Keywords

1 Background and Epidemiology

In the world of today, there has been a shift in the type of armed conflict and war, from well-defined battlefields to civilian and community targeting [1]; conflicts have also become more stretched out and prolonged with a tendency to wax and wane [2]. Over the last few decades, there has been a consistent and steady rise in the number of children living in conflict areas [3]. In 2017, an estimated 1.8 billion children live in areas or countries torn apart by armed conflict [3]. In terms of the total number of children living in such areas, Asia has the highest figures; yet this must be taken in the context of the overall population size [3]. It is in fact the Middle East—with an approximate 40%, or 2 out of 5 children living in conflict regions—which has the highest portion of children affected by conflict; relative to its overall population [3]. The numbers for Africa, Asia, the Americas, and Europe, are as follows: 26%, 16%, 11%, and 5%, respectively [3]. Quite alarmingly, more than 420 million children live less than 50 km away from actual fighting zones [3]. In 2017, approximately a third (33.7%) of the world’s children in conflict areas were reported to live in “high intensity” conflict regions where the census for battle-associated deaths exceeds 1000 children in a year’s time [3]. There is a wide array of harms that befall children and adolescents during the conflict, these include but are not limited to death, physical injury, disfigurement, disease [3, 4] the failure of structures that deliver preventive, curative, and ameliorative care [4], as well as the hindrance of proper humanitarian help such as medical care, which according to United Nation reports, has become more widespread in recent years [3]. Deeper wounds that involve the mental health and psychological well-being of these children have also been well-documented in the literature [5,6,7]. The aims of the present chapter are to (1) provide an overview of the impact of war on children's mental health; (2) explore some of the moderating factors in this complex relationship; (3) provide an overview of the assessment of children and adolescents exposed to war trauma; and (4) briefly review the evidence-based interventions and treatments that may help this vulnerable population.

2 Impact of War on Children’s Mental Health

2.1 Stressors and Resilience

Stressors that may lead to acute and chronic stress responses in children may be classified into primary and secondary [8]. Primary stressors relate to the direct experience of harm or danger of harm, while secondary stressors encompass the repercussions of the disaster (i.e., adversities such as loss of home and injury). In many cases, if given appropriate support, children recover from acute stress responses over the course of time [8]. The American Psychological Association defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of stress” [9]. Though resilience is an intricate concept and has been defined in many different ways; it generally refers to the capacity of a dynamic system to effectively adjust to disruptions that pose a danger to its viability; and an individual’s ability to achieve a stable course of healthy function following an adverse experience [10]. For children in particular; there is an added layer of complexity to the concept of resilience; as a number of factors including parents or caretakers, family, and community/social come into play and are necessary for resilience to develop in children [11]. In trying to understand what adds to the resilience of children who experience war, factors are conceptualized on three levels [12,13,14]. The first level pertains to the children themselves and their individual characteristics; this includes their coping styles whereby resilient children characteristically evaluate traumatic incidents as less devastating and are able not only to appreciate the existing social resources but also to use relevant cognitive-emotional means that are appropriate to the stresses of the particular traumatic incident [12, 15]. Family is at the second level, as it is the main contributor to the healthy development of a child, especially after exposure to trauma [16]. The existing literature documents the buffering effect that a protective family environment can have. A study by Barber in 2001 showed that better parental education, integration in the family, and good parenting safeguarded the mental health of Palestinian children exposed to military violence. Specifically, the development of antisocial behavior among adolescents was precluded if they had elevated levels of parental acceptance and support [17]. In another study among Palestinians, supportive parenting styles were related to creativity and cognitive capacity in children, which in turn, added to psychological adjustment despite heavy war trauma experiences [18]. What is more, constructive relationships with siblings and connectedness with peers can dampen the mental health effects of war trauma particularly when It comes to symptoms of anxiety and depression [19, 20]. Having explored this, it is worthwhile to be aware that there are a number of other factors that moderate the detrimental effects of war on children [21]. Table 18.1 lists the factors that were found to moderate the negative repercussions of war on children in the literature.

