TECHNICAL REPORT

Ayesha Kadir, MD, MSc, FAAP,a​ Sherry Shenoda, MD, FAAP,​b Jeffrey Goldhagen, MD, MPH, FAAP,​b ShellyThe Pitterman, Effects PhD,​c SECTION ON INTERNATIONALof Armed CHILD HEALTH Conflict on Children More than 1 in 10 children worldwide are affected by armed conflict. The abstract effects are both direct and indirect and are associated with immediate and long-term harm. The direct effects of conflict include death, physical and psychological trauma, and displacement. Indirect effects are related to a large number of factors, including inadequate and unsafe living conditions, aCentre for Social Paediatrics, Herlev Hospital, Herlev, Denmark; environmental hazards, caregiver mental health, separation from family, bDivision of Community and Societal Pediatrics, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida; and cUnited displacement-related health risks, and the destruction of health, public Nations High Commissioner for Refugees Regional Representative for the United States and the Caribbean, Washington, District of Columbia health, education, and economic infrastructure. Children and health workers Dr Kadir identified the need to write this Technical Report, conducted are targeted by combatants during attacks, and children are recruited or the literature review to support it, and wrote the first draft; Dr forced to take part in combat in a variety of ways. Armed conflict is both Shenoda identified the need to write this Technical Report, conducted the literature review to support it, and contributed to revisions; a toxic stress and a significant social determinant of child health. In this Dr Goldhagen contributed to revisions; Mr Pitterman contributed Technical Report, we review the available knowledge on the effects of armed to revisions and the figure; and all authors approved the final manuscript as submitted. conflict on children and support the recommendations in the accompanying This document is copyrighted and is property of the American Policy Statement on children and armed conflict. Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. INTRODUCTION The guidance in this report 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. 1 More than 1 in 10 children worldwide are affected by armed conflict.‍ All Technical Reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, Combat activities and population displacement caused by conflict have revised, or retired at or before that time. direct effects on child mortality and morbidity.‍ In addition, there are Technical Reports from the American Academy of Pediatrics benefit long-lasting indirect effects that are mediated by complex political, social, from expertise and resources of liaisons and internal (AAP) and economic, and environmental changes.‍ In 2015, there were 223 violent external reviewers. However, Technical Reports from the American 2 Academy of Pediatrics may not reflect the views of the liaisons or the conflicts, of which 43 were limited- or full-scale wars.‍ organizations or government agencies that they represent.

This Technical Report does not reflect the views of United Nations High The nature of war has changed.‍ Combat zones are increasingly3,4​ Commissioner for Refugees. widespread, weapons cause destruction on a larger scale,​ ‍ conflicts are 5 DOI: https://​doi.​org/​10.​1542/​peds.​2018-​2586 more protracted (waxing and waning over lengthier periods of time),​ and the availability and use of small arms facilitates the use of children 6 ’ as combatants.‍ These changes have led to geographically widespread, To cite: Kadir A, Shenoda S, Goldhagen J, et al. The Effects complex, and nuanced effects on children s physical, developmental, and of Armed Conflict on Children. Pediatrics. 2018;142(6): mental health and wellbeing.‍ Furthermore, the effects of armed conflict e20182586 continue long after hostilities have ceased.‍ Unexploded ordnances, such as landmines and cluster bombs, result in injuries and death for Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 6, December 2018:e20182586 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Timeline of International Agreements and Treaties Protecting Children and Medical 7 Personnel From Armed Conflict decades after combat has ended.‍ Year Agreements and Treaties Similarly, the adverse effects of 1948 Universal Declaration of Human Rights population displacement, the 1949 The Geneva Conventions I–IV: The Geneva Conventions comprise 4 treaties and 3 protocols destruction of health systems and that regulate the conduct of armed conflict. Together, they form the basis of international social infrastructure, environmental humanitarian law. Aspects of the conventions of particular relevance to child health ’ damage, and economic sanctions include the protection of the wounded and the sick, health and public health personnel, and may compromise children s access to humanitarian aid; the protected status of health facilities; the free passage of essential food, clothing, and medical supplies to the civilian population; and the protection of children who basic necessities, such as food, health are orphaned or separated.12 care, and education, for decades.‍ 1951 The UN Convention Relating to the Status of Refugees: The UN Convention Relating to the As a result, even short-lived armed Status of Refugees (1951) and the Protocol Relating to the Status of Refugees (1967), known conflicts affect child health and collectively as the Refugee Convention, are the foundation for the protection of refugees in wellbeing across the life course and international law. The convention defines the term refugee and establishes specific rights of refugees and the obligations of states for the provision and protection of these rights. through adulthood.‍ Because people who are internally displaced have not crossed an international border, The rules of war have also they do not fall under the protection of the Refugee Convention. However, people who are internally displaced retain all their rights and protection afforded under human rights and changed.‍ Schools, which have international humanitarian law.16,‍17​ been traditionally safe places, are 1959 UN Declaration of the Rights of the Child targeted, and children are often 1967 UN Protocol Relating to the Status of Refugees 1977 Protocols I and II of the Geneva Conventions attacked while 8,on9​ their way to or from school.