Effects of armed conflict on child health and development: A systematic review

War exposure and changes in eating behaviours in Ukrainian school-aged children: A cross-sectional online survey

The war in Ukraine has exposed children to extremely high levels of acute and chronic stressors, which can impact their eating behaviour (EB). We aimed to determine the prevalence of war-induced, stress-related disruptions in EB of Ukrainian children. We conducted a cross-sectional online survey among parents of 5- to 17-year-old children, who had experienced the war in Ukraine in February-May 2023. Guardians reported their child's various war exposure changes in EBs using a modified version of the Child Eating Behaviour Questionnaire. We assessed associations between total and medium-term EB changes and age, sex, and war exposure using bivariate correlations and χ2 tests. Logistic regression models were fitted to explore the associations between socio-demographic factors, war exposure and frequency of EB changes. Of the 4854 children, 63% had changes in EBs during the war. The most common EB changes included food cravings (38%), food fussiness (37%), and aversion to certain foods (29%). Of the reported EB changes, 40% were medium-term, lasting over a month, and related to altered attitudes towards food. Food insecurity (adjusted OR 2.35, 95% CI: 1.76-3.14), and displacement (internally 2.01, 1.19-3.42) emerged as the most influential determinants of medium-term EB changes. The findings underscore a significant and robust association between war-related exposures and an increased risk of frequent EB changes. As healthy EBs are learned during childhood and have been shown to track into adulthood, the identified disruptions in EB may have medium-term consequences for the physical and mental health of Ukrainian children.

Navigating the battlefield within: Exploring the interplay of political armed conflict, mental health, and emotion regulation

The study explored the intricate relationship between political armed conflict, mental health outcomes, and emotion regulation strategies, focusing on cognitive reappraisal and emotion suppression. Drawing on extensive literature, we examined the impact of the Israel-Hamas war on mental health, particularly post-traumatic stress symptoms (PTSS) and anxiety. Using data from a nationally representative sample of 517 Israeli adults surveyed four weeks after the October 7 war began, we conducted path analysis to examine the direct and indirect effects of conflict exposure on mental health outcomes mediated by emotion regulation. Cognitive reappraisal was positively associated with well-being, while emotion suppression was linked to higher levels of PTSS and anxiety and lower levels of well-being. Subjective exposure to war events was associated with higher levels of anxiety and PTSS, and cognitive reappraisal served as a protective factor for overall well-being. We also observed ethnicity, age, and gender differences in exposure levels and mental health outcomes. Emotion regulation emerges as a crucial factor in navigating the psychological challenges posed by war exposure, with cognitive reappraisal associated with positive mental health outcomes and emotion suppression linked to adverse effects.

Suicidality and Self-Harm Behavior of Adolescents During the Early Phase of the War in Ukraine

OBJECTIVE

War profoundly impacts people's lives, causing death, displacement, and psychological trauma, but research investigating suicidality of adolescents in this context has been limited. We compared suicidality or self-harm behavior among adolescents in regions that were, and were not, affected by Russia's initial invasion of Ukraine in 2014.

METHOD

This cross-sectional study comprised 2,752 school students aged 11 to 17 years from the war-affected Donetsk region and non-war Kirovograd region. Data collection occurred in 2016 and 2017 using self-report tools to assess suicidality or self-harm behavior; psychopathology including posttraumatic stress disorder (PTSD), depression, and anxiety; and war trauma exposure.

RESULTS

Adolescent girls in the war-affected region reported more suicide attempts (9.5% vs 5.1%; adjusted odds ratio [aOR] 1.8, 95% CI 1.2-2.8), suicidal ideation (39.3% vs 19.6%; aOR 2.6, 95% CI 2.01-3.3), or self-harm behavior (19.6% vs 13.1%; aOR 1.6, 95% CI 1.2-2.1), and boys reported more suicidal ideation (17.0% vs 9.8%; aOR 1.7, 95% CI 1.2-2.4). Boys and girls with PTSD, depression, or anxiety showed increased risks for any suicidality or self-harm. A dose-effect relation was observed between war trauma exposure and suicidality or self-harm. The association was strongest for adolescents who had experienced 5 or more different war trauma exposures (aOR 3.2, 95% CI 2.2-4.8).

CONCLUSION

War trauma exposure and psychopathology were strongly associated with suicidality or self-harm behavior, with a greater impact in girls than boys. The high prevalence of suicidality found in this study emphasizes the need for intervention on a large scale for adolescents living in war situations.

PLAIN LANGUAGE SUMMARY

In a cross-sectional study of two thousand seven hundred fifty-two 11- to 17-year-olds, adolescents who were exposed to the early phase of war in Ukraine showed increased risk for suicide attempts, suicidal ideation, or self-harm behavior among girls living in war-affected region compared to those in non-war region while boys reported increased risk for suicidal ideation only.

An analysis of paediatric clinical presentations in Northwest Syria and the effect of forced displacement, 2018-2022

Background

One in six children worldwide lives in a region exposed to armed conflict. In conflicts, children are among the most vulnerable, and at risk of adverse health outcomes. We sought to describe trends in child and adolescent morbidity in northwest Syria (NWS) and understand how forced displacement affects clinical utilisation during the Syrian conflict.

Methods

Retrospective data between January 2018 and December 2022 were obtained from the Syrian American Medical Society (SAMS), a non-governmental organisation that operates health facilities in NWS. After initial descriptive analyses were completed, we performed a seasonal-trend decomposition to estimate the seasonality of clinical presentations. We subsequently employed a multivariate regression model incorporating age, gender, residency status, season, and a random district-level intercept to measure the association between the odds of clinical consultation and forced displacement.

Findings

Across 51 reporting SAMS facilities, 2,687,807 clinical consultations were studied over a five-year period. Seasonality was demonstrated for every clinical consultation category. Higher levels of forced displacement were associated with increased odds of consultations for nutrition, trauma, NCDs and mental health and decreased odds of consultation for communicable diseases. Aside from traumatic injury, internally displaced persons (IDPs) had higher AORs of clinical consultations compared to host populations.

Interpretation

Forced displacement differentially impacts clinical utilisation among children in northwest Syria, and the effects of displacement persist for at least six months. Clinical needs vary by host/IDP status, sex, age, and season. This study can assist policymakers in forecasting the health needs of children in northwest Syria.

Emotional Competences in Adolescents Exposed to Colombian Armed Conflict During Their Childhood

Objective: Analyse the mediation role of emotional competences on behavior problems in adolescents exposed to Armed-Conflict Childhood Adversities (ACCA). Method: Families with adolescent children who studied in three schools in the municipality of Soacha, Colombia, were invited to participate in the study. One hundred and sixty-one participants were selected and pooled into three groups according to their Adverse Childhood Experiences (ACE) scores: lower-ACE (LACE), higher-ACE (HACE), and ACCA using the Adverse Childhood Experiences Questionnaire for Adolescents (ACE-QA). The Emotion Recognition Task, the Empathy for Pain Task, and the Child Behavior Checklist assessed teenagers' emotional functioning. Results: Teenagers exposed to ACCA more frequently experienced childhood adversities such as domestic violence, child abuse, and parental neglect. Moreover, these adolescents were less accurate in discriminating angry faces, reported higher control perception after social stressors, were more rigorous in punishing those who intentionally harmed others, and showed more internalizing behavior problems. In the mediational model, we found that: the control perception after social stress mediated the reduction of depressive symptoms in adolescents with ACCA history. Additionally, inaccuracy in perceiving angry faces and harsh punishment toward behaviors that intentionally harm others mediated the presence of thinking problems, anxiety, and rule-breaking behaviors. Conclusions: Colombian adolescents who experienced ACCA showed specific changes in their emotional competences, which mediate the parental report of behavioral problems. These results indicate the need for more focused interventions aimed at improving the emotional competences and mental health of adolescent victims of armed conflicts.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-024-00647-0.

