Children's reactions to war-related stress. Affective symptoms and behaviour problems

Presence of Sleep Disturbances Among Child Trauma Survivors: Comparison of Caregiver and Child Reports

A significant body of research has been devoted to demonstrating high rates of sleep impairment, and the subsequent adverse implications of sleep difficulties, among adult trauma survivors, particularly those diagnosed with posttraumatic stress disorder (PTSD). Yet considerably less work has been focused on sleep disturbances among trauma-exposed children, especially preschoolers. Pediatric research is paramount in light of the numerous developmental and functional implications that may result from sleep impairment. Prior studies have also documented disagreement between caregiver's and children's reports of trauma-related symptoms; however, the level of concordance rates regarding sleep difficulties is unknown in this population. The present study investigated the rates of multiple types of sleep disturbances using caregiver's and children's reports as well as caregiver-child concordance rates regarding these difficulties. Three hundred and forty-two treatment-seeking children ages of 3-18 years (M = 9.68, SD = 4.00; 61.1% female, 60.4% Black) and their caregivers were included in the study. Sleep disturbances were common in this sample, and children endorsed higher levels of sleep symptoms (range 46-72%) than their caregivers (range 14-51%). Nearly half (47%) of preschool children evinced significant sleep impairment per their caregiver. Inter-rater agreement between caregiver's and children's reports for all sleep symptoms were below acceptable levels (range κ = 0.01-.13), indicating that the concordance rate for caregiver-child trauma-related sleep problems is quite low. Findings illustrate the relevance of sleep disturbances among trauma-exposed children and point to the need to assess both caregiver's and children's symptoms regarding sleep impairment.

Trauma characteristics and sleep impairment among trauma-exposed children

Trauma-related sleep difficulties are quite common and their functional and clinical importance are increasingly recognized. High rates of sleep problems have been documented among trauma-exposed adults, particularly those diagnosed with posttraumatic stress disorder (PTSD); however, research with trauma-exposed children is relatively limited. Research specifically with child samples is critical due to the numerous developmental and functional implications that may result from sleep impairment. Characteristics of the traumatic event may play a key role in understanding sleep difficulties, yet, these associations are not well understood among trauma-exposed children. The current study therefore investigated whether aspects of the traumatic event (i.e., type, nature, chronicity, age of onset, removal from home, and complex trauma) were related to higher levels of sleep disturbances among 276 treatment-seeking children ages 6-18 years (M = 10.88, SD = 3.39; 63.4% female; 62.7% Black). Sleep problems were common in this sample. Domestic and community violence exposure were associated with higher levels of select sleep difficulties, as were interpersonal trauma, chronic trauma, a trauma that began early in life, and complex trauma. Nonetheless, type of trauma and characteristics of the traumatic event were largely unrelated to sleep problems on either caregiver's or children's reports. Removal from the home was not linked with sleep impairment. Although findings signify the relevance of sleep disturbances among trauma-exposed children, trauma characteristics may have limited influence on sleep problems.

Community Violence and Young South African Children's Involvement in Aggression

Five-year-old children from four different communities in South Africa were observed during their everyday patterns of play and social participation. The communities differed in terms of the levels of community violence that researchers encountered during two years of data collection. The results indicated that children from more violent communities were significantly more likely to be involved in aggressive episodes, and that this was particularly so in cases where children had more contact with older boys and men. The predictive model for involvement in aggression, as developed in this study, illustrates the importance of combining demographic variables with variables pertaining to children's actual behaviour. The results are also discussed in terms of their implications for young South African children; although growing up in violent communities is associated with greater involvement in aggressive behaviour, the degree to which this can be considered seriously pathological is called into question by some of the results.

