responses that escalate as a function of defense possibilities and proximity to dan-
ger. These reaction patterns provide optimal adaptation for particular stages of the
imminence of threat. The actual sequence of trauma-related response dispositions
acted out in an extremely dangerous situation depends on the appraisal of the threat
by the victim in relation to his/her own power to act (e.g. age, gender), as well
as the perceived characteristics of the threat or perpetrator (Schauer & Schauer,
2010 this volume; Schauer & Elbert, 2010 this book). Repeated experience of trau-
matic stress forms a fear network that can become detached from contextual cues,
such as time and location of the danger, and thus may lead to psychological disor-
ders or non-adaptation (Schauer et al., 2005). Traumatic events can be man-made
or caused by natural disasters. The former may involve state-sanctioned or orga-
nized violence (e.g. being in a situation of war and combat, torture riots, terrorism,
and mass killing) or interpersonal violence (e.g. experienced or witnessed killing
or mutilation, severe physical or sexual assault, sexual abuse, rape, and domestic
violence), as well as catastrophes (e.g. car accidents, airplane crashes, and acci-
dents involving poisonous substances). Traumatic natural disasters may be severe
ﬂoods, hurricanes, earthquakes, or volcanic eruptions. After repeated exposure to
traumatic stressors, post-traumatic stress disorder is the most likely psychiatric con-
dition that emerges among a range of possible trauma-spectrum disorders including
depression, suicidality, and substance abuse. The considerable similarities and con-
sistencies in the clinical manifestations of psychological disorders across diverse,
affected groups globally tend to outweigh cultural and ethnic differences (Garcia-
Peltoniemi, 1998; Schauer & Schauer, 2010). Across cultures, deﬁning symptoms
of PTSD are reported as follows (APA, 1994; Joshi & O’Donnell, 2003):
(1) Recurrent and intrusive distressing recollections of the event, including images,
thoughts, or perceptions (e.g. observable in children’s repetitive play or trauma-
speciﬁc re-enactments); recurrent and distressing dreams (e.g. for children,
nightmares with scary content of any nature); acting or feeling as if the
14 The Psychological Impact of Child Soldiering 325
traumatic event was recurring; intense psychological and physiological distress
at exposure to internal or external cues (e.g. observable in constriction of affect);
(2) Persistent avoidance of stimuli associated with the trauma and numbing of
(3) Persistent symptoms of heightened arousal and constant alertness. Children
often experience this as eating and sleeping problems, increased autonomic
arousal (e.g. sweating, raised heartbeat, and concentration difﬁculties), fore-
shortened sense of future (e.g. even small children can express hopelessness
in relation to ever growing up), recklessness and risk-taking behaviour, hyper-
activity, withdrawal, deﬁance, aggression, and also numerous psychosomatic
complaints (e.g. common are stomachaches and headaches) which result from
frequent alarm responses, easily elicited by trauma-related cues that may appear
in everyday life.
(4) In its most extreme forms, phenomena like derealization, depersonalization, or
symptoms that resemble psychosis have been noted.
In order to qualify as a psychiatric disorder, the disturbance must cause clinically
signiﬁcant distress or impairment in emotional, social, occupational, scholastic, or
otherwise important areas of functioning. In children, this is also observable as loss
of acquired skills (e.g. an impact on the child’s developmental functioning, such as
the ability to speak), as well as its persistence for a certain amount of time.
Age at traumatization is not a consistent predictor nor a protector from traumatic
stress reactions and the expression of symptomatology (Berman, 2001; Elbedour,
ten Bensel, & Bastien, 1993). The age of the individual at the time of exposure
does not seem to mediate symptom expression over time for a majority of suf-
fering survivors. There are also no signiﬁcant differences found in PTSD rates
across different developmental stages (Fletcher, 1996). Numerous studies suggest
that regardless of the passage of time, affected children and adolescents continue to
suffer from distressing symptoms, with PTSD being most persistent (Almqvist &
Brandell-Forsberg, 1997; Bichescu et al., 2005; Bremner & Narayan, 1998;
Dyregrov, Gjestad, & Raundalen, 2002; Elbedour et al., 1993; Goenjian et al., 1999;
Hubbard, Realmuto, Northwood, & Masten, 1995; Kinzie, Sack, Angell, Clarke, &
Ben, 1989; Kinzie, Sack, Angell, Manson, & Rath, 1986; Marshall, Schell,
Elliott, Berthold, & Chun, 2005; McFarlane, Policansky, & Irwin, 1987; Morgan,
Scourﬁeld, Williams, Jasper, & Lewis, 2003; Perry & Pollard, 1998; Ruf, Neuner,
Gotthardt, Schauer, & Elbert, 2005; Sack, Him, & Dickason, 1999; Schaal &
Elbert, 2006; E. Schauer, Catani, Mahendran, Schauer, & Elbert, 2005; M. E. Smith,
2005; P. A. Smith, Perrin, Yule, Hacam, & Stuvland, 2002; Thabet & Vostanis, 2000;
Yule et al., 2000).
Post-traumatic Stress Disorder
Investigating more than 3,000 war refugees, we (Neuner et al., 2004; Schauer et al.,
2003) found that the greater the number of different types of traumatic events
experienced by an individual (e.g. torture, ﬁghting, shelling, abduction, abuse/rape,
326 E. Schauer and T. Elbert
physical complaints depressive symptoms
traumatic event load
Probability for PTSD
1 2 3 4 5
Fig. 14.1 The probability to develop a PTSD increases with cumulative experience of types of
traumatic events experienced (upper left). Units on the abscissa correspond to classes of cumulative
experiences of traumatic stressors. The full range is about 25 different types experienced. Circles
indicate the observed average for PTSD for a particular event load. For those who have developed
a PTSD, depressive symptoms, functional impairment, and physical diseases also become more
likely with increasing exposure to traumatic stressors). Graph upper left: Data from survivors of
the Rwandan genocide, Kolassa et al., (in press). Other graphs: data from a survey in Sri Lankan
school children with PTSD due to the civil war, Schauer, E. (2008)
forcible female circumcision, car accident), the more likely the individual was to
have PTSD, with more pronounced symptoms. In our studies, PTSD prevalence
rates reached 100% for individuals having experienced a sufﬁciently large number
of different traumatic-event types (see Fig. 14.1). This building-block effect may
be a result of the development of a neural fear network, which is strengthened and
extended in response to each new traumatic event (Elbert et al., 2006).
During a traumatic event, perceptual and emotional features of the situation are
‘burnt’ into memory (Elbert & Schauer, 2002), forming the nucleus of a neural
network that is associated with the traumatic event. Subsequent traumatic events are
14 The Psychological Impact of Child Soldiering 327
associated with similar elements of a hot memory (i.e. physiological, like heart beat-
ing, sweating, as well as an emotional-like feeling, such as helpless and horriﬁed,
cognitive, such as I cannot do anything, and even sensory, such as man in uniform,
weapon). Network connections are strengthened through synchronous activation, so
that activity in one of the memory representations facilitates activity in the other.
Thus, memories of speciﬁc traumatic events will merge into an indistinct whole
and a fragmentation of autobiographic context-memory results (Elbert et al., 2006;
Kolassa & Elbert, 2007).
Research repeatedly has demonstrated the signiﬁcant relationship between the
number of traumatic-event types experienced and the likelihood of developing post-
traumatic stress disorder and other disorders of the trauma spectrum: the more
exposure to trauma, the more likely the development of psychological disorders
(Allwood, Bell-Dolan, & Husain, 2002; Catani, Jacob, Schauer, Mahendran, &
Neuner, 2008; Catani et al., 2005; Elbert et al., 2009; Kolassa & Elbert, 2007;
Kolassa et al., in press; Macksoud & Aber, 1996; Neuner et al., 2004; Schaal &
Elbert, 2006; Schauer et al., 2003; Steel, Silove, Phan, & Bauman, 2002). This effect
of cumulative exposure makes ex-combatants a highly vulnerable group, as they are
exposed to a great number and outstanding diversity of traumatic stressors.
Living with Post-traumatic Stress Disorder and Trauma Symptoms
Literature consistently shows that post-traumatic stress reactions are not transi-
tory entities, but rather persist over time. Studies from Western countries, e.g. with
Second World War veterans or political prisoners, found that PTSD has a high long-
term stability, up to 40 years after the trauma (Bichescu et al., 2005; Lee, Vaillant,
Torrey, & Elder, 1995). Even when a decline in symptoms is observed, it does not
equate complete recovery. Presently, we know that the suffering felt by survivors
of violence will last a few months, but a countless number of severely traumatized
individuals, especially those who have gone through cumulative traumatic events,
could suffer for the rest of their lives.
V.O., male, who was 18 years at time of therapy (October 2008), was abducted
twice (ﬁrst time age 4 for 7 years, second time age 13 for 2 years) by the LRA,
Northern Uganda. He explained:
My younger sister Aciro doesn’t get those problems that I have, when I forget every-
thing and act in strange ways when the memories from the bush come back. We are
alone, since my parents have been killed and living in a small hut in the camp makes
life difﬁcult when this thing comes over me. When my mind goes away, then my sis-
ter runs out and locks me up in the hut. Later, when I have stopped acting out and lie
down to sleep and stay quiet, she comes back. It can happen twice a day that I for-
get time and wake up in a strange place where I don’t know how I got there...but
this didn’t just start when I had reached home. Even out in the bush, when I would
sit somewhere, I started to see the ﬁlm of how I had killed in front of my eyes and I
also started thinking of how my father and mother were killed by the rebels, especially
how they were cut. The memories came back so much and it is all mixed in my mind.
Sometimes I would sit and a cold feeling would creep into my body and I would start
328 E. Schauer and T. Elbert
shivering and from a distance pictures of the killings came to appear in front of my eyes.
I used to cry so much and a great sadness had come into me. Problem now is that people in
the community think I am crazy and they want to take away our ancestral land from us, but
digging and harvesting is the only source of income we have.
In terms of magnitude, some research suggests that a critical mass of survivors
never recover from PTSD, but that ﬁgure can be much higher after exposure to
extreme, multiple, or deliberately inﬂicted psychological trauma. Systematic torture
or child soldiering, for example, can result in much higher rates of PTSD; some
authors report rates of up to 90% of survivors being affected (Basoglu et al., 1994;
Derluyn et al., 2004; Moisander & Edston, 2003; Mollica, McInnes, Poole, & Tor,
1998; Neuner et al., 2009). There is emerging clarity to the question of what type of
traumatic experiences will lead most likely to the development of trauma-spectrum
disorders. Perpetrator events, as well as surviving rape and cruel torture, seem to
have a predictive power in terms of likelihood of development of psychological
disorders. One example is given by O.B., a male, 18 years at time of therapy (May
2006), whose time as an active recruit was 5 years, and who was abducted by LRA,
Northern Uganda, at age 14:
Around 5 pm, we found more people. It was a man and his wife. In the distance, I saw two
children playing, boys of school-going age. I cannot say whether they had seen us coming.
The parents, however, looked so frightened when they saw us. People know that rebels do
bad things. The commander “A. Smart” said, come here and sit down. He asked them: “what
were you doing?” The people said: “we were just at home.” He replied: “we are going to kill
you.” The people looked frozen. Smart said: “look down.” Then he recruited two people,
Okello and me and he said: “Cut off their necks or I will kill you.” I was trembling with
fear. I knew that those who don’t kill will be killed themselves. These rebels had spent a
long time in the bush and had grown beards. I hadn’t even been in the bush for 1 year.
I was still considered newly recruited. Everybody had a gun, except me. I felt different to
them. I didn’t have a friend in the group. I also had different thoughts. Many of them had
no fear and no mercy. They liked killing. The commander gave me the hapanga and told me
to kill the man. Okello was given the woman. Rebels don’t kill people twice, they do it in
one stroke. So I knew it had to be one stroke. They had shown us at other times when they
killed how to do this. I cut hard and through the bones in the back. The head did not come
off completely, but the man was sinking forward. I was trembling. I looked around and I
saw that Okello had killed the woman. Then I saw the children. They had come closer and
they saw their parents now. They started crying. I still held the hapanga in my hand. All the
rebels noticed the children. Nobody spoke. I started thinking of my mother and became sad.
The memories of the day of my abduction and how the rebels had killed my mother came
back. Then the command for movement was given. I moved with the hapanga in my hand
as we went away. If you show how you feel you will be killed.
Another example is provided by F.O., a male, who was 13 years at time of therapy
(April 2006), and who had spent 3 years in abduction, with the LRA, Northern
One day, when I was 10 years old, I had gone to collect ﬁrewood outside in the bush with
my 3 uncles. As we were just tying up the logs, the rebels came. We had not heard them
coming. They told us to sit down. There were 5 of them. In fact, they were younger than my
uncles, all between 12 and 15 years. They were wearing dark green uniforms and had dread
locks and gum boots. They had guns and they were pointing them at us. They said: “who are
you?” And we tried to tell them that we are village people trying to collect ﬁrewood. They
14 The Psychological Impact of Child Soldiering 329
tied my uncles’ arms on their back and seated us apart. Since they did not tie me up, I was
sure they would kill me ﬁrst. My heart was racing, I had such fear. I started shaking all over
my body. They told me to bend forward to the ground while being seated. That way I could
not see a lot anymore what was going on around me. I could not hear anything anymore;
there was this high tone in my ear. A gun was pressing into the back of my neck. Next, we
were told to get up and carry the luggage, which they ﬁxed on my uncle’s head...When
morning came, we stopped near a river. We were told to sit down. I looked at my uncles and
felt such pity for them. They looked as if they knew that they are going to die...now two
rebels got up and we were all told to get up. We walked some distance to a clearing under a
tree. They told my uncles to lie down on their stomachs face down about three meters apart.
They gave me a big stick and told me to kill them: “hit them on the back of their heads”. I
was starting to shake. I threw the stick away and said: “I cannot do that. I have never killed
anybody.” I was so frightened my body was gripped by fear. They picked the stick back up
and handed it to me: “You hit or you will be killed ﬁrst.” There was no escape. The gun was
pointed at me. I aimed and closed my eyes. I started hitting the back of my uncles’ heads.
I hit three times on my ﬁrst uncle. He kept so quiet. No sound from him. The rebels stood
behind me: “if you hit slow we will stab you from behind.” Again, three times on the back
of the head of my next uncle. I was shaking with helplessness. Great sadness came over
me. The rebels said: “if you cry now we will kill you.” I hit my third uncle on the head.
Again complete quietness. There was blood and a cracking noise every time I hit. Finally
the rebels pulled me away. I prayed for the dead, as I was sitting there in sadness. I thought
of my mum, I was sure she could have helped me if she would have been here. I feel so
frightened that the spirit of the dead will come and haunt me. I have seen children in our
tent here in the center at night getting haunted by the spirits. They shout and scream and
get possessed. But then I remembered my uncles well. There was Opio, the oldest, he was a
nice man; he would even wash my clothes for me and cook for me. Then there was Okumu,
he was a clever and kind man; he taught me how to read and write. Then there was Robert,
a good man; he would bathe with me in the river and treat me like a brother. I know they
would never mean to harm to me. I know they would never send a bad spirit for me.
