Best practices for assessing and treating abused wartime children

Assessing and Treating Children Who Suffered Sexual, Psychological and Mental Abuse during Wartime

Besides a nurturing environment provided by their parents, all children also need basic daily living requirements. At present, the UN Convention on the Rights of the Child provides for three types of protections for all children as follows: (1) children have to be provided with adequate nutrients, shelter, family environment, education, healthcare and recreation; (2) children should be protected from abuse and exploitation; and (3) children should participate in decision making for themselves and in social, economic, religious, and political life (Malone, 2015). Children in general and girls in particular, though, are especially vulnerable to sexual, psychological and mental abuse during times of war (Ensor, 2014). Moreover, male and female children are also at greater risk of failing to receive aid services and other humanitarian assistance during wartime, with the latter being at greater risk (Ensor, 2014). Although it is reasonable to posit that combatants and noncombatants alike suffer during times of war, it is also clear that vulnerable populations such as children are especially susceptible to all types of exploitation and abuse. This paper provides a systematic review of the relevant peer-reviewed literature to identify best practices for assessing and treating children who have suffered from sexual, psychological and/or mental abuse during times of war drawing on recent examples from conflicts around the world. Finally, a summary of the research and important findings concerning the abuse of children during wartime are provided in the conclusion. Review and Analysis Background and overview While the precise causes of sexual, psychological and mental abuse vary according to time and place as well as the exigencies of the armed conflict that is involved, the adverse effects of war invariably place young people at greater risk of abuse. In this regard, Ensor (2014) advises that, “Proximity to violent situations and breakdown of social structures may indeed increase the exposure of displaced children (primarily girls, but also boys) to sexual abuse and other forms of exploitation” (p. 16). The historical record confirms that these types of abuses occur as almost a concomitant outcome of warfare, and the same patterns are taking place in the various hotspots around the world wherever armed conflict erupts. Even very young children are at high risk of being abused in countless ways, including being forced into military service as child-soldiers, sex work or slave labor. In fact, only the dates and places need to be changed with respect to the inevitable outcome for vulnerable populations during wartime, including most especially young people. For example, citing the ongoing bloody ethnic warfare in the east African nation of South Sudan, Ensor (2014) concludes that, “In South Sudan, members of the youngest generations are being differently affected, vis-a-vis their adult counterparts, by the processes shaping the socio-political landscape of their newly independent society” (p. 17). In some situations, however, the plight of children in wartime, again most especially young girls, is particularly severe due to cultural and religious beliefs that place them at a disadvantage from the outset. In this regard, Ensor emphasizes that, “The position occupied by most South Sudanese girls is not an easy one given not only the renewed conflict and adverse humanitarian conditions, but also the pronounced gender inequalities that characterize their ethnically diverse but consistently patriarchal society” (2014, p. 17). Likewise, an ongoing civil war in the southeast African nation of Mozambique has been characterized by brutal attacks on small children and even infants, most especially young girls (Trentini, 2016). Although such attacks are occurring throughout the country, they are concentrated in northern Mozambique where they take place at night and are therefore known as the “nocturnal war” where the attacks are widely regarded as being retribution from evil spirits rather than otherwise-normal human insurgents fighting yet another ethnic war. For instance, Trentini (2016) reports that, “People living in the neighborhoods of Nampula city, northern Mozambique, often speak of a war that is being waged at night, during which sick infants and small children figure more and more frequently as the preferred prey of malevolent ancestors, witches and new malign spirits that come at night, and who abduct and enslave them in order to harm their families” (p. 529). These superstitious beliefs have been accentuated by the largely covert manner in which the most recent civil war in Mozambique has been waged, causing growing numbers of already marginalized mothers to grow fearful of their own children. As one northern Mozambique grandmother put it: This war at night is becoming worse than the past one. At least, in the last war, we could recognize who was the enemy by their uniform and we fought with weapons. But in this war, you may not know who is harming you. Nowadays, your babies can harm you as well. And you do not know how to protect yourself. You see, during the Portuguese [era], we were educated and we respected our elderly. But now, our children are telling us: we do not respect you anymore. (as cited in Trentini, 2016, p. 531) Against this backdrop, it is little wonder that young people growing up in times of war are placed at the greatest disadvantage for exploitation and abuse. It is important to point out, however, that these types of abusive practices are not restricted to third world countries that have been ravaged by war for years or even decades and the prevalence of sexual, psychological or mental abuse is far greater in families of returning combat veterans in the United States when compared to the population at large. For example, according to Cesur and Sabia (2016), “Because of the substantial occupational stress that accompanies military service, families of servicemen have been identified by policymakers as a vulnerable population in need of protection” (p. 209). More troubling still, and although there is no solid evidence to support the charge, the empirical observations of some clinicians have caused them to charge that family members of combat veterans are tacitly encouraged to tolerate abusive behaviors as part of the transition process to civilian life. In this regard, Cesur and Sabia add that, “While official U.S. military policy treats domestic violence as a serious offense, there is at least some concern that military families are counseled to tolerate violence from returning veterans” (2016, p. 210). Taken together, it is clear that young people can become victimized and traumatized by various types of abuse as the direct result of war. Unfortunately, these same patterns occur time and again around the globe wherever and whenever war erupts. Therefore, identifying efficacious and evidence-based interventions for treating these young victims has assumed new importance and relevance in recent years as discussed further below. Interventions for abused and traumatized children Not surprisingly, the implications for the young people who become victimized by warfare are severe and even life-threatening. Indeed, a growing body of evidence confirms that young people exposed to traumatic events such as warfare can develop and suffer from the harmful effects of posttraumatic stress disorder (PTSD) in similar ways to their adult counterparts (Beals & Scott, 2012). It is important to note, though, that young