Chapter 36 Impact of Violence on Children
Violence, whether as the victim, perpetrator, or witness, whether in person or through the media, is a major public health problem throughout the world (Chapter 1). The focus of pediatrics should not be limited to the traditional care of violence-related injury. Exposure to violence disrupts the healthy development of children; pediatricians need to be aware of this risk factor. Pediatric providers also have a wider responsibility to advocate on local, state, national, and international levels for safer environments in which all children can grow and thrive.
Witnessing violence is detrimental to children. Because their scars as bystanders are emotional and not physical, the pediatric clinician may not fully appreciate their distress and thereby miss an opportunity to provide needed interventions. For children not living in war zones, the source of 1st exposure to violence is often domestic violence. In a survey conducted by the World Health Organization in 2005 among over 24,000 women in 15 sites in 10 countries worldwide, between 11% and 21% of women in most sites reported having been physically abused by their intimate partner, with a range from 13% in Japan to 61% in provincial Peru. In a sample from among over 2,500 women in the Cameroon, 39% reported physical and 15% sexual abuse from their spouses at least once in their lifetime. According to data from the National Center for Posttraumatic Stress Disorder (PTSD), 20-30% of American women will be physically abused by a partner at least once in their lifetimes, and 1.3 million women and 834,732 men are physically assaulted by an intimate partner annually. Each year in the USA, as many as 324,000 pregnant women experience intimate partner violence; pregnancy is one of the highest risk times for domestic violence to a woman. Slightly more than half of female victims of intimate violence live in households with children <12 yr of age; family violence is most likely to be perpetrated by those between the ages of 18 and 30 yr (“the child-rearing years”). The majority of children in these homes have witnessed violence; by some estimates, up to 3 million children per year. In a national survey, 50% of the men who frequently assaulted their wives also frequently abused their children. Most of the children were injured when they intervened to protect their mother from her partner (Chapter 37).
Another source of witnessed violence is community violence. Community violence in the USA is a serious problem that disproportionately affects children from low-income areas. More than 70% of school-aged children from low-income communities have observed domestic violence, assaults, arrests, drug deals, gang violence, and shootings. Young children living in high crime and violence areas observe death more frequently and at younger ages than children growing up in more secure surroundings. Witnessing acts of violence may be a significant stressor in children’s lives. If children’s coping skills are not sufficient to deal with violent situations, stress may be manifested as psychologic, physical, or behavioral symptoms.
The most ubiquitous source of witnessing violence for children in the USA is media violence. The average child 2-5 yr of age watches 20-30 hr of television a week, hours that are increasingly filled with scenes of violence not only on commercial television but also on news outlets. In addition, the wider array of “screen time” children are exposed to, including computer and video games, increases the opportunities for violent events to enter the lives of children. Although exposure to media violence cannot be equated to exposure to real-life violence, many studies confirm that media violence desensitizes children to the meaning and impact of violent behavior. Not all children are equally affected by media violence. Children most at risk from viewing violence may be children who are also exposed regularly to real-life violence in their homes and communities. Interventions to reduce exposure to media violence are noted in Table 36-1.
Table 36-1 PUBLIC HEALTH RECOMMENDATIONS TO REDUCE EFFECTS OF MEDIA VIOLENCE ON CHILDREN AND ADOLESCENTS
From Browne KD, Hamilton-Giachritsis C: The influence of violent media on children and adolescents: a public-health approach, Lancet 365:702–710, 2005.
Impacts of Violence
The violence children experience and witness also has a profound impact on health and development. In a cross-sectional analysis of a Head Start preschool age cohort, being abused, exposed to domestic violence, and having a mother using substances were associated with a higher number of health problems. Beyond injuries, violence affects children psychologically and behaviorally; it may influence how they view the world and their place in it. Children can come to see the world as a dangerous and unpredictable place. This fear may thwart their exploration of the environment, which is essential to learning in childhood. Children may experience overwhelming terror, helplessness, and fear even if they are not immediately in danger. Preschoolers are most vulnerable to threats that involve the safety (or perceived safety) of their caretakers. High exposure to violence in older children correlates with poorer performances in school, symptoms of anxiety and depression, and lower self-esteem. Violence, particularly domestic violence, can also teach children especially powerful early lessons about the role of violence in relationships. Violence may change the way that children view their future; they may believe that they could die at an early age and thus take more risks, such as drinking alcohol, abusing drugs, not wearing a seatbelt, and not taking prescribed medication.