Another example is given by M.O., a male, who was 19 years at time of therapy
(May 2006), and whose time as an active recruit was 8 years, having been abducted
by LRA at age 7 in Northern Uganda:
My sister was crying hard and she said: “I cannot walk anymore. See my feet, see how they
are swollen. Carry me, please carry me.” Our commander Bosco heard this. He was angry
now and said to me: “tell her to walk.” I was trying to pull my sister up, to make her stand
on her feet. I was so helpless and fearful. We were both crying now. I was a small boy, I was
eight years at the time and I could do nothing. My sister was six and she was tired, she could
not stand anymore. Then I saw Bosco bringing a hapanga. My mind was racing, I thought
he will kill both of us now. I had such fear in my chest. My heart was racing. He gave the
hapanga to me. Now I realized what would happen. Bosco said: “Cut your sister or you
both will die.” I didn’t move. Bosco slapped me with the blade of the hapanga on my back.
I just stood still. I didn’t move. Then he got the gun. He pointed it at me, “cut her and do it
fast,” was what he said. I saw three other rebels coming now. They all had guns and they all
pointed at me. I thought: “let me die as well.” I was not ready to move. Then I heard them
ﬁring the guns just above my head. My heart dropped. I was full of fear, I started trembling.
They would not wait long now. I raised my hand and in this moment my sister cried. She
shouted: “Don’t cut me. We are one.” I was crying and shaking and I replied: “Forgive me,
I am forced to do this.” Bosco gave me a kick again. I raised my hand and now the hapanga
came down on the back of my sister’s neck. She lay there ﬂat on her stomach with her arms
stretched out widely to both sides. Blood was coming out. She was still alive, the hapanga
had not killed her. Now the others took over and killed her. They had big wooden logs and
also took the hapanga and hit her hard on her head and she died. I looked at my little sister
330 E. Schauer and T. Elbert
how she laid there, arms stretched out, quiet now. My heart was racing. And her voice was
still with me, the way she had pleaded for her life. Such sadness settled now in me. My
sister was left on the ground and her voice was with me for a long time. Then it got dark.
I sat under a tree next to a mountain. There was food, but I could not eat. I also could not
sleep. I was thinking and thinking. The pictures were there and the voice of my sister in my
ear. I cried. In the morning, they gathered the group and the commander said: “if you don’t
walk, we will kill you just like we killed a person yesterday.” I could not get out of this
confused state for almost one week.
Yet, another example is given by A.A., a female, who was 15 years at time of
therapy (May 2006), and who was abducted at age 13 by the LRA in Northern
The commander looked around and saw me and my friend sitting in some distance and he
said: “call those two seated over there.” He called us to come in front. And he told us: “A
girl should be killed by a girl. Get the sticks and beat her to death.” I got so frightened
and started to shake. I said: “I don’t want to kill, I don’t know how to do this, I have never
harmed a person.” And he replied: “if you keep talking like this, then it will be Doris beating
you to death and not the other way around.” I feared so much now and they saw me shaking
and crying. They told us to lie down on the ﬂoor on our stomach and we received 10 canings
each from a boy, so as to make the fear and the crying stop. In my heart, I did not want to
kill. I knew I did not want this. Doris was lying on the ground next to us on her stomach.
We got up and lifted the sticks. They were about as thick as my hand wide and as long as
my arm. We started beating her. On her buttock, on her shoulders, on her back. I heard her
crying and shouting for help. Everybody was watching us. The commander sat right next
to us. We hit her again and again. I was shaking. It was such hard work, I was so helpless.
Doris cried and pleaded for help. The commander said: “if you don’t stop crying now, then
you have to kill a boy as soon as you are ﬁnished with her.” I felt so helpless. Then Doris
cried out my name. She shouted: “You are killing me, we are such good friends and now
you are killing me.” I slowed down the beating as much as I could and I answered her: “I
did not want to do this, I am forced to do this. If it was me, I wish I would not have to do
this.” After that she kept quiet. She was not crying anymore. We did not know when to stop
the beating, but the commander said: “Now she is dead, take her by the arms on each side
and pull her over to that place in the bush, then leave her there.“ Finally we were allowed
to leave the place. I went to where people were seated. I sat next to an older woman. Girls
who have freshly killed are not allowed to sit next to the boys. But there are older women,
who have killed often and know what to do, so you sit next to them. She consoled me and
she took me by the arm and told me not to cry. She said to me: “stop crying or else they will
kill you.” She sat near me and held my hand. After you kill you shouldn’t cry.
A study by Gloeckner (2007) found that the more violence children had been
forced to commit against others, the more PTSD symptoms could be expected.
Nader and colleagues (Nader, Pynoos, Fairbanks, al-Ajeel, & al-Asfour, 1993)
found that children who reported ‘hurting another human being’ scored highest
in terms of development of PTSD symptoms in war-exposed children in Kuwait.
Derluyn and colleagues (Derluyn et al., 2004) reported a prevalence of 97% post-
traumatic stress reactions of clinical importance in former child soldiers, among who
39% had to kill a person themselves and 77% of the children had witnessed killings
while in captivity. Other studies in veterans have furthermore shown that witness-
ing abusive violence and enormous cruelty was of especially high-traumatic valence
(Hiley-Young, Blake, Abueg, Rozynko, & Gusman, 1995; Nader et al., 1993).
14 The Psychological Impact of Child Soldiering 331
The Impact of Trauma on the Body
Beyond psychological suffering from the symptoms of PTSD, traumatized popu-
lations show signiﬁcantly elevated levels of physical morbidity and mortality. As
outlined above, in recent years, evidence has mounted that severe anxiety states –
stress at a traumatic level – lead to a functional and structural alteration of the brain
(Eckart et al., submitted; Kolassa & Elbert, 2007). The co-occurrence of several
pathogenic processes includes a permanent alteration of bodily processes, due to a
state of persistent readiness for an alarm response. Psychobiological abnormalities
in PTSD are observed as psychophysiological, neurohormonal, neuroanatomical,
and immunological effects (Boscarino, 2004; Kolassa et al., 2007; Neuner et al.,
2008; Schnurr & Jankowski, 1999). Trauma survivors, including child soldiers, fre-
quently report high rates of physical illness, involving a variety of physiological
systems. In a recent study (Sommershof et al., 2009), we observed a substan-
tial and clinically relevant change in immune function, based on a 34% reduction
of naïve and a 54% reduction of regulatory T cells following war and torture-
related PTSD. Thus, there seems to be a positive correlation not just between
developed psychiatric illnesses and prior trauma, but also a signiﬁcant relation-
ship between the amount of traumatic exposure and poor physical health outcomes.
An emerging body of literature is successfully exploring the relationship between
trauma-spectrum disorders, foremost PTSD and increased somatic complaints, such
as cardiovascular, pulmonary, neurological, and gastrointestinal complaints; various
types of somatic pain; susceptibility to infectious diseases; vulnerability to hyperten-
sion and atherosclerotic heart disease; abnormalities in thyroid and other hormone
function; increased risk of cancer and susceptibility to infections and autoimmune
disorders; and problems with pain perception, pain tolerance, and chronic pain
(Altemus, Dhabhar, & Yang, 2006; Boscarino, 2004; Dyregrov & Yule, 2006; Elbert
et al., 2009; Escalona, Achilles, Waitzkin, & Yager, 2004; Ford et al., 2001; Ironson
et al., 1997; Joshi & O’Donnell, 2003; Karunakara et al., 2004; Kessler, 2000;
McEwen, 2000; Neuner et al., 2008; S. J. Roberts, 1996; Rohleder & Karl, 2006;
Schnurr & Jankowski, 1999; Seng, Graham-Bermann, Clark, McCarthy, & Ronis,
2005; Somasundaram, 2001; van der Veer, Somasundaram, & Damian, 2003). It is
important to keep in mind that in post-disaster/conﬂict regions, children and their
parents, who remain in the area or are forced to migrate (asylum seekers, refugees,
IDPs), have not only survived an unusual number and types of traumatic stressors,
but also had to endure poverty related or other social stressors and adversities, such
as domestic violence, family separation, and child labor (Catani et al., 2008; Catani
et al., 2009). Child soldiering additionally contributes to the already heightened
stress load due to adversity. Taking into account the absence of health services in
this context, high child, adolescent, and adult mortality, epidemic rates of disease
transmission, as well as low life expectancy rates in many of today’s (post-)conﬂict
settings come as no surprise (AACAP, 1998; Dyregrov & Yule, 2006; Ehntholt &
Yule, 2006; Elbert et al., 2009; Karunakara et al., 2004; Miranda & Patel, 2005;
Neuner et al., 2008; Neuner, Schauer, Catani, Ruf, & Elbert, 2006; Odenwald et al.,
332 E. Schauer and T. Elbert
Further Psychological Consequences of Trauma Exposure
There are a multitude of further psychological consequences of experiencing trau-
matic life-threat. In sum, the response to war-related trauma by ex-combatants and
former child soldiers in countries directly affected by war and violence is complex
and renders the survivors vulnerable to various forms of psychological disorders,
whereby stressors may have a different impact during different developmental peri-
ods. During childhood and adolescence, the mind and brain are particularly plastic
and hence, stress has a great potential to affect cognitive and affective development.
Exposure to signiﬁcant stressors during sensitive developmental periods causes the
brain to develop along a stress-responsive pathway. As a consequence, the brain
and mind become organized in a way to facilitate survival in a world of deprivation
and danger, enhancing an individual’s capacity to rapidly and dramatically shift into
an intense angry, aggressive, or fearful ﬂeeing/avoiding state when threatened. This
pathway, however, is costly because it is associated with increased risk of develop-
ing serious medical and psychiatric disorders, like the aforementioned PTSD, and is
unnecessary and non-adaptive in peaceful environments (Elbert et al., 2006; Teicher,
Andersen, Polcari, Anderson, & Navalta, 2002).
Chronic danger or exposure to extreme stress requires costly developmental
adjustment in children. Though the core symptoms of PTSD are the most exten-
sively studied psychological consequences of war, they are clearly not the only
ones. In addition to associated features like survivor’s guilt or shame and changes
in personality, survivors may also suffer from substance-use disorders, affective
disorders, including major depression, suicidal ideation, and various forms of anx-
iety disorders (Bichescu et al., 2005; Boscarino, 2004, 2006; Catani et al., 2009;
Johnson & Thompson, 2008; Keane & Kaloupek, 1997; Lapierre, Schwegler, &
Labauve, 2007; Odenwald et al., 2007; Schauer, 2008). Surviving traumatic expe-
riences might be followed by social withdrawal, loss of trust, major changes in
patterns of behaviour or ideological interpretations of the world, and feelings of
guilt and shame (Dickson-Gomez, 2002; Janoff-Bulman, 1992).
Parallel to the trafﬁcking of light weapons, the global commerce of illicit pharmacological
stimuli served as an effective catalyst of war. (Maclure & Denov, 2006), p. 127
Systematic drug taking is especially reported among West African-based militia
movements. In fact, some authors consider hallucinatory drug intake a critical factor
that has contributed to the desensitization of boy soldiers during their prolonged
exposure to violent aggression and to prepare them for combat.
Utas and Jorgel (2008) described, in their account of the ‘West Side Boys’ child
soldiers of Sierra Leone, how most ﬁghters used drugs in abundance: crack cocaine,
smoked heroin, ephedrine, benzodiazepines, and marijuana:
14 The Psychological Impact of Child Soldiering 333
Drugs were used in military navigation both to enable soldiers to act courageously and
ultra-violently, and also to make ﬁghters relax in extreme settings of fear. (Utas & Jorgel,
2008, p. 502)
Drug abuse may also develop as a means of coping with PTSD (Chilcoat &
Breslau, 1998; Shipherd, Stafford, & Tanner, 2005). Gear (2002) notes that sub-
stance abuse can be seen as a way to escape the emotional burden associated with
extreme poverty and unemployment, at the same time being an attempt to cope with
trauma-related symptoms, and thus, is a form of self-medication. In several sam-
ples of Somali (ex-)combatants, our group (Odenwald, Hinkel, & Schauer, 2007;
Odenwald et al., 2007) found that those with PTSD used more drugs in order to ‘self-
medicate,’ especially those who indicated that drug use helped them forget stressful
war experiences (Odenwald et al., 2005). The main drug (ab)used in Somalia are the
leaves of the khat shrub that contain the amphetamine-like cathinone. In these stud-
ies, we could clearly demonstrate that PTSD leads to higher khat intake and this, in
turn, leads to a higher risk for the development of psychotic symptoms, such as para-
noia. In a large cross-sectional household survey, involving 4854 randomly selected
persons of the general population of Hargeisa, Somaliland, we (Odenwald et al.,
2005) observed that 12 years after the end of the liberation war and 6 years after the
last ﬁghting, 16% of the ex-combatants were severely impaired by complex psycho-
logical suffering, mostly severe psychotic disorders intermingled with drug abuse,
trauma-related disorders, and emotional problems. In most cases, uncontrollable
behaviour, like aggressive outbreaks, had led to the situation that helpless family
members had chained them for years to concrete blocks or trees in the backyard of
their compounds or that they had ended up in prison. Among the male adult popula-
tion, former combatants with civilian war survivors and persons who never had been
confronted with war (i.e. those who managed to ﬂee abroad before the war) were
compared. The rate of 8% of PTSD, depression, and drug abuse disorder in the
civilian war survivors doubled among the group of ex-combatants, and reached less
than 3% in those without direct war exposure. In a city like Hargeisa the Capital
of Somaliland, every fourth household had to care for one severely affected, dys-
functional young man in the household, drawing resources from all members of the
household and forcing the household to lose out on the support and capacity of one
male family member.
Depression and Suicidality
The signiﬁcant correlation between post-traumatic stress disorder and clinical
depression is scientiﬁcally well known. In a large study by Vinck and colleagues
(Vinck et al., 2007) in Northern Uganda, it was found that 52% of formerly abducted
children suffered from depression symptoms. A follow-up review of Pham et al.
(Pham et al., 2009) with former abductees showed that 40% fulﬁlled the symp-
tom criteria for major depression. In our study (Pfeiffer et al., submitted), using a
child soldier sample again from Northern Uganda, 16% of children who were ever
334 E. Schauer and T. Elbert
abducted had a fully developed major depression, with this rate increasing to 24%
in those who had stayed in captivity 1 month or longer.
The most disturbing ﬁnding is the risk of suicidality in the former child soldier
sample of Pfeiffer and colleagues (Pfeiffer et al., submitted). In this group, 34%
of children showed a risk of suicidality (17% of children at high risk), with this
rate rising to 37% (25% at high risk) in those who were forced to stay in captiv-
ity for 1 month and longer. Post-Vietnam studies showed highly elevated risks of
suicide among ex-combatants and veterans of war (Hendin & Haas, 1991; Kang &
Bullman, 2008; Lester, 2005). Having been an agent of killing and having been a
failure at preventing death and injury of others are especially related more strongly
to general psychiatric distress and suicide attempts (Fontana, Rosenheck, & Brett,
The few investigations that there are among children indicate a signiﬁcant cor-
relation between a childhood diagnosis of PTSD and suicidal ideation. Guilt might
play an important mediating factor. In the case of child soldiers, the guilt about hav-
ing killed members of the family, friends, or community members emerged as a key
predictor of suicidal ideation (Pfeiffer et al., submitted). Authors suggest that suici-
dal ideation may be increased additionally when the child’s functioning is impaired
(Famularo, Fenton, Kinscherff, & Augustyn, 1996). In an epidemiological study
in the LTTE-controlled areas of North-Eastern Sri Lanka (Elbert et al., 2009), we
observed a highly signiﬁcant relationship between PTSD and risk for suicide, which
was diagnosed for 26% of the children with PTSD, but only for 7% of children
without PTSD. The reasons for these epidemic proportions are unclear. Researchers
suggest that for some youngsters, self-poisoning seemed to be the preferred or only
method of dealing with difﬁcult situations (Eddleston, Sheriff, & Hawton, 1998).
