PSYCHOLOGICAL EFFECTS OF ARMED CONFLICTS ON CHILDREN

Armed conflicts have caused extreme social crises worldwide, where children represent the most vulnerable group, often experiencing severe trauma and violence in war zones. Globally, one in four children lives in a country affected by armed conflicts, natural disasters, or epidemics. This study aims to provide an overview of research on the psychological impact of armed conflicts on children, including the types of mental disorders that result after war trauma and interventions to minimize psychological damage after exposure to war and conflict. The research was based on a systematic review of the literature, using the Elsevier, Google Scholar, and PubMed databases. Key terms used in the research include: war and mental health or armed conflict, children or refugees and trauma or exposure to war trauma; and post-traumatic stress disorder. Children's continued exposure to war trauma is associated with mental health problems including post-traumatic stress disorder (PTSD), depression, suicidal thoughts or behaviors, dissociative disorders, depersonalization, derealization, numbing, catatonia, and behavior disorders, especially aggression and violent criminal behavior. Based on the studies used, the results show that the crises caused in children by wars has significant effects on mental health, such as anxiety, depression, post-traumatic stress, sleep disorders, and suicidal thoughts. The cited studies recommend increasing human resources for the identification, diagnosis, rehabilitation, and psychosocial support of children who are evacuated from war zones to other countries.


Introduction
Over one billion children worldwide live in countries or territories destroyed by armed conflicts, war, or terrorism, and 90% of the world's children and adolescents live in low-and middle-income countries.
Armed conflicts have a significant impact on mental health in affected populations, particularly among vulnerable groups such as children.Exposure to traumatic events is a major factor in the mental health consequences of war for children.However, for children in particular, the deleterious effects of war trauma are not limited to specific mental health diagnoses but include a broad and diverse set of developmental outcomes that have significant consequences for family relationships, peers, performance in school, and general satisfaction in life.
Wars fought in the last quarter of the century almost exclusively affect countries with low resources and are usually associated with a variety of risk factors at different ecological levels, e.g., extreme poverty, lack of resources for health insurance, the breakdown of the ISSN 2710-1460 WAPP school system, as well as an increase in the level of violence in the family and in the community.
Children are particularly sensitive to the stressors experienced by armed conflicts, and as a result, their effects are present in several aspects of life, such as mental health, physical health, academic achievements, and social relations.

Purpose and objectives of the research
The study examined the impact of armed conflict on children's mental health.The systematic literature review aims to identify and analyze the psychological effects of war on children.

Literature search terms and research process
Based on the object of the study, Google Scholar, Elsevier, and PubMed databases were used.The specific search terms were: armed conflict and mental health or war and children or exposure to combat events and post-traumatic stress disorder.