children do not necessarily have to be victims of warfare to develop PTSD, but it is reasonable to posit that during times of war there will be significantly greater opportunities for them to experience the types of traumatic events that can cause PTSD. As Beals and Scott (2012) point out, “To be a child diagnosed with PTSD, a list of criteria must be met. The child or adolescent must have experienced, witnessed, or been confronted with an event or events that involved actual or threatened death, serious injury, or physical integrity of self or others” (p. 32). Therefore, treating young people who have been sexually, mentally or psychologically abused as a result of warfare requires a careful assessment concerning the source or sources of their trauma, the nature of the trauma and the duration of the abuse. Likewise, cultural and religious factors such as in the case of children in northern Mozambique must also be taken into account. In addition, children’s social status also plays a role in how they respond to traumatic abuse. For example, Ee and Kieber (2013) report that, “Children born of wartime rape are particularly vulnerable and their case is complex as their needs intertwine with the needs of their mothers or their cultural community” (p. 386). Children who are born of wartime rape are vulnerable to abuse in a number of ways that can exacerbate their already traumatized lives, including social stigmatization, poor mother-child relationships, and widespread discrimination by their mainstream societies (Ed & Kieber, 2013). Responding to the needs of these young people is especially challenging due to the complexity of their situations and the various sources of ongoing trauma and abuse. In this regard, Ee and Kieber (2013) note that, “To assist children born of rape, clinicians are confronted with the challenge to develop a comprehensive perspective that considers the needs and rights of both children and mothers” (p. 387). Even the most comprehensive perspective, though, will do little or nothing to address the adverse effects of the abuse because children born of rape in some societies are viewed as being inextricably connected in the minds of others – including the mothers -- with the enemies that perpetrated the rape. As Ee and Kieber stress that, “Blaming the father is easy, because he is the absent rapist. Still, in the end, the child grows up not with the rapist father, but with a possibly dysfunctional mother and affected by callous opinions held by its community” (2013, p. 387). Therefore, formulating effective interventions for these children and their mothers first requires disassociating them from the actions of their rapist fathers and then providing them with the counseling and resources they need to manage their PTSD symptoms and regain control over their lives (Ee & Kieber, 2013). In this regard, Ee and Kieber (2013) conclude that, “If necessary, the mother needs to be empowered to combat and manage her post-traumatic stress and feelings of ambivalence when interacting with her child. In addition, the mother and child need to be enabled to challenge the convictions held by their cultural community” (p. 388). To the extent that such counseling and resources are not provided will likely be the extent to which mothers of children born of rape during wartime will remain hostile to their children, thereby further exacerbating their respective traumatized conditions. In addition, there are some interventions for children who have been victims of mental or psychological abuse who are suffering from PTSD that have proven efficacy, including trauma-focused cognitive behavioral therapy (TF-CBT). According to Beals and Scott (2012), “TF-CBT is a cojoint child and parental approach for children and adolescents, ages 3-18, who have experienced extreme emotional and behavioral impediments due to traumatic life events” (p. 32). Likewise, game-based cognitive behavioral therapy (GBCBT) can be used to treat children who have been the victims of sexual abuse (Beals & Scott, 2012). In this regard, Beals and Scott report that, “GB-CBT was designed to address the potential behavioral problems and symptoms typically associated with child sexual abuse and works to enhance children\\\\\\\'s knowledge of abuse and self-protection skills” (2012, p. 33). In addition, other CBT-based interventions have been developed in recent years that have shown promise in treating young people who have been traumatized and suffer from PTSD as a result. The development of this wide array of CBT-based interventions is attributable to the enormous complexities that are involved in treating young people who have been traumatized and the fact that a “one-size-fits-all” approach will not be effective. As Cloitre (2015) points out, “The development of diverse treatments is merited only if there are subgroups of trauma populations that differ from one another in important ways” (p. 37). Because young people who have been abused during times of war will manifest these effects in different ways and in varying degrees, it is also essential for clinicians to take the complexity of the trauma into account when formulating CBT-based interventions. According to Cloitre (2015), “Typically, these include emotion regulation difficulties, interpersonal difficulties, substance abuse problems, anger, dissociation, and suicidality” (p. 38). In sum, children are not only at greater risk of being abused during times of war, they lack a voice in bringing their experiences to light and the effects of this abuse may persist well into adulthood and potentially for the rest of their lives. Early childhood is an especially formative period in life and even a single traumatic event can have long-lasting effects. For children who are repeatedly abused, these effects can even become life-threatening. During an era when animal rights organizations pepper the mainstream media with advertisements soliciting funds for abandoned pets, millions of children around the world who have been traumatized by war continue to suffer in silence. Although a number of interventions have been developed in recent years that have proven efficacy in treating this vulnerable population, few young victims of abuse are fortunate enough to live in societies where these community-based resources are available. Conclusion Although precise figures are unavailable, it is reasonable to conclude that out of the tens of millions of victims of warfare in recent years, a significant percentage have involved noncombatant civilians, including most especially women and children. Because warfare is a truly unique human experience that requires actively trying to kill other human beings as sanctioned by the state, children represent an easy target that can be used to prosecute the types of total war that have been used since time immemorial. Turning even very young children into soldiers, using them as slave labor or sex workers is commonplace, but even when these overt types of abuse are not involved, young people invariably suffer from mental and psychological trauma as a direct result of witnessing the horrific events that characterize all types of warfare. Formulating an effective intervention for a young victims of abuse as a result of warfare is consequently even more challenging given the multiple sources of trauma that might be involved. In the final analysis, it is reasonable to conclude that treating young people who have been traumatized by sexual or psychological abuse is a daunting enterprise that requires sensitivity, cross-cultural competency and knowledgeable assessments as well as a thorough understanding of the social implications that are involved.