Determinants and Effectiveness of Children’s Coping with Political Violence

We examined how age and gender, and the intensity of political violence and stressful events influence children’s coping styles, and the effectiveness of coping. The participants were 185 Palestinian boys and girls of 10-13 years of age. Intensity of political violence was indicated by comparing a group tested before the Intifada ( N = 89) and a group during the Intifada ( N = 96). The results showed that older children used more emotional and cognitive coping, and a wider coping repertoire than younger ones. Boys used more Problem restructuring and behavioural coping than girls, who, for their part, used more emotional coping than boys. The more intensive the political violence was, the more Problem restructuring and the less Active fighting and Hostile confrontation children used. Further, during an intensively violent period of Intifada, children’s coping repertoire was narrow and involved little emotional and cognitive coping modes. Personal exposure to stressful events increased behavioural coping, Active fighting and Problem restructuring, and decreased emotional modes of coping. The effectiveness of coping styles in alleviating psychosocial problems varied according to the intensity of political violence. Problem restructuring, Active fighting, and behavioural coping were effective only during the Intifada, but not before the Intifada.

The Dose of Exposure and Prevalence Rates of Post Traumatic Stress Disorder in a Sample of Turkish Children Eleven Months After the 1999 Marmara Earthquakes

Since Turkey is a centrally prime earthquake zone, Turkey’s children are at risk for developing Post Traumatic Stress Disorder (PTSD) caused by earthquake exposures and threats of anticipated earthquakes. Given the gaps in the literature and the risk to children living in Turkey, the present study was undertaken to investigate the severity and prevalence of PTSD in 4th and 5th grade Turkish children after the notorious 1999 earthquakes in the city of Sakarya. Data were collected in May 2000. The research focus was to compare results between high-impact trauma and low-impact trauma groups according to percentage, severity and the frequency of PTSD diagnosis. Group means were compared for mild, moderate, severe and very severe categories of PTSD diagnosis. High and low impact groups were not significantly different in any category; the number of children who met the PTSD requirement was almost the same in both groups in number and severity.

Childhood adversities and traumata in Lebanon: a national study

BACKGROUND

The goal of this paper is to map the total occurrence and evaluate the risk of co-occurrence of childhood adversities (CA) and a wide variety of childhood traumatic events (including war) in a national sample.

METHOD

The nationally representative sample included 2,857 respondents and the instrument used was the Composite International Diagnostic Interview which screened for all CAs and traumatic events.

RESULTS

27.9% experienced CAs; the most common were parental death and parental mental/substance use disorder. 70.6% experienced a war-related traumatic event during their lifetime, and around half of them (38.1%) experienced it below the age of 18 years. 51.3% of the subjects experienced a traumatic event not related to war during their lifetime, and 19.2% experienced it before the age of 18 years. Sexual abuse, being a refugee during war, and experiencing a natural disaster were associated with female gender. Having any CA was associated with active war exposure (OR: 4.2, CI: 2.0-8.6); war-related direct personal trauma (OR: 3.9, CI: 1.5-10.0); war-related trauma to others (OR: 2.4, CI: 1.3-4.4); non-war direct personal trauma (OR: 3.8, CI: 2.0-7.4); and any non-war childhood traumatic event (OR: 1.9, CI: 1.1-3.1).

CONCLUSION

Childhood is awash with adversities and traumatic events that co-occur and should be measured simultaneously; otherwise, the effects of a subset of traumata or adversities could be wrongly thought to be the contributor to negative outcomes under study.

Sleep disturbance in pediatric PTSD: current findings and future directions

Many studies have provided strong evidence of a fundamental and complex role for sleep disturbances in adult posttraumatic stress disorder (PTSD). Investigations of adult PTSD using subjective and objective measures document sleep architecture abnormalities and high prevalence of sleep disordered breathing, periodic limb movement disorder, nightmares, and insomnia. PTSD treatment methods do appear to significantly improve sleep disturbance, and also studies suggest that treatments for sleep disorders often result in improvements in PTSD symptoms. Further, the most recent evidence suggests sleep abnormalities may precede the development of PTSD. Given the importance of sleep disorders to the onset, course, and treatment of adult PTSD, examination of sleep disturbances far earlier in the life course is imperative. Here we review the literature on what we know about sleep disturbances and disorders in pediatric PTSD. Our review indicates that the extant, empirical data examining sleep disturbance and disorders in pediatric PTSD is limited. Yet, this literature suggests there are significantly higher reports of sleep disturbances and nightmares in children and adolescents exposed to trauma and/or diagnosed with PTSD than in non-trauma-exposed samples. Sleep questionnaires are predominantly employed to assess sleep disorders in pediatric PTSD, with few studies utilizing objective measures. Given the important, complex relationship being uncovered between adult PTSD and sleep, this review calls for further research of sleep in children with PTSD using more specific subjective measures and also objective measures, such as polysomnography and eventually treatment trial studies.