‍ ‍ In many armed 1989 UNCRC: After the adoption of the Universal Declaration of Human Rights in 1948 and in recognition of the special need for protection of children, the UN adopted the Declaration conflicts, schools and educational of the Rights of the Child (1959). The declaration forms the basis for the UNCRC (1989), facilities are used by combatant which is a legally binding treaty in which 40 substantive rights of children are established. forces, including government forces, Particular attention is given to children who are affected by armed conflict, setting out a basic minimum standard for their care and the promotion of their health and wellbeing. as bases for8,9​ combat and to recruit children.‍ ‍ The result is reduced This includes the right to protection from violence and sexual exploitation; the right to freedom of thought and education, health services, and welfare services; and specific rights school enrollment, high dropout of children who are refugees, separated, and unaccompanied.14,‍15​ In 2000, the Optional rates, lower educational attainment, Protocol on the Involvement of Children in Armed Conflict was adopted and aimed at 18,​ poor schooling conditions,9,10​ and the preventing children <18 years old from being recruited for or taking part in hostilities. exploitation of children.‍ ‍ Similarly, ‍19 The United States ratified the optional protocol in 2002 but remains the only country that attacks on both government and has not ratified the UNCRC. 2000 Optional Protocol to the UNCRC on the Involvement of Children in Armed Conflict nongovernmental health facilities and mobile11 clinics are increasingly prevalent.‍ These attacks12 violate the Geneva Conventions and result in the death of patients and health violence associated with narcotics conflict and the targeting of health workers, the destruction of health trafficking and narco-gang violence.‍ workers and facilities by combatants 11 ’ infrastructure,​ and increasing HISTORICAL AND LEGAL CONTEXT are human rights violations.‍ Of barriers to care because of people s particular relevance is the UNCRC, a legally binding treaty in which fear of being injured11 or killed while seeking treatment.‍ 40 substantive rights for children Several legal declarations and are outlined and grouped into 3 DEFINITION OF ARMED CONFLICT treaties protect the health of children categories: protection, promotion, and health workers and preserve and participation (Table 2).‍ Specific access to health care during armed child rights include protection from For the purpose of this Technical conflict.‍ The most important of these violence and sexual exploitation, Report and13 the associated Policy include the Geneva Conventions freedom of thought, education, Statement,​ armed conflict is (1949), the United Nations (UN) health services, welfare services, defined as any organized dispute Refugee Convention (1951) and and specific rights of children that involves the use of weapons, 1967 Protocol, and the United who are refugees,14, separated,15​ and violence, or force, whether within Nations Convention on the Rights unaccompanied.‍ ‍ The United national borders or beyond them, of the Child (UNCRC) (1989) with States remains the only country that and whether involving state actors or its accompanying Optional Protocol has not ratified the UNCRC.‍ nongovernment entities.‍ Examples on the Involvement of Children in include international wars, civil wars, Armed Conflict (2000; Table 1).‍ To strengthen the legal protection and conflicts between other kinds of According to international law, the of children during armed conflict, groups, such as ethnic conflicts and involvement of children in armed the Optional Protocol to the UNCRC Downloaded from www.aappublications.org/news by guest on September 29, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 2 Summary of Key Articles of the UNCRC in the Areas of Protection, Promotion, and Participation Articles Rights morbidity and mortality under Rights of Protection: Keeping Safe From Harm 23 typical circumstances.‍ As a result, 6 Right to life 9 Right not to be separated from parents most published estimates of the 19 Right to be protected from all forms of abuse population health effects of armed 20 Right to special attention (eg, adoption and fostering if deprived of family) conflict are based on media reports 32 Right to be protected from economic exploitation and official pronouncements from 33 Right to be protected from illicit drugs governments and combating parties, 34 Right to be protected from all forms of sexual exploitation Rights of Promotion: Life, Survival, and Development to Full Potential which may politicize or intentionally23,37​ 24 Right to the highest standard of health care misrepresent information.‍ ‍ 27 Right to a standard of living adequate for a child’s physical, mental, spiritual, moral, and Deaths are also difficult to verify, social development and this may lead to underestimation.‍ Rights of Participation: Having an Active Voice For example, in a report by the 7, 8 Right to an identity (name, family, and nationality) 12, 13 Right to express views freely and be listened to UN special rapporteur on children 17 Right to have access to information and armed conflict, it was estimated 23 Right for children who are disabled to enjoy life and participate actively in society that thousands of children had38 died in the Syrian conflict in 2015.‍ However, only 591 child deaths were verified by the UN, which was adopted by the UN to prevent actions that cause harm to children accounts for barely 0.‍01% of the children younger than 18 years and directly relate to health care and 50000 deaths that other analysts old from being recruited into or health workers.‍ The commission of had estimated to2, have34​ occurred participating18 as combatants in any of these violations constitutes a during that year.‍ ‍ Other problems hostilities.‍ In the optional protocol, breach22 of international humanitarian in estimating the child health impact 16 years old is established as the law.‍ of armed conflict include the near absolute minimum age for voluntary GLOBAL BURDEN OF ARMED CONFLICT absence of population-level data recruitment, and signatories are ON CHILD HEALTH on morbidity and the tendency required to take all feasible measures to aggregate child and adult data.‍ to ensure that 16- and 17-year-old As a result, there are no pooled members of the armed forces do not estimates for the total number of Armed conflict is a public health take part in hostilities.