Some children exposed to severe and/or chronic violence may suffer from post-traumatic stress disorder (PTSD), exhibiting constricted emotions, difficulty concentrating, autonomic disturbances, and re-enactment of the trauma through play or action (Chapters 1 and 23). Although young children may not fully meet these criteria, certain behavioral changes are commonly associated with exposure to trauma, such as sleep disturbances, aggressive behavior, new fears, and increased anxiety about separations (“clinginess”). A particula4r challenge in treating and diagnosing pediatric PTSD is that a child’s caregiver exposed to the same trauma may be suffering from it as well.
The simplest way to recognize whether violence has become a problem in a family is to question both children (after ≈8 yr of age, depending on the child) and parents on a regular basis. This is particularly important during pregnancy and the immediate postpartum period when women may be at highest risk for being abused. It is important to assure families that they are not being singled out but that all families are asked about their exposure to violence. A direct approach may be useful: “Violence is a major problem in our world today and one that impacts everyone in our society. Thus I have started asking all my patients and families about violence that they are experiencing in their lives. …” In other cases, beginning with general questions and then moving to the specific may be helpful. “Do you feel safe in your home and neighborhood? Has anyone ever hurt you or your child?” When violence has impacted the child, it is important to gather details about symptoms and behaviors.
The pediatric clinician can effectively counsel many parents and children who have been exposed to violence. Regardless of the type of violence to which the child has been exposed, the following components are part of the guidance: careful review of the facts and details of the event, gaining access to support services, providing information about the symptoms and behaviors common in children exposed to violence, assistance in restoring a sense of stability to the family in order to enhance the child’s feelings of safety, and helping parents talk to their children about the event. When the symptoms are chronic (>6 mo in duration) or not improving, if the violent event involved the death or departure of a parent, if the caregivers are unable to empathize with the child, or if the ongoing safety of the child is a concern, it is important that the family be referred to mental health professionals for additional treatment.
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American Academy of Pediatrics, Committee on Public Education. Media violence. Pediatrics. 2001;108:1222-1226.
Augustyn M, Groves BM. Training clinicians to identify the hidden victims: children and adolescents who witness violence. Am J Prev Med. 2005;29(5 Suppl 2):272-278.
Bickham DS, Rich M. Is television viewing associated with social isolation? Roles of exposure time, viewing context, and violent content. Arch Pediatr Adolesc Med. 2006;160:387-392.
Browne KD, Hamilton-Giachritsis C. The influence of violent media on children and adolescents: a public-health approach. Lancet. 2005;365:702-710.
Davies P, Lee L, Fox A, et al. Could nursery rhymes cause violent behaviour? A comparison with television viewing. Arch Dis Child. 2004;89:1103-1105.
Graham-Bermann SA, Seng J. Violence exposure and traumatic stress symptoms as additional predictors of health problems in high-risk children. J Pediatr. 2005;146:309-310.
Holtrop TG, Fischer H, Gray SM, et al. Screening for domestic violence in a general pediatric clinic: be prepared!. Pediatrics. 2004;114:1253-1257.
Maikovich AK, Jaffee SR, Odgers CL, et al. Effects of family violence on psychopathology symptoms in children previously exposed to maltreatment. Child Dev. 2008;79:1498-1512.
Martin SL, Mackie L, Kupper LL, et al. Physical abuse of women before, during, and after pregnancy. JAMA. 2001;285:1581-1584.
Panter-Brick C, Eggerman M, Gonzalez V, et al. Violence, suffering, and mental health in Afghanistan: a school-based survey. Lancet. 2009;374:807-816.