A systematic review on the mental health of children and adolescents in areas of armed conflict in the Middle East

For many decades, the Middle East has been troubled with numerous long-standing armed conflicts and wars. Children and adolescents were not spared the trauma and its consequences. Exposure to traumatic events can result in mental, behavioural and emotional problems in children and adolescents. To date, this is the first paper that aims to systematically review the literature on the mental health of children and adolescents living in areas of armed conflict in the Middle East, specifically Israel, Palestine, Lebanon and Iraq. It explores factors that mediate between exposure to armed conflict and mental, behavioural and emotional problems and places them in a cultural context. Pubmed was searched and papers were identified using specific inclusion criteria. Seventy-one eligible studies were included. The main findings are that children and adolescents living in these conflict zones are exposed to high levels of traumatic experiences. Number of conflict-related traumatic experiences correlates positively with prevalence of mental, behavioural and emotional problems. Prevalence of post-traumatic stress disorder in children and adolescents is estimated to be 5-8% in Israel, 23-70% in Palestine and 10-30% in Iraq (insufficient data for Lebanon). The main determining factors identified were level and type of exposure, age, gender, socio-economic adversity, social support and religiosity. These findings bring to light the pressing need to provide children and adolescents living in conflict areas with help. They are useful in designing new interventions to strengthen child and adolescent resilience in areas of conflict worldwide. Specific recommendations are included.

Range and specificity of war-related trauma to posttraumatic stress; depression and general health perception: displaced former World War II children in late life

BACKGROUND

Dose-response relation of war experiences and posttraumatic stress, depression and poor health functioning in late life is well documented in war-affected populations. The influence of differing trauma types experienced by war-affected population in the study of dose-response relation of war trauma and psychological maladaptation in late life has not been investigated. We examined a subgroup of displaced elders and investigated whether specific trauma types were associated with differential health outcomes.

METHODS

From representative practitioner lists, matched groups of former displaced and non-displaced World War II children were assigned, yielding a total sample of 417 participants (response rate 50%). Measurement encompassed a self-report survey including the Impact of Event Scale-Revised, the Patient Health Questionnaire and the Harvard Trauma Questionnaire.

RESULTS

Consistent dose-relation between war-related experiences and posttraumatic stress or depressive symptoms in late life was found for both, displaced and non-displaced elders, whereas a gradient for poor health perception was only found in displaced people. Trauma types derived from principal component analysis showed differential associations with health outcomes. Human Right Violations emerged as risk factor for posttraumatic stress symptoms and Deprivation & Threat to Life as risk factor for depressive symptoms. Poor self-rated health was associated with multiple trauma types.

LIMITATIONS

Non-random recruitment, retrospective design and use of self-report.

CONCLUSIONS

Posttraumatic stress and depression are associated with war-related experiences more than 60 years after World War II. Results suggest that different trauma types lead to unique variants of syndrome configurations, which may result from different etiological factors.

Safe enough to sleep: sleep disruptions associated with trauma, posttraumatic stress, and anxiety in children and adolescents

Sleep disturbance is an essential symptom of posttraumatic stress disorder, and recent evidence suggests that disrupted sleep may play an important role in the development of posttraumatic stress disorder following traumatic stress. The authors review several aspects of sleep as it relates to posttraumatic stress disorder. First, there is an association between traumatic stress and different components of disrupted sleep in children and adolescents. Second, sleep disruption appears to be a core feature of other pediatric anxiety disorders, and the authors consider if this preexisting sleep vulnerability may explain in part why preexisting anxiety disorders are a risk factor for developing posttraumatic stress disorder following a traumatic event. Third, the authors consider attachment theory and the social context of trauma and sleep disruption. This article concludes with a consideration of the therapeutic implications of these findings.