Table 18.1 Factors that moderate the detrimental effects of war on children [21]
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2.2 War and Psychopathology in Children and Adolescents

According to some researchers, traumatic experiences represent a continuum and it is the magnitude of the stress or the effect of moderating factors rather than the nature of the stress itself that is more important in determining aftermaths. According to this perspective, traumatic events may result in a wide variety of and are a risk for a number of different psychopathologies; and the particular psychiatric outcome may be related to characteristics of the child him/herself rather than the traumatic exposure [22]. On the other hand, other research explores that different types of stress may be specifically associated with different types of psychopathologies. For example, dangerous experiences usually generate distinctive signs of fear in a child, while losing essential relationships (for example, death of a loved one) may result in dysphoria [23]. It is important to keep in mind that during war times, multiple traumatic exposures are the rule rather than the exception; and that cumulative experiences are associated with greater symptomatology [24, 25]. Exposure to war results in a myriad of behavioral, emotional, and mental problems in children and adolescents; and the number of conflict-related traumatic occurrences is positively correlated with the prevalence of these problems[7]. The severity of traumatic experience is also a robust predictor of outcome, but other factors such as children’s individual characteristics as well as elements related to their environment are also involved [26]. This range of exposure- and child-related influences entails that there are a number of possible targets for interventions intended to promote resilience in children [27]. In general, the more common diagnoses encountered in children exposed to war trauma are Post-Traumatic Stress Disorder (PTSD), depressive disorders, and anxiety disorders; and these may be comorbid [28]. A 2009 systematic review by Attanayake et al. of 17 studies included approximately 8000 children between the ages of 5 and 17 years, who have been exposed to wars in several regions including Central America, Bosnia, Cambodia, Rwanda, and the Middle East indicates that PTSD is the main sequel, with a prevalence of 47%, followed by depression (43%), and anxiety (27%) [6]. In the middle east, the prevalence of PTSD among children and adolescents in war zones is approximately 5–8% in Israel; it ranges between 23 and 70% in Palestine and between 10 and 30% in Iraq. As for Lebanon, litte is know about the prevalence of PTSD, althought the country faces major challenges. These numbers are similar to those in other war-burdened regions, namely 70% in Kuwait following the Iraqi invasion [29]; 52% in Bosnia-Herzegovina [30], and 50% among Cambodian children after war trauma [31]. Studies led after the War on Gaza (2008–2009) showed that more than half of children [32, 33], exhibited clinically significant post-traumatic stress symptoms, and a third endorsed symptoms of depression [33].

2.3 A complex Interplay of Factors That Perpetuate Psychological Suffering

Children and adolescents in war-afflicted regions are at risk of physical injury, torture, and witnessing or participating themselves in combat; they are at subsequent risk for several forms of violence including abuse and neglect [34,35,36,37,38]. There are also exposures to community and school-level violence [39] as well as domestic violence [35, 36]. Caregivers who have themselves endured armed conflict are in fact more likely to engage in child neglect and abuse, and there are higher rates of both child- and caregiver-reported child abuse in caregivers who suffer mental health illness or stress associated with their experience of armed conflict [34,35,36]. Conflict also precludes children from attending school and lowers their overall educational achievement [40, 41]. Economic sequelae of war also influence psychopathology, as rates of anxiety, post-traumatic stress disorder and depression in children and adolescents are higher in families who have lower income [42,43,44], perhaps because those with higher income are able to provide basic necessities during times of war[42]. Children may also take on adult responsibilities and obligations prematurely; this involves becoming providers for their families and delivering care for ill or disabled parents [45,46,47]. During war conflicts children may experience, be a witness to, and perpetrate acts of sexual violence and sexual exploitation [48, 49]. The sequelae of sexual violence are broad and far-reaching. A recent systematic review has categorized them into physical aftermaths such as pregnancy, sexual dysfunction, sexually transmitted illnesses, and traumatic genital injuries; and mental health consequences which include post-traumatic stress disorder, depression, and anxiety; as well as social outcomes such as rejection[50]. Conflicts also drive children and families to abandon their homes and flee within national or across international borders[48]; a journey during which they are vulnerable to illness, psychological trauma as well as exploitation and during which they may be separated from their families [51, 52]. Even in cases of re-settlement in a foreign country; post-migration socioeconomic factors influence the risk of developing depression, post-traumatic stress disorder, and anxiety [53].