‍ The optional 23 children killed, injured, orphaned, issue.‍ An estimated –246 million protocol was ratified by the US handicapped, and/or psychologically 20 children live in areas affected Senate in 2002.‍ The United States 1,24​ 26 traumatized by exposure to armed by conflict (Fig 1).‍ ‍ ‍ Forced has also passed a law stipulating that conflicts.‍ displacement is at a record high: 16-year-old children may not enlist more than 68.‍5 million people, and specifying that the voluntary Given the challenges described, it including 28 million children, enlistment of 17-year-old children is not surprising that there are few are currently living as refugees, requires the21 consent of a parent or prevalence studies on the indirect asylum seekers, stateless people,– guardian.‍ Furthermore, as of 2007, causes of mortality or morbidity or internally displaced people US policy has been that 17-year- ’ 27 31 among children affected by armed (see Table 3 for definitions).‍ ‍ ‍ olds may not be deployed to combat conflict.‍ Most of the literature is in Of the world s 25 million refugees, zones.‍ the form of case reports in which half are children: nearly 1 in 27,30​ researchers describe the type and 200 children across the globe.‍ ‍ The UN has identified 6 categories ’ distribution of injuries treated or The authors of the 2005 State of of human rights violations against “ ” smaller studies on communicable the World s Children report, children, known as the 6 grave disease transmission, perinatal Childhood Under Threat,​ violations.‍ These violations include health, nutrition, or environmental suggested that 90% of conflict- the killing and maiming of children, contamination.‍ Nonetheless, it is related deaths from 1990 to 2005 the abduction of children, the clear that the conditions created by were civilians, many of whom were recruitment or use of children as 32 armed conflict (social determinants children.‍ soldiers, sexual violence against of health, such as population children, attacks against schools However, the precise effect of – displacement, the destruction of or hospitals, and the denial22 of any given armed conflict on child34 36 infrastructure, and the deterioration humanitarian access.‍ The first 4 health is difficult to determine.‍ ‍ ‍ of heath and public health systems) are direct acts of violence against Conflicts disrupt the health significantly increase childhood children, and the last 2 are indirect information systems that report mortality and morbidity.‍ Although Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 6, December 2018 3 FIGURE 1 Children living in countries affected by armed conflict. Percentage of the overall population <18 years of age in countries affected by armed conflict, which is defined as any organized dispute that involves the use of weapons, violence, or force, whether within national borders or beyond them, and whether involving state actors or nongovernment entities.The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations. Source: United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision. Source: Melander, Erik, Therése Pettersson, and Lotta Themnér (2016) Organized violence, 1989–2015. Journal of Peace Research 53(5):727–742.

EFFECT OF ARMED CONFLICT ON CHILDREN’S PHYSICAL HEALTH there are no studies in which rates in infants and children younger researchers examine changes in the than 5 years old are also higher Direct Effects of Combat on Child hypothalamic-pituitary-adrenal in areas affected by conflict when Health axis after exposure to armed compared –with prewar data or data conflict, it can be argued that the from peaceful43 45 areas of the same severity and chronicity of the country.‍ ‍ The kinds of injuries children sustain stresses that children endure39 rise from armed conflict vary depending to the level of toxic stress with its Health facilities and health workers on the nature of combat, with all well-documented impact on physical are increasingly becoming casualties age groups being affected.‍ In Iraq and mental health across the life of armed conflict, including targeted and Afghanistan, the most common course.‍ attacks.‍ Reports from Syria,– Yemen, forms of war trauma in children50 Afghanistan, Nigeria, and 46Pakistan48 are blast and bullet injuries.‍ Blast Data on neonatal and infant health offer just a few examples.‍ ‍ ‍ In injuries are caused by explosions and can provide insight into how the 2014, 603 health workers were result in shockwave and shearing ’ conditions created by armed conflict killed and an additional 958 were 49 injuries, penetrating trauma, burns, indirectly affect children s health.‍ In injured in attacks in 32 countries.‍ crush injuries, and contamination conflict zones, there are higher rates The trend has become so common injuries from 51the explosive device or of stillbirth, low birth weight, preterm that the World Health Organization environment.‍ Children suffering birth, and perinatal mortality– than has developed a monitoring system from blast injuries usually present during peacetime or 40in 42peaceful areas to track49 these attacks and their with multiple injury sites and types.‍ of the same country.‍ ‍‍ Mortality effects.‍ Burns and severe head and neck Downloaded from www.aappublications.org/news by guest on September 29, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 3 Selected Definitions Definition STIs, although they are less likely Armed conflict Any organized dispute that involves the use of weapons, violence, or than girls to report these violations force, whether within national borders or beyond them, and whether 64 involving state actors or nongovernment entities because of stigma.‍ Those who Asylum seeker A person who seeks safety from persecution or serious harm in a survive their experiences suffer country other than his or her own and awaits a decision on the from psychological trauma and often application for refugee status under relevant international and face stigma and exclusion when 65 national instruments; in case of a negative decision, the person must they return to their communities.‍ leave the country and may be expelled, as may any nonnational in an irregular or unlawful situation, unless permission to stay is provided Children born of rape during armed on humanitarian or other related grounds31 conflicts are a population that Internally displaced people People or groups of people who have been forced or obliged to flee or requires special attention.