Mental health of Bosnian refugee children: a comparison of clinician appraisal with parent, child and teacher reports

This study compares clinician appraisal of Bosnian refugee children with independent parent, child and teacher reports. From whom and by what means can children "at risk" be reasonably identified? Forty-eight Bosnian refugee children (aged 7-20), resettled in Sweden 1994-95, were assessed clinically by means of a semi-structured interview. Thereafter, standardized mental health questionnaires were administered to parents (Achenbach's Child Behavior Checklist), children (Achenbach's Youth Self-Report and Macksoud's Posttraumatic Stress Reaction Checklist) and teachers (clinician designed School Competence Scale and Achenbach's Teacher's Report Form). On clinician interview, nearly half of the children (48%) were identified with one or more mental health problem "demanding further attention". Depressiveness was the single most prevalent symptom (31%); followed by post-traumatic stress (23%), and anxiety-regressiveness (15%). At the same time, 75% of the children were rated by teachers as "quite competent" in school. Parent, child and clinician appraisals of primary school children showed broad similarities. Teachers reported a similar prevalence of child distress, but identified different symptoms and different children demanding attention. Evaluation of teenage youths showed greater disparity: teenagers labeled their own symptoms more often as post-traumatic stress reactions and teachers identified few youths in need of attention. Inter-relatedness among parent, child and clinician appraisals supports the robustness of our semi-structured interview. At the same time, apartness of teacher report underscores the need to incorporate an outside-world vantage point in the process of risk assessment. Also, a more concrete presentation of post-traumatic stress reactions and a higher "further attention" threshold for inward emotional problems seem called for.

Practitioner review: assessment and treatment of refugee children and adolescents who have experienced war-related trauma

BACKGROUND

Increasingly clinicians are being asked to assess and treat young refugees, who have experienced traumatic events due to war and organised violence. However, evidence-based guidance remains scarce.

METHOD

Published studies on the mental health difficulties of refugee children and adolescents, associated risk and protective factors, as well as effective interventions, particularly those designed to reduce war-related post-traumatic stress disorder (PTSD) symptoms, were identified and reviewed. The findings are summarised.

RESULTS

Young refugees are frequently subjected to multiple traumatic events and severe losses, as well as ongoing stressors within the host country. Although young refugees are often resilient, many experience mental health difficulties, including PTSD, depression, anxiety and grief. An awareness of relevant risk and protective factors is important. A phased model of intervention is often useful and the need for a holistic approach crucial. Promising treatments for alleviating symptoms of war-related PTSD include cognitive behavioural treatment (CBT), testimonial psychotherapy, narrative exposure therapy (NET) and eye movement desensitisation and reprocessing (EMDR). Knowledge of the particular needs of unaccompanied asylum-seeking children (UASC), working with interpreters, cross-cultural differences, medico-legal report writing and the importance of clinician self-care is also necessary.

CONCLUSION

More research is required in order to expand our limited knowledge base.

Risk and protective factors mediating psychological symptoms and ideological commitment of adolescents facing continuous terrorism

This study evaluated symptoms, risk, and protective factors of adolescents from six Israeli schools exposed to continuous terrorism. All children in the grades selected at each school (7, 9, and 11) were administered anonymous assessment materials measuring posttraumatic, grief, and dissociative symptoms, as well as traumatic exposure, personal resilience, and family factors. A high number of risk factors increased the likelihood of negative symptoms. Perceived personal resilience served as a protective factor against symptom development, perhaps enforced by ideology. Girls living on the West Bank had less severe posttrauma and were more willing to make personal sacrifices for their country. Proactive interventions aimed at enhancing a child's personal resilience and ability to cope with continuous stress may help protect against later symptomatology following traumatic events. Facing terrorism, political ideology may serve a double edge sword: protecting against symptom development as well as contributing to the toxic cycle of violence.

Mental health in complex emergencies

Mental health is becoming a central issue for public health complex emergencies. In this review we present a culturally valid mental health action plan based on scientific evidence that is capable of addressing the mental health effects of complex emergencies. A mental health system of primary care providers, traditional healers, and relief workers, if properly trained and supported, can provide cost-effective, good mental health care. This plan emphasises the need for standardised approaches to the assessment, monitoring, and outcome of all related activities. Crucial to the improvement of outcomes during crises and the availability to future emergencies of lessons learned from earlier crises is the regular dissemination of the results achieved with the action plan. A research agenda is included that should, in time, fill knowledge gaps and reduce the negative mental health effects of complex emergencies.