3 Special Considerations in the Assessment of Children and Adolescents Exposed to War Trauma.

The assessment of children exposed to war trauma is different from adults. A key point is that a child’s clinical presentation depends on his or her developmental level [8], and the reactions to trauma can be most understood from the perspective of the children’s social, emotional, and cognitive development [54]. For example, younger children may show regressive behaviors while school-aged children may struggle at school, and older children or adolescents may engage in substance misuse [55]. Depression may be more common among older children as well [56]. Specific features of the stressor and the exposure to it, as well as individual-level factors such as age, developmental level, gender, previous history of psychiatric illness, and other larger-scale factors such as family characteristics and social environment all, play a role in the response to trauma and influence the recovery trajectory of the child/adolescent [57]. The extent of exposure to acutely dangerous experiences appears to predict a greater risk for the development of subsequent psychiatric symptoms [22, 58]. A number of children will show non-specific behavioral and emotional symptoms, such as new-onset fears; clinging, and over-reliance on caregivers; they may also exhibit low frustration tolerance, aggressive behaviors, and changes in their eating patterns [1].

While assessing the sense of safety in children, one should consider the following. Infants and very young children rely on their parents or caregivers to estimate the actual degree of danger while preschoolers start to consciously incorporate the safety and protection of their parents as well as their own in their representations of danger [59]. By school age, children begin to grasp the complexity of dangerous situations and start to visualize self-efficacy as they become more and more involved in the safety and protection of themselves and others [59]. By mid-adolescence, they rely on themselves and on peers to evaluate threats and protection [59].

To assess the impact of the traumatic or stressful events, one should assess what is spoken by the child as much as the behavioral and somatic manifestations, particularly in young children and in children with limited cognitive and verbal abilities. Magical thinking, confusion, and self-accusation are developmentally related examples of early childhood thinking and emotional processing after a traumatic experience [54]. In the very young age group ranging from infancy to 6 years old, the following are some of the manifestations of distress: fear, increased startling, seeking attention from caregivers, temper tantrums, crying spells, and sleep interruptions along with trouble sleeping [1]. These young children are also more prone to experience somatic symptoms, such as gastrointestinal pains and changes in bowel movements [1]. They also show alterations in their play, which may change to more aggressive or on the contrary more inhibited [1]. Play is an important area of focus, as children tend to reflect on their traumatic experiences in the content of play; such as re-enacting the trauma, repetitive play, fantasy devoid play as well as macabre themes in the play. Their play is also less rich in social interactions and with a predominance of negative affect [60,61,62]. Young children may exhibit sleep-related difficulties such as refusing to sleep alone, instance on sleeping with their parents; experiencing nightmares, and repeated awakenings[63,64,65,66,67]. On the other hand, while separation anxiety is a usual normative occurrence in younger children; it may become apparent in school-aged children as a manifestation of their distress[1]. In general, boys have more exposure to severe traumatic events than girls [42, 68]; and though both genders suffer from anxiety and depression symptoms; girls report considerably more symptoms of depression than boys [43]. After exposure to war trauma, adolescents experience elevated levels of intrusion, avoidance, and depression symptoms; with the female gender being a significant risk factor for depression[44]. What is more, adolescents who have increased exposure to war events and those who suffer from PTSD as a result, have greater rates of substance abuse and are more likely to be involved in violence within schools [69].

The following are some of the signs of distress in children exposed to war trauma across age groups: physical symptoms such as headaches and abdominal pain with no apparent physical origin; crying spells, sadness, or irritability; difficulties sustaining attention and focus; fear and anxiety; insomnia or hypersomnia; nightmares; recurrent thoughts about the traumatic event or avoiding discussion the event and avoiding reminders of the event; being distressed by reminders of the traumatic event; difficulties managing behavior or emotions; flashbacks; not engaging with others in play or in activities that were enjoyable and hopelessness [70].