Results
Based on the selective criteria, 14 items were considered appropriate for use (Fig. 1).For scientific articles, the study was designed and followed the guidelines of the report for systematic review in the PRISMA process (PRISMA, 2021).Or psychological disturbances that prevent them from functioning in daily life.Smith (2001) asserts that the most important variables that determine the effects of war on children's mental health are: deprivation of basic resources such as: shelter, water, food, school, and health care; broken family relationships due to loss, separation, or evacuation; stigma and discrimination significantly affecting identity; a pessimistic outlook; a constant sense of loss and grief; an inability to see the future with optimism; and the normalization of violence.In this regard, studies conducted in war zones show that exposure to traumatic events leads to the development of post-traumatic stress disorder (PTSD) in childhood and adulthood (Elbert et al., 2009).Traumatic exposure can be direct or indirect.Direct exposure occurs when a child has personal experience with a traumatic incident, such as living in a conflict zone or experiencing the death of a parent.Conversely, indirect exposure occurs through television, the Internet, or hearing others talk about a traumatic event.Indirect exposure through the media can also cause significant distress.After the 9/11 attacks and the Oklahoma City bombing, children who watched more television coverage of traumatic events experienced more post-traumatic stress symptoms (Fremont, 2004).Wars and armed conflicts are often associated with behavioral changes in children; for example, children may experience trauma, stress, anxiety, or depression due to the closing of a school, the destruction of infrastructure in their homes, or the loss of family members or friends (Liu, 2017).Chronic exposure to trauma is associated with mental health problems including posttraumatic stress disorder (PTSD), emotional disturbances, depression, and suicidal ideas.Toxic stress in children can inhibit the development of the brain and other organs and increase psychopathological damage, as well as cognitive and emotional impairment.The effects are likely to continue into adulthood, even after the war is over.Various studies have been conducted to determine the incidence of PTSD caused by exposure to traumatic war events.A study conducted with Kuwaiti children who had experienced the war found that 70% of them showed moderate to severe PTSD symptoms (Nader et al., 1993).A later study, involving a sample of Iranian children who had witnessed a public hanging near their school in Isfahan found that 75% reported a tendency for moderate to severe PTSD symptoms (Attari et al., 2006).According to a study conducted in Palestine, 41% of children in the Gaza Strip tended to show moderate to severe symptoms of PTSD (Thabet & Vostanis, 2000).The findings of another study showed that the incidence of post-traumatic stress in 121 Palestinian children exposed to bombing was twice as high as the results found in the previous study, 87% showed moderate to severe PTSD (Qouta et al., 2003).A recent study of Tamil families in post-war Sri Lanka found that children's exposure to mass trauma was one of the key predictors of children's self-reported victimization in their families.Findings reflected that about 47% of children exhibited moderate PTSD, 30.4% exhibited severe PTSD (Fasfous at al., 2013).In a study involving 96 Syrian children aged 10-14, conducted in a host camp in Munich, Germany, 45% of families reported that civil war was the main reason for leaving, 25% were also at personal risk 21% reported that they had lost their homes (Soykoek, 2017).So far, two studies have been conducted regarding the psychological effects of the war in Ukraine.The first was a cross-sectional study that measured post-traumatic stress disorder (PTSD) and found that 28.0% of 1,505 adolescents aged 10-15 years showed symptoms of PTSD (Kar, 2009).However, the study was conducted in a city not at war, and adolescents' experiences of war were not measured.The second study was a longitudinal study that measured the risk of PTSD and depression in adolescents.The authors found that 33.9% of 160 adolescents aged 15 to 17 who had PTSD developed depression, compared with 8.5% without PTSD.Children may experience acute PTSD, with hyperarousal, reexperiencing, and disrupted sleep, or chronic PTSD, characterized by dissociation, limited affect, and sadness.Exposure to trauma increases both internal and external reactions in children.Internal reactions, such as depression, suicidal thoughts, worry, and anxiety, were prevalent among Liberian youths exposed to armed conflict and in a study of 300 Syrian refugee children in Turkey (Chrisman & Dougherty, 2014).These Syrian refugee children, who were exposed to war, usually showed excessive anxiety and fear, manifested by behavior, dependence on parents, and fear of being alone or sleeping in the dark.The children were not only exposed to the war in their ISSN 2710-1460 WAPP country, but also to many traumatic events during the journey.A study conducted after Hurricane Katrina examined posttraumatic stress disorder (PTSD) and associated disorders in 70 preschool children (ages 3-6 years) and their caregivers.The rate of PTSD in children was 50.0% using age-adjusted criteria.The rate of PTSD was 62.5% for those who stayed in the city and 43.5% for those who evacuated (Scheeringa & Zeanah, 2008).A longitudinal study was conducted in the Gaza Strip with 234 children aged 7 to 12 years who had experienced war conflicts one year after the initial assessment, i.e., during the peace process.The rate of children reporting moderate-to severe PTSD reactions was reduced from 40.6% to 10%.PTSD reactions tend to decrease in the absence of further stressors, although a significant proportion of children still present a range of and behavioral problems (Thabet, 2020).According to a meta-analysis that assessed the overall prevalence of PTSD in refugee children, the results showed that 22.71% reported symptoms of PTSD and 13.81% presented high levels of depression (Blackmore et al., 2020b).Another study included 24,786 refugee children displaced in European countries; the data presented reported rates of PTSD ranging from 19.0% to 52.7% (Khamis et al., 2019).Findings indicated that unaccompanied minors had higher PTSD symptoms than other youths accompanied by parents or guardians (Michelson & Sclare 2009).A cross-sectional study involving 2,766 students aged 11 to 17 living in the war-affected Donetsk region and Kirovograd in central Ukraine was conducted from September 2016 to January 2017.The reported data showed that the trauma of war and daily stress in adolescents was about 60%; in adolescents who had witnessed armed attacks, it was 14%; and in those who had been victims of violence and had been forced to leave their homes, it was 28% (Osokina et al., 2023).
According to another study that aimed to assess post-traumatic stress disorders among children and adolescents in conflict-affected areas in the Amhara region of Ethiopia, of 846 children, 69.8% had experienced trauma, 36.45% had developed posttraumatic stress disorders (Biset, 2023).Research was conducted in Bosnia-Herzegovina with 186 children, of whom 48.4% were refugees.The results showed that posttraumatic stress disorder (PTSD) was present in 51.6% of the children.The prevalence of PTSD was higher among children who lost a parent but lived with the surviving parent than among children in orphanages.Depression was present in 22.6% of children, with no difference between groups.Children with the lowest rate of psychological disorders were those who lived with both parents (Hasanović et al., 2006).Selfreported survey data were collected from a sample of 2,004 parents of children aged under 18 years from the general population of Ukraine, approximately 6 months after the invasion by Russia.All participants had been exposed to at least one war-related stressor, and the mean number of exposures was 9.07.Additionally, 25.9% met diagnostic criteria for PTSD.Participants who had the highest exposure to war-related stressors were significantly more likely to meet criteria for PTSD compared to participants who were less exposed (Karatzias et al., 2022).In a study conducted in Palestine with 1029 students aged 11-17 years, the reported results showed that about 88.4% of the majority of children and adolescents had experienced personal trauma, and about 83.7% witnessed the trauma of others.The data also showed that the prevalence of PTSD was 53.5%.Children who had experienced personal trauma, the trauma of others, and property damage were significantly more likely to be diagnosed with PTSD than those who had not.The most severe trauma was personal trauma, followed by witnessing the trauma and then observing the destruction of residences or properties (El-Khodary et al., 2020).
Regarding the traumatic effects, an exhaustive explanation is given by Peseschkian's positive psychotherapy, which emphasizes that some traumas accumulate in the form of small, repeated psychic injuries that cause what is called "microtrauma".In an actual conflict, when coping mechanisms are overwhelmed, an old unconscious basic conflict may arise, pitting primary emotional needs such as trust, hope, or tenderness against secondary capacities or social norms such as order, punctuality, justice, or openness.When the previous compromise that worked to resolve the underlying conflict is no longer effective, an internal conflict arises, leading to symptoms that are seen as attempts at resolution.These conflict reactions can be represented using the Balance Model, although they may not bring solutions, they still have an impact (Peseschkian, 1987).