The psychosocial aspects of children exposed to war: practice and policy initiatives

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. Considering 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.

Children and war

Children bear disproportionate consequences of armed conflict. The 21st century continues to see patterns of children enmeshed in international violence between opposing combatant forces, as victims of terrorist warfare, and, perhaps most tragically of all, as victims of civil wars. Innocent children so often are the victims of high-energy wounding from military ordinance. They sustain high-energy tissue damage and massive burns - injuries that are not commonly seen in civilian populations. Children have also been deliberately targeted victims in genocidal civil wars in Africa in the past decade, and hundreds of thousands have been killed and maimed in the context of close-quarter, hand-to-hand assaults of great ferocity. Paediatricians serve as uniformed military surgeons and as civilian doctors in both international and civil wars, and have a significant strategic role to play as advocates for the rights and welfare of children in the context of the evolving 'Laws of War'. One chronic legacy of contemporary warfare is blast injury to children from landmines. Such blasts leave children without feet or lower limbs, with genital injuries, blindness and deafness. This pattern of injury has become one of the post-civil war syndromes encountered by all intensivists and surgeons serving in four of the world's continents. The continued advocacy for the international ban on the manufacture, commerce and military use of antipersonnel landmines is a part of all paediatricians' obligation to promote the ethos of the Laws of War. Post-traumatic stress disorder remains an undertreated legacy of children who have been trapped in the shot and shell of battle as well as those displaced as refugees. An urgent, unfocused and unmet challenge has been the increase in, and plight of, child soldiers themselves. A new class of combatant comprises these children, who also become enmeshed in the triad of anarchic civil war, light-weight weaponry and drug or alcohol addiction. The International Criminal Court has outlawed as a War Crime, the conscription of children under 15 years of age. Nevertheless, there remain more than 300000 child soldiers active and enmeshed in psychopathic violence as part of both civil and international warfare. The typical profile of a child soldier is of a boy between the ages of 8 and 18 years, bonded into a group of armed peers, almost always an orphan, drug or alcohol addicted, amoral, merciless, illiterate and dangerous. Paediatricians have much to do to protect such war-enmeshed children, irrespective of the accident of their place of birth. Only by such vigorous and maintained advocacy can the world's children be better protected from the scourge of future wars.

Children and war: current understandings and future directions

During the last decade, the number of children whose lives have been disrupted by war, oppression, terror, and other forms of conflict has grown tremendously. When the United Nations High Commission for Refugees was first established during the 1950s to provide international protection to refugees following World War II, it was estimated that there were 1.5 million refugees and displaced persons. Today there are approximately 14 million, about three-fourths of whom are women and children. Although the experiences of refugee children and adolescents vary considerably, many have witnessed or experienced the death or murder of loved ones. Upon resettlement, they face numerous challenges. Research with this population is a relatively new area of investigation, but there is evidence that many of these young people experience long-term physical and emotional health problems. In this article, current research findings are reviewed, the widespread emphasis in the literature on post-traumatic stress disorder (PTSD) is critically examined, future research directions are suggested, and implications for public health nurses are addressed.

Responding to the mental health needs of Latino children and families through school-based services

This article highlights the value and utility of school-based mental health services in addressing the unmet mental health needs of Latino children and families in the United States. To better understand our nation's rapidly growing Latino population, such critical factors as demographic characteristics, cultural values, and family structure are examined. Special attention is devoted to the daunting challenges and resultant trauma experienced by many of these children and families who have recently immigrated to this country from war-torn home-lands in Central America. The mental health status of Latino children is addressed, along with various service delivery issues and psychotherapeutic modalities to facilitate their personal adjustment and social adaptation in a culturally sensitive manner. The article concludes with the presentation of an innovative school-based mental health program that offers a range of services of demonstrated effectiveness in aiding Latino children and their families. Specific strategies for replicating the program model in other culturally diverse settings are also discussed.

War experiences and distress symptoms of Bosnian children

OBJECTIVE

The war in Bosnia has had a tremendous impact on civilians. Little is known about the impact of modern warfare on children. This survey documents the nature and frequency of war-related experiences among Bosnian children and describes their manifestations of selected psychological sequelae.