‍ Girls who to leave their homes or places of habitual residence, in particular become pregnant as a result of rape as a result of or to avoid the effects of armed conflict, situations may have ambivalent feelings toward of generalized violence, violations of human rights, or natural or human-made disasters and who have not crossed an internationally their children, and the children 31 recognized state border may not be accepted63 into their Refugee A person who “owing to well-founded fear of persecution for reasons of communities.‍ race, religion, nationality, membership of a particular social group, Environmental Hazards or political opinions is outside the country of his [or her] nationality and is unable or, owing to such fear, is unwilling to avail himself [or herself] of the protection of that country”31‍ Social determinants of The circumstances in which people are born, grow up, live, work, Armed conflict creates environmental health and age and the systems put in place to deal with illness. These hazards that continue to affect circumstances are in turn shaped by a wider set of forces: economics, children long after hostilities have social policies, and politics.33 Stateless person A person who is not considered as a national by any state under the ended.‍ Landmines and unexploded operation of its law. As such, a stateless person lacks those rights ordnances pose a major risk7 for death attributable to nationality: the diplomatic protection of a state, no and disability for decades.‍ Studies inherent right of sojourn in the state of residence, and no right of from Afghanistan, Eritrea, Laos, 31 return in case he or she travels. and Nepal revealed that children accounted for approximately– half

of all injuries caused66 70 by explosive remnants of war.‍ ‍ ‍ Children are injuries, and particularly52 penetrating against civilian populations have most likely to sustain injuries to head trauma,​ are the53 most common been issued60 as recently as May the upper67,71,​ 72​extremities, face, and and the most lethal.‍ This pattern 2018.‍ Children are thought to be at torso.‍ ‍ ‍ These injury patterns are differs from blast injury in adults, higher risk of toxicity from chemical seen because children are most often who more often53 suffer injuries to the weapons because of their smaller injured while playing, tampering with extremities.‍ The high prevalence mass, higher respiratory rate and an explosive– device, or performing of penetrating trauma sustained minute volume, smaller airway economic66 activities,68,73,​ 74​ such as herding by children in combat zones also diameter, lower fluid reserve, lower livestock.‍ ‍ ‍ ‍ ‍ Chemical weapons differs markedly from pediatric seizure threshold, and more limited and other chemical contaminants trauma in the United States, where cardiovascular stress response61 when can also have long-term effects.‍ blunt trauma is more common and54 compared with adults.‍ A recent systematic review and meta- mortality is significantly lower.‍ analysis of the association between Pediatric trauma patients in combat Estimates suggest that the prevalence Agent Orange and birth defects in zones have high mortality rates, of rape and sexual exploitation Vietnam revealed that children born which are likely attributable to both of children 62in armed conflict is to individuals who had been exposed the severity of the injuries sustained increasing.‍ In addition to the to Agent Orange were nearly twice as well as barriers in accessing54 psychological trauma of sexual as likely to have birth defects than adequate and timely care.‍ violence during armed conflict, girls children of individuals75 who were who suffer rape are less likely than unexposed.‍ The destruction of Chemical warfare has been – adults to seek medical attention and buildings, water supplies, wastewater documented in numerous conflicts55 58 are at increased risk for sexually systems, factories, fuel stations, and dating back to Word War I.‍ ‍‍ transmitted infections (STIs), farms has been shown to limit access Despite international law banning pregnancy, obstetric or gynecologic to potable water and sanitation the development, stockpiling,59 and complications (eg, vesicovaginal 63,64​ and release infectious and chemical use of chemical weapons,​ reports of fistulas), and subsequent infertility.‍ ‍ contaminants76 into the air, water, and the continued use of these weapons Boys also experience rape and soil.‍ The long-term effects of these Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 6, December 2018 5 hazards on child health have not been in the89, Syrian90​ Arab Republic in services when compared with local Damagewell studied to Health.‍ and Public Health 2013.‍ Similarly, there is a clear populations –even in countries with Infrastructure and the Targeting of relationship between violent conflict longstanding98 100 refugee resettlement Health Facilities and the incidence of HIV and/or89 programs.‍ ‍ ‍ In addition, children AIDS, tuberculosis, and malaria.‍ who are forcibly displaced often lack Countries experiencing high levels access to other basic needs, such

The destruction of health care and of armed conflict or political terror as food, potable water, adequate9 public health systems is a major are also vulnerable to other diseases sanitation, and education.‍ Crowding of cause of morbidity and mortality in associated with crowding, population people who are displaced in camps children affected by armed conflict.‍ displacement, and lack of access to and urban areas has been associated Children, especially those younger health care, such as the neglected82 with outbreaks of cholera84, and101​ other than 5 years– old, bear the highest tropical disease leishmaniasis.‍ communicable diseases.‍ Indeed, there is a direct dose- Disruptions in immunization burden77 of79 indirect conflict-related death.‍ ‍‍ Lower respiratory response relationship between the programs and a simultaneous tract infections, diarrhea, measles, intensity of violent conflict and the worsening of sanitary and living malaria, and malnutrition are among incidence of cutaneous82 and visceral conditions are associated with leishmaniasis.‍ outbreaks of vaccine-preventable the leading causes of mortality in 9,80​ children in conflict-affected areas.‍ diseases, such as measles, meningitis, Food may be used as a weapon of 84 and pertussis.