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on the psychosocial impact of armed conflict upon children go to:
Reproduced from Joshua Barenbaum, Vladislav Ruchkin, and Mary Schwab-Stone.
The psychosocial aspects of children exposed to war: practice and policy initiatives.
Journal of Child Psychology and Psychiatry 45:1 (2004), pp 41–62, by kind
permission of the Journal of Child Psychology and Psychiatry, which is published by
Blackwells (www.blackwellpublishing.com). Permission for printed use is not
The Coalition to Stop the Use of Child Soldiers unites national, regional and international organisations
and Coalitions in Africa, Asia, Europe, Latin America and the Middle East. Its founding organisations are
Amnesty International, Defence for Children International, Human Rights Watch, International
Federation Terre des Hommes, International Save the Children Alliance, Jesuit Refugee Service, the
Quaker United Nations Office-Geneva and World Vision International.
practice and policy initiatives
Joshua Barenbaum, Vladislav Ruchkin, and Mary Schwab-Stone
Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA
The atrocities of war have detrimental effects on the development and mental health of children that
have been documented since World War II. To date, a considerable amount of knowledge about various
aspects of this problem has been accumulated, including the ways in which trauma impacts child
mental health and development, as well as intervention techniques, and prevention methods. Consid-
ering the large populations of civilians that experience the trauma of war, it is timely to review existing
literature, summarize approaches for helping war-affected children, and suggest future directions for
research and policy. Keywords: War, children, psychopathology, assessment, treatment, policy.
?There never was a good war or a bad peace.?
(Benjamin Franklin, Letter to Quincy, 11 September
Despite increasing discussion in recent years (for
major reviews see Jensen & Shaw, 1993; Klingman,
2002a; Laor & Wolmer, 2002; Richman, 1993; Yule,
2000), the impact of armed conflict on children’s
lives and mental states has too often been minimally
addressed or even unrecognized (Machel, 1996,
2001). Children under war-time duress are largely a
voiceless population whose rights and needs are of-
ten subordinate to those of soldiers, and the neces-
sities of war. Children have been murdered, raped,
maimed, starved, exposed to brutality, and subject
to lack of control and chaos (Machel, 2001). In the
past ten years, approximately two million children
have been killed in war zones, and six million injured
or permanently disabled (Bellamy, 2002; UNICEF,
1996). Between 80 and 90% of those who die or are
injured in conflicts are civilians – mostly children
and their mothers. Of war-exposed survivors, 1 mil-
lion children have been orphaned (Bellamy, 2002;
Plunkett & Southall, 1998) and 20 million displaced
to refugee or internally displaced person’s camps
(Machel, 2001). Some contemporary ethnic struggles
have employed techniques of ethnic cleansing and
In wartime, children may be exposed to a large
number of traumatic events, including bombing,
shelling, and sniper-fire (Amnesty International,
1996), that often result in the loss of family mem-
bers, friends, community and social support struc-
tures (Machel, 1996). Beyond the risk of physical
injury, and direct threats to life, these traumas are
often multiple, severe, and chronic (Kinzie, 2001). In
addition, children are often exposed to other risks
associated with war-like situations, often more so
than adults. For example, 75% of the injuries in-
curred from landmines in the rural areas of Somalia
were to children between the ages of five and fifteen
years old (ICRC, 1994).
Despite these stark facts, children during and after
wars seldom receive the attention and assistance
required to cope with what they have experienced and
to support healing and further development (Machel,
1996). There is a growing need to increase public
awareness of child exposure to atrocities, to under-
stand the impact of such atrocities on mental health
and development, and most importantly, to develop
programs to curb and heal the effects of war experi-
ences on children and youth. This discussion will
outline the major areas that require specific atten-
approaches to diagnostic and treatment issues,
consideration of the psychosocial aspects of healing,
the role of mental health professionals in working
with children exposed to war, and will conclude by
making recommendations for future research.
Traumatic events and symptoms
Assessment of events
Understanding the effects of war trauma on children
has been complicated by the use of different ap-
although the most commonly used measure is the
Child War Trauma Questionnaire (CWTQ), which was
developed by Macksoud and colleagues (Macksoud,
1992; Macksoud, Dyregrov, & Raundalen, 1993;
Macksoud & Aber, 1996) for use in Lebanon after the
war with Israel, and then subsequently used with
some modifications across different settings (e.g.,
Dyregrov, Gjestad, & Raundalen, 2002; Miller,
El-Masri, Allodi, & Qouta, 1999). This measure (as
well as other available measures, see for example
Allwood, Bell-Dolan, & Husain, 2002; Kuterovac-
Journal of Child Psychology and Psychiatry 45:1 (2004), pp 41–62
? Association for Child Psychology and Psychiatry, 2004.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
number of times the child encountered them, which
are then summed together to produce a total score for
predicting the impact of war on child mental health.
of war may differ from place to place; also, several
studies have demonstrated the existence of an addit-
ive ?dose of exposure? effect, with higher levels of
exposure producing more severe reactions (e.g., All-
& Cohen, 2001). However, while the number of war
traumas experienced by a child is related to the
number of PTSD symptoms, various types of traumas
relate differentially to PTSD, and other mental health
outcomes. Some events may have only moderate, if
any, effects on child mental health, whereas the ef-
fects of others may be devastating. To date, however,
of any specific event on child symptomatology and
adjustment (e.g., Allwood et al., 2002; Durakovic-
Belko et al., 2003; Macksoud & Aber, 1996; Smith,
Perrin, Yule, Hacam, & Stuvland, 2002).