Child soldiers might simply lack adequate coping or interpersonal skills, such as
the ability to communicate anger and sadness, or might not be able to place trust in
supportive and positively guiding relationships with adults.
Dissociation and Derealization
Another, so-called associative feature of severe child traumatization, often seen in
former child soldiers, is the phenomenon of ‘dissociation.’ During times of trauma,
ﬁght or ﬂight responses are rarely options for children, as they are often physi-
cally unable to defend themselves or escape. The most readily accessible response
to the pain of trauma may be to activate dissociative mechanisms, involving dis-
engagement from the external world. Biological defense mechanisms are activated
by the central nervous system, such as depersonalization, derealization, numbing,
and in extreme cases, catatonia and ‘tonic immobility’ (Perry & Pollard, 1998). The
individual cascade of defense mechanisms that a survivor has gone through during
the traumatic event can replay itself whenever the fear network, which has evolved
peritraumatically, is activated again by internal or external triggers. Whereby
some survivors have experienced mainly peritraumatic sympathetic activation
14 The Psychological Impact of Child Soldiering 335
(ﬂeeing-feeling anxious; ﬁghting-feeling angry and acting out), others went through
the whole defense cascade, with parasympathetic dominance as an end point (e.g.
tonic immobility, no more voluntary movement, sensory de-afferentation, loss of
muscle tonus, fainting) (Schauer & Elbert, 2008).
Thus, peritraumatic dissociation might be allowing the child to psychologically
and physically survive the trauma. Over time, however, it often becomes non-
adaptive, emerging at inappropriate times during, for example, situations that may
trigger verbal or nonverbal/bodily memories of earlier trauma or at any other time
of perceived emotional threat. Children who have learned to cope with trauma by
dissociating are vulnerable to continuing to do so in response to minor stresses.
The continued use of dissociation as a way of coping with stress interferes with the
capacity to fully attend to life’s ongoing challenges. During dissociative episodes,
the child may stare off and appear as if he or she is daydreaming (Sack, Angell,
Kinzie, & Rath, 1986). Such children may be misdiagnosed, e.g. as suffering from
ADHD, inattentive type (Joshi & O’Donnell, 2003). Other children may freeze in
response to certain activating stimuli. Caregivers or teachers may misinterpret this
reaction as an act of deﬁance. If confronted, more anxious children can quickly
escalate to feeling threatened, ‘frozen,’ and ultimately resort to a classic ﬁght or
ﬂight response by becoming aggressive or combative over relatively minor events
(Joshi & O’Donnell, 2003; Schauer & Elbert, 2010). Other children may react to
stressors by dissolving into regressed, dissociative states that may contain micro-
psychotic episodes, including auditory command hallucinations. It is not uncommon
for severely traumatized children to hear voices commanding them to harm them-
selves or others, which is a dangerous, unpredictable condition. Consequently, such
adolescents can be erroneously misdiagnosed as suffering from a primary psychotic
disorder, such as schizophrenia.
Anti-social and Disruptive Behavior
PTSD is also signiﬁcantly associated with negative behavior against an individual’s
own family, the expression of anger and hostility to others, and self-harm (Burton,
Foy, Bwanausi, Johnson, & Moore, 1994; Deykin, 1999; Deykin & Buka, 1997;
Dodge, 1993; Dutton et al., 2006; Friedman & Schnurr, 1995; Golding, 1999; Joshi
& O’Donnell, 2003; Lewis, 1992; Perry & Pollard, 1998). Research shows that
former child soldiers have difﬁculties in controlling aggressive impulses and have
little skills for handling life without violence. These children show on-going aggres-
siveness within their families and communities, even after relocation to their home
villages (Wessels, 2006). In a qualitative study, Magambo and Lett (2004) reported
that former child soldiers in northern Uganda mainly applied physical violence to
resolve conﬂicts. Although the children sympathized with victims of violence, they
could not even think of non-violent alternatives, reﬂecting an absence of adequate
Most former child soldiers have spent several critical years of their develop-
ment in captivity, under the constant threat of abuse and manipulation by their
336 E. Schauer and T. Elbert
commanders. Most probably, this period affects the development of a personal
and collective identity (Kanagaratnam, Raundalen, & Asbjornsen, 2005). In
general, children exposed to war and child soldiering show a strong identiﬁcation
with their own group (Gloeckner, 2007; Jensen & Shaw, 1993) and develop a world-
view dominated by political and nationalistic categories (Punamaki & Suleiman,
1990), which often includes pro-war attitudes (Feshbach, 1994). In the Gloeckner
(2007) study, it emerged that the longer children had stayed in abduction, the
stronger was their rebel-related collective identity. But it may be that their col-
lective identiﬁcation might occur post hoc after return to their home communities.
Gloeckner explained that questions and discussions of family and community mem-
bers about the cruelty of the LRA’s actions may activate a process of reasoning
about what had happened. Former beliefs about ‘right’ and ‘wrong’ actions might
clash with current ones, and in order to regain cognitive homeostasis, identiﬁca-
tion with the rebel group is aspired. Interestingly, this study showed a positive
correlation between collective identiﬁcation and reactive aggression (physical and
verbal aggression and anger). In addition, Gloeckner ( 2007) reported that formerly
abducted children with PTSD might be especially vulnerable to accepting simplistic
models of ‘good versus bad’ – a black and white worldview, which is a known cog-
nitive distortion. Although a rigid political view might be protective during exposure
to war events, it might facilitate violent behavior after returning from the ﬁghting to
individuals’ home communities.
Children living in conditions of political violence and war have been described
as ‘growing up too soon’ and ‘losing their childhood’ (Boothby & Knudsen, 2000;
UNICEF, 2005, 2006). Levels of conscience seemed to be signiﬁcantly related to the
severity of PTSD symptomatology, but also with negative schematizations of self
and others and lower self-efﬁcacy ratings (Goenjian et al., 1999; Joseph, Brewin,
Yule, & Williams, 1993; Saigh, Mroueh, Zimmerman, & Fairbanks, 1995).
There is also the discussion on ideological commitment of former child sol-
diers to a cause and its inﬂuence on mental health. Some studies (Muldoon &
Wilson, 2001; Punamaki, 1996) indicate a protective mechanism, associating strong
ideology with good mental health in adolescents, however, mainly in individu-
als who were exposed to low levels of political violence. A recent study among
Tamil child soldiers shows that this protective mechanism only worked in the
group of those who were not among the highest exposure intensity group, e.g.
length of exposure, being wounded, having killed, having tortured, direct combat
(Kanagaratnam et al., 2005). Tibetan refugee children also reported that the sense of
participating in their nation’s struggle against an oppressor and their strong Buddhist
beliefs would have protected them against mental-health difﬁculties and acceler-
ated the healing process (Servan-Schreiber, Le Lin, & Birmaher, 1998). Cognitive
appraisals of experiences seem to matter in symptom development in various forms
14 The Psychological Impact of Child Soldiering 337
and strong feelings of guilt and responsibility might increase trauma symptoms. In
Kanagaratnam’s study (Kanagaratnam et al., 2005) personal achievement in combat,
popularity, knowledge and experience acquired by being a combatant, friendship,
and the support of the community were considered as the best of combat life by the
youngsters; death of friends, killings of their own people, guilt of being responsible
for unnecessary killings, and being confronted with morally conﬂicting situations
were the worst experiences for most of them.
Cognitive, Educational, and Occupational Impairment
When comparing abductees with non-abductees, Blattman (2006) came to the
conclusion that especially traumatic experiences during abduction had an adverse
impact on education, less years of schooling, greater reading problems, lower occu-
pational functioning, and lower work quality later in life. What research has shown
is that exposure to trauma in formative years may affect the maturation of the central
nervous system and the regulatory neuro-endocrine systems, as outlined above.
Resulting from exposure to traumatic stress and PTSD, the inability to concen-
trate and learn often translates into a refusal to attend school and eventual drop-out
(Dodge, 1993). In a study by Duncan (2000), college enrollment rates continued to
drop at each subsequent semester until, by their senior year, only 35% of students
who had suffered multiple abuses were in attendance. In addition, adolescents with
PTSD, compared to adolescents who have suffered a stressful experience but did
not develop PTSD, were shown to have signiﬁcantly lower scores on a standardized
achievement test compared to their controls (Saigh, Mroueh, & Bremner, 1997).
A study by McFarlane and colleagues (McFarlane et al., 1987) showed that
18% of surveyed children after a disaster were underachieving educationally after
8 months; this ﬁgure had a statistically signiﬁcant increase to 25% at 26 months.
The underachieving children were also those with the highest trauma symptom
scores and with the most days absent from school, reporting headaches, stom-
achaches, and feeling miserable and worried as their reasons for absenteeism. Perez
& Widom (1994) asserted that child abuse represents a signiﬁcant risk factor for
poor long-term intellectual and academic outcomes, e.g. lower IQ and reading abil-
ity. Findings of low IQ in traumatized children were also described by Mannarino
and Cohen (1986). In his book ‘Scarred minds,’ Somasundaram (1998) presented a
list of psychosocial problems in adolescents, sampled from six different schools and
colleagues across the war-affected North-Eastern educational zones of Sri Lanka.
Within that study, 28–65% of children reported loss of memory, 33–60% loss of
concentration, and 35–60% loss of motivation to achieve in education.
Besides psychometric testing for psychiatric disorders, our group (Elbert et al.,
2009) undertook cognitive and memory tests in a sub-sample validation group of
Tamil school children, residing at the time in the LTTE-controlled areas of North-
Eastern Sri Lanka. This region had been affected by two decades of civil war at
the time of assessment in 2002. All traumatized children with a diagnosis of PTSD
338 E. Schauer and T. Elbert
in the sample reported lasting interference of experiences with their daily life. The
neuropsychological testing and the investigation of school grades validated mental-
health outcomes further and accentuated some speciﬁc cognitive problems that were
associated with PTSD, especially the deﬁciency in memory functions. In fact, the
affected children’s performance decreased with the number of traumatic events
experienced. The children’s grades in school, when averaged separately for the two
groups and across disciplines, reﬂected that the problems in functioning were mental
in nature, with a focus on deﬁcits in the verbal abilities.
Employment possibilities are already scarce in post-war societies, and resear-
chers observe that ﬁnding a job is even more difﬁcult for ex-combatants (Gear, 2002;
Heinemann-Gruder, Pietz, & Duffy, 2003). Mogapi (2004) reported from the South
African DDR program that ex-combatants, who suffer from a trauma-spectrum dis-
order, have clear-cut difﬁculties on the job, suffer increased concentration problems,
and are more likely to act out aggressively in difﬁcult situations, which eventu-
ally leads to job loss. In turn, the situation of unemployment causes feelings of
helplessness and thus aggravates symptoms of depression in a downward-spiral
Psychological exposure and suffering from trauma can cripple individuals and fam-
ilies, even into the next generations. After having experienced organized violence,
affected parents can leave an imprint in their grandchildren’s generation (Yehuda,
Halligan, & Bierer, 2001). Concern about consequences for offspring, whose moth-
ers were stressed during pregnancy, derives from evidence gained in experimental
biology, as intrauterine stress shows to affect neurodevelopment in animals, which
are thought to be relevant to cognition, aggression, anxiety, and depression in
humans (Seckl & Holmes, 2007). Chronic maternal stress during pregnancy, for
example, interrupts healthy regulation of hormonal activity including cortisol, which
easily crosses the placenta during the ﬁrst two trimesters (Phillips, 2007; Sandman,
Wadhwa, Chicz-DeMet, Porto, & Garite, 1999; Sandman et al., 1999; Weinstock,
1997, 2005). Changed hormonal regulation then can promote a range of emo-
tional and cognitive impairments (Sapolsky, Krey, & McEwen, 1985; Sapolsky,
Uno, Rebert, & Finch, 1990). While the genome, the DNA sequence, remains unaf-
fected by acute stress responses, its readability (i.e. epigenetic alterations) may be
manipulated by a variety of conditions, notably stress hormones (Meaney, Szyf, &
Seckl, 2007). If a pregnant mother is affected by severe and chronic stress, epi-
genetic modiﬁcations in the child may act as a molecular or cellular memory that
tune the offspring for one or several generations for survival in a hostile environ-
ment, making generations more vulnerable for mental illnesses, including suicide
(Szyf, McGowan, & Meaney, 2008). The quality of how a mother is able to attach
to and care for her child alters the expression of genes in the child that regulate
behavioral and endocrine responses to stress, as well as hippocampal plasticity and
14 The Psychological Impact of Child Soldiering 339
development. These effects may contribute to the development of differences in
stress reactivity and certain forms of pathologic cognition.
Literature shows that boys and men with war and combat experiences are more
likely to exhibit violent behavior (Begic & Jokic-Begic, 2001; Bryne & Riggs,
1996; Catani et al., 2008; Glenn et al., 2002). The same can be expected for men
who have a history of child soldiering. In families where men show violent behav-
ior against women, children are maltreated as well (Edleson, 1999; Levendosky &
Graham-Bermann, 2001). In fact, domestic violence against the child’s mother dur-
ing the ﬁrst 6 months of life elevates the risk of physical child abuse three times,
while doubling the risk of emotional abuse and neglect of the child (McGuigan &
Pratt, 2001). Additionally, babies born to traumatized and socially stressed moth-
ers, which certainly can include formerly abducted child-mothers (i.e. women who
gave birth to babies in captivity), are born with a deformed stress regulating sys-
tem (HPA-a), which translates into babies’ higher and faster arousal peaks, longer
intervals of crying and irritability, and impaired affect regulation (Sondergaard
et al., 2003). Such behavior by infants is a challenge for any new parent, but is
a major challenge for a parent who her/himself suffers from a disorder of the
trauma spectrum, has little or no social support and lives in poverty. Parents of
‘highly stressed’ babies report less conﬁdence and joy in their role as caregivers
and the phenomenon of ‘negative reciprocity’ starts to develop (Papousek & von
Hofacker, 1998). In fact, research shows that behaviourally inhibited children,
who are fearful and have a tendency to withdraw, were regarded by their moth-
ers as hard to soothe and received less care and less maternal sensitivity as a
result. This, in turn, heightened the children’s sensitivity to stress and changed
their internal stress-diathesis system towards a biased attention to threat (Fox,
Hane, & Pine, 2007).
A child with reduced abilities for affect regulation, in combination with one
or two traumatized primary caregivers, is a very great potential risk constellation.
Internalized affects of violent and neglectful caretaker models deform the psyche
and can also imprint on the next generation. As a result, the family suffers from
heightened levels of stress, and psychiatric symptoms can be evoked in people
who live with an individual who suffers from PTSD. Violence and trauma at the
time of parents’ childhood may result in problematic attachment relationships that
have long-term consequences for mental health and interpersonal relationships for
their children. An intergenerational cycle of dysfunction is set in motion (Bowlby,
2004; Grossmann, Grossmann, & Waters, 2005; Lewis, 1992; Qouta, Punamaki, &
Sarraj, 2003; Smith, Perrin, Yule, & Rabe-Hesketh, 2001; Solomon, 1988; Zuravin,
McMillen, DePanﬁlis, & Risley-Curtiss, 1996).