‍ Children who The deterioration of health war, and the effect of food insecurity are displaced are at high risk for systems during armed conflict is on child health is exacerbated by trafficking, violence, and exploitation, characterized by the destruction of the destruction of health and public including sexual violence, labor, physical infrastructure, disruptions health programs used to target detention by government authorities, in supply chains, and the diversion malnutrition.‍ Attacks on crops and – xenophobic attacks from the of state funds from health to the livestock, food stores and shops, and 9,81​ 84 general public, bullying in schools, military.‍ ‍ ‍ Health workers and transport links compromise the food – 30 and domestic violence.‍ Half of health care facilities are increasingly supply during periods of conflict, and primary school aged children who targeted by combatants, resulting infrastructure and agriculture may are refugees and 75% of adolescent in the killing and flight of the require years to recover after the 102 85 9,77,​ 91​ refugees are out of school.‍ health workforce.‍ In some recent cessation of hostilities.‍ ‍ ‍ Children instances, military operations have in conflict and humanitarian EFFECT OF ARMED CONFLICT ON CHILDREN S MENTAL AND been conducted under the guise settings have high levels of moderate ’ PSYCHOSOCIAL HEALTH of public health services, thus and severe acute– malnutrition, undermining local trust in health anemia, and 77,other92​ 94 nutritional workers and placing86 health teams deficiencies.‍ ‍ ‍ For example, a at risk for attack.‍ Families may report on South Sudanese refugee Exposure to armed conflict has social be increasingly reluctant to seek children living in camps in Ethiopia and psychological repercussions that endure long after the termination medical care at both formal87 and described global acute malnutrition 103 informal health facilities,​ fearing rates of 25% to 30% in children of hostilities.‍ As with physical health, postconflict mental health that children in the facilities81,83​ will 6 months to 5 years of age with a is dependent on multiple factors, be targeted by attacks.‍ Sieges, severe acute malnutrition93 prevalence snipers, and active fighting may also Forcedof 5.‍7% Displacementto 10%.‍ including mental health status before prevent families from traveling to the conflict, the nature of the conflict, health facilities.‍ exposure to stressors, and the 104 cultural and community context.‍ The conditions created by armed Displacement, whether within the conflict compromise key public borders of the country or across Children who are affected by war health functions, including vaccine international boundaries, carries have an increased prevalence of delivery, health surveillance, and82, 88​ with it specific health risks and needs posttraumatic stress disorder disease outbreak investigation,​ ‍ that are influenced by conditions– (PTSD), depression, anxiety, and resulting in increased rates of 89 before the journey, during95 travel,97 behavioral and104 psychosomatic infectious disease transmission.‍ and in the place of arrival.‍ ‍ ‍ Low- complaints.‍ Pooled estimates from

Previously eradicated, vaccine- income regions27 host 85% of refugees a systematic review of nearly 8000 preventable diseases may reemerge worldwide.‍ Children who are children who were exposed to war in conflict-affected areas, as forcibly displaced have more limited revealed that the prevalence of PTSD evidenced by an outbreak of polio access to health care and basic is 47%, that of depression is 43%, Downloaded from www.aappublications.org/news by guest on September 29, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS and that of anxiety is 27%, although children who are refugees in high- to 40% of children116 associated with rates are lower among children105 income countries include parental armed groups but three-quarters115 with more remote exposures.‍ support and family cohesion, self- of child suicide bombers.‍ Young children ages 0 to 6 years reported support from friends, self- – exhibit increased anxiety, fear, reported positive school experience,110 Children who were associated with startling, attention seeking, temper and same ethnic origin foster care.‍ armed groups experience particular tantrums, sadness, and crying as In LMICs, children who are displaced physical, developmental, and mental well as difficulty sleeping106 alone and benefit from repatriation to their health risks; barriers in access to frequent awakenings.‍ They are countries109 of origin once it is safe to health services; and significant more likely to suffer psychosomatic do so.‍ obstacles to social reintegration.‍ In symptoms, such as stomach aches SPECIAL GROUPS addition to physical injury and death, and irregular bowel movements, they are at high risk for HIV and other Children Associated With Armed and they demonstrate alterations STIs, obstetric complications,64 and in their play, which can become Groups substance abuse.‍ Social isolation, either more106 aggressive or more loss of identity, and being forced to withdrawn.‍ Parental mental act in strictly defined gendered roles health has an important influence Children are recruited or forced to negatively affect mental health and on the mental health of children participate in armed conflict in many can result in a disconnect between affected by conflict,106 particularly in different ways, including as soldiers, these children and their families and young children.‍ Adolescents with cooks, domestic workers, porters, communities114 on return to civilian cumulative exposure to war events human shields, mine sweepers,19,32,​ 62,​ 112,​gang113​ life.‍ Abduction, younger age of and those with PTSD resulting from members, and sex slaves.‍ ‍ ‍ ‍ conscription, exposure to violence, war events have also been found The number of children associated female sex, and community stigma have significantly107 higher rates of with armed forces and armed are associated with PTSD,113 depression, substance abuse.‍ groups worldwide is unknown but is anxiety, and hostility.‍ Those thought to run into the hundreds of who have lost parents and/or were The mental health impact of 113 thousands,​ suggesting a pervasive involved in raping, injuring, or killing displacement appears to vary violation of the UNCRC optional have worse mental health outcomes depending on where children are 62 protocol on the involvement of than those who have not.‍ Children resettled.‍ Factors that negatively 18 children in armed conflict.