An additional issue is that the effect of any par-
ticular event may differ in its degree of impact on any
particular individual,andis relatedboth to emotional
and physical proximity (Pfefferbaum, 1997), and to
individual factors, such as premorbid personality
(e.g., Schnur, Friedman, & Rosenberg, 1993), or pre-
existing psychopathology (Masten, Best, & Garmezy,
1990; Perrin, Smith, & Yule, 2000). A methodological
concern here is related to the use of variable as op-
posed to person-oriented analytic approaches. How-
tendency is to consider variables as independent
entities that take on lives of their own.
Yet another methodological problem is that data
describing exposure to war and other potentially
traumatizing events are not always adequately
treated statistically (see Netland, 2001, for a critical
review). In particular the reliability of exposure
measures should not be demonstrated by internal
consistency, test–retest, or inter-rater correlations
based on counts of events, as the occurrence of one
event does not increase the probability of another
(Netland, 2001); thus, the events cannot be consid-
ered as alternative estimates of an underlying con-
struct of exposure (Netland, 2001; Neugebauer,
1984). As Netland (2001) notes, most researchers
using factor analytic approaches attempt to find a
restricted number of events that best represent the
event category, either for scale construction, or for
compiling summary measures to analyze relation-
ships between exposure and psychological outcome
variables. However, such methods as factor analytic
applicable here, as the constructs measuring expo-
sure variables merely group single indicators to-
gether, and should not be considered as latent
variables that determine the indicators (Netland,
2001). Rather, categorization of events must be done
on a rational basis, or the impact of any particular
event should be considered separately, such as in
the studies by Macksoud and Aber (1996) and Smith
et al. (2002). However, even with this approach, it is
difficult to account for all factors that determine
individual variability in traumatic response.
Symptoms associated with trauma
The first literature on the effects of war on children
dates largely from World War II, and is sparse and of
variable quality. Not until the 1980s was more sys-
tematic enquiry conducted, but during the past two
decades a number of relief agencies and researchers
alike have noted the marked presence of psycho-
(Ajdukovic & Ajdukovic, 1993; Baker, 1990; Cairns &
Dawes, 1996; Garbarino & Kostelny, 1996; Geltman
& Stover, 1997; Gibson, 1996; Kocijan-Hercigonia
et al., 1996; Punamaki, Qouta, & El-Sarraj, 2001;
Tomkiewicz, 1997). In addition to other, non-trauma-
specific types of psychopathology, posttraumatic
stress disorder (PTSD) has increasingly emerged as a
common psychiatric diagnosis for individuals who
have experienced war-like circumstances (Summer-
field, 1996). It is generally accepted now that children
represent a highly vulnerable population, for whom
levels of symptoms may often be higher than for
adults (e.g., Chimienti, Nasr, & Khalifeh, 1989). Re-
cent literature also suggests that childhood trauma
can have a lasting impact on child cognitive, moral,
and personality development, interpersonal relation-
ships, and coping abilities (e.g., Arroyo & Eth, 1985;
Terr, 1983; Pynoos & Nader, 1988; Sack et al., 1993).
Excellent descriptions of clinical symptoms in chil-
dren exposed to trauma in general (Pfefferbaum
1997; AACAP official action, 1998), and to war
trauma in particular (Jensen & Shaw, 1993; Laor &
Wolmer, 2002; Yule, 2000, 2002) have been provided
in detail elsewhere and will not be reviewed in this
article. For the purposes of this paper, we will assume
that the reader is generally familiar with the reactions
of children and adolescents to traumatic experiences,
and will attempt to concentrate on other, more con-
troversial and less well-established issues.
Assessment of symptoms
The vast majority of wars take place in developing
countries and most refugees originate, as well as
seek refuge in, developing countries. However, only a
small fraction of research is carried out in these
countries, and often studies are conducted when the
refugees have settled in a safer environment in
developed countries, which differ from their home-
lands culturally and economically. Thus, clinical
symptoms presented by refugees in such contexts
may be influenced by discontinuation of exposure,
but also by differences in environment, and in many
cases by vague ideas about the future. From a public
health perspective, assessing symptoms and provid-
Joshua Barenbaum, Vladislav Ruchkin, and Mary Schwab-Stone
ing support to large populations of children exposed
to war trauma soon after the conflict but in their
home countries, rather than later in a country of
exile, is a more important but also more difficult
An overarching consideration is the context for
data collection, given the extreme circumstances of
traumatized children and families, where imple-
mentation of research is often met with resistance
(Laor & Wolmer, 2002). Research assessments may
be perceived as unempathic, foreign, exploitive and
abusive, and victims and refugees may believe that a
research study satisfies a foreign agenda that lacks
relevance (Laor & Wolmer, 2002). Pure research in a
situation of despair can easily lead to mistrust, and
may potentially compromise the effectiveness of
other relief operations. The assessment of trauma-
tized children in war-time situations is also compli-
cated by the magnitude of trauma and deprivation,
limited economic and treatment resources, as well as
by the presence of other problems that seem to be or
are of greater priority. Thus, in planning trauma and
war relief efforts, assessment and research proced-
ures should be introduced as an integrated com-
ponent of recovery efforts that will necessarily and
understandably fall subordinate to the promotion of
social cohesion and functioning.