The amount of stress encountered in early life sensitizes an organism to a cer-
tain level of adversity; high levels of early-life stress may result in hypersensitivity
to stress later, as well as to adult depression. Beyond epigenetic factors, fearful-
ness and nurturance are transmitted from generation to generation through maternal
behaviour (Parent et al., 2005). Traumatized parents are challenged in providing
secure attachment, because post-traumatic symptoms of emotional numbing might
be hindering emotional closeness. Symptoms of hyperarousal, such as irritability,
340 E. Schauer and T. Elbert
might make it even more challenging to regulate babies and their own affect ade-
quately. Parental sensitivity in pre-empting a child’s need might be impaired, and
‘high expressed emotions’ without sufﬁcient verbalization of the context can ren-
der a small child helpless in understanding parental motivation and intention. It has
been shown that if children live in such unpredictable reward–punishment environ-
ments, their psycho-physiological arousal is signiﬁcantly heightened and will over
time lead to a changed hypothalamic–pituitary–adrenal axis. Beyond coincidence,
researchers clearly note higher rates of psychiatric morbidity in children of sur-
vivors, compared with non-traumatized comparison groups (Ben Arzi, Solomon, &
Dekel, 2000; Bramsen, van der Ploeg, & Twisk, 2002; Dekel & Solomon, 2006;
Dirkzwager, Bramsen, Ader, & van der Ploeg, 2005; Franciskovic et al., 2007;
Solomon et al., 1992; Weinstock, 1997).
A partner, father, or grandmother suffering from traumatization can behave like
a distant, fearful stranger, who cannot tolerate closeness or emotional expression,
even within the family unit. Survivor’s intense and bizarre way of self-expression
in form of irritability, jumpiness, or hypervigilance may be so extreme as to appear
like paranoia and can engender fear, confusion, and a sense of powerlessness in fam-
ily members (Al-Turkait & Ohaeri, 2008; MacDonald, Chamberlain, Long, & Flett,
1999). On the other hand, children of survivors can be equally affected by their par-
ents’ symptoms of numbing and avoidance, which are associated with substantial
decrements in parent–child relationship quality and which prevent normal emo-
tional expression and closeness (Lauterbach et al., 2007). Consequently, children
are forced to operate within a domestic context in which intimacy, as well as affect
regulation, is severely impaired (Almqvist & Broberg, 2003). Avoidance symptoms
seem to have an additional deleterious effect on the parent–child relationship satis-
faction. Studies on fathers, who have experienced numerous war events, show that
feelings of detachment and numbing can carry over to their children, leading to
behavioural problems in the child (Ruscio, Weathers, King, & King, 2002; Samper,
Taft, King, & King, 2004). Based on the vulnerability of surviving a war or growing
up in a post-conﬂict setting, children, in turn, might also become more vulnerable
to forces that incite violence (Somasundaram, 2002; Uppard, 2003).
Social Stigma of Returning Girls and Women
Between the years 1990 and 2003, girls were present in ﬁghting forces (govern-
ment forces, paramilitary/militia, and armed opposition groups) in 55 countries,
and in 38 of these countries they were involved in situations of armed conﬂict
(McKay & Mazurana, 2004). Girls’ roles typically overlap and include work-
ing as spies and informants, in intelligence and communications, and as military
trainers and combatants. They are health workers and minesweepers, and they
may conduct suicide missions. Other support roles include raising crops, selling
goods, preparing food, carrying loot and weapons, and stealing food, livestock, and
seed stock. It is important to understand that underlying these various roles and
14 The Psychological Impact of Child Soldiering 341
activities, girls’ participation is central to sustaining a force because of their pro-
ductive and reproductive labor. As such, they replicate traditional societal gender
roles and patriarchal privilege, whereby girls (and women) serve men and boys.
Honing their labor is a foundation, upon which ﬁghting forces throughout the world
rely (McKay & Mazurana, 2004). The following are three examples of the partici-
pation of girls. The ﬁrst is described by V.A., a female, 20 years at time of therapy
(May 2006), who had spent 10 years in abduction with the LRA, Northern Uganda:
There were many other battles, but this had been the worst one I had been in. This time they
had sent us out to do work in Atiak at night. We separated in smaller groups and were told
to loot the IDP camp there. We were just about to enter when the dogs barked. I squatted
down with others and waited in some distance. The boys went ahead. The idea for us girls
was to shoot and scare soldiers and make the group seem larger. I had a newly abducted
girl with me. A bomb came so fast that I didn’t realise it even detonating. My body was
paralyzed and the bomb particles entered my body. My left arm, the inside of my left leg
and my right leg got wounded. We tried to ﬂee, but I could just move a small distance. The
aeroplane came back to attack us, I ran, taking the newly abducted with me...
J.A. is a female, 15 years at time of therapy (May 2006), who spent 1 year in
abduction with the LRA, Northern Uganda:
It was evening and we were waiting along the roadside. We were many. Most of the rebels
had guns, just like government soldiers. We were in Anaka, hiding in the grass. We had
formed two groups on either side of the road. The rebels with guns were in the front line,
then the other children were seated further behind in the bush. I was in the back. The men
are the ones who do the shooting. Us girls were told to wait and ambush. The command for
the boys was to look out for army vehicles and shoot those. Then we heard the sound. It was
a lorry. It was noisy and colored like an army car. There were people seated in the cabin,
but also many on the back of the truck. My heart was bumping. I feared that these were
government soldiers and that they would attack us. But I saw civilians and calmed down.
The command for shooting was given. Then we saw the truck burning. There was a big ﬁre
and people burnt. We took the loads and ran...
A.A. is a female, 15 years at time of therapy (May 2006), who spent 3 years in
abduction with the LRA in Northern Uganda:
They untied me and I was told to sit with a man. He was a lot older than me, he looked
mature, like a grown-up. I was 13 years at the time. I didn’t like him at ﬁrst sight, but I had
to sit down next to him. He told me that he had sent the boys to go and get him a girl to
be his wife and that I am the one. Then he asked my name only. He spoke no more. My
heart was beating much. I was scared, since I was not sure what he meant. Some people
were cooking greens and I ate some food. After a while the man asked me to come with
him. We went to a clearing under a tree. First, I thought that he takes me aside from the
others, because he wants to kill me. He told me to lie and said that we would sleep there. I
lied down on my side, like going to sleep. He was upset about this and started to beat me.
I was surprised. He slapped my face and head. He said: “Don’t act stupid. You know what I
want from you.” Then he pushed me unto the ground and laid on me. My heart was beating
really fast now. He had a bad body smell. Then he forced himself into me. He said: “if you
cry, I will kill you.” When I heard his words, I got so scared that I actually started crying.
This made him put a gun to my head. He warned me. I could feel the gun. I stopped crying.
He continued raping me and when he was ﬁnished he left me alone. He told me to get up.
I was not able to. Everything in my body pained. From then on, he raped me every night. I
realised that this is how it would be for me. Every night we went to that tree.
342 E. Schauer and T. Elbert
Key gender-based experiences of both women and girls during armed con-
ﬂicts consist of sexual violence, including torture, rape, mass rape, sexual slavery,
enforced prostitution, forced sterilization, forced termination of pregnancies, giv-
ing birth without assistance, and being mutilated (United Nations, 2002). Girls in
ﬁghting forces in Mozambique, Northern Uganda, and Sierra Leone reported sexual
violence, and abducted girls were almost universally raped (McKay & Mazurana,
2004). As was the situation in Sierra Leone, sex labor in Angola was integral to the
function of girl soldiers (Stavrou, 2005). Again, depending on the context, when
they reach puberty, girls may supply reproductive labor through giving birth to and
rearing children, who become members of the force. For example, in the LRA ﬁght-
ing force in Northern Uganda, the leader Joseph Kony has been proliﬁc in fathering
large numbers of children, who have grown up in his force. Physically, girl sol-
diers are challenged to survive as they cope with illnesses, exhaustion, wounds,
menstrual difﬁculties, complications from pregnancy and birth, sexually transmitted
diseases, and a host of other maladies, such as malaria, intestinal parasites, tuber-
culosis, anaemia, diarrhea, malnutrition, disabilities, scars, and burns (McKay &
Mazurana, 2004; Stavrou, 2005).
Returning women, who are perceived to have had sexual relations with combat-
ants, whether forced or voluntarily and/or bring back children from such encounters,
belong to the most stigmatized group of survivors. An example is given by M.K.,
who is a female, 22 years at time of diagnostic interview (January 2009), and who
had been abducted for 6 months by Interahamwe groups, North Kivu, DRC:
Since I was able to run from the Interahamwe and have managed to survive the time in the
forest, my husband does not talk to me anymore. They found me in a village and brought
me to this hospital. Now I am pregnant from the many weeks of rape in the forest and I
am infected, there is a white liquid running from my vagina and great pain in my abdomen.
One of the nurses gave me a mobile phone the other day and I called my husband in Goma,
but he hung the phone up on me when he heard my voice; even though he was there the
night I was raped and abducted by the rebels from our own house. The worst thing is that I
had to leave my two small children behind that night. How are they doing without me? My
son was only 9 months old at the time and I was still breastfeeding him. Sometimes I miss
him so much that I have visions of him lying in a corner of the room here in the hospital
all naked and hungry and crying and I go there and take him into my arms and console him
until one of the women wakes me up from this day dream, I notice that I have tears running
from my eyes.
Most communities regard the illegitimate children as a shame, not only on the
child and mother, but also on the family and the community as a whole, sometimes
forcing mothers to choose either between their child or their community (Redress,
2006). Schalinski and research team (Schalinski et al., submitted) found that a great
number of returning women in Eastern Congo are living in forced separation from
their husbands and experience homelessness after they are back from captivity. This
is especially the case when they are feared infected with STDs and HIV and if
they bring back a child from the time in the forest. In many cultural settings, girls
are unable to get married or re-married and ﬁnd it difﬁcult to enter a new sup-
portive partnership, within which to bring up their children in civilian life. The
environments into which girls reintegrate are also problematic. Domestic violence
14 The Psychological Impact of Child Soldiering 343
and sexual violence are more common in IDP camps and communities of war-torn
areas, as men can be traumatized, depressed, alcoholic, or otherwise aggravated, due
to the strain of war, which can contribute to violent behaviour (Redress, 2006).
Demobilization and reintegration services are still a novelty for formerly
abducted girls and women. Gender disparities that privilege boy soldiers over girls
mean that few girls enter or beneﬁt from formal demilitarization and demobiliza-
tion or from rehabilitation and reintegration programs where the re-adjustment
process can be fostered. These programs are mainly designed to restore security,
and as female combatants are not seen as a major security threat, they are insuf-
ﬁciently targeted (Bouta, 2005). In a study conducted in ﬁve provinces of Eastern
Democratic Republic of Congo, 23 girls, as compared with 1,718 boys, were demo-
bilized by four international NGOs, despite girls being recruited or abducted as
extensively as boys; it was estimated that girls comprise 30–40% of children in
ﬁghting units (Verhey, 2004). Girls’ and women’s full reintegration most likely
encompasses a much more holistic approach, including mental health, reproduc-
tive health and vocational training interventions, because it can not be assumed
that traditional socioeconomic support within marriage is an option for most female
The Challenges of Demobilization and Reintegration
of Child Soldiers
Most children get freed from captivity or from armed groups during combat.
A signiﬁcant number has stayed out in the bush for several years during key phases
of their development, making them feel unfamiliar and at times afraid of civilian life.
Three examples follow. The ﬁrst is K.K.G.’s experience, who is a male, 16 years
at time of diagnostic interview (March 2009), and who spent 3 years as an active
recruit, joining at age 13 years:
How did I get out? The MONUC freed me together with many others. It was a ﬁerce battle
that day, but they won over us. My commander was freed too and he could go his way.
I think he lives in Kinshasa today. Those over 18 years could just take off after a few days,
they were given amnesty and some got offers by the Congolese army to join them. But we
children were taken to different child rehabilitation centers in the province. That is how I
ended up in Bukavu. When I was taken away the commander said to the UN people: “You
know that you are taking my son. I will get him back that is for sure. You just wait for me”.
Since that day I am afraid. I know he has made his way to Bukavu. He has already once
waited for me outside the gates of the children’s center, telling me to come back to the bush
with him. I don’t know what I should do? I fear him greatly, but I also fear this new life.
B.O. is a male, 15 years at time of therapy (May 2006), who spent 4 years as an
active recruit, abducted by the LRA at age 12 in Northern Uganda:
On the 25th of December, Christmas day, we had gone out to get sugar cane. It was 6 pm in
the evening, just before it was getting dark. As we were already in the ﬁelds and harvesting,
the UPDF started ﬁring. There were 7 of us rebels, but the soldiers were many. They were
all hiding in the ground. The ﬁring started and I tried to escape. Suddenly a bullet hit me on
344 E. Schauer and T. Elbert
my back and it came out in the front, just above my heart. I started vomiting blood. There
was this piercing, sharp pain. When I was breathing, it felt like air was coming through
the hole. I was sure that now the time had come, I would die. I kept bleeding, I just let the
blood. I knew I must run, so I made it up to the end of this garden. I was so afraid that the
soldiers would come and get me. I had been left alone. The others had left me. I laid down
again with my face down on the ground and fell unconscious. Soldiers saw me and caught
me the next day. I was so frightened of them, you never knew whether they would kill you
now. They brought me to the nearest IDP camp, where they had a small military post. They
asked: “Where is your gun?”, “Where is your commander?” “Where are the other rebels?”
I told them how we got separated, that I had been alone...I slept in the barracks for two
more nights together with the soldiers. Finally they brought me to Gulu...Tomorrow I will
go back home. First my father has told me to see him in Kitgum, but he is a man who likes
alcohol much, he drinks a lot and is poor. I ﬁnally hope to live with my dear mother. The
thing that is most important for me is my education. I think I can make it, I want to go back
to school so much. I just have to ﬁnd the necessary money. I am sure I will. And one day I
will be a tailor.
A. A. is a female, 15 years at time of therapy (May 2006), who was abducted at
age 13 by the LRA in Northern Uganda:
We were cooking as the intelligence boy came and told us that soldiers were moving towards
our settlement. We abandoned everything and UPDF started to chase us. We had been cross-
ing a swamp when we found the soldiers hiding. We were running on one side and soldiers
on the other. I could see them and at some point we just scattered. The UPDF saw me also,
but they did not aim at me. They saw that I was a girl. I saw many rebel children falling
and dying that day though. Ojok was also there. I liked him a lot. He had been the one
who abducted me. Ojok never got used to killing. He even refused to do it. I liked him for
that. He had a rank in the rebel group. Whenever Ojok saw me being sad, he came over to
me and told me that he will think of a plan to take me home. He was like a brother to me.
I saw him running and ran behind him. I got so frightened. Ojok told me that we are safe
and that I should not worry, but I knew it was not true. I knew we might die any moment.
We kept running. After some time I was hiding under a tree. Ojok saw that, he looked at me
and said: “Get up, we will go home now.” As we started off, we met another girl. We took
her along as well. In a way, both of us were afraid of Ojok. We could not be sure that he
would deliver us. Would he trick us? He reassured us that he would release us. We were so
far from a place of release. We had to walk another night and day to get there. On the way
we passed an old military camp. The soldiers called us and we went to them. They said:
“don’t fear, you are home now.”