‍ Children associated with armed groups display affect mental health and social are recruited into armed conflict gendered differences in mental health wellbeing among children who are because they are easier to condition outcomes, with girls being more displaced in low- and middle-income and control in part because their likely to have anxiety, depression, countries (LMICs) include exposure to 112 108 cognitive and social development is and feelings of hostility than boys.‍ mass trauma and family violence,​ 32 109 not yet complete.‍ The description Protective factors for psychosocial displacement,​ social isolation, ’ given by children released from the adjustment include perceptions loss of social status, and perceived 104,109​ Lord s Resistance Army in Uganda of respect, understanding, and discrimination.‍ ‍ Among children and the Democratic Republic of acceptance from family members; who are resettled in high-income the Congo provides insight into social support; and educational countries, risk factors for negative 113,117​ the harrowing process of turning a and economic opportunities.‍ ‍ mental health outcomes include child into a soldier: newly abducted Despite growing knowledge about exposure to postmigration violence, children are placed in strictly their health risks and needs, children multiple changes of residence in controlled environments, socially who were associated with armed host countries, parental exposure isolated, forced to deidentify with groups continue to face social stigma to violence, poor financial support, their families and communities, and and have limited access to treatment having a single parent, and having a 114 32,64,​ 113​ 110 made to develop new identities.‍ and rehabilitative care.‍ ‍ parent with a psychiatric disorder.‍ To force the acquisition of these Furthermore, states are increasingly Learning problems in these children new identities, children may arresting and detaining children who have been associated with traumatic be required to kill members of are perceived to be associated or experiences, detention, barriers in 19,32​ their own families.‍ ‍ A more potentially associated with armed communication, low expectations 118 recent phenomenon is the use of groups,​ and these children are from teachers, bullying, and 111 children as young as 8 years old to often held in conditions that violate discrimination.‍ 115 conduct suicide bombings.‍ This their rights as articulated in the

Protective influences on the mental phenomenon has a disproportionate UNCRC and do not meet international118 health and social wellbeing of impact on girls, who constitute up standards for juvenile justice.‍ Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 6, December 2018 7 Children Who Are Unaccompanied and Separated armed conflict may also face health professional interpreters improves137 and social risks related to the the quality of translations,​ conflict.‍ News and media coverage reduces unnecessary diagnostic Armed conflict separates children 138 of war and extreme violence events investigations and treatments,​ from their families, as evidenced by have been shown to increase reduces the cost of care, and the increasing numbers of children 139,140​ PTSD symptoms among US school increases patient satisfaction.‍ ‍ fleeing conflict between both state 129 children.‍ Children of deployed The use of informal or untrained and nonstate actors without parents US military personnel have higher interpreters has been found to be or guardians.‍ The number of children 139 rates of emotional and behavioral detrimental to care.‍ who are unaccompanied and 130,131​ problems and substance abuse ‍ separated who applied for asylum Disaster training courses are and are at a higher risk for worldwide nearly tripled in 2015 available for clinicians in the United 27 physical abuse and neglect both to a staggering 98400 children.‍ – States.‍ These courses can be useful during and after parental return These children often do not possess 131 133 for providers who work in conflict from deployment.‍ ‍ official documents, making it settings as well as for general INTERVENTIONS TO PREVENT AND challenging for authorities to identify MITIGATE THE EFFECTS OF ARMED pediatricians who are involved in their age, risks,119 needs, and rights to CONFLICT ON CHILDREN the care of children who are refugees protection.‍ Health workers may and children who141, 142​are remote from be asked to assess their age, but a armed conflict.‍ ‍ Such courses lack of reliable methods and the use can assist providers in understanding Many interventions have been of arbitrary practices place these the context-specific health needs of undertaken by individuals, groups, children at risk for inappropriate children, the management of chronic 120 and societies to protect children and treatment by authorities.‍ When conditions, and the care of children treat those who have been affected they are identified by authorities with special health care needs in by armed conflict.‍ Despite a wealth and brought into state care, conflict and postconflict settings.‍ of experience, few studies have been children who are unaccompanied conducted, and the evidence base Child-focused nongovernmental and separated may face migration for interventions used to prevent organizations, multilateral detention, discriminatory treatment, and mitigate the effects of conflict on international organizations, and long delays in family reunification Interventionschildren remains to Protect limited .‍and the US military have a wealth of (if reunification is possible), and – Promote Physical Health experience in trauma-informed limited access to health care, social 131,143​ 146 30,121​ care.‍ ‍ ‍ Providing trauma- services, and education.‍ Health informed care involves making issues of particular concern include Children who are affected by armed specific alterations in the care setting infections, nutritional deficiencies, conflict require care from clinicians and the delivery of care that take into and mental health problems relating who are familiar with their health account the traumatic experiences to their traumatic experiences, – risks and needs and who are skilled of patients and caregivers and the particularly anxiety, depression, and 147 122 125 in providing care to children from way trauma has affected them.‍ PTSD.‍ ‍‍ Their young age, lack different cultural and language Promoting the participation of of documentation, and subsequent backgrounds.