As previously mentioned, signs of distress in children may vary according to age categories and developmental level. Below are some examples of distress stratified by age groups [70, 71]:

  1. 1.

    Preschool Children: Preschool children may experience a regression to younger behaviors which may include bed-wetting, thumb-sucking, and mutism. They may have unexplained physical symptoms as well as trouble separating from their parents or caregivers. They may also throw temper tantrums or have aggressive behaviors such as throwing kicking, biting, or hitting. They may be reluctant to engage in play or engage in a repetitive re-enactment of the traumatic event during their play.

  1. 2.

    Elementary School Children: These children may experience difficulties with concentration, memory, and attention, causing them to struggle in school. They may also have peer problems and aggression toward others. They may present with new-onset fears such as fear of separation from parents or caregivers and fear of something bad happening. They may isolate themselves from others; and may experience anger and irritability as well as feelings of sadness, self-blame, and guilt.

  2. 3.

    Middle and High school children and Adolescents: This category of children/adolescents may experience more complex emotions, such as a sense of guilt or responsibility for bad things that have happened; feelings of shame or embarrassment, and helplessness. They may have difficulties in interpersonal relationships with their parents, teachers, friends, and family. They may have changes in their perception of the world or experience a loss of faith. Alternatively, they may have conduct problems or engage in substance use or misuse.

Because children are embedded within families, and because it is the parents who usually are the closest and most impactful people in a child’s development, particularly during the early years[72], it is crucial to incorporate parental mental health in the overall evaluation of a war-affected child. Indeed, children in families where a parent has suffered from war trauma may experience secondary traumatization and may suffer from the repeated use of ineffective coping skills by the distressed parent, generally the mother [73]. Furthermore, the psychological distress of parents mediates and moderates the connection between war trauma and developmental consequences in children including behavioral and emotional problems [72]. In particular, parental distress after exposure to war trauma may present a specific risk for depressive symptoms in the child [74]. In young children, the effect of the parents’ responses may have an equal or bigger impact than that of the actual traumatic experience [75]. Not only is there a correlation between parental and children’s psychopathology but the family environment and parental functioning moderate the relationship between exposure to trauma and outcome for children [1].