Roy E, Haley N, Leelere P, et al. Mortality in a cohort of street youth in Montreal. JAMA. 2004;292:569-574.
Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001 terrorist attacks. N Engl J Med. 2001;345:1507-1512.
U.S. Department of Justice: Violence by intimates: analysis of data on crimes by current or former spouses, boyfriends, and girlfriends, March 1998.
Waterston T, Mok J. Violence against children: the UN report. Arch Dis Child. 2008;93:85-88.
World Health Organization. Violence against women (website). www.who.int/mediacentre/factsheets/fs239/en/index.html. Accessed March 17, 2010
World Health Organization. Summary report: WHO multi-country study on women’s health and domestic violence against women (website). http://www.who.int/gender/violence/who_multicountry_study/summary_report/summary_report_English2.pdf.
36.1 Bullying and School Violence
Bullying is the assertion of power through aggression that involves a bully repeatedly and intentionally targeting a weaker victim through social, emotional, or physical means. Bullying affects a large number of children and lays the groundwork for long-term depression, suicidality, psychotic symptoms, conduct problems, and psychosomatic concerns seen in children. Children can move between being a bully, victim, bully-victim (both a bully and a victim at different times), or bystander. Bullying can be direct, involving physical aggression such as hitting, stealing, and threatening with a weapon or verbal aggression such as name-calling, public humiliation, and intimidation, or it can be indirect, involving relational aggression such as spreading rumors, social rejection, exclusion from peer groups, and ignoring. Bullying occurs most frequently at school when there is minimal supervision during breaks, recess, and lunch at playgrounds, in hallways, and en route to and from school. Technology creates unique venues for this behavior through text messaging, mass emailing, and Internet chat rooms and message boards.
Bullying is a common occurrence for schoolchildren. Bullying occurs in all countries, affecting 9% to 54% of youth. In the USA, 30% of middle and upper school students report moderate or frequent involvement with bullying as a victim, perpetrator, or bully-victim. National studies have found 7% of children aged 12-18 yr self-report being bullied while at school, with higher rates seen among rural and public schools and in lower grades. Older children are less likely to talk about their victimization, with only 50% of all children confiding in anyone. Boys are twice as likely as girls to be bullies, more than three times as likely to be bully-victims, and twice as likely to be victims.
Involvement in bullying is associated with poorer psychosocial adjustment; bullies, victims, and bully-victims report greater health problems and poorer emotional and social adjustment. Victims tend to be either physically weak and emotionally vulnerable or provocative, with attention or conduct problems. Overall, both victim groups are anxious, insecure, lonely, and lack social skills; their external characteristics do not necessarily set them apart from others. They may have learning disabilities, autism spectrum disorder, or poor physical skills. Victims can have lower social status and higher social marginalization and isolation. They have more depression, psychosomatic complaints, medication use, and suicidality. Chronic or severe victimization in childhood has been shown to be associated with psychotic symptoms in early adolescence. Long-term consequences in adulthood of being bullied as a child include depression, poor self-esteem, and abusive relationships.
Bullies have higher rates of both conduct disorders and social standing. They have the lowest rates of adjustment problems because of their higher social status. They make friends that support their bullying behavior but other peers avoid them. Bullies who acknowledge their behavior have higher rates of depression and psychologic distress compared to those who deny their bullying behavior. They have higher negative attitudes toward school and use more tobacco, alcohol, and other drugs. Childhood bullies have a fourfold increase in criminal behavior by their mid-twenties and are at higher risk of dropping out of school. They have lower likelihood of being employed and having stable long-term romantic relationships. The bully-victim has problems with peer relationships and high rates of depression, loneliness, alcohol use, and weapon carrying.
School violence is a common but non-normative aspect of development occurring throughout the world. An estimated 25% of elementary school children in the USA are bullied or bully other children. Almost 40% of U.S. schools report a least 1 violent incident to police, with over 600,000 victims of violent crime per year. Among 9th to 12th graders, 8% were threatened or injured on school property in the last 12 months, and 14% were involved in a physical fight over the last year. At the extreme, 16 students a year on average are victims of homicide at schools. These are more likely to occur at the beginning of each semester with perpetrators previously giving warning signals. Whereas urban schools experience more episodes of violence, the episodes of rare “rampage” gun violence in rural and suburban schools demonstrate that no region is immune to lethal violence.