METHODS

A cross-sectional survey of 364 internally displaced 6- to 12-year-old children and their parents living in central Bosnian collectives was conducted during the war. Parents were surveyed for their children's war experiences; the children were surveyed for war-related distress symptoms.

RESULTS

The children were exposed to virtually all of the surveyed war-related experiences. The majority had faced separations from family, bereavement, close contact with war and combat, and extreme deprivation. The prevalence and severity of experiences were not significantly related to a child's gender, wealth, or age, but were related to their region of residence, with children from the region of Sarajevo having the highest prevalence of experiences. Almost 94% of the children met Diagnostic and Statistical Manual of Mental Disorders, 4th ed, criteria for posttraumatic stress disorder. Significant life activity affecting sadness and anxiety were reported by 90.6% and 95.5% of the children, respectively. High levels of other symptoms surveyed were also found. Children with greater symptoms had witnessed the death, injury, or torture of a member of their nuclear family, were older, and came from a large city.

CONCLUSIONS

The war-related experiences of the children studied were both varied and severe, and were associated with a variety of psychological sequelae. This experience underscores the vulnerability of civilians in areas of conflict and the need to address the effects of war on the mental health of children.

The impact of war on the mental health of children: a Salvadoran study

OBJECTIVE

This ecologically conceptualized, intensive study assesses the mental health impact of the Salvadoran Civil War on 54 12-year-olds, born into the war, exposed to different levels of war violence.

METHODS

Half of the students came from a repopulated country village and half from an industrial neighborhood near the capital city. Children, their mothers or caretakers, and their teachers responded to interviews and some instruments.

RESULTS

Children from the repopulated village reported higher war experience and lower mental health. The personal/social impact of the war was more important than family togetherness or war intensity in determining the mental health of the children. Children's intelligence was highly related to surviving with higher mental health. Higher socioeconomic status (SES) and education of parents was related to better mental health. Controlling for intelligence, children who experienced the highest personal-social impact of war showed the poorest mental health. Children with high war experience were most likely to have difficulty in imagining the future.

CONCLUSIONS

Intelligence and the foreshortening of future vision are variables that should be controlled for and investigated in outcome studies of trauma. Treatment for survivors should include aid in planning for the future.

Clinical description of children's anxiety during the Gulf War

Interviews were carried out with 322 children, ages 5 to 16 years, to examine the association of war experience and their anxiety. Body language was used as indicator of anxiety. Girls showed significantly more discrete body movements than boys.

Child development: vulnerability and resilience

Many of the challenges facing children now are a function of changing times, including increase in urbanization, political violence, changing family forms, and in some areas decreased supplies of adequate food. This review focuses particularly on those changes in which children are the victims and which induce new threats for them, rather than on problems such as child disability or mental illness. The outcome variables of interest in this paper are dimensions of children's psychosocial development, including cognitive development, psychological adjustment and aggression, whereas the companion paper in this issue (Caldwell P., Child survival: vulnerability and resilience in adversity in the European past and the contemporary Third World, Soc. Sci. Med.) [1] focuses on physical aspects of children's development. The risks that are hurdles in the process of development of a young child begin from conception and carry on into later life. To address them all would be impossible; thus, in order to do justice to the issues at hand, we have chosen those risks that, in our view, are important in a child's psychosocial development in developing countries. This paper will thus provide a discussion of the concepts of risk and resilience, then apply these concepts to the analysis of three examples of risk faced by children today: nutritional threats (e.g. malnutrition due to decline in breastfeeding); family dynamics and types of family forms (e.g. child fostering and non-traditional families); and experiences of violence (domestic or political). In each case, the same four questions will be addressed: what are the consequences of the risk factor for children, what are the etiologies and conditions of risk, are there any children who seem to cope with the risk factor successfully and what are some of the protective factors, and what interventions or programs would help support these children?