Preferred clinical screening tools are those that
involve direct interactions with the child, and meas-
ures that are simple and quick to administer, reli-
able, valid, sensitive, and specific (Laor & Wolmer,
2002; Smith, Perrin, Dyregrov, & Yule, 2003; Stal-
lard, Velleman, & Baldwin, 1999). Child self-reports
have been increasingly utilized to document symp-
toms, as parents and teachers are prone to under-
estimate the extent of children’s suffering (Handford,
Rigamer, 1986; Yule & Williams, 1990). The majority
of measures used to assess symptom states in war-
exposed children have included PTSD and general
anxiety measures, grief screens, and inventories of
depressive symptoms. Since the effectiveness and
description of many of these measures have been
amply provided elsewhere (e.g., Pfefferbaum, 1997;
Stichick, 2001), they will not be discussed here. It
should be noted, however, that most self-reports
provide only crude affirmations of prevalence rates,
and although various instruments are available for
assessing PTSD-related symptoms, none is ideal
(AACAP Official Action, 1998; Garmezy, 1986; Krat-
ochwill, 1996), as a great number of false positive
and false negatives are often produced (see e.g.,
Sack, Seeley, Him, & Clarke, 1998; Yule & Udwin,
1991), and cutoff scores may vary depending on the
studied population. Certainly, no instrumentation
can replace the careful clinical interview in the dia-
gnostic formulation (AACAP Official Action, 1998).
An initial screening for traumatic symptoms and
psychosocial impairment is essential when planning
for therapeutic interventions. It is crucially im-
portant to carefully separate those in urgent need of
interventions from those whose needs are less
pressing, as there is some evidence that children
who do not experience posttraumatic symptoms may
be negatively affected by involvement in therapeutic
interventions along with more traumatized children
(Laor, 2002; Wolmer, Laor, & Yazgan, 2003).
Prevalence of symptoms
Considering the wide range of potential psycho-
pathological manifestations associated with severe
distress, a better understanding of the dynamics of
trauma-related symptoms in war-exposed children is
crucial. While it is clear that not all children develop
psychopathological symptoms, conclusions regard-
ing the magnitude of traumatization reported in re-
cent studies tend to vary, with estimates of the
prevalence of symptoms ranging from 22% in Israeli
children after scud missile attacks (Laor et al., 1997)
and 27% in Lebanese children exposed to shelling
(Saigh, 1991), to 48% among Cambodian (Kinzie,
Sack, Angell, Manson, & Rath, 1986) and 52% among
Central American refugee children (Cervantes, Sal-
gado-de-Snyder, & Padilla, 1989), to 70% among
Kuwaiti children after 5 months of military occupa-
tion (Nader, Pynoos, Fairbanks, al-Ajeel, & al-Asfour,
1993) and 93.8% in children displaced during the
Bosnian war (Goldstein, Wampler, & Wise, 1997). It
has also been suggested that once the conflict is over,
there is a natural decrease in symptoms of post-
traumatic stress (Laor et al., 1997; Punamaki et al.,
2001); thus, the number of children needing profes-
sional help may diminish markedly with successful
promotion of psychosocial healing at family, com-
munity and institutional levels (see below).
Duration of symptoms
The issue of duration of symptoms is also quite
controversial. Some authors contend that the effects
of war experiences are enduring (Elbedour, ten
Bensel, & Bastien, 1993; Stein, Comer, Gardner, &
Kelleher, 1999). In fact, significant levels of psycho-
logical dysfunction and posttraumatic stress have
been documented even years after the traumatic
events were incurred (e.g., Kinzie et al., 1986; Sack
et al., 1993; Terr, 1983). In a study of Iraqi children
conducted after the Gulf War, the prevalence of
posttraumatic stress symptoms
stable at 80% over a two-year period (Dyregrov et al.,
2002). In another study, 48% of Khmer youths dis-
played symptoms related to trauma 8 to 12 years
later (Kinzie, Sack, Angell, Clarke, & Ben, 1989). Not
all studies support this perspective, however. In
various studies from different geographic areas the
majority of children exposed to war and/or political
violence exhibited no signs of clinical disorder
(Cairns & Dawes, 1996; Perrin et al., 2000), or their
symptoms were fleeting or short lived (Weine et al.,
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Manuscript accepted 25 July 2003
Joshua Barenbaum, Vladislav Ruchkin, and Mary Schwab-Stone