Bullying and weapon carrying may be important precursors to more serious school violence. Among perpetrators of violent deaths at school, 20% had been bullying victims, and 6% of all students carried a weapon to school in the last 30 days. Nonlethal violence, mental health problems, racial tensions, student attacks on teachers, and the effects of rapid economic change in communities can all lead to school violence. Individual risk factors for violence include low intelligence, poor academic performance, early aggression, victimization as a child, and substance abuse.
Family risk factors comprise early childbearing, low parental attachment and involvement, authoritarian or permissive parenting styles, and poverty. There is more school violence in areas with higher crime rates and more street gangs, with little improvement with additional security measures. These risks take away students’ ability to learn in a safe environment and leave many children with traumatic stress and grief reactions. Behavioral genetics and developmental psychology are beginning to elucidate the bidirectional gene-environment interactions that promote these endemic episodes of violence.
Pediatric providers are in a unique position to screen, treat, and advocate for reducing the impact of school violence by assisting those affected and seeking to prevent further occurrences. Signs of a child being bullied include physical complaints such as insomnia, stomachaches, headaches, and new onset enuresis (Chapter 21.3). Psychologic symptoms such as depression (Chapter 24), loneliness, anxiety (Chapter 23), and suicidal ideation may occur. Behavioral changes such as irritability, poor concentration, school avoidance, and substance abuse are common. School problems such as academic failure, social problems, and lack of friends can also occur. Additional vigilance must be made for those children with chronic medical illnesses, obesity, physical deformities, and learning disabilities or autism spectrum disorder who may be potential targets. A bully may be more difficult to identify due to the bully’s desire to obscure the behavior. Children who are aggressive, overly confident, lacking in empathy, and having conduct problems may need careful screening. The physical, behavioral, psychologic, and school symptoms of bullying may overlap with other conditions such as medical illness, learning problems, and psychologic disorders.
Management of bullying and school violence involves systemic interventions with parents, victims, bullies, and the school. Interventions should include supporting families, victims, and bullies; identifying and referring those children in need of further academic and mental health services; and expecting behavioral change from the bully and social change from the school environment. The clinician should listen empathetically to the child to help empower and reassure him or her. The clinician should not blame the victim or trivialize the child’s concern. Suggestions should include having the child seek social support from teachers and friends and avoid situations where the bullying may occur. Role-playing an encounter can be helpful for the child. Extracurricular activities like drama clubs, mentoring programs, and sports can be used to help to bolster the child’s self-esteem. The clinician should identify safety issues such as suicidal ideation and plans, substance abuse, and other high-risk behaviors.
Once a bully is identified and appropriate screening for family risk factors is completed, the clinician should educate the parents and child about the seriousness of the behavior and its potential consequences. The clinician should label the behavior as the problem and help the family and child to acknowledge the behavior as hurtful. For example: “Do you feel bad when other children hurt your feelings?” “Bullying hurts other children’s feelings.” The school and parents should ensure accountability for the child’s subsequent behavior. Parental mental health and resource risk factors should also be addressed.
Beyond individual and family based interactions, providers also can advocate for systemic interventions through school-community violence and bullying prevention programs. Targeted school curriculums or social skills group interventions have not been found to reduce bullying in several well-done studies. Successful interventions involve whole school approaches that involve multiple disciplines. These broad-based programs simultaneously include school-wide rules and sanctions, teacher training, classroom curriculum, conflict resolution training, and individual counseling. Mentoring programs and an increased number of social workers can also be helpful in reducing bullying. Addressing access to firearms, involving community organizations and parents, enhancing the built environment of schools and community, and supporting youth self-esteem are important in creating a safe school climate. Targeting larger societal risk promoters of violence in the neighborhood and school culture are also avenues for improving school violence. In Denmark an intensive national level policy has lead to the reduction in school bullying prevalence from 25% to 11%.
