pediatrics
December 2018, VOLUME142 /ISSUE 6

The Effects of Armed Conflict on Children

  1. Sherry Shenoda, MD, FAAPa,
  2. Ayesha Kadir, MD, MSc, FAAPb,
  3. Shelly Pitterman, PhDc,
  4. Jeffrey Goldhagen, MD, MPH, FAAPa,
  5. SECTION ON INTERNATIONAL CHILD HEALTH
    1. aDivision of Community and Societal Pediatrics, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida;
    2. bCentre for Social Paediatrics, Herlev Hospital, Herlev, Denmark; and
    3. cUnited Nations High Commissioner for Refugees, Washington, District of Columbia
    1. Dr Shenoda identified the need to write this policy statement, conducted the supporting literature review, and wrote the first draft of the manuscript; Dr Goldhagen identified the need to write this policy statement and wrote the first draft of the manuscript; Dr Kadir and Mr Pitterman contributed to revisions; and all authors approved the final manuscript as submitted.

    Abstract

    Children are increasingly exposed to armed conflict and targeted by governmental and nongovernmental combatants. Armed conflict directly and indirectly affects children’s physical, mental, and behavioral health. It can affect every organ system, and its impact can persist throughout the life course. In addition, children are disproportionately impacted by morbidity and mortality associated with armed conflict. A children’s rights–based approach provides a framework for collaboration by the American Academy of Pediatrics, child health professionals, and national and international partners to respond in the domains of clinical care, systems development, and policy formulation. The American Academy of Pediatrics and child health professionals have critical and synergistic roles to play in the global response to the impact of armed conflict on children.

  1. Abbreviations:
    AAP
    American Academy of Pediatrics
    UNCRC
    United Nations Convention on the Rights of the Child
  2. If we are to reach real peace in this world, and if we are to carry on a real war against war, we shall have to begin with the children.

    Mahatma Gandhi

    Background

    The acute and chronic effects of armed conflict on child health and well-being are among the greatest children’s rights violations of the 21st century. For the purpose of this policy statement and the associated technical report,1 armed conflict is defined as any organized dispute that involves the use of weapons, violence, or force, whether within national borders or beyond and whether involving state actors or nongovernmental entities (Table 1). Examples include international wars, civil wars, and conflicts between other kinds of groups, such as ethnic conflicts and violence associated with narcotics trafficking and gang violence involving narcotics. Civilian casualties have increased such that 90% of deaths from armed conflicts in the first decade of the 21st century were civilians,2 a significant number of whom were children.35 Children are no longer considered as simply collateral damage in many armed conflicts. Instead, they are targeted by combatants.6

    TABLE 1

    Selected Definitions

    As a result, children bear a significant burden of conflict-associated morbidity and mortality.35 The effects on the physical, mental, developmental, and behavioral health of children are profound, with all organ systems in the developing child affected as a result of direct injury. Children are also affected indirectly through deprivation and toxic stress, which can have a lasting effect on health across the life course. For example, children affected by armed conflict have an increased prevalence of posttraumatic stress disorder, depression, anxiety, and behavioral and psychosomatic complaints, which persist long after cessation of hostilities.911

    Given the global prevalence of armed conflict and its pervasive effects on children, it is critically important that child health professionals understand these effects and respond both domestically and globally.

    Effects of Armed Conflict on Children

    The effects of armed conflict on children are both direct and indirect.1 Direct effects take the form of physical injury, developmental delay, disability, mental and behavioral health sequelae, and death. Military actions, violence associated with drug trafficking, indiscriminate airstrikes, and other forms of armed conflict have the intended and unintended consequence of killing and maiming children.12 Indirect effects relate to the destruction of infrastructure required by children for their optimal survival and development, environmental exposures, and other downstream effects on social determinants of health, such as worsened living conditions and ill health of caregivers.6,1317 For example, the destruction of health infrastructure and the disruption of health systems result in breakdowns in vaccination programs, disease surveillance, and access to health and dental care.14,18 Traditionally safe spaces for children (eg, schools, hospitals, and play areas) are increasingly affected by armed groups as a result of indiscriminate crossfire, looting, or direct targeting. The results are disruptions in schooling and impaired economic growth and development.6,12,16,19 Besieged populations or those whose farms and fields have been destroyed are vulnerable to acute and chronic malnutrition, with subsequent effects on growth, immune and metabolic systems functioning, and cognitive development.20