The impact of the peace treaty on psychological well-being: a follow-up study of Palestinian children

This research examined the impact of the Israeli-Palestinian peace treaty and Palestinian children's perception of it on their self-esteem and neuroticism. We also studied the relative importance of earlier exposure to traumatic experiences and psychosocial resources indicated by the children's creativity, intelligence and political activity in influencing their psychological well-being after the peace treaty. The sample used was a follow-up group of 64 Palestinian children of 11-12 years of age, living in the Gaza Strip. The results showed that the level of neuroticism was significantly lower after the peace treaty than before. The children's earlier exposure to traumatic experiences was still significantly related to high neuroticism and low self-esteem after the peace treaty. Acceptance of the treaty and participating in the subsequent festivities mitigated the negative impact of the traumatic experiences on their well-being. Increased neuroticism and decreased self-esteem were found only among children who refused to accept the peace treaty and did not participate in the festivities. Creativity and Intifada activity promoted their post-peace treaty well-being, in terms of psychosocial resources. The more creative the children were, the more their neurotic symptoms decreased because of the treaty and the higher self-esteem they had after it. The more active the children were during the Intifada, the more their self-esteem increased because of the treaty.

The impact of the Gulf armed conflict on the health and behaviour of Kuwaiti children

This study deals with the psychological reactions of Kuwaiti children to war-related stresses in the early period of the Gulf crisis following the summer 1990 Iraqi invasion of Kuwait. A sample of 106 children was drawn from Kuwaiti displaced families and a comparable control sample was obtained from Saudi families in Riyadh, Saudi Arabia. An interview checklist of symptoms of physical and psychological distress was administered to the index child and a female key informant in each household of cases and controls. Most Kuwaiti children were exposed to unpleasant war experiences. It was found that Kuwaiti children exhibited a substantially greater degree of dysfunctional social and emotional behaviour. The types of adverse behaviours were a function of the child's age, sex and experience of aggression. The findings support the notion that a negative relationship exists between armed conflict and the health and behaviour of the children. The complex needs of children exposed to violence require professionals to seek ways of combining psychodynamic interventions and relief programmes.

The Orphans of Eritrea: A Comparison Study

The social-emotional state and cognitive development was compared between a group of 74 4-7-year-old Eritrean orphans and refugee children living in families. Both groups had been exposed to the chronic stresses of war and drought and the orphans had, in addition, lost both parents to the violence of war, and were living in an overcrowded orphanage- Contrary to expectations, there were relatively few clinically significant differences between comparison groups. The orphans showed more behavioral symptoms of emotional distress, but performed at a more advanced level on cognitive and language performance measures. The findings suggest that when group care is child-centered, it can under some circumstances be a viable solution for unaccompanied children in countries where adoption and foster care are not realistic alternatives.

Teachers' perceptions of maladaptive behaviour in Lebanese refugee children

Research on the psychological status of children who are refugees from war has led to varying results. Children from war conditions or who have been subject to evacuation have been shown to have relatively low levels of disturbed behaviour, have internalising symptoms of anxiety or depression, display behaviour with aggressive features, and suffer slight psychological disturbance, depending on their caretakers' response to the stressful experience. Based on the contrasting evidence and observations within an inner Melbourne Muslim school, this study aimed to determine whether more behaviour problems existed in Muslim children from Lebanese families. Compared with other war refugee Muslim immigrant children, Lebanese children were not found to be more aggressive, but were more anxious. Lebanese males displayed more inattentive behaviour at school than non-Lebanese males. Sex differences were found in adaptive functioning within Lebanese and non-Lebanese groups. Differences in school performance and adaptive functioning were found between Lebanese and normative samples when males and females were analysed separately. These results are discussed in the context of teacher expectations and perceptions of culturally acceptable behaviour.

Children as victims of war: current knowledge and future research needs

Recent international events have drawn attention to the effects of war-related events and processes on children and their families. This review of the literature concerning the existence, frequency, and type of social, emotional, and behavioral problems in children exposed to war indicates significant methodological problems in previous research. Available evidence suggests that massive exposure to wartime trauma seems likely to overwhelm most children's defenses; however, children's cognitive immaturity, plasticity, and innate adaptive capacities may mitigate war's effects in low-to-moderately intense wartime settings, resulting in self-protective, adaptive, cognitive styles that allow effective functioning after acclimatization. Promising recent research has shifted from the focus on psychopathology to social awareness, values, and attitudes. More research will be needed to determine how age, developmental, family, and community factors may mediate the strength and nature of wartime effects, and to determine which interventions are most effective in a variety of settings and cultural contexts.