American Medical Association’s Council on Scientific Affairs (CSA). Featured CSA report: bullying behaviors among children and adolescents (A-02) full text (website). www.ama-assn.org/ama/pub/category/14312.html. Accessed April 20, 2005
American Medical Association’s Council on Scientific Affairs (CSA). Report 11 of the Council on Scientific Affairs (I-99) full text: school violence (website). www.ama-assn.org/ama/pub/category/13596.html. Accessed April 20, 2005
Department of Health and Human Services. Take a stand! Lend a hand! Stop bullying now! (website). stopbullyingnow.hrsa.gov/kids/. Accessed March 17, 2010
Fekkes M, Pijpers FI, Verloove-Vanhorick SP. Effects of anti-bullying school program on bullying and health complaints. Arch Pediatr Adolesc Med. 2006;160(6):638-644.
Gini G, Pozzoli T. Association between bullying and psychosomatic problems: a meta-analysis. Pediatrics. 2009;123:1059-1065.
Jenson JM, Dieterich WA. Effects of a skills-based prevention program on bullying and bully victimization among elementary school children. Prev Sci. 2007 Dec;8(4):285-296.
Moore M, Petrie C, Braga A, et al. Deadly lessons: understanding lethal school violence (website). editors; National Research Council www.nap.edu/openbook.php?isbn=0309084121&page=1 Accessed March 17, 2010
Nansel TR, Craig W, Overpeck MD, et al. Cross-national consistency in the relationship between bullying behaviors and psychosocial adjustment. Arch Pediatr Adolesc Med. 2004;158:730-736.
National Center for Education Statistics. Indicators of school crime and safety: 2004 (website). nces.ed.gov/pubs2005/crime_safe04/index.asp. Accessed March 17, 2010
Schreier A, Wolke D, Thomas K, et al. Prospective study of peer victimization in childhood and psychotic symptoms in a nonclinical population at age 12 years. Arch Gen Psychiatry. 2009 May;66(5):527-536.
Vreeman RC, Carroll AC. A systematic review of school-based interventions to prevent bullying. Arch Pediatr Adolesc Med. 2007;161(1):78-88.
36.2 Effects of War on Children
The impact of war on children is devastating, and its effects can last for decades after hostilities have ceased. In collected health surveys it was found that for 13 war-prone countries, 7.5% of the victims were children aged <15 yr. Based on statistics accrued by the United Nations Children’s Fund (UNICEF), of the 3.6 million people killed as a result of military conflict between the years 1990 and 2003, 90% were civilian and 50% were children. During the past decade, the effects of war on children has not abated, and children continue to be the victims of warfare taking place on the Asian subcontinent, sub-Saharan Africa, and the Middle East.
Mortality and morbidity related to the long-term effects of war and civil strife are often higher than that occurring during actual fighting. War and violence are not listed as leading causes of childhood mortality; but the regions with the highest levels of child mortality, especially among children <5 yr of age, are the same locations involved in military conflicts. Nations, especially the least developed, devote substantial portions of their budgets to military expenditures at the expense of the health care infrastructure; a proportion of deaths attributed to malnutrition, environmentally related infectious disease, or inadequate immunization are related to the effects of war.
The morbidity of children exposed to conflicts is significant (Table 36-2). Many more children are physically harmed than killed. The number of children who have suffered serious injuries in the past 15 yr is estimated to be 6 million; over 20 million children have been displaced from their homes as a result of war and associated human rights violations. Children bear the psychologic scars of war resulting from exposure to violent events, loss of primary caregivers, and forced removal from their homes. During periods of war, children are more susceptible to exploitation in the forms of forced conscription as soldiers, sexual exploitation, and slavery. There are ≈300,000 soldiers under the age of 18 yr who are actively participating in military conflicts worldwide. Lacking the appropriate education and socialization, the moral compass of these children is often misaligned. They are not capable of understanding the sources of conflict or why they have been targeted. Their thought processes are more concrete; it is easier for them to dehumanize their adversaries. Children, who themselves are exposed to violence and cruelty, often become the worst perpetrators of atrocities.