Psychiatric distress and malfunctioning, especially when expressed as outward
aggression, irritation, an acting out of intrusions (e.g. ﬂash-backs) and dissociation,
exacerbates ex-combatants’ difﬁculties in reintegrating into communities and the
wider society (Pfeiffer et al., submitted). Ex-combatants suffering from psychiatric
distress might face double stigmatization for having engaged in combat and for
being noticeably psychologically affected. Beyond the multitude of psychological
problems that former child soldiers might be struggling with, there are other hin-
drances that can adversely affect the successful reintegration. Child soldiers carry
a special burden of simultaneously being the recipient and perpetrator of violence
(Boothby & Knudsen, 2000); they are, therefore, a distinct group among children
and adolescents in war regions. They are victimized twofold, because they ﬁrst are
exposed to traumatic experiences and later are blamed and stigmatized for the atroci-
ties they have committed (Bayer et al., 2007). In many cases child soldiers are forced
14 The Psychological Impact of Child Soldiering 345
to commit atrocities against civilians, at times against own family and community
members, which they are required to do so as to cut-off return routes and to inﬂict
increased terror and psychological harm on home communities. These practices may
force the recruited soldiers to violate their own moral principles and to break from
any social attachment (Amone-P’Olak, 2007), ultimately resulting in a pull factor
for re-recruitment. This fact alone challenges their integration and re-acceptance.
However, after such traumatizations, not just the formerly abducted child, but
also the community has changed. On the communal level, the reintegration of ex-
combatants is a reciprocal process that happens within the host communities where
the former ﬁghters are settled. The attitudes of the host communities towards the ex-
combatants are of particular importance for reintegration success (Kingma, 2000).
In some cases, because of assumed or actual abusive violence that combatants have
perpetrated against civilians during war times, the attitudes of host communities
towards former combatants are negative. There is no doubt, and there is empirical
evidence, that adequate social support and other supportive community practices
are truly important mediators of the expression of trauma-related symptoms (Ahern
et al., 2004; Basoglu et al., 1994; Brewin, Andrews, & Valentine, 2000; Coker
et al., 2002; Johnson & Thompson, 2008; Kovacev & Shute, 2004; Mollica, Cui,
McInnes, & Massagli, 2002). A strategy of social support can be an additional sup-
portive element for affected communities, who have lost children to abduction and
child soldiering; yet, this is possible only when a sufﬁcient number of adult com-
munity members remain at least partly protected from the psychological impact
of armed conﬂict, organized violence, and forced displacement. However, many
key community members, such as parents, teachers, elders, counselors, nurses,
lawyers, and doctors in post-conﬂict settings suffer from physical, as well as mental
impairment, incapacitating their normal, healthy ability to function as caretak-
ers, providers, and role models. Neither local healers nor religious leaders, who
have traditionally offered health-related services, or carried out re-integration mea-
sures for individuals who had committed harm in the community, nowadays have
remained unaffected by the stressors of war and violence (Glenn et al., 2002;
Human Rights Watch, 2000; Kenyon Lischer, 2006; Pittaway, 2004; Solomon, 1988;
UNHCR, 2003; van de Put, Somasundaram, Kall, Eisenbruch, & Thomassen, 1998;
Widom, 1989). As members of the Children and War Foundation (Dyregrov, Gupta,
Gjestad, & Raundalen, 2002, p. 138) state:
There are some war situations that are so unprecedented, i.e. massacres in the community,
that no cultures have societal healing or coping mechanisms to apply.
Thus, the culturally indigenous mechanisms of healing and reconciliation at the
family and community level, which might have served in the rehabilitation of return-
ing child soldiers, are in most settings not available anymore. It is not surprising that
former abductees report difﬁculties when coming home to their community after
abduction, especially those who met criteria for symptoms of PTSD. Researchers
(MacMullin & Loughry, 2004; Pham et al., 2009) have found that formerly abducted
children in Northern Uganda do experience difﬁculties in psychosocial adjustment,
346 E. Schauer and T. Elbert
especially when suffering from clinical symptoms of the post-traumatic stress syn-
drome and depression. Affected youngsters not only experience more feelings of
hopelessness and fear, but also more difﬁculties with regard to peer interaction,
family interaction, and community activities, when compared with less clinically
In reintegration programs, ex-combatants with PTSD are considered an espe-
cially problematic group. Recent studies, which have examined the prevalence of
psychological effects after conﬂict, suggest that traumatic exposure and resultant
symptoms of PTSD and depression can inﬂuence how individuals perceive mecha-
nisms aimed at promoting justice and reconciliation. In 2004, Pham and colleagues
(Pham, Weinstein, & Longman, 2004) investigated this association in 2074 adult
survivors of the Rwandan genocide. The ﬁndings indicated that traumatic exposure
and PTSD symptoms were associated with negative attitudes towards reconcilia-
tion. Bayer’s group (Bayer et al., 2007) undertook a similar research, in that they
tried to understand the association of trauma and PTSD symptoms with openness to
reconciliation and feelings of revenge among former Ugandan and Congolese child
soldiers. The results indicated that those among the group of former child soldiers
(girls and boys alike), who showed clinically relevant symptoms of PTSD, had sig-
niﬁcantly less openness to reconciliation and signiﬁcantly more feelings of revenge
than those with fewer symptoms. Likewise, the children with PTSD symptoms
might regard acts of retaliation as an appropriate way to recover personal integrity
and to overcome their traumatic experience. In the former Yugoslavia, Basoglu and
team (Basoglu et al., 2005) similarly found that PTSD severely impedes processes of
reconciliation and reintegration: war survivors exposed to war-related traumata dis-
played stronger emotional responses to perceived impunity, including anger, rage,
distress, and desire for revenge, than those who did not experience war. Moreover
traumatized survivors showed less belief in the benevolence of people and reported
demoralization, helplessness, pessimism, fear, and loss of meaning in and control
over life. Vinck et al.’s (2007) study found a very similar association between sur-
vivors’ symptoms of PTSD and depression and their attitude toward peace. Those
who met the PTSD symptom criteria were more likely to favor violent means to
end the conﬂict, while those with depression symptoms were less likely to identify
non-violence means to achieve peace. In these populations, psychological symp-
toms associated with the trauma may be closely related to a desire for retribution,
rather than restorative ways to deal with past violence.
There seems to be also a link between symptoms of traumatization, aggres-
sion, and perceived stigmatization in returning, former child soldiers (Allen &
Schomerus, 2006; Annan & Blattman, 2006; Corbin, 2008; Pfeiffer et al., submit-
ted). In the United States, attitudes of the home environment were found to have a
high impact on adult ex-combatants’ ability to cope with war and trauma and the
subsequent psychopathological development. This effect has been conceptualized
as the ‘home-coming reception’ (Fontana & Rosenheck, 1994). Having belonged to
a faction that was very abusive towards civilians during the civil war in Sierra Leone
had a signiﬁcant negative effect on reintegration (Humphreys & Wienstein, 2005).
Our study (Pfeiffer et al., submitted) showed that stigmatization of any kind (e.g.
14 The Psychological Impact of Child Soldiering 347
being called names, such as ‘killer,’ being accused by community members to have
an ‘evil rebel mind’ or ‘disturbed mind,’ or being forcefully pushed away from the
well while fetching water) is reported by 73% of the formerly abducted youths. In
this study, stigmatization was also found to be associated with symptoms of PTSD
and clinical depression, as well as with elevated levels of aggression. Stigmatization
was connected more closely to heightened levels of psychopathology than to the
mere fact of having been abducted. The authors’ assumption is that children, who
have a mental illness as a result of their time in the bush and show symptoms of the
trauma spectrum, are the ones who are stigmatized, primarily because they behave
‘different’, e.g. experience nightmares, behavioural acting out, are prone to bizarre-
looking forms of dissociation, and choose to stay alone and distant from others. In
the same sample, increased levels of aggression (e.g. verbal, physical, anger, and
hostility) were found in the group of former abductees, with 31.6% showing height-
ened aggressiveness. Aggression was associated with having a history of abduction,
an increased level of perceived stigmatization, heightened symptoms of psycholog-
ical disorders, and having survived a higher number of traumatic experiences. The
score on aggression additionally showed a connection to higher identiﬁcation with
the rebel group. Interestingly, having been forced to kill and the duration of abduc-
tion did not predict heightened aggression, suggesting that it is the overall score
of psychological symptoms, resulting from traumatic experiences during abduction,
which drives levels of aggression and stigmatization, as well as identiﬁcation with
the rebel group. There were no gender differences in these ﬁndings.
Social isolation and the formation of ex-combatants as a distinct civilian sub-
group area consequence of the combined effects of factors, which include host
communities’ negative attitudes towards ex-combatants and their psychological
problems causing difﬁculties in social interactions. The risk of re-recruitment
heightens when ex-combatants fail to reintegrate economically and socially into
their civil host communities. When a sufﬁciently large number of former combat-
ants and of civilians are affected by war-related psychological problems, and remain
without assistance for psychological rehabilitation, the opportunity to initiate self-
sustained ways of living and with it, substantial economic development, will be
considerably reduced. Another round in the cycle of violence seems inevitable if
psychological wounds are not addressed. Children know that hidden weapons and
former comrades are always waiting somewhere out there.
I often think of all these children out there who still suffer and try to survive. So many
people out there went through the same thing as I did. When I go through town here, there
are so many children I recognize from the bush and they recognize me. Those who know me
from the bush when we meet say, “we came back, and now you are also back, who would
have thought?” If they can manage, I can also survive. When you ask me about 5 years
from now where I would like to be in life, then I say, if all goes very well I will survive and
be alive.” V.O., male, 18 years at time of therapy (October 2008), who was abducted twice
(ﬁrst time at age 4 for 7 years, second time at age 13 for 2 years) by the LRA, Northern
348 E. Schauer and T. Elbert
Social and traumatic stress, caused by multiple experiences of violence, has a
severe negative impact for the reintegration of ex-combatants and child soldiers
on several levels. Rehabilitative efforts on all related levels are needed to increase
the successful reintegration of former combatants into civil society; most impor-
tantly, their mental-health needs must be attended to. A most likely, but largely
unstudied, driver of the cycle of violence might be the detrimental impact of expe-
riencing massive violence and abuse on individuals’ psychological functioning,
and the related social dynamics and consequences for communities. Reconciliation
and peace building might be impeded by the psychological problems of a crit-
ical mass of individuals. In particular, large-scale violence may cause patterns
of emotional and cognitive processing, which might feed into further violence
(Schauer & Schauer, 2010 this volume). War-related severe stress, even though
transient, indelibly changes an individual on various levels. On a cognitive level,
traumatic experiences shatter the most fundamental beliefs about safety, trust, and
self-esteem, which lend instability and psychological incoherence to the individ-
ual’s internal and external worlds (Janoff-Bulman, Berg, & Harvey, 1998). As
a consequence of a shattered belief system, the world is perceived as basically
unsafe, frightening, and evil. Victims feel weak, dependent, and without the con-
trol and competence that is vital for the psychological and cognitive coping with the
environment. Severely psychologically affected, formerly abducted children need
more clinical, therapeutic attention, rather than unspeciﬁc psychosocial or social
approaches. In reality, current rehabilitation interventions for former child soldiers
focus on brief vocational training, family tracing, and reuniﬁcation. The latter two
are done with the assumption being that once a child lives with his or her family
again, the psychological wounds will automatically heal.
It must be clearly understood that as of today, no structures are in place to ade-
quately address the psychological rehabilitation needs of formerly abducted children
and child soldiers in the Great Lakes region of Africa or any other resource-poor,
conﬂict-stricken region of the world. In fact, child combatants have a particularly
high risk of being left out or marginalized by international programs in the reintegra-
tion process (Colletta, Boutwell, & Clare, 2001). They are especially vulnerable for
reintegration failure. Only in recent years, the fact that both these vulnerable groups
and ex-combatants in post-conﬂict countries suffer from psychological problems
has been recognized. The acknowledgement that many of them are unable to proﬁt
from standard reintegration tools, due to severe psychological distress, daily mal-
functioning, and gender-based discrimination, is slowly leading to the inclusion of
special program steps for this group. The lack of programs is a clear neglect of the
international community’s obligation to psychologically rehabilitate former child
soldiers, according to Article 39 of the United Nations Convention on the Rights of
the Child (United Nations, 1987).
In the absence of psychological rehabilitation services, efforts to promote social
reconstruction may be undermined, because rates of abduction are near 50% of
the overall population in war-affected regions, such as Northern Uganda, Angola,
and parts of the Democratic Republic of Congo (Pfeiffer et al., submitted; Roberts,
Ocaka, Browne, Oyok, & Sondorp, 2008; Vinck et al., 2007). A critical mass of
14 The Psychological Impact of Child Soldiering 349
affected persons in a given society can, therefore, be assumed lost as potential
pro-active, mediating community agents for change and development (Schauer &
Schauer, 2010 this volume). These child ex-combatants are, to a great extent,
impaired in their daily functioning. This outcome of traumatization has far-reaching
consequences for the process of reconciliation, peace building and development
within their communities and post-war areas at large. It might even fuel cycles
of violence, reaching into following generations. Providing them with speciﬁc,
trauma-focused, public mental-health services (see Chapters 9, 16) might be a key
component for breaking this vicious circle.
Acknowledgements We highly appreciate the hard work and dedication of our team members at
the NGO vivo (www.vivo.org), as well as the adjunct Department of Clinical Psychology at the
University of Konstanz, Germany (www.clinical-psychology.uni-konstanz.de). Most importantly,
our respect and thanks goes to our local counselors and collaborating colleagues in the various
places of (post-)conﬂict, but especially to all the boys and girls who have experienced abduction
and child soldiering and who persevere so bravely in their struggle for a better tomorrow. Research
for this chapter was supported by the NGO vivo, the Deutsche Forschungsgemeinschaft (DFG),
the University of Konstanz, Germany, the European Refugee Funds (EFF and ERF), as well as the
‘Herz fuer Kinder Fund’, Hamburg, Germany.
AACAP. (1998). AACAP Ofﬁcial Action. Practice parameters for the assessment and treatment of
children and adolescents with post traumatic stress disorder. Journal of the American Academy
of Child and Adolescent Psychiatry, 37(10 Supplement), 4S–26S.
Ahern, J., Galea, S., Fernandez, W. G., Koci, B., Waldman, R., & Vlahov, D. (2004). Gender,
social support, and posttraumatic stress in postwar Kosovo. The Journal of nervous and mental
disease, 192(11), 762–770.
Al-Turkait, F. A., & Ohaeri, J. U. (2008). Psychopathological status, behavior problems, and family
adjustment of Kuwaiti children whose fathers were involved in the ﬁrst gulf war. Child and
Adolescent Psychiatry and Mental Health, 2(1), 12.
Alfredson, L. (2001). Sexuelle Ausbeutung von Kindersoldaten: Globale Dimensionen und Trends
[Sexual exploitation of child soldiers: Global dimensions and trends]. Terre des Hommes.
Allen, T., & Schomerus, A. (2006). A Hard Homecoming, Lesssons Learned form the Reception
Center Process in Northern Uganda. New York & Washington: United Nations Children
Fund & United States Agency for International Development.
Allwood, M. A., Bell-Dolan, D., & Husain, S. A. (2002). Children’s trauma and adjustment reac-
tions to violent and nonviolent war experiences. Journal of the American Academy of Child and
Adolescent Psychiatry, 41(4), 450–457.