‍ There is some evidence children and their caregivers in their barriers in access to care and for a positive effect of cultural health care provides them with a protection place children who are competence training on patient sense of control over their situations, unaccompanied and separated 134 outcomes.‍ Conversely, studies on which is critical to promote healing at a high risk for trafficking and ’ migrant health have revealed that and avoid exacerbating or causing exploitation even after they are in 148 providers lack of familiarity with further trauma.‍ Measures such as the care of responsible authorities 126 migrant health conditions and health the creation of child-friendly spaces, in the destination country.‍ Of the determinants can negatively affect communicating with the help of nearly 90000 unaccompanied minors 135,136​ the effectiveness of care.‍ ‍ In trained cultural mediators, the use of who applied for asylum in Europe in 127 some settings, medical interpreters play in care provision, and informing 2015,​ at least 10000 have gone 128 serve in a dual role of language children and their caregivers of what missing.‍ Children With Remote Exposure to mediators and cultural mediators; will take place during health care Armed Conflict they translate between languages visits can alleviate fear, promote and also identify and explain health mutual trust, and ultimately improve

concepts and cultural needs that care, follow-up,139,148,​ 149​ and adherence to Children who are not in close are relevant to the encounter and therapy.‍ ‍ Simple measures proximity to or are displaced by the care of the patient.‍ The use of such as asking the patients what Downloaded from www.aappublications.org/news by guest on September 29, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS would make them most comfortable on technology), researchers found these children look toward education158 during consultations, leaving the that the medical home model was to improve their lives and futures.‍ door slightly ajar when feasible, or feasible with dedicated primary In light of this and in consideration allowing the patients to sit closer care leadership, adequate financial of the cultural 159stigma associated with to the door may alleviate feelings148 of resources, cultural and language152 mental illness,​ providing mental powerlessness or imprisonment.‍ expertise, and family buy-in.‍ As health services in a school setting a population with special health may be more socially and culturally The use of child-friendly spaces can 160 and social care needs, children acceptable.‍ be adapted to the medical home who are affected by armed conflict model for the provision of trauma- In addition to addressing and their families stand to benefit informed care in the United States.‍ psychological trauma and promoting ’ from the trauma-informed services Child-friendly spaces are defined by mental health in children who “ of a pediatrician housed in a the UN Children s Fund as spaces that are affected by armed conflict, compassionate medical home.‍ support the resilience and wellbeing Interventions to Protect and psychosocial and mental health Promote Mental Health of children and young people programs are a means161 to promote through community-organized, resilience in children.‍ Resilience structured activities conducted in a is a positive adaptive process in ” safe, child-friendly,150 and stimulating Psychosocial interventions are the face of exposure162 to negative environment.‍ ‍ Such spaces, used during complex humanitarian events or threats.‍ Children who whether they are in schools, emergencies to restore stability are affected by war often exhibit community settings, or health in the lives of children who153 are immense adaptability, which can be facilities, are specifically adapted to affected by armed conflict.‍ This cultivated to mitigate the toxic stress meet the needs of children.‍ They may is achieved by establishing routines effects of armed conflict.‍ Intelligence, include colorful decorations directed and engaging young people and their emotional regulation, and coping toward a child audience, toys and caregivers in activities to support contribute to resilience and should be child-sized furniture, and relevant the wellbeing of the community.‍ viewed as dynamic processes163 rather equipment that is designed for use In postconflict environments, this than as personal traits.‍ Factors by children.‍ The use of child-friendly may be accomplished by rebuilding that enhance resilience may include spaces is one approach to mitigate homes, schools,153 and health care social support, caregiver mental traumatic stressors while addressing centers.‍ In settings that are health, membership in a religious the physical, psychological, and remote from conflict, such as asylum community, cultural values, and behavioral health needs of these centers, this is accomplished by access to child care and163 schools in children.‍ reuniting families, providing them war-affected regions.‍ with their own shelters, and enrolling In addition, pediatricians caring 154 Studies of resilience among children children in school.‍ The use of for children who are affected by who are affected by war reveal the child-friendly spaces for psychosocial conflict often find that it is important importance of context in the kinds of and educational interventions has to recognize the health needs of factors that are protective and how been successful in promoting child caregivers and families, facilitate these factors influence resilience mental health both during and after access to care when necessary, 149 outcomes.‍ Community acceptance conflict.‍ and ensure that children and their has a protective effect on adaptive families have access to relevant Psychosocial interventions have been behaviors and mental health social and legal assistance.‍ This is used successfully to complement outcomes in children who have112 been consistent with guidance from the psychiatric interventions in children103 associated with armed groups ; American Academy of Pediatrics, with diagnosed mental illnesses.‍ however, this effect has not been which states that children should Coordinated psychosocial and mental generally observed in other children “ 164 have access to care in a medical health interventions– in schools have who are affected by conflict.‍ home that is continuous, been found103, to155​ be157 beneficial, especially Parental support has been associated165 comprehensive, family centered, in LMICs.