After cessation of hostilities, children are still at risk for life-endangering injuries from landmines and unexploded ordnance. The International Campaign to Ban Landmines estimates that there are up to 20,000 land mine, cluster munitions, and unexploded ordnance casualties per yr; a significant proportion are children. The U.S. Centers for Disease Control and Prevention (CDC) reported for a 5 yr period ending in 2006 that of the 5,741 individuals who were killed or injured by landmines or unexploded ordnance, 47.2% were children under the age of 18 yr. Injuries and death tended to occur while children were either playing or involved in household chores, and in contrast to adults, a large proportion of the injuries involved upper extremity amputation.
Children do not have the physical or intellectual capabilities to defend themselves. It is easier for adults to victimize children rather than other adults. Older children’s curiosity, desire for adventure, and imperfect assessment of risk often lead them to participate in dangerous behavior. Younger children, because of their small size and immature physiology, are more susceptible to disease and starvation, and are more likely to sustain fatal injuries from ballistic projectiles and explosive devices such as mines. Specific types of warfare can have a disproportionate effect on children. In a survey of war-related mortality in Iraq from 2003-2008, it was found that approximately 10% of the violence-related fatalities were children. Most children succumbed to either small-arms gunfire or suicide bombs (35%). When compared to adults, a proportionately higher rate of children died as a result of the usage of indiscriminant types of weaponry such as mortars, missiles, and aircraft-delivered bombs; 40% of the total casualties in these types of attacks were children.
During times of war, there is a breakdown of social inhibitions and cultural norms. Aberrant behavior such as rape, torture, and pillaging, which would be nearly inconceivable in times of peace, is common during war. Children may be attacked or used as human shields. Instincts such as parents’ desires to protect their children may be extinguished.
The changing nature of war has adversely affected children. Conventional warfare in which armies of professional soldiers representing different countries battle each other has become less common. Intrastate conflicts in the form of civil war are more frequent. Of the 190 armed conflicts occurring after World War II, 75% of them were intrastate. These conflicts are often rooted in ethnic or religious differences, and the participants are frequently nonprofessional “irregulars” who lack discipline and accountability to higher echelons, and are directed by those who do not acknowledge or respect international accords governing warfare. Often the military resources of the antagonists are disproportionate, leading the weaker protagonist to develop compensatory tactics that can include guerrilla and terrorist activities, while the stronger side often resorts to the disproportionate use of force. Low-intensity conflicts have become more common. These types of conflicts are often characterized by military activities targeting civilian populations with the goal of disrupting normal routines and generating publicity for the perpetrators. Children are often victims, as this serves to maximize the impact of terrorist activity. A particularly tragic example was the takeover of a public school in Beslan, Russia, in 2004; more than 800 children, together with their teachers and parents, were taken hostage and many of them were subsequently killed.
Terrorism and organized urban-based gang warfare violence have become more prevalent. Violence perpetrated by terrorists groups or gangs is designed to coerce and/or intimidate both individuals and entire societies. The destruction of the New York City World Trade Center Towers in 2001 and the nearly 3,000 fatalities showed that highly organized and motivated terrorists have few inhibitions and can strike anywhere. Biologic and chemical terrorism has also been realized with nerve gas attacks on subways in Japan and the release of anthrax spores in the USA. Children are more susceptible to chemical and biologic toxins because of their higher respiratory rates, more permeable skin, and other developmental vulnerabilities. Heavier-than-air gases such as sarin and chlorine cling to the ground and are more likely to be inhaled by children, who are relatively short (Chapter 704). Many of the protective devices against these agents were developed for adults and may not provide adequate protection for infants and young children.
The media has had a significant role in exacerbating the effects of war on children. Media coverage of war and terrorist events is extensive and graphic. Children, who are more impressionable than adults, often view this material in an uncontrolled fashion. Uncensored pictures of victims, unbridled violence, people in shock, or family members searching through ruins for relatives may traumatize children and even encourage inappropriate behavior. Overt broadcast propaganda glorifying war and violence may sway children to participate in militaristic or antisocial activities.