Almqvist, K., & Brandell-Forsberg, M. (1997). Refugee children in Sweden: post-traumatic stress
disorder in Iranian preschool children exposed to organized violence. Child Abuse & Negl,
Almqvist, K., & Broberg, A. G. (2003). Young children traumatized by organized violence together
with their mothers – the critical effects of damaged internal representations. Attachment &
human development, 5(4), 367–380; discussion 409–314.
Altemus, M., Dhabhar, F. S., & Yang, R. (2006). Immune function in PTSD. Annals of the
New York Academy of Sciences, 1071, 167–183.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders –
DSM-IV-TR (Vol. 4th ed., Text Rev.). Washington.
Amone-P’Olak, K. (2005). Psychological impact of war and sexual abuse on adolescent girls in
Northern Uganda. Intervention, 3(1), 33–45.
350 E. Schauer and T. Elbert
Amone-P’Olak, K. (2007). Coping with Life in Rebel Captivity and the Challenge of Reintegrating
Formerly Abducted Boys in Northern Uganda. Journal of Refugee Studies, 20(4), 641–661.
Annan, J., & Blattman, C. (2006). Survey of war affected youth. Kampala: United Nations Children
APA. (1994). Diagnostic and Statistical manual of mental disorders – DSM-IV-TR (Vol. 4th ed.,
Text Rev.). Washington.
Barath, A. (2002). Children’s well-being after the war in Kosovo: survey in 2000. Croatian Medical
Journal, 43(2), 199–208.
Basoglu, M., Livanou, M., Crnobaric, C., Franciskovic, T., Suljic, E., Duric, D., et al. (2005).
Psychiatric and cognitive effects of war in former yugoslavia: association of lack of redress for
trauma and posttraumatic stress reactions. The journal of the American Medical Association,
Basoglu, M., Paker, M., Paker, O., Ozmen, E., Marks, I., Incesu, C., et al. (1994). Psychological
effects of torture: a comparison of tortured with nontortured political activists in Turkey.
American Journal of Psychiatry, 151(1), 76–81.
Bayer, C. P., Klasen, F., & Adam, H. (2007). Association of trauma and PTSD symptoms with
openness to reconciliation and feelings of revenge among former Ugandan and Congolese child
soldiers. The journal of the American Medical Association, 298(5), 555–559.
Begic, D., & Jokic-Begic, N. (2001). Aggressive behavior in combat veterans with post-traumatic
stress disorder. Military Medicine, 166(8), 671–676.
Ben Arzi, N., Solomon, Z., & Dekel, R. (2000). Secondary traumatization among wives of PTSD
and post-concussion casualties: distress, caregiver burden and psychological separation. Brain
injury, 14(8), 725–736.
Berman, H. (2001). Children and war: current understandings and future directions. Public Health
Nursing, 18(4), 243–252.
Beth, V. (2001). Child soldiers: Preventing, demobilizing and reintegraing (No. 23). Washington:
Bichescu, D., Schauer, M., Saleptsi, E., Neculau, A., Elbert, T., & Neuner, F. (2005). Long-
term consequences of traumatic experiences: an assessment of former political detainees in
Romania. Clinical practice and epidemiology in mental health, 1(1), 17.
Blattman, C. (2006). The consequences of child soldiering. Retrieved January 30, 2007, from
Blattman, C. (2007, 4 February 2009). The causes of child soldiering: evidence from Northern
Uganda. Paper presented at the Meeting of the International Studies Association 48th Annual
Convention, Hilton Chicago.
Boothby, N. (1994). Trauma and violence among refugee children. In A. J. Marsella, T.
Bornemann, S. Ekblad & J. Orley (Eds.), Amidst peril and pain: The mental health and well-
being of the world’s refugees (pp. 239–259). Washington, DC, USA: American Psychological
Boothby, N., & Knudsen, C. M. (2000). Waging a new kind of war. Children of the gun. Scientiﬁc
American, 282(6), 60–65.
Boscarino, J. A. (2004). Posttraumatic stress disorder and physical illness: results from clinical and
epidemiologic studies. Annals of the New York Academy of Sciences, 1032, 141–153.
Boscarino, J. A. (2006). Posttraumatic stress disorder and mortality among U.S. Army veterans 30
years after military service. Annals of Epidemiology, 16(4), 248–256.
Bouta, T. (2005). Gender and disarmament, demobilization and reintegration: Building blocs for
Dutch policy. The Hague: Netherlands Institute of International Relations ‘Clingendael’.
Bowlby, R. (2004). Fifty Years of Attachment Theory. London: Karnac Books.
Bramsen, I., van der Ploeg, H. M., & Twisk, J. W. (2002). Secondary traumatization in Dutch
couples of World War II survivors. Journal of Consulting and Clinical Psychology, 70(1),
Bremner, J. D., & Narayan, M. (1998). The effects of stress on memory and the hippocampus
throughout the life cycle: implications for childhood development and aging. Development and
psychopathology, 10(4), 871–885.
14 The Psychological Impact of Child Soldiering 351
Brett, R., & Specht, I. (2004). Young soldiers: Why they choose to ﬁght. Colorado: Lynne Rienner.
Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttrau-
matic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology,
Bryne, C. A., & Riggs, D. (1996). The cycle of trauma: relationship aggression in male Vietnam
veterans with symptoms of posttraumatic stress disorder. Violence and Victims, 11, 213–225.
Burton, D., Foy, D., Bwanausi, C., Johnson, J., & Moore, L. (1994). The relationship between
traumatic exposure, family dysfunction, and post-traumatic stress symptoms in male juvenile
offenders. Journal of Traumatic Stress, 7(1), 83–93.
Cairns, E. (1996). Children and political violence. Oxford, UK: Blackwell.
Catani, C., Jacob, N., Schauer, E., Mahendran, K., & Neuner, F. (2008). Family violence, war, and
natural disasters: a study of the effect of extreme stress on children’s mental health in Sri Lanka.
BMC Psychiatry, 8, 33.
Catani, C., Schauer, E., Elbert, T., Missmahl, I., Bette, J. P., & Neuner, F. (2009). War trauma, child
labor, and family violence: life adversities and PTSD in a sample of school children in Kabul.
Journal of Traumatic Stress, 22(3), 163–171.
Catani, C., Schauer, E., Onyut, L. P., Schneider, C., Neuner, F., Hirth, M., et al. (2005, June 2005).
Prevalence of PTSD and building-block effect in school children of Sri Lanka’s North-Eastern
conﬂict areas. Paper presented at the European Society for Traumatic Stress Studies (ESTSS),
Chilcoat, H. D., & Breslau, N. (1998). Posttraumatic stress disorder and drug disorders: testing
causal pathways. Archives of General Psychiatry, 55(10), 913–917.
Child Soldier. (2001). Questions & Answers. Retrieved 22 September, 2006, from http://www.
Coalition to Stop the Use of Child Soldiers. (2004). Child soldiers global report 2004.
Coalition to Stop the Use of Child Soldiers. (2007). Who are child soldiers? Questions & Answers
Retrieved September 4, 2009, from http://www.child-soldiers.org/coalition/the-coalition
Coalition to Stop the Use of Child Soldiers. (2008). Child soldiers global report 2008. Retrieved
February 2009, from http://www.child-soldiers.org/childsoldiers
Coker, A. L., Smith, P. H., Thompson, M. P., McKeown, R. E., Bethea, L., & Davis, K. E. (2002).
Social support protects against the negative effects of partner violence on mental health. Journal
of Womens Health and Gender Based Medicine, 11(5), 465–476.
Colletta, N., Boutwell, J., & Clare, M. (2001). The World Bank, Demobilization, and Social
Reconstruction. In C. C. o. P. D. Conﬂict (Ed.), Light weapons and civil conﬂict – controlling
the tools of violence. New York: Rowman & Littleﬁeld Publishers.
Collier, P. (2003). Breaking the conﬂict trap: Civil war and development policy. Oxford: Oxford
Corbin, J. N. (2008). Returning home: resettlement of formerly abducted children in Northern
Uganda. Disasters, 32(2), 316–335.
Dekel, R., & Solomon, Z. (2006). Secondary traumatization among wives of Israeli POWs: the role
of POWs’ distress. Social Psychiatry and Psychiatric Epidemiology, 41(1), 27–33.
Derluyn, I., Broekaert, E., Schuyten, G., & De Temmerman, E. (2004). Post-traumatic stress in
former Ugandan child soldiers. The journal Lancet, 363(9412), 861–863.
Deykin, E. Y. (1999). Posttraumatic stress disorder childhood and adolescence: A review.
Retrieved 01 October 2006, from www.tgorski.com
Deykin, E. Y., & Buka, S. L. (1997). Prevalence and risk factors for posttraumatic stress disorder
among chemically dependent adolescents. American Journal of Psychiatry, 154(6), 752–757.
Dickson-Gomez, J. (2002). The sound of barking dogs: violence and terror among Salvadoran
families in the postwar. Medical Anthropology Quarterly, 16(4), 415–438.
Dirkzwager, A. J., Bramsen, I., Ader, H., & van der Ploeg, H. M. (2005). Secondary traumatization
in partners and parents of Dutch peacekeeping soldiers. Journal of Family Psychology, 19(2),
Dodge, K. A. (1993). Social-cognitive mechanisms in the development of conduct disorder and
depression. Annual Review of Psychology, 44, 559–584.
352 E. Schauer and T. Elbert
Druba, V. (2002). The problem of child soldiers. International Review of Education, 48(3–4),
Duncan, R. D. (2000). Childhood maltreatment and college drop-out rates: Implications for child
abuse researchers. Journal of Interpersonal Violence, 15(9), 987–995.
Dutton, M. A., Green, B. L., Kaltman, S. I., Roesch, D. M., Zefﬁro, T. A., & Krause, E. D. (2006).
Intimate Partner Violence, PTSD, and Adverse Health Outcomes. Journal of Interpersonal
Violence, 21(7), 955–968.
Dyregrov, A., Gjestad, R., & Raundalen, M. (2002). Children exposed to warfare: a longitudinal
study. Journal of Traumatic Stress, 15(1), 59–68.
Dyregrov, A., Gupta, L., Gjestad, R., & Raundalen, M. (2002). Is the Culture Always Right?
Traumatology, 8(3), 135–145.
Dyregrov, A., & Yule, W. (2006). A Review of PTSD in Children. Child and Adolescent Mental
Health, 11(4), 176–184.
Eckart, C., Stoppel, C., Kaufmann, J., Tempelmann, C., Hinrichs, H., & Elbert, T., et al. (2010).
Patients with PTSD show structural alterations in neural networks associated with memory
processes and emotion regulation. Journal of Psychiatry and Neuroscience. in press.
Eddleston, M., Sheriff, M. H. R., & Hawton, K. (1998). Deliberate self harm in Sri Lanka: an
overlooked tragedy in the developing world. BMJ, 317(7151), 133–135.
Edleson, J. L. (1999). The overlap between child maltreatment and woman battering. Violence
against Women, 5(2), 134–154.
Ehntholt, K. A., & Yule, W. (2006). Practitioner review: assessment and treatment of refugee chil-
dren and adolescents who have experienced war-related trauma. Journal Child Psychology and
Psychiatry, 47(12), 1197–1210.
Elbedour, S., ten Bensel, R., & Bastien, D. T. (1993). Ecological integrated model of children of
war: individual and social psychology. Child Abuse and Neglect, 17(6), 805–819.
Elbert, T., Rockstroh, B., Kolassa, I. T., Schauer, M., & Neuner, F. (2006). The Inﬂuence of
Organized Violence and Terror on Brain and Mind – a Co-Constructive Perspective. In P. Baltes,
P. Reuter-Lorenz & F. Rosler (Eds.), Lifespan development and the brain: the perspective of
biocultural co-constuctivism (pp. 326–349). Cambridge, UK: Cambridge University Press.
Elbert, T., & Schauer, M. (2002). Burnt into memory. Nature, 419(6910), 883.
Elbert, T., Schauer, M., Schauer, E., Huschka, B., Hirth, M., & Neuner, F. (2009). Trauma-related
impairment in children – an survey in Sri Lankan provinces affected by armed conﬂict. Child
Abuse and Neglect, 33, 238–246.
Escalona, R., Achilles, G., Waitzkin, H., & Yager, J. (2004). PTSD and somatization in women
treated at a VA primary care clinic. Psychosomatics, 45(4), 291–296.
Famularo, R., Fenton, T., Kinscherff, R., & Augustyn, M. (1996). Psychiatric comorbidity in
childhood post traumatic stress disorder. Child Abuse and Neglect, 20(10), 953–961.
Feshbach, S. (1994). Nationalism, Patriotism and Aggression. In R. Huesmann (Ed.), Aggressive
behavior: Current perspectives. New York: Springer.
Fletcher, K. E. (1996). Childhood posttraumatic stress disorder. In E. J. Mash & R. Barkley (Eds.),
Child psychopathology (pp. 242–276). New York, USA: Guilford Press.
Fontana, A., & Rosenheck, R. (1994). Traumatic war stressors and psychiatric symptoms among
World War II, Korean, and Vietnam War veterans. Psychology and Aging, 9(1), 27–33.
Fontana, A., Rosenheck, R., & Brett, E. (1992). War zone traumas and posttraumatic stress disorder
symptomatology. Journal of Nervous and Mental Disease, 180(12), 748–755.
Ford, J. D., Campbell, K. A., Storzbach, D., Binder, L. M., Anger, W. K., & Rohlman, D. S.
(2001). Posttraumatic stress symptomatology is associated with unexplained illness attributed
to Persian Gulf War military service. Psychosom Medicine, 63(5), 842–849.
Fox, N. A., Hane, A. A., & Pine, D. S. (2007). Plasticity for Affective Neurocircuitry: How the
Environment Affects Gene Expression. Current Directions in Psychological Science, 16(1),
Franciskovic, T., Stevanovic, A., Jelusic, I., Roganovic, B., Klaric, M., & Grkovic, J. (2007).
Secondary traumatization of wives of war veterans with posttraumatic stress disorder. Croatian
Medical Journal, 48(2), 177–184.
14 The Psychological Impact of Child Soldiering 353
Friedman, M. J., & Schnurr, P. P. (1995). The Relationship between Trauma, Posttraumatic Stress
Disorder and Physical Health. In M. J. Friedman, D. S. Charney & A. Y. Deutch (Eds.),
Neurobiologica and Clinical Consequences of Stress: From Normal Adaptation to PTSD
(pp. 507–524). Philadelphia: Lippincott-Raven Publishers.
Garcia-Peltoniemi, R. E. (1998). Clinical manifestations of psychopathology In NIMH (Ed.),
Mental health services for refugees. Rockville MD: US Department of Health.
Gear, S. (2002). Wishing us away: Challenges facing ex-combatants in the ‘new’ South
Africa. Violence and Transition Series, 8, from http://www.csvr.org.za/docs/militarisation/
Glenn, D. M., Beckham, J. C., Feldman, M. E., Kirby, A. C., Hertzberg, M. A., & Moore, S.
D. (2002). Violence and hostility among families of Vietnam veterans with combat-related
posttraumatic stress disorder. Violence and Victims, 17(4), 473–489.
Gloeckner, F. (2007). PTSD and collective indentity in former ugandan child soldiers. University
of Konstanz, Konstanz.
Goenjian, A. K., Stilwell, B. M., Steinberg, A. M., Fairbanks, L. A., Galvin, M. R., Karayan, I.,
et al. (1999). Moral development and psychopathological interference in conscience function-
ing among adolescents after trauma. Journal of the American Academy of Child and Adolescent
Psychiatry, 38(4), 376–384.
