Children of War and Opportunities for Peace

Abused and tortured, while required to wound and kill—such is the daily world of nearly a quarter of a million child soldiers. More than 2 million children have been killed in war in the last decade and 6 million have been permanently disabled or injured.¹ One and a half million individuals are displaced due to war and conflict in Uganda alone.² It is estimated that more than 30 armed conflicts are occurring around the globe at present involving more than 25 countries¹ and in 30 situations the rights of children are being gravely violated.³ Conflicts in Iraq and Afghanistan are the most familiar to people in the United States. Other conflicts are equally as deadly and are building legacies that will require decades or centuries from which to recover, a timeline that goes beyond individual goals and only exists in the collective human desires to change the world for the better.

Medical care and medical professionals are often the leaders of the caring and humanitarian effort.⁴ The studies in this issue of JAMA by Bayer et al,⁵ Vinck et al,⁶ and Bolton et al² on war-affected populations in Uganda reflect this effort to bring medical knowledge to the disaster of war, importantly both to care for its survivors and to identify opportunities for peace building.

The war in Uganda has raged between the Lord's Resistance Army (LRA) and the government since the 1980s. The LRA initially represented the oppressed Acholi minority but over the years has become an army of kidnapped children led by a messianic rebel leader without clear political goals and has been responsible for terrorizing the country with brutal acts of violence, mutilations, and the abduction of children. The military use of children has a long history: David's service to King Saul, French drummer boys in Napoleon's army, young boys who served as “powder monkeys” on the ships of the Royal Navy and flag bearers in the American Revolution, Hitlerjugend (Hitler Youth) in Nazi Germany who were formed into combat units for the defense of Berlin, and, more recently, suicide bombers.

Children are especially vulnerable to recruitment because of their emotional and physical immaturity. Many are refugees displaced from home, separated from families, orphaned, and with little means of support or access to education or employment. Some join armed militias to have security and access to food and shelter. The militias become a source of security, a surrogate family, and guarantor of meals, clothing, and shelter, or a chance to express rage and sense of oppression. Once recruited—or abducted—these children often serve as porters, cooks, couriers, spotters, and spies as well as human shields, sexual entertainment, and war fighters.^{7 - 8}

Bayer et al⁵ conducted a survey of 169 former child soldiers from Uganda and the Democratic Republic of the Congo living in rehabilitation centers; most had been forcibly recruited by the LRA. These former child soldiers were a mean age of 12 years at the time of this survey and had served for an average of 3 years. Bayer et al documented high rates of exposure to war-related trauma, such as threats of being killed or injured (70.4%), killing others (54.4%), and forced sexual contact (34.9%). Not surprisingly, the prevalence of posttraumatic stress disorder (PTSD) symptoms was high (34.9%) among these former child soldiers. The absence of an association with trauma exposure, a well-documented aspect of the disorder,⁹ could well be the result of a ceiling effect of the high rate of trauma exposure in this group.

In a well-designed population-based study of 2585 displaced adults in northern Uganda, Vinck et al⁶ found that patterns of trauma exposure, which generally also related to the amount of trauma exposure, were associated with increasing risk for both PTSD and depression symptoms.

Bolton et al² conducted a study of 667 adolescents in war-affected northern Uganda using a rigorous randomized controlled trial design to test culturally sensitive group interpersonal psychotherapy compared with a creative play intervention and wait list control for locally defined syndromes with depressive symptoms. The study found that group interpersonal psychotherapy was an effective intervention for these depression-related syndromes, particularly for female adolescents.

The most novel aspects of these studies are their implications for peace making. Bayer et al⁵ found that the more PTSD symptoms that children experienced, the less likely they were willing to reconcile and the more they harbored feelings of revenge toward those who harmed them. Whether this was due to the trauma exposure or the disorder is less clear, but in either case, the association indicates the complexity of building a safe and peaceful nation and region. Whether treatment of PTSD alters the willingness to reconcile (which may be more related to safety and the distance needed to keep oneself safe) or feelings of revenge (a part of repairing one's own trauma and reestablishing a just world) has yet to be determined. Longitudinal and intervention studies will be needed to address this important aspect of nation building and restoring.

Even more directly, Vinck et al⁶ also examined 4 types of trauma exposure (ie, experiencing low levels of trauma; witnessing trauma; being threatened and physically injured; and being abducted) and their association with violent and nonviolent means to achieve peace and 3 definitions of peace (end of violence, unity, and socioeconomic development). Differences by regions, which are markers for ethnicity and cultural differences, were found across many of the outcomes. However, importantly, Vinck et al also found that those with PTSD symptoms were more likely to see violence as the means to achieve peace and to define peace as the end of violence, as did those with greater education. In contrast, nonviolence as a means to achieve peace was less likely to be reported by those with depression and more likely to be reported by those with at least a primary education. Only older age was associated with defining peace as socioeconomic development. Because a stepwise multiple regression approach was used by Vinck et al, a number of competing hypotheses to explain these results cannot be ruled out. However, the results of this study indicate the importance of understanding war-affected survivors' varying attitudes toward peace and the possible means to achieve peace. The study also highlights interventions that might affect peacemaking and nation building (eg, treatment of PTSD and depression and education programs).

No one endures war-related traumatic events unchanged. Little is known about the changes in values and hopes and views of the future that exposure to such trauma engenders. Children who are still learning to regulate mood and aggression are certainly even more vulnerable to these life-changing forces.¹⁰ The researchers reporting the results of their studies in this issue bring much-needed attention to the violence of war and the resulting mental health problems. Deeper appreciation of the effects of exposure to war-related trauma as well as improved understanding of individuals' attitudes toward reconciliation and the means to achieve peace may contribute to development of interventions to address the barriers to recovery not only from disease and illness but from lost futures and visions of life.