    Many children affected by armed conflict are forcibly displaced from their homes.21 Of the 68.5 million people forcibly displaced worldwide in 2017, more than 25 million were refugees living outside of their countries of origin; over half of these refugees were children, many of whom had spent their entire childhoods as people displaced.21 The number of unaccompanied immigrant children has also reached record numbers, and this group is at a high risk for exploitation, trafficking, and psychological problems.2125

    Hundreds of thousands of children worldwide are also thought to be involved in armed conflict as combatants.26,27 Children associated with armed groups (child soldiers) are victims of severe human rights violations. They may be threatened with death, deprived of food, given drugs, or forced to take part in armed combat in other ways.26,27 They are at risk for physical and mental injury, death, sexual exploitation, rape, and sexually transmitted infections. After escaping, these children are also at risk for prolonged detention, during which they are treated as perpetrators rather than victims.12

    Recommendations for Mitigating the Effects of Armed Conflict on Children

    The American Academy of Pediatrics (AAP) and pediatric health professionals play critical and synergistic roles in responding to the impact of armed conflict on children. A children’s rights–based approach provides a framework for addressing the breadth of these effects. Armed conflicts violate multiple children’s rights, as enumerated in the United Nations Convention on the Rights of the Child (UNCRC).17 Among these violations, the United Nations has identified 6 constituting grave human rights violations that constitute a breach of international humanitarian law: (1) recruitment and use of children, (2) killing or maiming of children,28 (3) sexual violence against children, (4) attacks against schools or hospitals, (5) abduction of children, and (6) denial of humanitarian access.28

    Informed by the articles of the UNCRC and by the human rights principle of indivisibility and interdependence, it is important for child health professionals to address all rights relevant to children affected by armed conflict if optimal health and development are to be realized. Toward this end, the AAP offers the below recommendations.

    Opportunities for Clinical Practice

    Clinicians caring for immigrant children in the United States should be prepared to address the physical, mental, and behavioral health effects of armed conflict. Child health professionals working in many settings outside the United States will also need to be prepared to respond to the direct and indirect effects of armed conflict.29,30

    1. Child health professionals and staff who care for children affected by armed conflict should have access to training in trauma-informed care and to the development of trauma-informed practices.31 In trauma-informed care, child health professionals recognize the realities of children’s traumatic life experiences and respond to the effects of this trauma on children’s health, development, and well-being.32 They seek to mitigate the harmful effects of these experiences by providing multidisciplinary and age-appropriate services that reflect children’s need for physical, mental, emotional, and sexual and reproductive health care as well as providing social work and legal services. Child health professionals with a trauma-informed practice are knowledgeable regarding the effects of trauma, sensitive in their response to trauma, and function to help mitigate the effects of trauma.

    2. Child health professionals should be prepared to diagnose and provide initial management for prevalent mental health conditions among children exposed to armed conflict, such as depression, anxiety, and behavioral and psychosomatic complaints.9,10 When possible, management strategies may include partnership with mental and behavioral health providers in the community to promote collaborative networks to care for these children as well as partnerships with organizations promoting resilience and social integration.3336 Referring parents or caregivers who are affected for care can also mitigate the effect of parental stress on child health.

    3. Child health professionals should be trained to provide culturally effective care.37 As affirmed in previous policy statements, the AAP defines culturally effective pediatric care as “the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of all cultural distinctions, leading to optimal health outcomes.”38 This includes working effectively with language services and with families with limited literacy.1

    4. Child health professionals in the United States and abroad are encouraged to collaborate with local refugee resettlement organizations and other public and private sector organizations, such as schools, health systems, and social services, to facilitate the integration of children and families into their communities and to help families meet unmet needs.25,39 Multisector collaboration plays a critical role in supporting (a) children in maintaining a sense of their identity and the ability to associate with peers; (b) the integrity of families and swift family reunification; (c) protection from abuse and neglect; (d) special care and education for children with disabilities; (e) the highest standard of medical care; (f) enrollment in eligible social programs and services; (g) an adequate standard of living; (h) access to educational opportunities that meet the special needs of the child; (i) access to play and cultural activities; (j) protection from child labor, drug abuse, sexual exploitation, trafficking, and other forms of exploitation; and (k) access to rehabilitative care.