Social connections related to health and well-being needs identified by children and adolescents affected by displacement in Lebanon: a participatory research study

Introduction

The social connections surrounding children and adolescents support them in facing challenges and seeking help, ultimately acting as a protective factor in their mental, physical, and behavioral health outcomes across the life course. In complex contexts of political instability and dislocation, these social resources are often fractured, strained, or altogether unavailable, which restricts access to essential services and affects outcomes for these populations. This study aims to identify, characterize, and visually depict social connections related to the health and well-being needs of children and adolescents affected by displacement in Lebanon, by pilot testing the Participatory Assessment Tool for Mapping Social Connections (PATMSC). We hypothesize that this unique methodology will identify and describe different social connections by group quickly and efficiently.

Methods

An initial scoping review of scientific and grey literature followed by stakeholder interviews identified nutrition, mental health, and abuse scenarios that guided the PATMSC (a mixed- method data collection tool that identifies and visualizes types and qualities of social connections) topics. The PATMSC was piloted among children, caregivers, and providers affected by displacement in Lebanon.

Results

There were seven groups (Syrian children, Syrian adolescents, Syrian caregivers, Lebanese/Palestinian children, Lebanese/Palestinian adolescents, Lebanese/Palestinian caregivers, and providers) with a total of 42 participants across the PATMSC workshops. Syrian children identified the most connections across all scenarios (66 nodes) and Lebanese/Palestinian adolescents identified the fewest connections across all scenarios (26 nodes). Family and community nodes were highly connected across all scenarios. 56% of participants asked their family connections for help. Family connections were the most used by children (71%) and provider (33%) subgroups. Participants were asked for help by family connections the most (59%). Within subgroups, children (84%), Lebanese/Palestinian participants (73%), providers (50%), and caregivers (36%) were also asked for help by family connections the most.

Discussion

The study highlights that children, adolescents, and their caregivers in displaced settings in Lebanon have varied social connections when exploring resources related to key areas of concern. Overall, there is an importance placed on the role of family members in their social networks. However, the social connections and resources available differ depending on the circumstances, as evidenced by the variation in connections named across the three scenarios. Understanding the components of social networks, what drives them, and how they differ by sector, is essential in planning and maintaining programs and policies that meet evolving needs in resource-constrained settings.

Global development assistance for early childhood care and education in 134 low- and middle-income countries, 2007-2021

INTRODUCTION

Low- and middle-income countries (LMICs) often dedicate limited domestic funds to expand quality early childhood care and education (ECCE), making complementary international donor support potentially important. However, research on the allocation of international development assistance for ECCE has been limited.

METHODS

We analysed data from the Creditor Reporting System on aid projects to assess global development assistance for ECCE in 134 LMICs from 2007 to 2021. By employing keyword-searching and funding-allocation methods, we derived two estimates of ECCE aid: a lower-bound estimate comprising projects primarily focusing on ECCE and an upper-bound estimate comprising projects with both primary and partial ECCE focus, as well as those that could benefit ECCE but did not include ECCE keywords. We also assessed aid directed to conflict-affected countries and to ECCE projects integrating COVID-19-related activities.

RESULTS

Between 2007 and 2021, the lower-bound ECCE aid totaled US$3646 million, comprising 1.7% of the total US$213 279 million allocated to education. The World Bank led in ECCE aid, contributing US$1944 million (53.3% out of total ECCE aid). Low-income countries received less ECCE aid per child before 2016, then started to catch up but experienced a decrease from US$0.8 (2020) per child to US$0.6 (2021) per child. Funding for ECCE projects with COVID-19 activities decreased from a total of US$50 million in 2020 to US$37 million in 2021, representing 11.4% and 6.6% of annual total ECCE aid, respectively. Over 15 years, conflict-affected countries received an average of US$0.3 per child, a quarter of the aid received by non-conflict-affected countries (US$1.2 per child).

CONCLUSION

Although ECCE aid increased significantly between 2007 and 2021, its proportion of total educational aid fell short of UNICEF's suggested 10% minimum. Recommendations include increasing the share of ECCE aid in total educational aid, increasing aid to low-income and conflict-affected countries, and investing more in preparing ECCE programmes for future global crises.

Psychological distress among students in Egypt and Jordan during the initial months of the Gaza war

BACKGROUND

Psychological distress has significantly impacted students in Egypt and Jordan. These countries have faced many challenges, including the COVID-19 pandemic, the fallout from the conflict in Syria, and the war in Ukraine. These crises have had far-reaching consequences, affecting the economy, food security, and energy supplies, particularly with the increased number of refugees in these countries. Amid these existing complexities, the ongoing war in Gaza further exacerbates the situation, compounding mental health challenges. Therefore, this study aimed to analyze how the war in Gaza impacted the mental health of students in Egypt and Jordan.

METHODS

We conducted a cross-sectional study involving students from Egypt and Jordan between December 2023 and January 2024. The questionnaire incorporated the Brief Symptom Inventory 18 (BSI-18) to assess the overall general distress score, as well as the domains of anxiety, somatization, and depression.

RESULTS

A total of 1509 Jordanian and Egyptian students were included in the study, of which 66% were female. Approximately 18% of the students had an elevation (≥ 50) in their BSI-18 total score. Females scored significantly higher in general distress [30 (18-44.25) vs. 24 (11-41), p < 0.001], and all three dimensions. The univariate predictors for elevated general distress (≥ 50) were being Egyptian (OR 1.49, 95% CI 1.08 to 2.08, p = 0.014), watching social media multiple times a day (OR 3.04, 95% CI 1.97 to 4.69, p < 0.001), and having a Palestinian connection (friend, neighbor, colleague, or relative) (OR 1.63, 95% CI 1.23 to 2.16, p < 0.001). These three predictors were retained in the backward stepwise multivariate regression analysis model. The univariate predictors for moderate and marked general distress (≥ 57) were watching social media multiple times a day (OR 3.26, 95% CI 1.78 to 5.99, p < 0.001) and having a Palestinian connection (OR 1.49, 95% CI 1.05 to 2.14, p = 0.026). Only the former was retained in the backward stepwise multivariate regression analysis.

CONCLUSION

General distress has increased among students in Egypt and Jordan throughout the War in Gaza. Mental, psychological, and social support activities are necessary for these students, particularly those watching social media multiple times daily. The development of coping skills to manage the additional stressors of war and socioeconomic status necessitates further research within this group of students.

Coming of age in war: Early life adversity, age at menarche, and mental health

Armed conflict and forced migration (ACFM) represent a set of extreme environments that are increasingly common for children and adolescents to experience. Adolescence may constitute a sensitive period (puberty and psychoneurological maturation) through which ACFM adversity leaves a lasting mark. Adolescence has become a focal point for analysis and intervention as it relates to the effects of early life adversity on puberty, linear growth, and mental health. Research in public health and psychological science suggests early life adversity (ELA) may accelerate puberty, heightening risks for mental health disorders. However, it is not well substantiated whether ACFM-derived adversities accelerate or delay relative pubertal timing. Secondly, ACFM provides salient context through which to probe the relationships between nutritional, psychosocial, and demographic changes and their respective impact on puberty and mental health. We conducted a narrative review which 1) examined constructions of early life adversity and their proposed influence on puberty 2) reviewed empirical findings (n = 29 studies, n = 36 samples) concerning effects of ACFM ELA on age at menarche and 3) discussed proposed relationships between early life adversity, puberty, and mental ill-health. Contrary to prior research, we found war-derived early life adversity was more consistently associated with pubertal delay than acceleration and may exert counterintuitive effects on mental health. We show that ELA cannot be operationalized in the same way across contexts and populations, especially in the presence of extreme forms of human stress and resilience. We further discuss the ethics of puberty research among conflict-affected youth.

Close relationships with caregivers as protective factor for the mental health and functioning of war-affected Congolese youth

BACKGROUND

Supportive social connections are a crucial determinant of the mental health and adjustment of youth in conflict-torn regions. Conflict-affected youth face particular risks to their well-being due to high levels of trauma exposure and perpetration of violent acts as members of armed groups and post-conflict discrimination. However, little is known about the possible protective role of close relationships with caregivers in the aftermath of trauma. This study examined whether a higher perceived quality of relationships with caregivers would attenuate the associations between exposure to traumatic experiences and four indicators of adjustment (posttraumatic stress symptoms [PTSS], emotional problems, behavioural problems, criminal behaviour) in a sample of 268 war-affected youth (61.2% male, Mage = 16.31 years) living in Bukavu, Democratic Republic of Congo. More than half of the present sample (56.7%) were former members of armed groups.

