By Verity Hubbard
Explosive violence challenges, and sometimes shatters, the three fundamental assumptions that provide children with a sense of well-being: that the world is benevolent, it is meaningful, and that the self is worthy[1].
Grief, anger, self-blame, disbelief, depression, and anxiety have all been well-documented in children who have experienced explosive violence. These effects are likely to persist into adulthood -- long after the violence has stopped. How a child responds to the explosive violence that might enter their young lives is dependent on the nature of the blast, the circumstances of the conflict, the quality of social care and health provision, the direct and indirect impacts of the blast on the child or their caregivers, on family stability and income, their age, and the state of their mental and physical health before the blast, to name just some.
Exactly how such violence predictably impacts a child in all its myriad of ways, though, is not always clear. Consensus on the consequences of conflict and explosive violence on children's psychological health is far from settled. The mental health disorders, PTSD and other psychological disorders that children are diagnosed with following conflict are wide and varied, and the tendency to view the experiences of children in conflict through the lens of western psychoanalysis has also been critiqued.
The UN describes the 'deep mental scars' that are inflicted on children living in conflict -- and this is undeniable. But a growing number of medical journals also offer hope -- suggesting that children are often resilient to the psychological stressors caused by a blast -- perhaps even more so than adults. As Professor Renos Papadopoulos, Director of the 'Centre for Trauma, Asylum and Refugees', stressed in an interview with AOAV: "children are distorted by their experience, but they also grow from it".
Impact from direct exposure
Explosive violence primarily takes place in a conflict setting, making the psychological effects of a blast difficult to pin point as they are often compounded by poverty, displacement, and the insecurity of war. The mental health impact of explosive weapons can range from disorders such as Post Traumatic Stress Disorder (PTSD), toxic stress, bedwetting, loss of appetite and social withdrawal.
PTSD is one of the most common mental health problems that may develop among individuals who have directly experienced or witnessed life-threatening events in violence and war. In conflict studies, research on PTSD has predominantly focused on returned veterans, and so knowledge regarding the disease has largely come from the military population. Despite PTSD being the most common mental health problem among refugee children, the disorder among the cohort has received scant attention and research.
There is, undeniably, a strong correlation between the exposure to explosive violence and PTSD in children. A survey on child mental health published following the 2013 Boston Marathon bombings revealed that about 11% of those who attended the event showed symptoms of PTSD six months after. Only 0.4% present the same symptoms in a normal population. In 2009 military bombs stockpiled in Mbagala, Dar es Salaam, exploded, killing 26 people, injuring about 600, and destroying 9,049 homes. A study of the blast found that 92.8% of child participants exhibited PTSD symptoms. In a different report on the same event in Mbagala, child participants were asked if they had experienced any traumatic events in which they felt that their life or the life of someone else was in danger. Of the children's responses, 76% named bomb blasts as a "traumatic experience".
The prevalence of PTSD in children and adolescents in conflicts in the Middle East was found to be high: 23%--70% in Palestine, 10%--30% in Iraq, and 5%--8% in Israel. A study of families living in the Gaza strip found that children who had lost their homes due to bombardment suffered 'severe' to 'very severe' PTSD in comparison to a control group who had not experienced bombardment.
Comparisons of the prevalence of PTSD in children as opposed to adults are, however, inconclusive. Evidence suggests that children are less likely to present signs of trauma after a blast or talk about their experiences. This can skew research findings because their conditions are more likely not to be flagged and their needs overlooked by medical staff.
Gender disparities have also been identified. Girls have more than three times the odds of suffering from PTSD compared to boys, however this difference seems to emerge more in adolescence. While the gender discrepancy may be explained by physiological or hormonal differences, it may also be due to the "socialization of trauma exposure" in which girls have have been 'taught' to experience and exhibit trauma differently to boys.
Landmines have been found to be strongly associated with anxiety disorder. Following a landmine injury, the essential trust between a child and their everyday surroundings appears often to be broken. A 2015 study of child victims of landmines and unexploded ordinance (UXO) following the Iraq-Iran War (1980--88) found that almost half (47%) of the survivors presented one or multiple psychiatric problems. Anxiety disorder was present in 34.6% of subjects, and PTSD in 25.6%. The study also showed that the nature of the injury caused by the blast could affect the type of mental disorder displayed by the child. In the same study, amputation which is required in 11-31% of paediatric injuries was "generally accompanied by mental disorder".
Impacts from indirect exposure to a blast
Children can be psychologically impacted by explosive violence even if they do not experience a blast first-hand. 'Interpersonal exposure' is when a child suffers trauma from the loss of a loved one or caregiver during a blast. In protracted conflict such as Iraq, this is endemic. Field work conducted by Save the Children in 2017 revealed that 90% of displaced children from Mosul had lost love ones, and were suffering from nightmares and toxic stress.