    5. Child health professionals working with refugees in camps or in conflict settings should have access to special preparation to do so. In addition to general preparation for international work40 (such as credentialing, establishing clear roles and responsibilities, and understanding conditions that are locally prevalent), clinicians working in camps or conflict settings will be more effective if they are familiar with internationally recognized standards for child protection and the care of children in humanitarian emergencies in addition to having preparation to manage physical injuries caused by armed conflict, sequelae of sexual violence, psychological trauma, and malnutrition, as appropriate within their scope of practice.4144

    Opportunities for Systems Strengthening

    Optimal health and development for children exposed to armed conflict require community, health, and social systems equipped to fulfill the protection, promotion, and participation rights of these children (Tables 2 and 3). The structure and scope of systems will vary depending on the place in which they are being implemented and the vulnerabilities of the children being served.

    TABLE 2

    Summary of Key Articles of the UNCRC in the Areas of Protection, Promotion, and Participation

    TABLE 3

    Resources (Online)

    1. Systems serving children exposed to armed conflict should provide access to physical, mental, behavioral, developmental, oral, and rehabilitation health services.17 In secure environments, such as countries where children have received asylum, pediatricians may contribute to the development of policies, protocols, and resources to implement systems of care in which the holistic needs of each child are addressed. As affirmed in previous AAP policy statements, this includes advocating for insurance coverage and mental health parity as well as close collaboration with government agencies and community organizations to ensure that newly arrived child refugees or those seeking asylum are referred to medical, behavioral, and dental health homes and receive legal representation when needed.25,39,46,49

    2. Systems should protect children from abuse and exploitation. As articulated in the UNCRC, children have special and extensive rights of protection from all forms of abuse and exploitation. As such, domestic and global systems, such as government border agencies and state departments, must protect children (displaced and nondisplaced) affected by armed violence from (a) kidnapping in secure and nonsecure zones, (b) all forms of violence (including sexual violence and child marriage), (c) inappropriate placement and adoption practices, (d) child labor, (e) drug abuse, (f) trafficking and other forms of exploitation, and (g) unjust detention or punishment.17

    3. Systems should enhance environments capable of promoting optimal health and well-being. Governments should develop systems so that all children are registered at birth, no children are stateless, and children separated from their parents or caregivers by national borders have opportunities for reunification. Governments should also prohibit separation of children from their families (except in limited circumstances, such as abuse and neglect cases), regularly review care plans for children in state custody so that these plans remain in the best interest of the child, provide special care for children with disabilities so they may lead full and independent lives, protect children from sexual violence and exploitation, provide all children with an adequate standard of living that meets their needs (particularly with regard to food, clothing, and housing), and ensure that all children may attend school.17

    4. Child health professionals should work individually and within systems to enhance the participation of children and youth in their communities. Children and youth have the right to (a) respect for their views; (b) freedom of expression of thought, conscience, and religion; (c) freedom of association; (d) respect for privacy; and (e) access to information.17 It is important to refrain from viewing children affected by armed conflict as helpless victims. Not only do they have the capacity for resilience in the face of seemingly debilitating circumstances but they are also agents for peace in their own right.17 The active participation of children should be encouraged in their care, in their communities, and in the development of programs and policies directed toward them.

    5. More research is needed to advance our understanding of the health and developmental sequelae of armed conflict as well as of the mitigating factors and evidence-based interventions to promote health and well-being. Domains for additional research include the physical, developmental, and psychosocial health effects of exposure to armed conflict on children; the contributions of social determinants to these effects; the burden of pediatric morbidity and mortality attributable to armed conflict; intervention strategies; and optimal child health metrics for humanitarian response. Pediatricians may collaborate with academic institutions, pediatric societies, governments, and international nongovernmental organizations to support this research.