METHODS

Data were collected using quantitative structured interviews and analyzed through regression models using the PROCESS macro.

RESULTS

Higher cumulative trauma exposure was significantly related to higher levels of PTSS and emotional problems, while more frequent perpetration of war-related violence was significantly related to higher levels of PTSS, behavioural problems, and criminal behavior. The perceived quality of relationships with caregivers significantly moderated the associations between youth's cumulative trauma exposure and all four outcomes. At higher perceived quality of relationships with caregivers, the associations between trauma exposure and emotional problems, behavioural problems, and criminal behaviour were no longer significant and the association with PTSS was significantly weakened. Higher perceived quality of relationships with caregivers was also directly significantly related to lower levels of mental health problems and criminal behaviour.

CONCLUSIONS

The findings suggest that interventions that focus on strengthening relationships with caregivers are crucial for supporting the mental health and functioning of youth who experienced and perpetrated war-related violence.

Prevalence and correlates of malaria and undernutrition among acutely febrile children visiting temporary malaria screening sites in war-torn areas of Northeast Ethiopia

BACKGROUND

Malaria and undernutrition pose challenges for children in conflict-affected areas. Understanding the prevalence and risk factors for these issues in war-torn communities is important to effectively design aid efforts and select interventions. This study aimed to determine the prevalence and correlates of malaria and undernutrition among febrile children in northeast Ethiopia to help address these problems.

METHODS

A cross-sectional study was conducted from November 2022 to January 2023. Four hundred twenty-two children were enrolled using a systematic random sampling technique. Data on associated factor variables were collected via questionnaire. Capillary blood samples were collected from each child to prepare thick and thin blood films, which were stained with Giemsa and examined microscopically. Height and weight measurements were also taken using a meter and a standard calibrated balance. The data were analyzed in SPSS 26.0 using bivariable and multivariable logistic regression to determine associations between correlates, malaria infection, and undernutrition. Statistical significance was set at p < 0.05.

RESULTS

The overall malaria prevalence among screened children at temporary sites in the conflict-affected areas of Northeast Ethiopia was 65.9% (278/422). Plasmodium falciparum, P. vivax, and mixed infections accounted for 74.1%, 19.8%, and 6.1% of the cases, respectively. The presence of stagnant water (P<0.01), improper utilization of ITN, inadequate number of ITNs per family size (P<0.01), and absence of environmental management (P<0.01) were independent predictors of malaria. On the other hand, the overall undernutrition prevalence was 54.7% (231/422), including 26.5% underweight, 16.8% stunted, and 11.4% wasted. Dietary diversity score (P<0.01), meal frequency (P<0.01), and confirmed malaria infection (P<0.01) were significantly associated with underlnutrition.

CONCLUSION

Both malaria and undernutrition burdens were high among the children in this study. The findings suggest combined prevention measures for malaria and undernutrition should be strengthened in this region.

Father-separation and well-being in forcibly displaced Syrian children

Forcibly displaced children often face separation from their parents, particularly fathers. These children endure the hardships of war, displacement, and the loss of a key attachment figure. Despite the critical role of attachment in children's well-being during periods of heightened stress, the impact of separation due to war and displacement has received little attention in empirical work. Findings from 1544 Syrian refugee children (Mage = 10.97, SD = 2.27) living in informal settlements in Lebanon with their mothers (Mage = 38.07, SD = 8.49), including 367 father-separated children, show that father-separated children experienced more war-related events and worse refugee environments. Structural equation modelling showed that beyond the direct relation of war exposure and quality of the refugee environment on well-being, father separation was uniquely related to more depressive symptoms and worse self-development, but not to anxiety, PTSD, or externalising problems in children. Maternal parenting did not explain these outcomes, though it had a protective function for children's well-being.

The current situation of health equity in underserved areas of Afghanistan

Background

In Afghanistan, providing universal health coverage (UHC) in accordance with the principles of the UHC declaration is challenging on two fronts: the geographic topography of the country and the prevailing gender dynamics within the local culture.

Methods

We conducted a desk review of underserved areas in the context of health services by gathering and analyzing existing literature, reports, and data using a combination of keywords and phrases such as: "underserved areas," "healthcare disparities," "access to healthcare," and "health services." The primary data were derived from an analysis of underserved populations conducted by the World Health Organization (WHO) Afghanistan's Emergency Program, supplemented by information from in-country partners. In addition to other reports, this review focused on analyzing the geographical availability of primary healthcare (PHC) services by employing the guidelines set forth in the SPHERE framework. It also took into account the social dynamics within the Afghan population that may create barriers to equity in terms of demand and access to PHC services.

Results

Although there are a significant number of primary healthcare facilities in operation (4,242), they are unevenly distributed across different regions of Afghanistan, resulting in almost 25% of the population being underserved. The underserved population is nearly equally distributed between genders, with the majority residing in rural communities. Women of childbearing age represent 28% of the underserved population. Children under the age of five represent 16-18% of the underserved population in all regions, except in the western region, where they represent between 12 and 13%. Individuals over 60 years of age represent 1-3% of the underserved population across all regions. More than 50% of the population in the Central Highlands of Afghanistan is underserved, followed by the western and southern regions. Ghor province in the western region has the highest proportion of underserved populations, followed by Zabul province in the southern region.

Conclusion

Afghanistan is currently experiencing a protracted humanitarian crisis, with millions of people living in poverty and lacking access to healthcare. This situation exposes them to serious risks such as disease epidemics, starvation, and maternal and child mortality. It is crucial to implement alternative strategies to reach the most affected populations and to increase funding for the delivery of healthcare services in Afghanistan.

Maternal Perceptions and Responsiveness to Cry in Armed Conflict Zones: Links to Child Behavior Problems

Crying is a typical infant behavior that activates parental caregiving behaviors, acting as "human alarms" important for the infant's survival. When living under war-related threat, the auditory system may be sensitized given its importance for survival, potentially impacting maternal cry processing. Children living in armed-conflict zones are at increased risk for behavior problems, which may relate to both direct exposure and indirect effects through their parents' perceptions and behaviors. This hypothesis was examined in a sample of mothers and their first-born children (aged 10-45 months) living in the Gaza vicinity area in Israel, chronically exposed to missile alarms (high-exposure; n = 45), and a comparison group (low-exposure; n = 86). Group differences in child behavior problems and maternal perceptions of and responsiveness to cry were investigated. A moderated indirect-effect of maternal cry perceptions on child behavior problems via maternal responsiveness to cry was examined. In the high-exposure group, children had more externalizing problems and mothers rated cries as more aversive. Maternal cry perception was indirectly related to child behavior problems via responsiveness to cry only in the high-exposure group: higher perceptions of cry as aversive or the child as distressed were related to faster responding to crying, and faster cry responsiveness was linked with fewer behavior problems. Results suggest that in armed-conflict zones with auditory warning signals, the parental caring system may be easily activated by cries due to the strong association between alarms and threat. Furthermore, children may need their mothers to react faster when feeling distressed, possibly because of the surrounding threat.

Exploring the Self-Reported Physical and Psychological Effects in a Population Exposed to a Regional Conflict

BACKGROUND

Conflict profoundly impacts community health and well-being. While post-conflict research exists, little is known about initial effects during active hostilities.

OBJECTIVE

To assess self-reported changes in health behaviors, distress, and care access within one month of regional warfare onset in a conflict-affected community.

METHODS

An online survey was conducted in November 2023 among 501 residents (mean age 40.5 years) of a community where war began October 7th. Measures evaluated physical health, mental health, diet, substance use, sleep, weight changes, and healthcare access before and after the declaration of war.

RESULTS

Relative to pre-war, respondents reported significantly increased rates of tobacco (56%) and alcohol (15%) consumption, worsening sleep quality (63%), elevated distress (18% sought help; 14% needed but didn't receive it), and postponed medical care (36%). Over a third reported weight changes. Distress was higher among females and those endorsing maladaptive coping.

CONCLUSION

Within one month, substantial impacts on community psychosocial and behavioral health emerged. Unmet mental health needs and risk-taking behaviors were early indicators of conflict's health consequences. Continuous monitoring of conflict-affected communities is needed to inform tailored interventions promoting resilience and prevent entrenchment of harms over time.