In 2020, Syrian-American writer Lina Sergie Attar interviewed Abeer, a young Syrian widow with six children living in Burj al-Barajneh, a refugee camp in Lebanon. Abeer's husband was killed in a 2015 bombing claimed by ISIS. Abeer recounted the psychological trauma suffered by her eldest daughter from that day forward: "She had beautiful handwriting once," Abeer said. "Now she can't speak properly." The violence of a death, it is clear, can ripple through a family, even for generations.
Second-hand exposure to violence is often experienced by children -- a climate of insecurity and fear generated by explosive violence. In the 2013 Boston Marathon Bombing, media coverage was shown to increase PTSD symptoms among US children far from the blast. During the attack, children who had more than three hours of media exposure of the bombings (and the subsequent manhunt) exhibited PTSD symptoms.
Interestingly, levels of anxiety related to the violence in Gaza were also higher in children living there who had not been directly exposed to bombardments but may have witnessed explosive violence on local television (39% vs 22%).
Trauma can also be inherited. Children of parents with symptoms of PTSD are easily deregulated or distressed and appear to face more difficulties in their psychosocial development compared to children of parents who do not suffer from PTSD. One study of refugees in Denmark found that children of parents with PTSD were at increased likelihood of requiring psychiatric treatment. The phenomenon of intergenerational transmission is also seen in the increased rates of mental illness in the children of Holocaust survivors.
Longer-term impacts
Experiencing trauma has a significant impact on a child's cognitive development. When confronted with adversity, the toxic stress response is activated. Toxic stress can disrupt development of the brain and other organs, increasing psychopathology as well as cognitive and emotional impairment. According to Dr Hilary Franke of the University of Arizona Department of Pediatrics, toxic stress in children causes "permanent changes to brain architecture".
Trauma also affects a child's emotional, and social development. Mental health disorders diminish a child's ability to engage in daily life, to focus in school, and build meaningful relationships with their peers. For example, after the Gulf War, Kuwaiti boys with greater exposure to war trauma were found to be less likely to pursue further education and more likely to suffer from PTSD, poor sleep quality, high body mass index, and poor self-reported health in adulthood. Mental health disorders are often accompanied by social stigmatization and societal rejection.
Culture and community
*Studies have shown that culture and community help mediate trauma; they give meaning to a child's experience of war and provide mechanisms for healing. However, within the ecology of war, parenting, relationships with teachers, and social networks are also affected by trauma and toxic stress, making them less productive and potentially harmful. A 2020 study found evidence to suggest that parents worrying about daily survival in the context of armed conflict can become less nurturing and more aggressive towards their children.
The impact on children of social media, shared violent videos captured on mobile phones, and the wider community contemplation and fixation on a violent event is poorly understood or examined.
What we know about successful interventions
Without early intervention, children's mental health disorders can continue into adulthood. Untreated adults who suffered adverse childhood experiences can be up to 12 times more at risk from alcoholism, drug misuse, depression, and suicide attempts than those who have not had such experiences.
Psychological support after an explosion has been shown to be helpful for children experiencing trauma. After the Manchester Bombings in 2017, a Resilience Hub was established to identify those in need of psychological support. This intervention was proven to be successful, with children that registered with the Hub earlier and thus received support faster, exhibiting fewer symptoms and improving more rapidly.
This level of psychological support seen after the Manchester bombings, however, simply does not exist in war-torn, low-and middle-income countries. These countries lack planned, sufficient, and integrated mental health services. Iraq has 3 child psychiatrists; Yemen has 2; Libya, Afghanistan and Syria do not have any (or at least none reported) according to the World Health Organisation.
The previously mentioned 2015 study on the psychological impact of landmines in Iran observed that mines and UXOs were often situated in poor and rural areas, meaning that blast victims were a considerable distance from health and psychiatric care centres.
Not only are children often unable to access specialised paediatric psychiatric care, the wide-area effects of explosive weapons rob them of any kind of therapeutic environment, such as home, school or parks**. **According to Dr Paul Wise, Professor of Paediatrics and Health Policy at Stanford University, the absence of "normalizing environment... only exacerbates long-term mental health effects".
Conclusion
Psychology is an imprecise science. Some studies claim children are uniquely affected by explosive weapons, others emphasise their unique resilience. Some tentative conclusions can be made, however.
First, it is clear that explosive weapons subject children to feelings of uncertainty, insecurity and terror, but how a child will recover is far more difficult to predict and dependent on a multiplicity of factors.
Second, intervention can ameliorate mental health issues associated with explosive weapons and this support should be culturally appropriate.
Finally, while research has been conducted on the long-term psychological effects of blast injuries in countries such as the US, UK and Ireland, there is a need for research on children's long-term experiences in post-conflict areas in the least developed countries.
Research support provided by Martha Greenhough
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