4 The Interplay Between Direct Physical Injuries, Pain, and Mental Health

There is a wide array of possible physical harms affecting all organ systems that may befall children as a result of penetrating injuries, burns, crush injuries, and blunt trauma [48]. Chronic physical illness places children at a higher risk of behavioral and emotional problems as well as at an increased risk of developing psychiatric disorders [76]. Between a quarter to a third of children who suffer from burns display some PTSD symptoms [77, 78], they may also suffer from anxiety and mood symptoms, sleep problems, as well as conduct, learning, and attention problems [79]. Interestingly, pathways leading to the development of PTSD in children with burns are mediated by separation anxiety and dissociative responses, with trauma magnitude being a mediator of both pathways, and pain having an influence on the development of PTSD indirectly through separation anxiety; thereby highlighting the complex and dynamic interaction between pain, family effects and the development of PTSD [80]. During the acute phase of burn injuries, for example, children experience a psychological reaction to the trauma of the burn injury itself and to its subsequent treatment [81]. Anxiety, fear, and pain frequently have comparable symptoms, particularly in younger children who may experience dread, tremulousness, restlessness, muscle tension, tachycardia, dizziness, sweating, dyspnea, cold hands and feet, excessive worries; nightmares as well as difficulties falling asleep [81]. Therefore, the child and adolescent psychiatrist, psychologist, or clinician assesses injury severity to plan interventions that can alleviate pain and reinforce coping strategies to manage the risk of death, disability, and effects on body image [82]. Later on, in the recovery process, children may show aggression, disruptive behaviors, mood symptoms, learned helplessness, enuresis and encopresis, food refusal as well as sleep and attention difficulties [82]. Some suggested methods for the psychiatric care of the injured child include pain management, brief consultation, and crisis intervention followed by brief psychotherapeutic techniques [82]. As a first step, explaining and clarifying what is going on and what is going to happen, as well as giving the children reasonable choices about how a procedure can be performed boosts their sense of control, and can help diminish their sense of being a victim. For example, during dressing changes, a child may gain a sense of control by aiding in the removal of the dressing and will trust this will cause him or her less distress [83]. Particular attention should be paid to pain. While pharmacological interventions remain the core of pain treatment, it is important to be mindful of the large number of psychological factors that accompany pain and that may contribute to the sensation of pain [83]. These include emotional distress, stressful memories, anticipatory apprehension about both the treatment of the injury itself and the recovery period, as well as being restricted in a new and possibly frightening hospital environment. These factors are the target of psychotherapeutic interventions [83, 84]. Specific intervention approaches include cognitive behavioral therapy, hypnosis, relaxation training, guided imagery, art, music, and play therapies as well as biofeedback and distraction therapy [85,86,87,88]. In biofeedback, patients learn through self-regulation to voluntarily control body processes [89]. Common methods of distraction [81, 90] that help in alleviating pain in burned children are playing, reading a story, watching television, and listening to music [91]. Other techniques include biofeedback, massage [92], and even virtual reality [93]. The two principal psychotherapeutic methods used to treat an injured child are psychodynamic psychotherapy and cognitive behavioral therapy, and they are generally used together and explicitly oriented to the pain [94], the injury itself, coping with surgery, and other needed medical care, as well as addressing responses to disfigurement or disability and grieving losses [28]. Cognitive restructuring, management of anxiety, strategies to cope with anger, and exposure-based interventions are the main features of cognitive behavioral therapy in injured children who suffer from PTSD [95] and in those with facial deformities [96]. Table 18.2 lists some strategies to help children cope with anger. Further on in the recovery process, clinicians should be mindful that burn disfigurement impacts children’s self-confidence, affects their social interactions, and marks their identity [97]. These children are more likely to be bullied [98]. In adolescents, predictors of positive body image and improved self-esteem are linked to perceived social support [99]. This applies to all other types of acquired disabilities.

Table 18.2 Techniques to help children coping with anger
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5 Interventions for Recovery from War Trauma Among Children and Adolescents

Research in the field of the resilience of war-exposed children and their growth post-trauma has recognized potentially changeable protective processes that may become the focus of interventions [21, 100]. Once the armed conflict is over; essential needs such as primary health care, limiting the spread of infectious diseases, access to clean water, food, shelter, and sanitation must be met; and educational activities should be started or reinstated as soon as possible [100]. Indeed, a large number of children may improve when access to water, food, shelter, health care, and security is restored [71]. Other children and adolescents will need dedicated support, with particular consideration for the child, family, and group. This psychological first aid should be delivered by health workers [71]. Lastly, children who suffer from exceptionally stressful reactions may require focused support for months; this may encompass counseling by social workers, teachers, and health care workers as well as broader social and cultural activities with Non-Governmental Organizations or groups within the community [71]. In general, the principles of management in line with those of Psychological First Aid include the following: (1) Creating a sense of safety, (2) instilling calm and lessening physiologic arousal, (3) reinstating a sense of personal efficacy, (4) re-establishing a sense of connectedness to others, and (5) imparting hope [101]. For those who will be working on the front line with traumatized children, it is important to keep in mind that the goal of Psychological First Aid for children is to provide relief from distress, help their current needs, and to foster adaptive functioning, and does not aim to gather details of painful experiences and loss [71].