Providing Compassionate, Evidence-Based Care for Refugee, Immigrant, and Migrant Children

Immigrant children experience diverse migration paths to the United States facing unique challenges that impact their health and well-being. This article provides an overview of the pathways to health care and physical, mental, and behavioral health considerations for refugee and immigrant children. Health equity and cultural humility frameworks are reviewed. Approach to care guidance and clinical pearls are provided for the initial medical assessment in addition to medical screening, mental health, education, and developmental health. The importance of health literacy and advocacy are highlighted, emphasizing their ability to address health inequities and improve care.

The backyard: Cumulative trauma of children from East Jerusalem who were removed from their homes

BACKGROUND

Few studies examined child abuse and neglect and its consequences in the context of a complex socio-political reality such as East Jerusalem. Additionally, research typically addresses trauma resulting of child maltreatment from the perspective of the children. Yet, little is known about the perceptions of the parents whose children were removed from their home by court order.

OBJECTIVE

This study explored the perceptions of families in East Jerusalem whose young children were removed from their home by an Israeli court order. Specifically, the parents' perceptions of the trauma experienced by their children and of the responses of their children to the removal from home.

METHODS

Semi-structured interviews with 22 caregivers (13 mothers, 8 fathers, and one aunt) of children at risk from East Jerusalem. The qualitative analysis was based on the principles of grounded theory.

RESULTS

The analysis of the data revealed five risk factors attributed by the parents to their children's situation: Their young age, the abuse and neglect, the secondary victimization, the removal from home, and living in a conflict zone such as East Jerusalem.

CONCLUSIONS

These risk factors of the children who are at the center of this study result in a cumulative trauma which intensifies their vulnerability. The lack of early childhood educational services in East Jerusalem places these children under the radar of the social service. Therefore, it is essential for policymakers to provide the necessary resources to these families.

The Helping Hand in Ukraine: feasibility and potential impact

BACKGROUND

New services are needed to prevent the mental health consequences of the war in Ukraine. Ten adolescents self-recruited to use and evaluate the Ukrainian version of the Helping Hand (HH) in Odesa, Ukraine. From April to June 2023, they participated in a 10-session group program where they played the cognitive behavioral game app, shared stories, and engaged in activities to enhance their coping skills.

METHODS

A mixed-method, quantitative-qualitative design was used to get insight into the feasibility and potential impact of the HH on Ukrainian adolescents' mental health and well-being during the war. A questionnaire to the adolescents assessed the feasibility of the intervention; anxiety and depression symptoms were assessed before and after the intervention by a standardized and validated adolescent-completed questionnaire. An interview with the psychologist who implemented the intervention was used to interpret the data completed by the adolescents.

RESULTS

Eight of 10 adolescents completed the HH intervention, and the psychologist found the HH helpful and culturally appropriate. The average anxiety and depression symptoms decreased from before the intervention (M = 20.4) to after (M = 15.0), showing a moderate effect size.

CONCLUSION

The results indicated that the HH has a high potential to prevent mental health consequences in Ukraine.

The efficacy of psychosocial interventions for grief symptoms in bereaved children and adolescents: A systematic review and meta-analysis

BACKGROUND

The present meta-analysis investigates the efficacy of psychosocial interventions in bereaved children and adolescents.

METHOD

We conducted a systematic review searching PsycINFO, PsycARTICLES, PubMed, MEDLINE, PSYNDEX, Web of Science, CINAHL and ERIC. Random-effects meta-analyses examined the effect of interventions on symptoms of grief, posttraumatic stress disorder (PTSD) and depression in controlled and uncontrolled studies.

RESULTS

We included 39 studies (n = 5.578). Post-treatment, preventive interventions demonstrated a significant effect on grief (uncontrolled studies: g = 0.29, 95%CI [0.09;0.48]; controlled studies: g = 0.18, 95%CI [0.03;0.32]). For symptoms of PTSD and depression, only uncontrolled preventive studies yielded significant effects (PTSD: g = 0.24, 95%CI [0.11;0.36]; depression: g = 0.28, 95%CI [0.10;0.45]). Interventions targeting youth with increased grief-related distress demonstrated a significant effect in uncontrolled studies on grief (g = 1.25, 95%CI [0.94;1.57]), PTSD (g = 1.33, 95%CI [0.85;1.82]) and depression (g = 0.61, 95%CI [0.45;0.77]). A controlled effect size could only be calculated for PTSD symptoms (g = 0.71, 95%CI [0.15;1.27]).

LIMITATIONS

Interventions varied widely, contributing to high heterogeneity. Only a small number of studies with mostly limited quality could be analysed.

CONCLUSIONS

Psychosocial interventions may ameliorate grief symptoms in bereaved youth, especially when targeting youth with elevated grief distress. However, the effects observed in uncontrolled studies are substantially reduced when controlling for the natural course of bereavement. Given the increasing number of children worldwide bereaved through ongoing crises, research on interventions is surprisingly sparse.

Parental conscription and cumulative adverse experiences in war-affected children and adolescents and their impact on mental health: a comment following Russia's invasion of Ukraine in 2022

BACKGROUND

With Russia's invasion of the Ukraine on February 2022, Ukrainian children and adolescents have been exposed to several stressful life events. In addition to the confrontation with war, flight and parent-child separation due to flight and forced displacement, the majority underwent another challenge at the initial phase of the war: the fatherly separation due to conscription.

MAIN BODY

In the literature, the negative effects of exposure to war and flight/refuge, parent-child separation due to flight or forced displacement and parental deployment are well established. In the context of self-experienced war, the effects of parent-child separation caused by compulsory military service have not yet been sufficiently taken into account. However, the findings of the literature on the impact of these events on the mental health of children and adolescents show that they are at high risk for developing numerous psychological and behavioral problems.

CONCLUSION

As children's and adolescents' mental health might be severely affected by war and its consequences, interventional programs that address the special needs of those children and adolescents are crucial.

Children Fleeing War-Exploring the Mental Health of Refugee Children Arriving in Israel after the Ukraine 2022 Conflict

BACKGROUND

In February 2022, Ukraine suffered a devastating assault by Russia, leading to destruction, casualties, and mass displacement. Among those displaced were over 1.5 million children. Forced displacement exposes children to a heightened risk of mental health issues.

OBJECTIVE

This study investigated the prevalence of Post-traumatic stress disorder (PTSD) and other mental health issues among child refugees shortly after their displacement from Ukraine to Israel. It aimed to identify factors influencing PTSD development and explore their associations.

METHODS

The study included 59 child refugees who had arrived in Israel after fleeing the war in Ukraine. Parents completed self-report questionnaires to assess their children's mental health.

RESULTS

Only three children met the DSM diagnostic criteria for PTSD, with higher scores in the negative cognition and re-experiencing clusters. Over half of the children exhibited general mental health problems, with approximately 40 % showing internalizing problems, and 30 % showing externalizing problems. The study also found a significant comorbidity between PTSD symptoms and internalizing problems. Additionally, internalizing problems emerged as the sole significant predictor of PTSD levels when considering factors such as age, gender, economic status, parents' work status, internalizing problems, and externalizing problems.

CONCLUSIONS

Child refugees frequently experience psychological distress, even if they do not meet the formal diagnostic criteria for PTSD. They often exhibit other distress symptoms, primarily internalizing problems, which can be challenging to detect. A deeper understanding of the challenges faced by refugee children can inform the development of targeted assistance programs and the recruitment and training of personnel in host countries.

Young children's development after forced displacement: a systematic review

OBJECTIVES

To examine the impact of displacement experiences on 0- to 6-year-old children's social-emotional and cognitive development, as well as influencing factors on reported outcomes.

STUDY DESIGN

We systematically searched MEDline, Psyndex, Cochrane Library, Web of Science, Elsevier, TandF, Oxford Journal of Refugee Studies, Journal of Immigrant & Refugee Studies, and Canada's Journal on Refugees for existing literature regarding social-emotional and cognitive outcomes in children directly exposed to forced displacement due to political violence. Results were synthesized in the discussion and displayed using harvest plots.