‍ ‍ ‍ School-based with better school performance,​ ” coordinated, compassionate,151 and programs help children overcome life satisfaction, and positive culturally effective.‍ ‍ In a study difficulties that are associated with perceptions of health in 2 large cross- of the feasibility of using a medical forced migration and positively sectional studies of adolescents in166 the home model in children with special affect self-esteem, motivation, and occupied Palestinian territories.‍ ≥ 155,156​ health care needs (60% of whom self-efficacy.‍ ‍ Studies conducted Among unaccompanied minors,125 well- had 5 medical problems and with children who have experienced supported living167 arrangements,​ >40% of whom were dependent armed conflict universally reveal that religious faith,​ strong social Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 142, number 6, December 2018 9 support systems, and healthy168 capacity of existing medical4,169​ facilities wellbeing are among the greatest interpersonal relationships have or establish new facilities.‍ child rights violations of the 21st protective effects on mental health century.‍ The destructive effects of Experience has shown that and adaptation to new environments.‍ conflict include all 6 grave child strong collaboration between Researchers in studies of resilience rights violations as well as a broad the health sector and other provide insight into promising range of both direct and indirect sectors, including immigration, ways to protect and promote the effects that follow children through civil protection authorities, wellbeing of children who are the life course and into adulthood.‍ education, and nongovernmental affected by armed conflict.‍ However, Despite the extraordinary number organizations, results in a more interventions used to promote of children living in areas affected effective management of complex ’ resilience should not be considered by conflict, our understanding of emergencies and better health as a replacement for mental health the scale of conflict s effects on outcomes for people who are interventions in children who are children, the nuances of these 163 displaced and for receiving traumatized.‍ 171 effects, and ways to mitigate and populations.‍ On the basis of Public Health and Health System treat them remain limited.‍ It is experience in work in Europe with Interventions incumbent on pediatricians, allied the ongoing migration crisis and ’ child health care providers, public the US Centers for Disease Control health professionals, researchers, and and Prevention s Refugee Health In conflict zones and refugee settings, policy makers to address the impact Program, adequate preparedness public health work is typically of armed conflict on children as a also requires good health focused on rapid epidemiologic critical and priority issue.‍ Children surveillance in sending, transit, and assessment, the development of must be counted.‍ receiving countries and effective early warning systems for infectious LEAD AUTHORS communication of this information disease surveillance, and response 171,172​ Ayesha Kadir, MD, MSc, FAAP to health care providers.‍ ‍ to potential and actual outbreaks of Sherry Shenoda, MD, FAAP 77 Jeffrey Goldhagen, MD, MPH, FAAP infectious diseases.‍ In addition, To inform clinical and public health Shelly Pitterman, PhD in public health responses, disease preparedness and interventions, prevention, including vaccination data on short- and long-term SECTION ON INTERNATIONAL CHILD HEALTH pediatric morbidity and mortality campaigns, the establishment of EXECUTIVE COMMITTEE, 2017–2018 sanitation systems and potable attributable to armed conflict are Parminder S. Suchdev, MD, MPH, FAAP, water supplies, and mass food77,169​ critical.‍ Although several databases Chairperson distribution, is prioritized.‍ ‍ are used to track mortality directly Kevin J. Chan, MD, MPH, FAAP In cases of protracted from armed conflict, these do not Cynthia R. Howard, MD, MPH, FAAP displacement, the administration include disaggregated data on Patrick McGann, MD, FAAP Nicole E. St Clair, MD, FAAP of routine vaccinations may also be children.‍ There are numerous case 170 Katherine Yun, MD, MHS, FAAP implemented.‍ reports and descriptive studies of Linda D. Arnold, MD, FAAP, Immediate-Past child health outcomes in conflict Chairperson Other prevention measures include settings that are used to help the establishment of surveillance characterize specific groups, but STAFF systems to detect conflict- and these do not provide a broad or Vayram Nyadroh displacement-related morbidity and nuanced understanding of the effects of a given conflict on children.‍ the development of interventions to ABBREVIATIONS There is an urgent need to establish mitigate77 their effects on population health.‍ Supplementary feeding methods of data collection that programs and targeted food can be used during armed conflict LMIC: low- and middle-income distribution may be established in to monitor short- and long-term country areas where there is a demonstrated morbidity, mortality, and the effects PTSD: posttraumatic stress burden of micronutrient deficiency of interventions.‍ 169 disorder or acute malnutrition.‍ Contingency CONCLUSIONS STI: sexually transmitted planning and the training of frontline infection staff can be used to facilitate the UN: United Nations early detection of disease and Armed conflict is a neglected social UNCRC: United Nations the implementation of needed determinant of child health, and 77 Convention on the interventions.‍ Finally, support may the acute and chronic effects of Rights of the Child be provided to repair or improve the armed conflict on child health and Downloaded from www.aappublications.org/news by guest on September 29, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS Address correspondence to Ayesha Kadir, MD, MSc, FAAP. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2018 by the American Academy of Pediatrics 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.​ or​ g/cgi/​ doi/​ 10.​ 1542/​ peds.​ ​2018-2585.​

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Downloaded from www.aappublications.org/news by guest on September 29, 2021 The Effects of Armed Conflict on Children Ayesha Kadir, Sherry Shenoda, Jeffrey Goldhagen, Shelly Pitterman and SECTION ON INTERNATIONAL CHILD HEALTH Pediatrics originally published online November 5, 2018;

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