Exposure to war and violence can have a significant impact on a child’s psychosocial development. Displacement, loss of caregivers, physical suffering, and the lack of appropriate socialization all contribute to abnormal child development (see Table 36-2). Often the reactions are age-specific (Table 36-3). Preschoolers may have an increase in somatic complaints and sleep disturbances, and have acting-out behavior such as tantrums or excessively clinging behavior. School-aged children will show regressive behavior such as enuresis and thumb sucking. They too have an increase in somatic complaints; there is often a negative impact on school performance. For teenagers, psychologic withdrawal and depression are common. Adolescents often exhibit trauma-stimulated acting-out behavior. Motivated by the desire for revenge, they may be quick to join in the violence and contribute to the continuation of conflict.
Table 36-3 MANIFESTATIONS OF STRESS REACTIONS IN CHILDREN AND ADOLESCENTS EXPOSED TO WAR, TERRORISM, AND URBAN VIOLENCE
CHILDREN ≤5 YEARS
CHILDREN 6-11 YEARS
ADOLESCENTS 12-17 YEARS
There is an increased incidence of both acute stress reactions and PTSD (Chapter 23). The true incidence is difficult to assess because of the heterogeneous nature of war, degree of exposure to violence, and methodologic challenges related to the precise characterization of PTSD. The incidence of PTSD increased from 2% to 10.5% among New York City metropolitan area school-aged children and adolescents after the destruction of the World Trade Center. Risk factors for having a more serious psychologic response to a violent event include severity of the incident, personal involvement (physical injury, proximity, loss of a relative), prior history of exposure to traumatic events, female gender, and a dysfunctional parental response to the same event.
The manifestations of PTSD in children differ from those of adults, and include anxiety, disorganized and agitated behavior (hypervigilance, hyperactivity), autonomic hypersensitivity, somatization, depression, and sleep disturbances. The onset of PTSD symptomatology can be delayed; it is not unusual for children to develop PTSD many years after the traumatic event. Children do not have to be directly exposed to violent activity, and media coverage of terrorist events may be sufficient to trigger PTSD.
The trauma experienced by children during war can have lifelong effects. Studies on children imprisoned in concentration camps or evacuated from their homes in London during the Battle of Britain show that these individuals were at greater risk for PTSD, anxiety disorders, and a higher level of dissatisfaction with life. Individuals who suffered wartime trauma can pass on certain traits to their children, including a greater propensity for PTSD. On the positive side, children are extremely resilient. With appropriate support from family and community together with timely and intensive psychologic intervention, children can recover and lead normal productive lives despite the searing trauma that they may have experienced.
War and terror violate the human rights of children, including the right to life, the right to be nurtured and protected, the right to develop appropriately, the right to be with family and community, and the right to a healthy existence. Several international treaties and conventions have been ratified beginning with the Fourth Geneva Convention (1949) that set forth guidelines regarding appropriate treatment of children in times of war. The United Nations Convention on the Rights of the Child (1990) delineated specific human rights inherent to every child (defined as any individual younger than the age of 18 yr). The Rome Statute of the International Criminal Court that was enacted in 2002 declared that the conscription or enlistment of children younger than the age of 15 yr is a prosecutable war crime. These statutes are not well-known among the general population; there is a need for greater public education in this area.
Although these treaties and conventions define the extent of protection afforded to children, the means of enforcement available to the international community is limited. Individuals, motivated by religious fervor, nationalistic zeal, or ethnic xenophobia, are unlikely to curb their activities because of fear of prosecution. These treaties better serve in heightening awareness regarding the protected status of children in wartime, and perhaps deter high-ranking leaders who fear being held accountable for war crimes.