Golding, J. M. (1999). Intimate Partner Violence as a Risk Factor for Mental Disorders: A Meta-
Analysis. Journal of Family Violence, 14(2), 99–132.
Grossmann, K. E., Grossmann, K., & Waters, E. (2005). Attachment from infancy to adulthood:
The major longitudinal studies. New York: Guilford Press.
Heinemann-Gruder, A., Pietz, T., & Duffy, S. (2003). Turning Soldiers into a Work Force –
Demobilization and Reintegration in Post-Dayton Bosnia and Herzegonvina (Brief No. 27)
(pp. 0–46). Bonn International Center for Conversion.
Hendin, H., & Haas, A. P. (1991). Suicide and guilt as manifestations of PTSD in Vietnam combat
veterans. American Journal of Psychiatry, 148(5), 586–591.
Hicks, M. H., & Spagat, M. (2008). The Dirty War Index: A Public Health and Human Rights Tool
for Examining and Monitoring Armed Conﬂict Outcomes. PLoS Medicine, 5(12), e243.
Hiley-Young, B., Blake, D. D., Abueg, F. R., Rozynko, V., & Gusman, F. D. (1995). Warzone
violence in Vietnam: an examination of premilitary, military, and postmilitary factors in PTSD
in-patients. Journal of Traumatic Stress, 8(1), 125–141.
Hubbard, J., Realmuto, G. M., Northwood, A. K., & Masten, A. S. (1995). Comorbidity of psychi-
atric diagnoses with posttraumatic stress disorder in survivors of childhood trauma. Journal of
the American Academy of Child and Adolescent Psychiatry, 34(9), 1167–1173.
Human Rights Watch. (2000). Seeking Protection: Addressing Sexual and Domestic Violence in
Tanzania’s Refugee Camps. Human Rights Watch.
Human Rights Watch. (2009). DRC: ICC’s First Trial Focuses on Child Soldiers [Electronic
Version]. News. Retrieved August 2009 from http://www.hrw.org/en/news/2009/01/22/drc-icc-
Humphreys, M., & Wienstein, J. (2005). Disentangling the determinants of successful disarmament
and demobilization (No. 69). Washington, DC: Center for Global Development.
ICRC. (1994). Children and War. Geneva, Switzerland: International Committee of the Red Cross.
International Labor Organization (ILO). (2003). Wounded Childhood: The Use of Child
Soldiers in Armed Conﬂict in Central Africa. Retrieved 30 January, 2007, from http://www.
Ironson, G., Wynings, C., Schneiderman, N., Baum, A., Rodriguez, M., Greenwood, D., et al.
(1997). Posttraumatic stress symptoms, intrusive thoughts, loss, and immune function after
Hurricane Andrew. Psychosomatic medicine, 59(2), 128–141.
Janoff-Bulman, R. (1992). Shattered Assumptions. New York: Free Press.
Janoff-Bulman, R., Berg, M., & Harvey, J. H. (1998). Disillusionment and the creation of
values: from traumatic losses to existential gains. In J. H. Harvey (Ed.), Perspectives on loss –
a sourcebook. Philadelphia: Pa.: Brunner/Mazel.
354 E. Schauer and T. Elbert
Jayawardena, W. (2001, October 21). Over sixty per cent of all forced recruitment to the Tigers are
children. Review of the 26th and 27th Bulletin of the University Teachers for Human Rights
Jaffna. The Sunday Island, 7–9.
Jensen, P. S., & Shaw, J. (1993). Children as victims of war: current knowledge and future research
needs. Journal of the American Academy of Child and Adolescent Psychiatry, 32(4), 697–708.
Johnson, H., & Thompson, A. (2008). The development and maintenance of post-traumatic stress
disorder (PTSD) in civilian adult survivors of war trauma and torture: a review. Clinical
Psychology Review, 28(1), 36–47.
Joseph, S. A., Brewin, C. R., Yule, W., & Williams, R. (1993). Causal attributions and post-
traumatic stress in adolescents. Journal of Child Psychology and Psychiatry, 34(2), 247–253.
Joshi, P. T., & O’Donnell, D. A. (2003). Consequences of child exposure to war and terrorism.
Clinical Child and Family Psychology Review, 6(4), 275–292.
Kaldor, M. (1999). New and old wars: organized violence in a global area. London: Blackwell.
Kanagaratnam, P., Raundalen, M., & Asbjornsen, A. E. (2005). Ideological commitment and post-
traumatic stress in former Tamil child soldiers. Scandinavian journal of psychology, 46(6),
Kang, H. K., & Bullman, T. A. (2008). Risk of suicide among US veterans after returning from the
Iraq or Afghanistan war zones. Jama, 300(6), 652–653.
Karunakara, U. K., Neuner, F., Schauer, M., Singh, K., Hill, K., Elbert, T., et al. (2004). Traumatic
events and symptoms of post-traumatic stress disorder amongst Sudanese nationals, refugees
and Ugandans in the West Nile. African Health Sciences, 4(2), 83–93.
Keane, T. M., & Kaloupek, D. G. (1997). Comorbid psychiatric disorders in PTSD. Implications
for research. Annals of theNew York Academy of Sciences, 821, 24–34.
Kenyon Lischer, S. (2006). Dangerous sanctuaries: Refugee camps, civil war and the dilemmas of
humanitarian aid. New York: Cornell University Press.
Kessler, R. C. (2000). Posttraumatic stress disorder: the burden to the individual and to society.
Journal of Clinical Psychiatry, 61 (Suppl 5), 4–12; discussion 13–14.
Kingma, K. (2000). Demobilization in sub-saharan Africa. London: Macmillan Press.
Kinzie, J. D., Sack, W., Angell, R., Clarke, G., & Ben, R. (1989). A three-year follow-up of
Cambodian young people traumatized as children. Journal of the American Academy of Child
and Adolescent Psychiatry, 28(4), 501–504.
Kinzie, J. D., Sack, W. H., Angell, R., Manson, S., & Rath, B. R. (1986). The psychiatric effects of
massive trauma on Cambodian children. Journal of the American Academy of Child Psychiatry,
Kolassa, I. T., & Elbert, T. (2007). Structural and functional neuroplasticity in relation to traumatic
stress. Current Directions in Psychological Science, 16, 326–329.
Kolassa, I.-T., Ertl, V., Eckart, C., Kolassa, S., Onyut, L. P., & Elbert, T. (in press). The proba-
bility of spontaneous remission from PTSD depends on the number of traumatic event types
experienced. Psychological Trauma: Theory, Research, Practice, and Policy.
Kolassa, I. T., Wienbruch, C., Neuner, F., Schauer, M., Ruf, M., Odenwald, M., et al. (2007).
Altered oscillatory brain dynamics after repeated traumatic stress. BMC Psychiatry, 7, 56.
Kovacev, L., & Shute, R. (2004). Acculturation and social support in relation to psychosocial
adjustment of adolescent refugees resettled in Australia. International Journal of Behavioral
Development, 28, 259–267.
Lapierre, C. B., Schwegler, A. F., & Labauve, B. J. (2007). Posttraumatic stress and depression
symptoms in soldiers returning from combat operations in Iraq and Afghanistan. Journal of
Traumatic Stress, 20(6), 933–943.
Lauterbach, D., Bak, C., Reiland, S., Mason, S., Lute, M. R., & Earls, L. (2007). Quality of parental
relationships among persons with a lifetime history of posstraumatic stress disorder. Journal of
Traumatic Stress, 20(2), 161–172.
Lee, K. A., Vaillant, G. E., Torrey, W. C., & Elder, G. H. (1995). A 50-year prospective study of the
psychological sequelae of World War II combat. The American Journal of Psychiatry, 152(4),
14 The Psychological Impact of Child Soldiering 355
Lester, D. (2005). Suicide in Vietnam veterans: The Suicide Wall. Archives of suicide research,
Levendosky, I. A., & Graham-Bermann, S. A. (2001). Parenting in battered women: the effects of
domestic violence on women and their children. Journal of Family Violence, 16(2), 171–192.
Lewis, D. O. (1992). From abuse to violence: psychophysiological consequences of maltreatment.
Journal of the American Academy of Child and Adolescent Psychiatry, 31(3), 383–391.
MacDonald, C., Chamberlain, K., Long, N., & Flett, R. (1999). Posttraumatic stress disorder and
interpersonal functioning in Vietnam War veterans: a mediational model. Journal of Traumatic
Stress, 12(4), 701–707.
Macksoud, M. S., & Aber, J. L. (1996). The war experiences and psychosocial development of
children in Lebanon. Child Development, 67(1), 70–88.
Maclure, R., & Denov, M. (2006). “I didn’t want to die so I joined them”: Structuration and the
process of becoming boy soliers in Sierra Leone. Terrorism and Political Violence, 18, 119–135.
MacMullin, C., & Loughry, M. (2004). An investigation into the psychosocial adjustment of former
abducted child soldiers. Journal of Refugee Studies, 17(4), 460–472.
Magambo, C., & Lett, R. (2004). Post-traumatic stress in former Ugandan child soldiers. Lancet,
Mannarino, A. P., & Cohen, J. A. (1986). A clinical-demographic study of sexually abused
children. Child Abuse & Neglect, 10(1), 17–23.
Marshall, G. N., Schell, T. L., Elliott, M. N., Berthold, S. M., & Chun, C. A. (2005). Mental
health of Cambodian refugees 2 decades after resettlement in the United States. Jama, 294(5),
McEwen, B. S. (2000). Allostasis and allostatic load: implications for neuropsychopharmacology.
Neuropsychopharmacology, 22(2), 108–124.
McFarlane, A. C., Policansky, S. K., & Irwin, C. (1987). A longitudinal study of the psychological
morbidity in children due to a natural disaster. Psychological Medicine, 17(3), 727–738.
McGuigan, W. M., & Pratt, C. C. (2001). The predictive impact of domestic violence on three types
of child maltreatment. Child Abuse & Neglect, 25(7), 869–883.
McKay, S., & Mazurana, D. (2004). Where are the girls? Girls in ﬁghting forces in Northern
Uganda, Sierra Leone and Mozambique: Their lives during and after war. Montreal: Rights
Meaney, M. J., Szyf, M., & Seckl, J. R. (2007). Epigenetic mechanisms of perinatal programming
of hypothalamic-pituitary-adrenal function and health. Trends in molecular medicine, 13(7),
Miranda, J. J., & Patel, V. (2005). Achieving the Millennium Development Goals: Does Mental
Health play a Role? PLoS Medicine, 2(10), 0962–0965.
Mogapi, N. (2004). Reintegration of soldiers: The missing piece. International Journal of Mental
Health, Psychosocial Work and Counselling in Areas of Armed Conﬂict, 2(3), 221–225.
Moisander, P. A., & Edston, E. (2003). Torture and its sequel – a comparison between victims from
six countries. Forensic science international, 137(2–3), 133–140.
Mollica, R. F., Cui, X., McInnes, K., & Massagli, M. P. (2002). Science-based policy for psychoso-
cial interventions in refugee camps: a Cambodian example. The Journal of nervous and mental
disease, 190(3), 158–166.
Mollica, R. F., McInnes, K., Poole, C., & Tor, S. (1998). Dose-effect relationships of trauma to
symptoms of depression and post-traumatic stress disorder among Cambodian survivors of
mass violence. The British journal of psychiatry, 173, 482–488.
Mollica, R. F., Poole, C., Son, L., Murray, C. C., & Tor, S. (1997). Effects of war trauma on
Cambodian refugee adolescents’ functional health and mental health status. Journal of the
American Academy of Child and Adolescent Psychiatry, 36(8), 1098–1106.
Morgan, L., Scourﬁeld, J., Williams, D., Jasper, A., & Lewis, G. (2003). The Aberfan disaster:
33-year follow-up of survivors. The British journal of psychiatry, 182, 532–536.
Muldoon, O. T., & Wilson, K. (2001). Ideological commitment, experience of conﬂict
and adjustment in Northern Irish adolescents. Medicine, conﬂict, and survival, 17(2),
356 E. Schauer and T. Elbert
Nader, K. O., Pynoos, R. S., Fairbanks, L. A., al-Ajeel, M., & al-Asfour, A. (1993). A preliminary
study of PTSD and grief among the children of Kuwait following the Gulf crisis. The British
journal of Clinical Psychology, 32(Pt 4), 407–416.
Neuner, F., Kurreck, S., Ruf, M., Odenwald, M., Elbert, T., & Schauer, M. (2009). Can asylum
seekers with posttraumatic stress disorder be successfully treated? A randomized controlled
pilot study. Cognitive Behaviour Therapy, 34(3), 1–11.
Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of
posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a
randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(4), 686–694.
Neuner, F., Schauer, E., Catani, C., Ruf, M., & Elbert, T. (2006). Post-tsunami stress: a study of
posttraumatic stress disorder in children living in three severely affected regions in Sri Lanka.
Journal of Traumatic Stress, 19(3), 339–347.
Neuner, F., Schauer, M., Karunakara, U., Klaschik, C., Robert, C., & Elbert, T. (2004).
Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder
through previous trauma among West Nile refugees. BMC Psychiatry, 4, 34.
Odenwald, M., Hinkel, H., & Schauer, E. (2007). Challenges for a future reintegration programme
in Somalia: outcomes of an assessment on drug abuse, psychological distress and preferences
for reintegration assistance. Intervention, 5(2), 124–129.
Odenwald, M., Hinkel, H., Schauer, E., Neuner, F., Schauer, M., Elbert, T., et al. (2007). The
consumption of khat and other drugs in Somali combatants: a cross-sectional study. PLoS
Medicine, 4(12), e341.
Odenwald, M., Neuner, F., Schauer, M., Elbert, T., Catani, C., Lingenfelder, B., et al. (2005). Khat
use as risk factor for psychotic disorders: a cross-sectional and case-control study in Somalia.
BMC Medicine, 3,5.
Onyut, L. P., Neuner, F., Ertl, V., Schauer, E., Odenwald, M., & Elbert, T. (2009). Trauma,
poverty and mental health among Somali and Rwandese refugees living in an African refugee
settlement – an epidemiological study. Conﬂict and Health, 3,6.
Papousek, M., & von Hofacker, N. (1998). Persistent crying in early infancy: a non-trivial condition
of risk for the developing mother-infant relationship. Child Care Health and Development,
Parent, C., Zhang, T. Y., Caldji, C., Bagot, R., Champagne, J. P., & Meaney, M. (2005). Maternal
Care and Individual Differences in Defensive Responses. Current Directions in Psychological
Science, 14(5), 229–233.
Pearn, J. (2003). Children and war. Journal of Paediatrics and Child Health, 39(3), 166–172.
Perez, C. M., & Widom, C. S. (1994). Childhood victimization and long-term intellectual and
academic outcomes. Child Abuse & Neglect, 18(8), 617–633.
Perry, B. D., & Pollard, R. (1998). Homeostasis, stress, trauma, and adaptation. A neurodevelop-
mental view of childhood trauma. Child and Adolescent Psychiatric Clinics of North America,
7(1), 33–51, viii.
Pfeiffer, A., Ertl, V., Schauer, E., Elbert, T. (submitted). PTSD, Depression and anxiety disorders
of formerly abducted children in Northern Uganda.