Conclusions
The findings of the cited studies show that exposure to armed conflicts or experiencing combat events causes severe trauma and increases the risk of mental disorders.Previous research has found that the trauma of nonviolent war can affect mental well-being in the same way as direct trauma.Forced evacuation exposes children to additional stressors, including separation or loss of family members, close peers, the community, etc.Exposure to war trauma increases both internal and external reactions in children.Internal reactions, such as depression, suicidal thoughts, worry, and anxiety, were prevalent among young Liberians and Syrian refugees exposed to armed conflicts.These children who were exposed to war showed excessive anxiety and fear, manifested by dependent behaviors, attachment to parents, and fear of being alone or sleeping in the dark.Traumatic events and daily stress were strongly associated with psychological distress in adolescents living in a war-torn region of Ukraine.These findings can help understand, measure, and address the long-term impact that the current escalating war in Ukraine will have on the mental health and social functioning of children and adolescents.Based on the results of the studies, it is recommended to undertake mass controls of children and adolescents for the identification and diagnosis of mental health disorders and to increase human resources for treatment, rehabilitation, and psychosocial support.Interventions should take into account children's background, including gender, age, where they live, and their socio-economic status (e.g., family income, parental education level, family size), to alleviate psychological symptoms and increase their resilience.Parenting practices appear to play a crucial role in children's psychological well-being in a war context, both as a risk and a protective factor.Consequently, adequate health care programs for wartraumatized communities require individual and family-level approaches.The latter would assess and treat possible problems between the parents as well as in the parent-child relationship.This can stop a potentially vicious cycle of war trauma, psychopathology, and dysfunctional family dynamics, including the abuse of women and children.

Fig 1 .
Fig 1. Flow chart of the research strategy