5.1 Encounter with the Trauma-Affected Child or Adolescent

In general, the evaluation of the child begins with extracting the storyline of the trauma, preferably from the child himself or herself [28]. Children as young as ages 2–12 years can remember details of stressful incidents after injury [102]. Throughout the child’s narrative, it is important to be mindful of his or her account of related memories, thoughts, and feelings, the occurrence of alterations, and potential recurrent themes [103]. Afterward, in addition to assessing existing symptoms, it is important to look into the child's developmental history and the presence of previous psychopathology [28]. This information may be obtained from the parent or caretaker whenever possible. Before beginning the assessment of traumatized child or adolescent, patience is of the utmost importance. The interviewer should not take for granted that children or their parents/caregivers will respond positively straightaway [71]. The interviewer must remain sensible, sensitive, and attentive and must follow the pace of the child, all the while providing support for difficult emotions [71]. Accepting that the child may be experiencing difficult emotions such as anger, guilt and grief is paramount, and this involves avoiding telling the child or adolescent how he or she should feel, and rather mirroring the feelings of sadness; and acknowledging the overwhelming nature of these emotions [71]. Equally imperative is to offer hope to the child without dismissing or minimizing the reality of the situation [71]. Figure 18.1 provides general instructions when performing an interview with a child/adolescent following a traumatic experience. Specifically, the use of active listening helps to reinforce cooperation and nurtures understanding between the interviewer and the child/adolescent [71]. Active listening is a communication technique based on the work of psychologist Carl Rogers, which involves providing full attention to the speaker; and encompasses both verbal and non-verbal communication approaches [104]. There are five elements to active listening: (1)attentive focus, (2) paraphrasing, (3) encouragement, (4) questioning/clarifying, and (5) summarizing [71]. In attentive focus, the emphasis is on listening while avoiding interruptions, regardless of what the child is saying; and on being aware of one’s own body language [71]. In paraphrasing the interviewer may restate important words spoken by the child/adolescent, and may reprise what was heard in a descriptive rather than an interpretative way; for example, by using statements such as “I understand what you are saying”; ”Did I understand correctly?”; and “It sounds like this experience made you feel scared; is that so? [71]. Depending on the context of the assessment, and the level of acuity of the situation, the interviewer may be faced with an emotionally overwhelmed and very distressed child or adolescent. Stabilization of this state of hypervigilance and hyperarousal may be achieved through the use of some relaxation and grounding techniques [71], examples of which are shown in Figure 18.2. As previously mentioned, it is imperative to involve the parents/caregivers in the evaluation of traumatized children and adolescents. Priority should be given to educating the parents/caregivers about the wide range of signs and symptoms and possible reactions of their child’s distress depending on the child’s age and development level [71], keeping in mind that parents are themselves traumatized or at least heavily affected by the situation which means that they are also in need of active listening and support.

Fig. 18.1
A document with 6 checkboxes with instructions given as, having the encounter take place in a discreet and private location, questions should be simple and open-ended, speaking unhurried and gentle, allowing for parents or caregivers to be present during the interview, and so on.

General considerations in the interview of a child/adolescent following a traumatic experience

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Fig. 18.2
A text document reads 5 instructions which are listed as promoting attention and the focus on the here and now, having them notice their surroundings and name items that may be found in the immediate environments, helping the child stabilize his or her respiration, helping the child focus on immediate goals, keeping the emphasis on problems that have potential solutions and validating negative emotions.

Examples of relaxation and grounding techniques

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5.2 Evidence-Based Approaches for Treating War-Affected Children and Adolescents

There is increasing awareness and emphasis on incorporating the mental health and psychosocial support needs of people who experience humanitarian crises into humanitarian aid responses [105]. Mental health and psychosocial support programs are defined as any local or external support that purposes to safeguard or promote psychosocial well-being [106] or to prevent or treat mental health problems [107]. This definition is used broadly in the area of humanitarian emergencies to describe strategies devised to tackle the mental health and psychosocial difficulties of people in disaster and conflict situations [108]. There are numerous challenges to implementing proper evidence-based interventions in low and middle-income countries following trauma. These include the paucity of mental health services, insufficiently qualified clinicians, and barriers to modifying established interventions to the needs of contexts that are specific to low and middle-income countries [109]. The more common mental health and psychosocial support interventions relate to community-based social support, structured social activities, providing information and counseling, psychoeducation, and fostering awareness [110].