RESULTS

Our search generated 9,791 articles of which 32 were selected for review and evaluation according to NICE criteria. Included studies provided results for 6,878 forcibly displaced children. Measured outcomes were diverse and included areas such as peer relations, prosocial behavior, family functioning, play, intelligence, learning performance, and language development. Repeated exposure to adverse experiences, separation from parents, parental distress, as well as duration and quality of resettlement in the host country were reported as influencing factors in the reviewed studies.

CONCLUSION

As protective factors like secure and stable living conditions help to promote children's development, we call for policies that enhance participation in the welcoming society for refugee families. Early integration with low-threshold access to health and educational facilities can help to mitigate the wide-ranging negative consequences of forced displacement on young children's development.

Creating a difference - a role for the arts in addressing child wellbeing in conflict-affected areas

BACKGROUND

Details findings from a project on the potential for arts activities and art therapy to support the mental health and wellbeing of children living in Kashmir.

METHODS

The intervention engaged 30 school children over the course of one year who produced various forms of artwork and performances. In this paper, we report on project impacts, drawing on some of our qualitative measures including observations and interviews.

RESULTS

Our research details impacts and improvements in areas of emotional expression, belonging, and agency. We also found an important role for schools to create safe, secure, and caring spaces to allow students to express themselves and work through traumatic feelings in a non-judgemental way.

CONCLUSIONS

School-based arts interventions can play an important role in the mental health and wellbeing of children. Critical here, however, are dedicated space, time, and resources to provide a supportive environment and to sustain activity in long-term.

Development, Insults and Predisposing Factors of the Brain's Predictive Coding System to Chronic Perceptual Disorders-A Life-Course Examination

The predictive coding theory is currently widely accepted as the theoretical basis of perception and chronic perceptual disorders are explained as the maladaptive compensation of the brain to a prediction error. Although this gives us a general framework to work with, it is still not clear who may be more susceptible and/or vulnerable to aberrations in this system. In this paper, we study changes in predictive coding through the lens of tinnitus and pain. We take a step back to understand how the predictive coding system develops from infancy, what are the different neural and bio markers that characterise this system in the acute, transition and chronic phases and what may be the factors that pose a risk to the aberration of this system. Through this paper, we aim to identify people who may be at a higher risk of developing chronic perceptual disorders as a reflection of aberrant predictive coding, thereby giving future studies more facets to incorporate in their investigation of early markers of tinnitus, pain and other disorders of predictive coding. We therefore view this paper to encourage the thinking behind the development of preclinical biomarkers to maladaptive predictive coding.

Epidemiology of dental caries in internally displaced children during wartime in Ukraine

OBJECTIVE

Aim: To conduct a comprehensive analysis of the oral health status of this vulnerable population in order to collect objective data that will contribute to the development of effective strategies for maintaining and improving oral health in wartime conditions.

PATIENTS AND METHODS

Material and Methods: This epidemiological study was carried out within the initial 6 months of the full-scale invasion of the country. The oral health indices of 1050 internally displaced children, aged 3 to 17 years, seeking dental care at the Municipal Children Dental Clinic in Poltava, were analyzed.

RESULTS

Results: The total sample comprised 620 children aged 6-11 years (mean = 8.5, SD = 0.76), with a gender distribution of 52% boys and 48% girls. The participants were divided into three age groups: Group I (6-7 years), Group II (8-9 years), and Group III (10-11 years). The average prevalence of dental caries, as measured by the dmft + DMFT index, was 76.5%, with prevalence increasing with age. Specifically, the prevalence of dental caries based on the dmft index was lower in children of Group III (66.6%) compared to Group I (79.49%).

CONCLUSION

Conclusions: The analysis of the oral status among internally displaced children aged 6-11 years revealed higher dental caries prevalence and intensity compared to local children. Notably, children aged 6-7 years showed a high rate of caries in temporary teeth.

Terrorism and child mortality

How does terrorism affect child mortality? We use geo-coded data on terrorism and spatially disaggregated data on child mortality to study the relationship between both variables for 52 African countries between 2000 and 2017 at the 0.5 × 0.5° grid level. Our estimates suggest that moderate increases in terrorism are linked to several thousand additional annual deaths of children under the age of five. A panel event-study points to economic effects that are larger and compound over time. Interrogating our data, we show that the direct impact of terrorism tends to be very small. Instead, we theorize that terrorism causes child mortality primarily by triggering adverse behavioral responses by parents, medical workers, and policymakers. We provide tentative evidence in support of this argument.

Assessment of Paediatric Forensic Cases Under the Age of 18 Who Presented to the Emergency Clinic: The Case of Kilis, a Border City with Syria

AIM

This study was conducted to determine the paediatric forensic cases under the age of 18 from of the year of the outbreak of war.

DESING AND METHODS

The population of the study included 16,970 people under the age of 18, who were accepted as forensic cases among 88,052 cases, who presented to the emergency department of Kilis State Hospital between January 2011 and November 2019. The application time of the patients, their nationality, age, gender, their types of application to the emergency department, the event causing the forensic case, and the follow-up and treatment methods in the emergency department were recorded on the standard data entry form.

RESULTS

Among all the paediatric forensic cases, it was determined that 52.0% were Syrian, 70.8% were boys, 30.0% were in the age range of 11 and 15 years and 20.5% had an outpatient treatment.

CONCLUSIONS

In this study, although juvenile forensic rates are consistent with the literature, the higher forensic cases of Syrian nationality was determined as a striking result.

PRACTICE IMPLICATIONS

Today, considering extraordinary situations such as wars and armed conflicts, more refugees may benefit from Turkish healthcare services in the in the forthcoming periods and it is important for community health to conduct studies in this field.

Hope and life satisfaction in Palestinian children victim of military violence: The predictive role of agency, potentially traumatic experiences and symptoms of trauma

BACKGROUND

Children exposed political violence deploy resources to maintain functioning, hope and life satisfaction.

OBJECTIVE

We sought to explore whether or not children promote hope and life satisfaction trough agency, psychological difficulties, potentially traumatic experiences and symptoms in Palestine.

PARTICIPANTS AND SETTING

965 children (494 males and 471 females) in multiple geographical contexts, and areas were involved.

METHODS

We administered the War Child Agency Assessment Scale, Child Hope Scale, Multilevel Students'Life Satisfaction Scale-Bref, the Strength and difficulties scale, the Child Revised Impact of events Scale, and Trauma Checklist, and performed regression analysis; hope and life satisfaction were dependent and agency, strength and difficulties, trauma symptoms and traumatic events independent variables.

RESULTS

Specific forms of agency predicted life satisfaction (β = 0.219; ** p < .01, social agency; β = 0.11; ** p < .01, with agency in education) and hope (β = 0.07; ** p < .05, agency on free movement), while mental difficulties (conduct problems, β = -0.09; ** p < .01; hyperactivity, β = -0.07; ** p < .05; β = -0.15; ** p < .01 with life satisfaction) (conduct problems, β = -0.06; ** p < .05, and difficulties in pro-social behaviour, β = -0.21; ** p < .01 with hope), traumatic events (β = -0.16; ** p < .01, with life satisfaction; β = -0.15; ** p < .01, with hope) and trauma symptoms (β = -0.09; ** p < .05, with hope) were negatively associated with the dependents variables.

CONCLUSIONS

We found a positive role of social, educational, and freedom of movement agentic behaviours in fostering hope and life satisfaction.

The mental functioning of school-age children in Poland since the outbreak of war in Ukraine and during the subsequent refugee crisis

BACKGROUND

There is growing body of research focusing on the functioning of children who have fled from war-torn areas. However, there is currently lack of data regarding the functioning of children residing in host countries.

OBJECTIVE

The aim of this study is to examine the presence of emotional problems, negative attitudes, interpersonal problems, and functional difficulties among Polish children during the first month after the outbreak of war and initial phase of the current refugee crisis.

PARTICIPANTS AND METHOD

The study group comprised children aged 9-15 (N = 360), living in Poland. The Children's Depression Inventory 2 (CDI-2) and The Cognitive Triad Inventory for Children (CTIC) was used to measure emotional functioning. The study took place 7 to 39 days after the outbreak of the war in Ukraine.