Several organizations, either non-governmental or under the auspices of the United Nations, are involved in mitigating the effects of war on children. These organizations, which include the International Red Cross, UNICEF, United Nations Refugee Agency (UNCHR), World Health Organization, and Médicins Sans Frontières (Doctors Without Borders) have had a significant impact on reducing violence-related casualties in war-torn regions. The infusion of humanitarian aid into developing countries often improves overall mortality and morbidity by increasing the level of medical and social services available to the general population. Other organizations such as Amnesty International, Stockholm International Peace Research Institute, and Physicians for Human Rights actively monitor human rights abuses involving children and other civilian groups. In 2005, the United Nations Security Council approved the establishment of a monitoring and reporting system designed to protect children exposed to war. United Nations–led task forces will conduct active surveillance in regions of conflict and monitor the killing or injuring of children, recruitment of child soldiers, attacks directed against schools or hospitals, sexual violence against children, abduction of children, and denial of humanitarian access for children.
War is a chronic condition and health providers need to be prepared to treat childhood casualties resulting from military or terrorist activity as well as caring for children suffering from the aftermath of war or related violence. Community and hospital pediatricians need to be involved in community disaster planning. General disaster planning often ignores the unique needs and requirements of children; in planning for a possible chemical attack, appropriate resuscitation equipment suitable for children needs to be stockpiled. The signs of biologic infection or chemical intoxication are different for children, and pediatricians and emergency personnel need to be aware of these differences (Chapter 704). Surveys of pediatricians and other health care providers indicate that many feel unprepared for bioterrorism attacks. Professional organizations such as the American Academy of Pediatrics (AAP) and the CDC have published position papers; there is a special section in the AAP Red Book that presents guidelines for treating specific pathogens likely to be utilized in biologic warfare. In regions where violent terrorist activity is likely, pediatricians, nurses, and rescue personnel should consider becoming certified in the Red Cross Basic and Advanced Trauma Life Support.
Pediatricians need to be cognizant of the effects that war and terror can have on parents and children. Parents, who themselves are under tremendous strain, may not be sensitive to the effects that the same stressors have on their children. Pediatricians should draw out both parents and children, and encourage them to talk freely about their feelings. Child health care providers can be instrumental in educating parents to be more aware of inappropriate responses by children to war and violence. When necessary, pediatricians can serve their families by referring them to appropriate support services.
Just as it is important to administer first aid for physical trauma, it is also critical to provide psychologic first aid to victims of trauma. There is also an online primer from the National Child Traumatic Stress Network entitled “Psychological First Aid,” which provides practical information for treating children in need of acute psychological support (www.ptsd.va.gov/professional/manuals/manuals-pdf/pfa/PFA_2ndEditionwithappendices.pdf). In day-to-day patient interactions, a pediatrician is most likely to confront situations related to stress reactions such as PTSD. Recognition of PTSD is essential so that early treatment can be initiated. Clues to the presence of PTSD include changes in behavior, school performance, affect, and sleep patterns, and an increase in somatic complaints. Because the triggering event is neither temporally nor physically proximate, it should not dissuade the pediatrician from making an appropriate referral to mental health professionals who are expert in childhood stress disorders. There are several brief and easy to administer psychological instruments based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for PTSD, such as the Trauma Symptom Checklist for Children and the Impact of Events Scale—8 items for children (IES-8). Many are available on the Internet (www.ptsd.va.gov).
It is not to be expected that health care personnel remain neutral in times of war. Pediatricians, similar to other individuals, are motivated by patriotism, nationalistic pride, political ideologies, and religious fervor. They often serve as military physicians and may be active participants in military campaigns. Medical profession standards demand from each physician that he or she treat all patients equitably without regard to their background. Both international law and professional medical societies ban physicians from actively participating in torture or other activities that infringe on human rights, including those of children. It is difficult to countenance any situation in which a health professional, even acting as a representative of his or her country, might directly or indirectly injure a minor.
Conversely, health professionals have an important role in preventing the atrocities that occur to children. In their role as advocates for the rights of children, pediatricians can be instrumental in focusing public attention on the precarious situation of children exposed to brutality and mayhem that are part and parcel of organized violence. They can promulgate the message that war and terror should not be allowed to rob children of their childhood.
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