    Opportunities for Public Policy Advocacy

    A precedent exists for the involvement of physicians and health organizations in the prevention of and response to armed conflict and war.5052 The AAP supports the generation and implementation of policies that advance the health, development, well-being, and rights of children affected by armed conflict and displacement.45

    1. Core human rights principles should be integrated into US policy. In addition, the AAP reaffirms its commitment to advocate for policies that conform to the principles of the UNCRC and supports US ratification.

    2. The participation of children younger than 18 years of age in armed conflict should be ended. This recommendation is consistent with both the recommendation of the 26th International Conference of the Red Cross and Red Crescent and the Optional Protocol to the UNCRC on the Involvement of Children in Armed Conflict.47,53 The United States, as a signatory of the Optional Protocol, should continue to work with international partners to eliminate the participation of children in direct hostilities.47,54

    3. All children affected by armed conflict, including children associated with armed groups and children displaced, should be protected from all forms of torture and deprivation of liberty, including extended or arbitrary detention. Former child combatants, including children conscripted as gang members, are among the victims of armed conflict and should be treated as such. It is imperative to recognize the physical, mental, and behavioral health effects of their experiences and to prevent their further traumatization in detention centers and extrajudicial proceedings.55,56

    4. Governments and nongovernmental entities have an obligation to uphold the Geneva Conventions with respect to maintaining the sanctity of safe places for children and ensuring medical and educational neutrality. Civilian homes, schools, playgrounds, and health facilities must be safe places for children to live, learn, and receive medical care. Child health professionals are also charged to uphold human rights norms, such as nondiscrimination, in these safe places.54

    5. Special protection and humanitarian assistance should be afforded to child refugees and children displaced. Children fleeing armed conflict should be allowed to petition for asylum and should be screened for evidence of human trafficking.46,57 Governments should prevent statelessness and family separation by ensuring rights to a name, nationality, and identity by registering all children. Doing so overcomes the barriers to accessing education, health care, and employment, which result from statelessness.58

    6. Children should not be separated from their families during displacement and resettlement. An intact family is the optimal environment for children’s health and well-being. In the event of separation, family reunification should be prioritized.

    7. Children should be protected from landmines, unexploded ordnances, small arms, and light weapons through clearing efforts and strict control on their sale, ownership, and safe storage. Environmental hazards, such as unexploded ordnances and landmines, injure and kill children long after conflicts have ended.59,60 The availability and durability of small arms facilitates the use of children by armed groups, heightens levels of violence, and results in greater levels of violence postconflict.61

    8. Children should be afforded a voice in creating policy and programs that prevent and mitigate harmful effects of armed conflict. Children affected by armed conflict are often from minority groups whose history, language, or culture has been suppressed. They have a right to be heard, to have their opinions considered in decisions affecting them, to access nonbiased information, to associate with peers, and to have freedom of expression, association, and culture. These rights should be implicitly and explicitly integrated into the principles and into the implementation and evaluation strategies of all policies.

    9. Children affected by armed conflict should have access to educational opportunities as part of an environment conducive to their reintegration into society. There is strong evidence to suggest that education for boys and girls at all levels reduces most forms of political violence.62 However, education currently receives less than 2% of all humanitarian funding, and girls are more likely than boys to be excluded from education.48 Because education is a priority for many children63 and essential for their well-being, child health providers may advocate for their educational rights and access, especially during humanitarian emergencies.

    Lead Authors

    Sherry Shenoda, MD, FAAP

    Ayesha Kadir, MD, MSc, FAAP

    Shelly Pitterman, PhD

    Jeffrey Goldhagen, MD, MPH, FAAP

    Section on International Child Health Executive Committee, 2017–2018

    Parminder S. Suchdev, MD, MPH, FAAP, Chairperson

    Kevin J. Chan, MD, MPH, FAAP

    Cynthia R. Howard, MD, MPH, FAAP

    Patrick McGann, MD, FAAP

    Nicole E. St Clair, MD, FAAP

    Katherine Yun, MD, MHS, FAAP

    Linda D. Arnold, MD, FAAP, Immediate Past Chairperson

    Staff

    Vayram Nyadroh

    Footnotes

    • Address correspondence to Sherry Shenoda, MD, FAAP. E-mail: sshenoda{at}thechildrensclinic.org.
    • Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

    • The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    • All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

    • This policy statement does not reflect the views of UNHCR.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    • COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-2586.

    References