RESULTS

The children reported more emotional problems (t(359) = 9.340; p < .001; d = 0.49) with a negative mood (t(359) = 6.692; p < .001; d = 0.35) and negative self-esteem (t(359) = 9.632; p < .001; d = 0.51). The severity of depression symptoms was the highest in the first week after the outbreak of the war (F(5,354) = 2.472; p < .05; η2 = 0.03). The view of the self (F(1,358) = 3.858; p = .05; R2 = 0.01) and of the world (F(1,358) = 5.359; p < .05; R2 = 0.02) improved over time; however, their vision of the future remained unchanged.

CONCLUSION

The results shows that children who are not directly affected by the war can also display difficulties in mental functioning. In the initial months following the outbreak of the war and during the early stage of the current refugee crisis, Polish children demonstrated significantly higher levels of emotional problems and negative self-esteem. Moreover, the perception of oneself and the world appeared to be influenced by the duration since the onset of the war.

Development and Implementation of DIALOG+S in the School Setting as a Tool for Promoting Adolescent Mental Well-Being and Resilience in a Post-Armed Conflict Area in Colombia: Exploratory Cluster Randomized Controlled Trial

BACKGROUND

Educational settings are ideal for promoting mental well-being and resilience in children. The challenges of the COVID-19 pandemic made evident the important role that teachers and school counselors play in the mental health of their students. Therefore, it is imperative to develop and implement cost-effective interventions that allow them to identify and address mental health problems early, especially in post-armed conflict areas, to reduce the burden of mental disorders in this population.

OBJECTIVE

This study aimed to adapt an existing patient-focused digital intervention called DIALOG+ from an adult clinical setting to an adolescent educational setting and to assess the feasibility, acceptability, and estimated effect of implementing this intervention as a tool for promoting quality of life, mental well-being, and resilience.

METHODS

We conducted an exploratory mixed methods study in 2 public schools in postconflict areas in Tolima, Colombia. This study was conducted in 3 phases. In the adaptation phase, focus groups were conducted with students and teachers to identify changes required in DIALOG+ for it to be used in the school setting. The exploration phase consisted of an exploratory cluster randomized controlled trial. A total of 14 clusters, each with 1 teacher and 5 students, were randomly allocated to either the experimental (DIALOG+S) group or to an active control group (counseling as usual). Teachers in both groups delivered the intervention once a month for 6 months. Through screening scales, information was collected on mental health symptoms, quality of life, self-esteem, resilience, and family functionality before and after the intervention. Finally, the consolidation phase explored the experiences of teachers and students with DIALOG+S using focus group discussions.

RESULTS

The changes suggested by participants in the adaptation phase highlighted the central importance of the school setting in the mental health of adolescents. In the exploratory phase, 70 participants with a mean age of 14.69 (SD 2.13) years were included. Changes observed in the screening scale scores of the intervention group suggest that the DIALOG+S intervention has the potential to improve aspects of mental health, especially quality of life, resilience, and emotional symptoms. The consolidation phase showed that stakeholders felt that using this intervention in the school setting was feasible, acceptable, and an enriching experience that generated changes in the perceived mental health and behavior of participants.

CONCLUSIONS

Our results are encouraging and show that the DIALOG+S intervention is feasible and acceptable as a promising opportunity to promote well-being and prevent and identify mental health problems in the school context in a postconflict area in Colombia. Larger, fully powered studies are warranted to properly assess the efficacy and potential impact of the intervention and to refine implementation plans.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number (ISRCTN) registry ISRCTN14396374; https://www.isrctn.com/ISRCTN14396374.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/40286.

Humanitarian Outpatient Pediatric Endeavor (HOPE): A Novel Specialist Ambulatory Health-Care Concept in Conflict Areas

With the collapse of the medical system in Syria, Israel began providing Syrians with humanitarian aid, first to the war-injured and then general medical treatment. We developed a novel specialist ambulatory care concept to provide medical care for Syrian children. Children with their caregivers were transported by bus across the border from Syria to our medical center in Israel for day-stay outpatient-clinic advanced evaluation and treatment due to coordination between Syrian, Red Cross, and Israeli authorities, including Israeli Defense Forces. This retrospective field report includes 371 Syrian children treated as outpatients at Galilee Medical Center between January 2016 and September 2018. In our experience, this novel pediatric ambulatory care concept has been feasible, efficient, and successful in providing specialist care for children in a crisis region devoid of access to health care. We believe it can also serve adult patients and be implemented in other crises and disasters scenarios.

Effects of clustering and timing of early life stress exposure on mood problems, ADHD symptoms, and problematic drinking

OBJECTIVE

Exposure to early life stress (ELS) may lead to long-term health consequences. The Early Life Stress Questionnaire (ELSQ) is a retrospective measure of multiple ELS and their timing. Latent class analysis (LCA) has not been applied to the ELSQ and questions regarding timing are rarely explored. This study examined the effects of clustering and timing of ELS exposure on internalizing and externalizing symptoms.

METHOD

Data from 1095 participants in the NIAAA Natural History Protocol were analyzed. LCA was conducted on 18 ELS items. Regression and correlational analyses examined associations of latent classes with sociodemographic variables and clinical outcomes.

RESULTS

LCA revealed three classes: Class 1: Minimal ELS (54.2%), Class 2: Moderate ELS (33.2%), and Class 3: Multiple and High ELS (12.6%). Black/African American participants were more likely to be in Class 2, and participants with low household income were more likely to be in Classes 2 and 3. Family history of problematic alcohol use and individual alcohol use disorder diagnosis were linked to Classes with higher ELS exposure. Compared with Class 1, Class 2 reported higher anxiety symptoms, depressive symptoms, ADHD symptoms, and problematic drinking, and Class 3 reported the highest levels across all these outcomes. Regarding timing, earlier exposure to ELS (e.g., sustained family conflict and witnessed domestic violence) was associated with higher psychopathological symptoms.

CONCLUSIONS

The ELSQ can effectively capture clustering and timing of exposure to multiple ELS. Greater and earlier exposure to ELS were positively associated with internalizing and externalizing symptoms, underscoring the need for early and well-timed intervention.

The effect of conflict on child and adolescent health in Amhara region, Ethiopia: Cross-Sectional Study

BACKGROUND

Currently, conflict become common phenomenon in the world affecting the lives of millions of children. Due the continued conflict in Ethiopia millions of children are suffering from extreme levels of violence, lack of basic humanitarian needs, and lack of health services.

OBJECTIVE

This study was designed to assess the effect of conflict on child and adolescent health in Amhara region, September 2022.

METHODS

A community-based cross-sectional study was employed among children agedd < 18 years in conflict affected areas of Amhara region. The sample size was determined using a single population proportion formula. Data was collected through face-to-face interviews of children or child legal guardians. Data was cleaned, verified, and entered into EpiData version 3.1 and analysis was done using SPSS version 24 statistical software.

RESULT

Seven hundred and ninety-eight children agedd less than 18 years were involved with a response rate of 94.33 percent. More than one thirds (276, 34.59%) of children were displaced due to the conflict. Three hundred and thirty one (41.48%) children get diseased with the majority didn't receive treatment. More than two thirds (557, 69.80%) of children had experienced violence of different types. One hundred and thirty four (41.23%) children had acute malnutrition with two third (66.42%) of them had severe acute malnutrition.

CONCLUSION

Conflict had deadly impacts on the lives of children and adolescents. It causes massive displacement, lack of basic humanitarian needs, extreme level of violence, hunger and malnutrition, and lack of health services. The government and other national and international humanitarian aids should give special attention to children living in war zone of Amhara region. In addition, rehabilitation services and resilience training should be designed and provided to children affected by the conflict.

Environment and child well-being: A scoping review of reviews to guide policies

Background

Acting on social determinants is the most effective, efficient, and fairest strategy to improve population health and health equity. Because of their vulnerability and dependence, children are particularly exposed to the deleterious effects of their living environment. Taking these issues into account in the development of public policies and identifying levers for action are crucial. The objective of this scoping review of reviews is to identify the main environmental determinants on children's health and development, and their mechanisms of effect, to be addressed by public policies.