Randomized trials in conflict-affected areas propose that brief and structured intervention may improve outcomes in traumatized children and adolescents when carefully applied [111, 112]. A 2011 meta-analysis that comprised four randomized controlled trials in children and adolescents who experienced mass traumatic events showed that school-based interventions did not improve symptoms of post-traumatic stress disorder per se, but that psychosocial interventions (group interpersonal psychotherapy, group meetings with parents, and school-based interventions) were beneficial for internalizing symptoms (anxiety or depression) [110]. However, there is much heterogeneity in the literature, and the effects of various programs may depend on the initial intervention objectives [113], the characteristics of the program itself, as well as its quality and delivery [107, 114]. The specifics of the target population also play a role, including the type of trauma exposure, gender, level of social support, and context-related considerations such as degree of insecurity [115]. It is therefore important to identify common practice features of interventions that are successful at inducing targeted change [114]. It is equally important to describe different effects for dissimilar subgroups of participants [116] with regard to age, gender, socioeconomic level, geographic location, and trauma exposure [117]. A 2017 systematic review evaluated the effectiveness of mental health and psychosocial support programs in areas affected by humanitarian crises, though these were not limited to war-ridden areas [107]. The programs were likely to use cognitive behavioral techniques or other psychotherapy modalities including interpersonal grief-focused therapy and narrative exposure and were typically given in school-based environments, for the longest duration of 3 months [107]. The following evidence emerged:

  1. 1.

    Strong evidence is that the programs reduce functional impairment but have little impact on anxiety.

  2. 2.

    Moderate evidence that the programs marginally improve symptoms of post-traumatic stress disorder conduct problems, and psychological distress; and that they may have no effect on depression or prosocial behaviors.

  3. 3.

    Moderate evidence that Trauma-focused cognitive behavioral therapy is helpful in effectively ameliorating post-traumatic stress disorder symptoms as well as emotional and conduct problems.

  4. 4.

    Moderate evidence is that classroom and school-based interventions do not help reduce anxiety.

  5. 5.

    Moderate evidence that Narrative Exposure Therapy helps functional impairment but has little effect on post-traumatic stress symptoms.

6 Conclusion

War-related consequences are common worldwide and relate not only to the direct impact of war on the children themselves but also to major societal breakdowns, leading to consequential psychiatric morbidity [118,119,120,121]. War consequences such as death, injury, illness, disability, child soldiers, sexual violence as well as social and cultural losses [122] to name a few perpetuate psychological suffering in children exposed to war. Post-traumatic stress disorder, depression, and anxiety are among the most common disorders after traumatic events, including physical injuries; but other problems include sleep and elimination difficulties, conduct, learning, and attention problems as well as longer terms effects on body image and self-esteem may become apparent. The clinical presentation of distress in a child is developmentally dependent and must be grasped from the perspective of the child’s social, emotional, and cognitive development. The elaboration of clear, consistent, and effective interventions for managing war-related traumatic experiences can only be done through a better understanding of conflicts and the multitude of mental health problems that result from them[123]. It is imperative to keep in mind the importance of social resources in trauma—particularly the role of family—and their potential to shield children from the detrimental effects of war, as well as their contribution to the resilience of children [124, 125]. Cognitive behavioral therapy and trauma-focused cognitive behavioral therapy, remain validated therapeutic approaches for children and adolescents who suffer from trauma-related symptoms. The potential for children to recover is inherently related to resilience, which in turn depends on broader systems of care. Residual symptoms in children who have experienced war may be considered normal reactions to very abnormal situations; therefore there is a need for longer-term follow-up of these children, to better understand which symptom dimensions remain as psychopathology; and which fade away when a normal life balance is restored. Lastly, when trauma exposure becomes chronic and danger is ongoing, strong reactions may become a mechanism for survival, rather than a manifestation of psychopathology. More research is needed into what strategies work best to foster resilience in war-exposed children and to help them overcome, step by step, the difficulties they may face in the long road to recovery.

These children without a childhood

Without youth and without joy

Who shivered helplessly

With sorrow and cold

Who defied suffering

And silenced their turmoil

But lived in hope

Are like you and me

Charles Aznavour