Pham, N. P., Vinck, P., & Stover, E. (2009). Returning home: Forced conscription, reintegra-
tion, and mental health status of former abductees of the Lord’s Resistance Army in northern
Uganda. BMC Psychiatry, 9(23).
Pham, P. N., Weinstein, H. M., & Longman, T. (2004). Trauma and PTSD symptoms in Rwanda:
implications for attitudes toward justice and reconciliation. Jama, 292(5), 602–612.
Phillips, D. I. (2007). Programming of the stress response: a fundamental mechanism underlying
the long-term effects of the fetal environment? Journal of Internal Medicine, 261(5), 453–460.
Pittaway, E. (2004). The ultimate betrayal: An examination of the experience of domestic
and familiy violence in refugee communities. Retrieved August18, 2006, from http://www.
Punamaki, R. L. (1996). Can ideological commitment protect children’s psychological well-being
in situations of political violence? Child Development, 67(1), 55–69.
14 The Psychological Impact of Child Soldiering 357
Punamaki, R. L., & Suleiman, R. (1990). Predictors and effectiveness of coping with political
violence among Palestinian children. The British journal of Br J Social Psychology, 29(Pt 1),
Qouta, S., Punamaki, R. L., & Sarraj, E. E. (2003). Prevalence and determinants of PTSD among
Palestinian children exposed to military violence. European Child & Adolescent Psychiatry,
Ramsbotham, O., & Woodhouse, T. (1999). Encyclopedia of International Peacekeeping
Operations. Oxford: ABC-Clio.
Redress. (2006). Victims, perpetrators or heroes? Child soldiers before the international criminatl
court. London: The Redress Trust, Seeking Reparation for Torture Survivors.
Roberts, B., Ocaka, K. F., Browne, J., Oyok, T., & Sondorp, E. (2008). Factors associated with
post-traumatic stress disorder and depression amongst internally displaced persons in northern
Uganda. BMC Psychiatry, 8, 38.
Roberts, S. J. (1996). The sequelae of childhood sexual abuse: a primary care focus for adult female
survivors. Nurse practitioner, 21(12 Pt 1), 42, 45, 49–52.
Rohleder, N., & Karl, A. (2006). Role of endocrine and inﬂammatory alterations in comorbid
somatic diseases of post-traumatic stress disorder. Minerva Endocrinol, 31(4), 273–288.
Ruf, M., Neuner, F., Gotthardt, S., Schauer, M., & Elbert, T. (2005, June 2005). PTSD among
Refugee Children – Prevalence and Treatment. Paper presented at the European Conference for
Traumatic Stress Studies – ESTSS, Stockholm, Sweden.
Ruscio, A. M., Weathers, F. W., King, L. A., & King, D. W. (2002). Male war-zone veterans’
perceived relationships with their children: the importance of emotional numbing. Journal of
Traumatic Stress, 15(5), 351–357.
Sack, W. H., Angell, R. H., Kinzie, J. D., & Rath, B. (1986). The psychiatric effects of mas-
sive trauma on Cambodian children: II. The family, the home, and the school. Journal of the
American Academy of Child Psychiatry, 25, 377–383.
Sack, W. H., Him, C., & Dickason, D. (1999). Twelve-year follow-up study of Khmer youths
who suffered massive war trauma as children. Journal of the American Academy of Child and
Adolescent Psychiatry, 38(9), 1173–1179.
Saigh, P. A., Mroueh, M., & Bremner, J. D. (1997). Scholastic impairments among traumatized
adolescents. Behaviour research and therapy, 35(5), 429–436.
Saigh, P. A., Mroueh, M., Zimmerman, B. J., & Fairbanks, J. A. (1995). Self-efﬁcacy expectations
among traumatized adolescents. Behaviour research and therapy, 33(6), 701–704.
Samper, R. E., Taft, C. T., King, D. W., & King, L. A. (2004). Posttraumatic stress disorder symp-
toms and parenting satisfaction among a national sample of male Vietnam veterans. Journal of
Traumatic Stress, 17(4), 311–315.
Sandman, C. A., Wadhwa, P. D., Chicz-DeMet, A., Porto, M., & Garite, T. J. (1999).
Maternal corticotropin-releasing hormone and habituation in the human fetus. Developmental
Psychobiology, 34(3), 163–173.
Sandman, C. A., Wadhwa, P. D., Glynn, L., Chicz-DeMet, A., Porto, M., & Garite, T. J. (1999).
Corticotropin-releasing Hormone and Fetal Responses in Human Pregnancy. Neuropeptides,
Sapolsky, R. M., Krey, L. C., & McEwen, B. S. (1985). Prolonged glucocorticoid exposure
reduces hippocampal neuron number: implications for aging. Journal of Neuroscience, 5(5),
Sapolsky, R. M., Uno, H., Rebert, C. S., & Finch, C. E. (1990). Hippocampal damage asso-
ciated with prolonged glucocorticoid exposure in primates. Journal of Neuroscience, 10(9),
Schaal, S., & Elbert, T. (2006). Ten years after the genocide: trauma confrontation and posttrau-
matic stress in Rwandan adolescents. Journal of Traumatic Stress, 19(1), 95–105.
Schalinski, I., Schauer, M., Elbert, T., Schauer, E., Maedl, A., Winkler, N. (submitted). Dissociative
Responding to Traumatic Stress as a Risk Factor for PTSD and Depression Symptoms.
Schauer, E. (2008). Trauma therapy for children in war: build-up of an evidence-based large-scale
mental health intervention in North-Eastern Sri Lanka. University of Konstanz, Konstanz.
358 E. Schauer and T. Elbert
Schauer, E., Catani, C., Mahendran, K., Schauer, M., & Elbert, T. (2005, June). Building
local capacity for mental health service provision in the face of large-scale traumatisation:
a cascade-model from Sri Lanka. Paper presented at the European Society for Traumatic Stress
Studies (ESTSS), Stockholm, Sweden.
Schauer, M., & Elbert, T. (2008). Neural Network Architecture in response to Traumatic Stress:
Psychophysiology of the defense cascade and implications for PTSD and dissociative disorders.
Paper presented at the Biannual Meeting of the Society for Applied Neuroscience, San Seville.
Schauer, M., & Elbert, T. (2010). Dissociation: Etiology and treatment. Journal of Psychology,
Schauer, M., Neuner, F., & Elbert, T. (2005). Narrative exposure therapy: A short-term intervention
for traumatic stress disorders after war, terror, or torture. Göttingen: Hogrefe & Huber.
Schauer, M., Neuner, F., Karunakara, U., Klaschik, C., Robert, C., & Elbert, T. (2003). PTSD
and the “building block” effect of psychological trauma among West Nile Africans. ESTSS
(European Society for Traumatic Stress Studies) Bulletin, 10(2), 5–6.
Schauer, M., & Schauer, E. (2010). Trauma-focused public mental health interventions – A
paradigm shift in humanitarian assistance and aid work. In E. Martz (Ed.), Trauma rehabili-
tation after war and conﬂict: Community and individual perspectives. New York: Springer.
Schnurr, P. P., & Jankowski, M. K. (1999). Physical health and post-traumatic stress disorder:
review and synthesis. Seminars in Clinical Neuropsychiatry, 4(4), 295–304.
Schreiber, W. (2005). Das Kriegsgeschehen 2004. Daten und Tendenzen der Kriege und
bewaffneten Konﬂikte. Wiesbaden: VS Verlag fuer Sozialwissenschaften.
Seckl, J. R., & Holmes, M. C. (2007). Mechanisms of disease: glucocorticoids, their
placental metabolism and fetal ‘programming’ of adult pathophysiology. Nature clinical
practice. Endocrinology & metabolism, 3(6), 479–488.
Seng, J. S., Graham-Bermann, S. A., Clark, M. K., McCarthy, A. M., & Ronis, D. L. (2005).
Posttraumatic stress disorder and physical comorbidity among female children and adolescents:
results from service-use data. Pediatrics, 116(6), e767–776.
Servan-Schreiber, D., Le Lin, B., & Birmaher, B. (1998). Prevalence of Posttraumatic Stress
Disorder and Major Depressive Disorder in Tibetan Refugee Children. Journal of the American
Academy of Child and Adolescent Psychiatry, 37(8), 874–879.
Shipherd, J. C., Stafford, J., & Tanner, L. R. (2005). Predicting alcohol and drug abuse in Persian
Gulf War veterans: what role do PTSD symptoms play? Addictive Behaviors, 30(3), 595–599.
Sivayokan, S. (2006). Personal e-mail conversation. In E. Schauer (Ed.). Jaffna, Sri Lanka.
Smith, M. E. (2005). Bilateral hippocampal volume reduction in adults with post-traumatic stress
disorder: a meta-analysis of structural MRI studies. Hippocampus, 15(6), 798–807.
Smith, P. A., Perrin, S., Yule, W., Hacam, B., & Stuvland, R. (2002). War exposure among chil-
dren from Bosnia-Hercegovina: psychological adjustment in a community sample. Journal of
Traumatic Stress, 15(2), 147–156.
Smith, P. A., Perrin, S., Yule, W., & Rabe-Hesketh, S. (2001). War exposure and maternal reac-
tions in the psychological adjustment of children from Bosnia-Hercegovina. Journal of Child
Psychology and Psychiatry, 42(3), 395–404.
Solomon, Z. (1988). The effect of combat-related posttraumatic stress disorder on the family.
Psychiatry, 51(3), 323–329.
Solomon, Z., Waysman, M., Levy, G., Fried, B., Mikulincer, M., Benbenishty, R., et al. (1992).
From front line to home front: a study of secondary traumatization. Family Process, 31(3),
Somasundaram, D. (1998). Scarred minds: the psychological impact of war on Sri Lankan tamils.
London & New Delhi: Sage.
Somasundaram, D. (2001). War trauma and psychosocial problems: patient attendees in Jaffna.
International Medical Journal, 8, 193–197.
Somasundaram, D. (2002). Child soldiers: understanding the context. BMJ, 324(7348),
Somasundaram, D. (2007). Collective trauma in northern Sri Lanka: a qualitative psychosocial-
ecological study. International Journal of Mental Health Systems, 1(5).
14 The Psychological Impact of Child Soldiering 359
Sommershof, A., Aichinger, H., Engler, H., Adenauer, H., Catani, C., Boneberg, E. M., et al.
(2009). Substantial reduction of naive and regulatory T cells following traumatic stress. Brain
Behavior and Immunity.
Sondergaard, C., Olsen, J., Friis-Hasche, E., Dirdal, M., Thrane, N., & Sorensen, H. T. (2003).
Psychosocial distress during pregnancy and the risk of infantile colic: a follow-up study. Acta
Paediatrica, 92(7), 811–816.
Southall, D., & Abbasi, K. (1998). Protecting children from armed conﬂict. The UN convention
needs an enforcing arm. BMJ, 316(7144), 1549–1550.
Stavrou, V. (2005). Breaking the silence: Girls forcibly involved in the armed struggle in
Angola. Richmond, Virginia, Ottawa: Christian Children’s Fund and Canadian International
Steel, Z., Silove, D., Phan, T., & Bauman, A. (2002). Long-term effect of psychological trauma
on the mental health of Vietnamese refugees resettled in Australia: a population-based study.
Lancet, 360(9339), 1056–1062.
Szyf, M., McGowan, P., & Meaney, M. J. (2008). The social environment and the epigenome.
Environmental and Molecular Mutagenesis, 49(1), 46–60.
Teicher, M. H., Andersen, S. L., Polcari, A., Anderson, C. M., & Navalta, C. P. (2002).
Developmental neurobiology of childhood stress and trauma. Psychiatric Clinic sof North
America, 25(2), 397–426, vii–viii.
Thabet, A. A., & Vostanis, P. (2000). Post traumatic stress disorder reactions in children of war: a
longitudinal study. Child Abuse & Neglect, 24(2), 291–298.
Toole, M. J., & Waldman, R. J. (1993). Refugees and displaced persons. War, hunger, and public
health. Jama, 270(5), 600–605.
Toole, M. J., & Waldman, R. J. (1997). The public health aspects of complex emergencies and
refugee situations. Annual Review of Public Health, 18, 283–312.
UNHCR. (2003). Sexual and Gender-Based Violence against Refugees, Returnees and Internally
Displaced Persons – Guidelines for Prevention and Response: United Nations Refugee Agency.
UNICEF. (2002). Child protection from violence, exploitation and abuse: Armed conﬂict.
Retrieved August, 19, 2006, from http://www.unicef.org/protection/index_armedconﬂict.html
UNICEF. (2005). State of the World’s Children 2005. Retrieved August, 19, 2006, from
UNICEF. (2006). An end to violence against children. New York: United Nations Children Fund.
United Nations. (1987). Convention on the Rights of the Child. New York, USA: UN.
United Nations. (2002). Woman, peace and security; a study submitted by the Secretary-General
pursuant to Security Council resolution 1325 (2000). New York: UN.
Uppard, S. (2003). Child soldiers and children associated with the ﬁghting forces. Medicine,
conﬂict, and survival, 19(2), 121–127.
Utas, M., & Jorgel, M. (2008). The West Side Boys: military navigation in the Sierra Leone civil
war. Journal of Modern African Studies, 46(3), 487–511.
van de Put, W. A., Somasundaram, D. J., Kall, K., Eisenbruch, M. I., & Thomassen, L. (1998).
Community mental health programme in Cambodia: Facts and thoughts on the ﬁrst year. Pnom
Penh, Cambodia: Transcultural Psychosocial Organisation – TPO.
van der Veer, G., Somasundaram, D. J., & Damian, S. (2003). Counselling in areas of armed
conﬂict: the case of Jaffna, Sri Lanka. British Journal of Guidance & Counselling, 31(4),
Verhey, B. (2004). Reaching the girls: Study on girls association with armed forces and groups in
the DRC: Save the Children UK and the NGO Group: CARE, IFESH and IRC.
Vinck, P., Pham, P. N., Stover, E., & Weinstein, H. M. (2007). Exposure to war crimes and
implications for peace building in northern Uganda. Jama, 298(5), 543–554.
Weinstock, M. (1997). Does prenatal stress impair coping and regulation of hypothalamic-
pituitary-adrenal axis? Neuroscience and Biobehavioral Reviews, 21(1), 1–10.
Weinstock, M. (2005). The potential inﬂuence of maternal stress hormones on development and
mental health of the offspring. Brain Behavior and Immunity, 19(4), 296–308.
360 E. Schauer and T. Elbert
Wessels, M. (2006). Child soldiers: Stolen childhoods. Cambridge: Harvard University Press.
Widom, C. S. (1989). Does violence beget violence? A critical examination of the literature.
Psycholigical Bulletin, 106(1), 3–28.
Yehuda, R., Halligan, S. L., & Bierer, L. M. (2001). Relationship of parental trauma exposure and
PTSD to PTSD, depressive and anxiety disorders in offspring. Journal of Psychiatric Research,
Yule, W. (2002). Alleviating the Effects of War and Displacement on Children. Traumatology, 8(3),
Yule, W., Bolton, D., Udwin, O., Boyle, S., O’Ryan, D., & Nurrish, J. (2000). The long-term
psychological effects of a disaster experienced in adolescence: I: The incidence and course of
PTSD. Journal of Child Psychology and Psychiatry, 41(4), 503–511.
Zuravin, S., McMillen, D., DePanﬁlis, D., & Risley-Curtiss, C. (1996). The intergenerational cycle
of child maltreatment: continuity versus discontinuity. Journal of Interpersonal Violence, 11(3),