Methods

We conducted a scoping review of reviews in accordance with the method developed by Arksey and O'Malley, and Levac and colleagues' methodology advancement and the PRISMA guideline. Inclusion criteria were identified with the PICos (population-phenomena of interest-context-study design) framework. We used the PubMed database and conducted a thematic analyze.

Results

Forty-seven articles were selected. Their analysis allowed us to identify five categories of interdependent environmental determinants of child health: i) urban design ii) contaminants, iii) parenting environment, iv) social conditions, v) climate change. Together and in a systemic way, they act on the health of the child.

Conclusion

The review carried out allows us to propose a pragmatic framework for clarifying the effects of the physical, social, and economic environment on children's health and wellbeing.

Pediatric traumatic brain injuries in war zones: a systematic literature review

Background

Pediatric casualties in war zones are a devastating consequence of armed conflicts, causing significant challenges for affected children, especially in the context of poor access to care. This study aimed to understand traumatic brain injuries (TBIs) in this high-risk population and to identify and provide information for the stakeholders, as well as to recognize severe long-term consequences and develop strategies to prevent them, thus minimizing their burden while aiding in the management of these cases.

Methods

We carried out a systematic literature review following PRISMA guidelines to identify publications discussing traumatic brain injuries in children in the context of war zones, and we analyzed all the collected data.

Results

Our study showed that head injuries were the most common casualty in war zones; male and female children were affected, and the mean age was 8-10 years. Most children were reported to be from Afghanistan, and blasts were the most common mechanism of injury. The mortality fluctuated from 3 to 47%.

Conclusion

There is a lack of evidence-based information regarding the characterization, approach, and management of children with TBI in conflict zones. While the world finds ways to live in peace, there is an urgency to research, train, and deploy enough specialists to these areas, if governments are serious about improving outcomes for this population.

The impacts of the Syrian conflict on child and adolescent health: a scoping review

BACKGROUND

The Syrian conflict has had a profound impact on Syrian children and adolescents. We sought to determine the extent and range of literature on the conflict's health effects on this vulnerable population.

METHODS

A scoping review describing the impact of the Syrian conflict on children was undertaken while utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews methodology. Qualitative thematic analyses were undertaken to both identify patterns of morbidity and mortality and gaps in evidence.

RESULTS

A total of 982 articles meeting search criteria were identified between 1 January 2011 and 30 April 2021. After iterative screening, 12 were identified from academic databases and 4 were identified from grey literature and hand searching, yielding a total of 16 studies for final, full-text analysis. Four distinct themes recurred in the literature; these include children suffering from violent injury, a resurgence of communicable diseases, malnutrition and micronutrient deficiency and impacts on their mental health.

CONCLUSIONS

The health of children and adolescents in Syria has been significantly impacted by the indiscriminate attacks against civilians, flagrant human rights violations and the disintegration of the national health care system. Neonates were largely absent from the literature. The themes from this scoping review can inform health programming priorities by aid organizations.

Prioritizing children's mental health amidst Sudan's humanitarian crisis: policy recommendations for immediate action

The humanitarian crisis precipitated by the ongoing conflict in Sudan poses profound risks to the health and welfare of the country's children. This paper explores essential policy interventions to safeguard child mental health services under these challenging circumstances. Crucial strategies include enhancing healthcare accessibility for children and their caregivers, promoting education, and improving household living conditions. Additionally, it is vital to provide improved access to information about nutritious food and strengthen health systems in areas directly exposed to conflict. Cooperation with international aid organizations is paramount to delivering medical supplies to functioning health facilities. The paper also recommends partnerships with local non-governmental and humanitarian organizations to execute public health programs effectively. These multi-faceted policy measures underscore the importance of a comprehensive response to ensure the health and well-being of children amid the turmoil in Sudan. Through these strategies, we aim to provide a blueprint for policymakers and humanitarian organizations to mitigate the devastating impacts of the conflict on the country's most vulnerable population.

Bosnian Paternal War Orphans: Mental Health in Postwar Time

ABSTRACT

More research on the medium- and long-term effects of childhood exposure to war, including orphanhood, is needed. We compared 50 orphans 1 who lost their father during the war in Bosnia and Herzegovina (1992-1995) and 50 age- and sex-matched adolescents from two-parent families during 2011-2012 in terms of sociodemographic characteristics, behavioral/emotional problems, depression, resilience, maternal mental health, and perceived social support. The two groups differed on sociodemographic factors, that is, number of children, family composition, income, school grades, and refugeehood. Paternal war orphans did not differ in terms of adolescent mental health and resilience from their nonorphaned peers, controlling for sociodemographic variables. The mothers of orphans had comparably more posttraumatic psychopathology. As for perceived resources for social support, orphans identified those comparably more often among distant relatives and in the community, that is, religious officials and mental health professionals, and less often among siblings, paternal grandparents, paternal and maternal uncles/aunts, school friends and teachers. Our findings suggest that contextual factors may play an important role in orphans' postwar mental health.

Association between war-related traumatic events and blood pressure trajectory: a population-based study among the mid-aged and older Palestinian adults living in Gaza

Background

Little is known regarding health status in an environment characterized by instability and ongoing war risks. This study investigated hypertension disease burden and associations of war-related traumatic events with blood pressure (BP) trajectory over time amongst mid-aged and older Palestinian adults in Gaza Strip.

Methods

From nine primary healthcare centers, medical records between 2013 and 2019 were collected for 1,000 mid-aged and older Palestinian adults living in Gaza. Multinomial logistic regression analysis examined associations between war-related traumatic events and BP trajectories derived using latent class trajectory analysis (LCTA).

Results

The prevalence of self-reported injury (of participants or their family members), death of a family member, and violence due to house bombing was 51.4%, 54.1%, and 66.5%, respectively. In total, 22.4% and 21.4% of participants had constant-very-high (CVH) systolic BP (SBP) (>160 mmHg) and diastolic BP (DBP) (>95 mmHg), and normal-stable SBP and DBP was found only 54.9% and 52.6%, respectively. Injury (participants or family members), death of a family member, and violence due to house bombing during wars were associated with CVH SBP with odds ratios [95 CI, OR = 1.79 (1.28-2.48), 1.90 (1.36-2.65), and 1.44 (1.01-2.05)], respectively. The corresponding figures were [95 CI, OR = 1.92 (1.36-2.71), 1.90 (1.35-2.68), and 1.62 (1.13-2.38)] for CVH DBP. Living in debt was positively associated with CVH SBP, [95 CI, OR = 2.49 (1.73-3.60)] and CVH DBP, [95 CI, OR = 2.37 (1.63-3.45)].

Conclusion

The disease burden related to war-related traumatic events is high and positively related to adverse BP trajectory among the mid-aged and older Palestinians living in Gaza. Intervention programs are needed to manage and prevent chronic diseases in this vulnerable population.

Examining the relationship between armed conflict and coverage of maternal and child health services in 35 countries in sub-Saharan Africa: a geospatial analysis

BACKGROUND

Armed conflict is on the rise in sub-Saharan Africa and affects public infrastructures, including health systems, although evidence on population health is sparse. We aimed to establish how these disruptions ultimately affect health service coverage.

METHODS

We geospatially matched Demographic and Health Survey data with the Uppsala Conflict Data Program Georeferenced Events Dataset, covering 35 countries for the period from 1990 to 2020. We relied on linear probability models with fixed effects to capture the effect of nearby armed conflict (within 50 km of the survey cluster) on four service coverage indicators along the continuum of maternal and child health care. We also investigated effect heterogeneity by varying conflict intensity and duration, and sociodemographic status.

FINDINGS

The estimated coefficients represent the decrease in the probability (in percentage points) of the child or their mother being covered by the respective health service following deadly conflicts within 50 km. Any nearby armed conflict was associated with reduced coverage for all examined health services, with the exception of early antenatal care: early antenatal care (-0·5 percentage points, 95% CI -1·1 to 0·1), facility-based delivery (-2·0, -2·5 to -1·4), timely childhood vaccination (-2·5, -3·1 to -1·9), and treatment of common childhood illnesses (-2·5, -3·5 to -1·4). For all four health services, the negative effects increased for high-intensity conflicts and were significant throughout. When examining conflict duration, we did not find negative effects on the treatment of common childhood illnesses in prolonged conflicts. The analysis on effect heterogeneity revealed that, except for timely childhood vaccination, the negative effects of armed conflict on health service coverage were more pronounced in urban settings.

INTERPRETATION

Our findings suggest that health service coverage is significantly affected by contemporaneous conflict, but health systems can adapt to provide routine services, such as child curative services, in situations of prolonged conflict. Our analysis underlines the importance of studying health service coverage during conflict both at the finest possible scales and across different indicators, pointing at the need for differential policy interventions.

FUNDING

None.

TRANSLATIONS

For the French and Portuguese translations of the abstract see Supplementary Materials section.

Area level indirect exposure to extended conflicts and early childhood anthropometric outcomes in India: a repeat cross-sectional analysis

BACKGROUND

Protracted, internal conflicts with geographic variations within countries, are an important understudied community exposure for adverse child health outcomes.

METHODS

Violent events from the Uppsala Conflict Data Program (UCDP) between January 2016-December 2020 and January 2010-December 2015, were included as exposure events for children sampled in National Family Health Surveys (NFHS) 5 (2019-21) and NFHS 4 (2015-16), respectively. Geocoded data from UCDP were merged with residential clusters from NFHS, to identify children living in villages or urban blocks situated at <= 50 km from conflict sites. Within these clusters, which we defined as conflict exposed, we studied risks of stunting, underweight and wasting in children, prenatally, and in 0-3 years. We assessed sensitivity on a subsample of siblings with discordant conflict exposures.

RESULTS

For NFHS 5, exposure to violence between 0 and 3 years was associated with 1.16 times (95% CI 1.11-1.20) higher risks of stunting, 1.08 (1.04, 1.12) times higher risks of underweight, and no change in wasting. In-utero violence exposure was associated with 1.11 times (95% CI 1.04-1.17) higher risks of stunting, 1.08 (95% CI 1.02-1.14) times higher risks of underweight, and no change in wasting, among children <= 2 years. In 17,760 siblings of 8333 mothers, exposure to violence during 0-3 years, was associated with a 1.19 times higher risk of stunting (95% CI - 0.24 to 0.084). Incremental quartiles of violence exposure had higher risks of stunting and underweight until quartile 3.

CONCLUSION

In-utero and early childhood indirect exposure to protracted conflicts were associated with increased stunting and underweight in India. Given the continued exposures of such historically and contextually rooted internal conflicts in many LMICs, chronic violence exposures should be targeted in public health policies as important social and political determinant of child health.

Adapting Reach Up and Learn in Crisis and Conflict Settings: An Exploratory Multiple Case Study

OBJECTIVES

In 2019, >71 million children aged <5 had spent their entire lives in conflict-affected settings. Compounding adversities including violence, poverty, and displacement have immediate and long-term effects on early childhood development, health, behavior, and well-being. In response, adaptations of Reach Up have been implemented in conflict and crisis settings.

METHODS

This article uses exploratory multiple case study methodology, drawing from implementation and qualitative data from 3 interventions: a mobile phone-based intervention promoting nurturing care among Rohingya and crisis-affected host communities in Bangladesh; Reach Up amid acute violence and displacement in Northeast Syria; and Reach Up group sessions and home visits integrated with health services for an indigenous population in Venezuela.

RESULTS

In Bangladesh, tailoring interactive voice response messages improved responsiveness to the developmental needs of young children, yet complementary in-person services were identified as a key program enhancement. In Syria, rapid adaptations of Reach Up addressed the needs of families in acute crisis, including social-emotional learning games for school-aged children. In Venezuela, Reach Up, coupled with complementary lactation counseling, yielded high rates of uptake and satisfaction, and children's language development was highlighted as a key area of growth.

CONCLUSIONS

Recommendations to promote early childhood development in crisis and conflict settings include: (1) cultural adaptation based on a holistic understanding of children and caregivers' needs; (2) the integration of child and family safety and linkages with complementary services on the basis of community needs and priorities, and (3) the importance of designing for scale through blended models and costing analyses.

Impact of the Russian Invasion on Mental Health of Adolescents in Ukraine

OBJECTIVE

Very limited evidence is available on the psychological impact of war on adolescents in Ukraine. This study compared war experiences and posttraumatic stress disorder (PTSD), anxiety and depression in adolescents living in war-torn and peaceful regions of Ukraine, more than 2 years after Russia first invaded in 2014.

METHOD

The cross-sectional study included 2,766 students aged 11 to 17 years living in the war-torn Donetsk region and in Kirovograd in central Ukraine. Self-reported PTSD, depression, and anxiety were assessed by Harvard Trauma Questionnaire, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7. Data were collected from September 2016 to January 2017. Binary and multinomial logistic regression models were used to examine the association between PTSD, anxiety, and depression and regions.

RESULTS

War trauma and daily stress were higher in adolescents in the Donetsk region; 881 (60.2%) adolescents had witnessed armed attacks, 204 (13.9%) were victims of violence, and 409 (27.9%) were forced to leave their homes. They also had significantly increased risks for PTSD (odds ratio [OR] 4.11, 95% CI 2.37-7.13), severe anxiety (OR 3.10, 95% CI 1.83-5.27), and moderately severe/severe depression (OR 2.65, 95% CI 1.79-3.92).

CONCLUSION

Traumatic events and daily stress were strongly associated with psychological distress in adolescents living in a war-torn region in Ukraine. These findings can help in understanding, measuring, and addressing the long-term impact that the current escalating war in Ukraine will have on adolescents' mental health and social functioning.

When State Violence Comes Home: From Criminal Legal System Exposure to Intimate Partner Violence in a Time of Mass Incarceration

Exceptionally high rates of partner violence perpetration are evident among men returning from prison. Two bodies of scholarship, one on family stress and another on exposure to state violence, each suggest that criminal legal system exposure could promote partner violence perpetration via changes in men's behavioral health and interpersonal approach and in couples' conflict dynamics. Such relationships have not been tested in quantitative research. Structural equation models were fitted to longitudinal, couples-based survey data from the Multi-site Family Study on Incarceration, Parenting, and Partnering. Participants included men returning from a state prison term in five U.S. states (N = 1112) and their committed intimate or co-parenting partners (N = 1112). Models tested hypothesized pathways from three dimensions of criminal legal system exposure to later partner violence perpetration. In fitted models, men's childhood criminal legal system exposure predicts their post-prison partner violence perpetration via adult post-traumatic stress symptoms, reactivity, avoidance, and dysfunctional couple conflict dynamics. Men's cumulative criminal legal system exposure in adulthood predicts their post-prison partner violence perpetration via addiction and dysfunctional couple conflict. These initial results suggest that mass-scale incarceration could worsen partner violence via men's psychological and interpersonal adaptations to criminal legal system contact, particularly when such contact is sustained or occurs at a developmentally significant period in the life course.

Weathering within war: Somatic health complaints among Vietnamese older adults exposed to bombing and violence as adolescents in the American war

OBJECTIVE

People living in war may experience deteriorating health via weathering (wear and tear) from long-term exposures to psychosocial and environmental stressors. Weathering embodied in somatic health complaints may illuminate the effects of war on health.

METHODS

We investigate whether wartime stress exposures occurring during adolescence and early adulthood affect weathering in late adulthood via linear regression with data from the Vietnamese Health and Aging Study (VHAS). VHAS is a cross-sectional study wherein investigators surveyed 2447 adults aged 60+ in four districts of northern and central Vietnam in 2018. These same individuals ranged in age from seven to 52 in 1965, with most having been in adolescence or early adulthood at the peak of the American war in Vietnam (1965-1975). The sample used for this study (n = 2254) were participants in the first VHAS wave in 2018.

RESULTS

We find older Vietnamese adults exposed to higher-intensity provincial bombing suffer more numerous somatic health complaints (unstandardized β = 0.005, SE = 0.001, p = 0.001). Additionally, greater health complaints emerge among older adults whose most intense bombing exposures were at younger ages of adolescence (< age 15) as compared to those whose peak exposures were in older ages (19-25) (unstandardized β = 0.62 95%, SE = 0.19, p = 0.01).

CONCLUSION

Our findings suggest that age of exposure to armed conflict is a critical determinant of weathering across the life course.