Journal of Refugee Studies Vol. 5. No. 2 1992
Displaced Children:
Psychological Theory and
Practice from the Field
NEIL BOOTHBY
Institute of Policy Sciences and Public Affairs, Duke University
On-going political crises around the world have created a sense of urgency
among the international community about the need to provide psychosocial
support to displaced children. But are we prepared to undertake this work? This
paper examines the usefulness of available information, professional literature,
and training models for the actualities of providing mental health care to
children displaced by political conflict or civil war. It uses the author's field
experience and research in Southeast Asia, Central America, and southern
Africa as a basis for examining the efficacy of several interrelated issues:
What are the different kinds of events that make war and political conflict a
uniquely stressful experience for children? What has been learned about children's
responses to this range of stressful and traumatic events? What are the implications
of the above findings for mental health initiatives involving war and refugee
populations? What are some of the wider political, social, and cultural issues
confronted when attempting to implement psychosocial support programs for
displaced populations?
Introduction
It has long been recognised that psychological costs may be associated with
forced displacement and the process of adaptation to another socio-cultural
context, but never before in history has the forcible uprooting of so many people
been accompanied by the additional trauma of direct experiences of violence
(Vernez 1990). During the past two decades, as the number of wars has increased,
so too have the numbers of individuals affected by war, not simply as innocent
bystanders caught accidentally in the crossfire, but as targets of deliberate
strategy to terrorize and displace civilian populations (Widgren 1988). Most waraffected groups tend to be from the poorest social classes, often in rural villages
and small towns. Children, however, appear to be especially vulnerable to
exposure to violence (Boothby 1988). A recent survey of the health needs of
refugee children in Sweden suggested that more than 60 per cent of them had
been exposed to violence in their countries of origin, either as immediate
witnesses or participants (Leyens and Mahjoub 1989).
© Oxford University Press 1992
Displaced Children 107
Children displaced within war-affected countries may be exposed to violence
and additional tragedies for longer periods of time than children who seek asylum
abroad. In Mozambique, a team of researchers undertook a representative survey
of the experiences of 504 war-affected children in that country (Boothby, Upton
and Sultan 1991). Children interviewed for the study came from 49 districts
representing seven of Mozambique's ten provinces and covering a broad
geographical range, from Maputo in the south to Nampula Province in the north.
Mozambican social workers asked a randomly selected sample of 277 boys and
227 girls between 6 and 15 years of age to describe their war-related experiences
in detail. These open-ended interviews, guided by a set of questions and
conducted in native languages, took place in deslocado camps, schools or
children's homes. The results were staggering:
—77% had witnessed murder, often in large numbers
— 88% had witnessed physical abuse and/or torture
— 51% had been physically abused or tortured themselves
—63% had witnessed rape and/or sexual abuse
—64% had been abducted from their families
—75% of the abducted children were forced to serve as porters or human cargo
carriers
—28% of the abducted children (all boys) were trained for combat
Though the phenomenon of violence as a factor in the growth and
development of displaced children is hardly new, it is just emerging as a subject
of rigorous study. The dangerous and varied circumstances faced by children
in war zones have made careful research difficult and comparisons of findings
between war-affected groups risky. Western models of psychotherapy, a
common treatment option in stable and affluent social contexts, have been
applied in unstable and impoverished settings with little success. Orphanages,
children's villages, and other institutional child care programmes born out of
Europe's response to displaced children in the aftermath of World War I and
World War II have been transferred to other cultural contexts, all too often,
with negative consequences. Pro-family and pro-community services, such as
family tracing and reunification programmes and participatory mental health
initiatives, have been neglected, or initiated too late or too slowly to be of
maximum benefit to the child (Ressler, Boothby, and Steinbock 1988). The gap
between theory and practice—between our need to know more and our need
to act now—appears to be especially great when viewed from the perspective
of the field.
In an effort to bridge the gap between theory and practice, this paper examines
the usefulness of available professional literature for the actualities of providing
psychological support to children displaced by violent political conflict and war.
The opening section offers a brief overview of literature that focuses on the
different kinds of events that make war and political conflict a uniquely stressful
experience for children. The second section sketches a broad clinical picture
of children's responses to these events, while the third section links these
108 Neil Boothby
theoretical observations to different mental health approaches. The final section
examines some of the wider political, cultural and social issues confronted in
attempts to implement primary mental health programmes for displaced
communities and war-affected countries.
Contexts of War and Political Conflict
Observation of war combatants led to the recognition of a stress disorder
as a predictable or 'normal' reaction to the witnessing of or involvement in
violent activities. This recognition of a stress disorder as a normal or
predictable response to violence and severe stress eventually was expanded
to include children through research into the effects of war-associated
conditions, such as air raids and evacuation, during World War II. These
studies, while of enormous value in highlighting many of the issues involved,
frequently lacked a theoretical underpinning, did not include appropriate
control groups, and were often observational in nature. Not surprisingly,
the results of these early studies were contradictory. Some research suggested
a marked increase in psychological disturbance in children subjected to sporadic
bombings of cities, with symptoms ranging from active inhibition to terror states
(Wolf 1945). Most research, however, indicated that the psychological effects
of air raids on children were less serious than might be expected and, in
general, were associated either with separation from parents or with the
anxiety transmitted from parents during bombardments (Isaacs 1941; Burbury
1941; Freud and Burlingham 1943; Burt 1943). When parents could maintain
day-to-day care routines and project high morale their children were 'buffered'
or protected from the most harmful potential traumatic effects of exposure
to bombardments.
Elsewhere in Europe, serious psychological and behavioural disturbances
were commonly observed among other groups of war-affected children
(Pinsky 1949; UNESCO 1952). These were boys and girls whose war
experiences, including family loss and separation, were compounded by other
traumas and deprivations, including the witnessing of murder, homelessness,
hunger, persecution, and direct involvement in violent activities. Sprengel, a
psychotherapist working at a children's village in Germany after the war,
identified a group of children she described as 'totally uprooted'. This group
consisted of children between the ages of eight and eleven who had lost both
parents during their preschool years. These early losses were followed by several
changes in caretakers and complicated further by persecution, physical abuse,
and environmental deprivation. The interactive effects of loss of family and
community followed by severe trauma and deprivation were devastating. By
the time they reached the children's villages, they were extremely distrustful
of adults and very active, often aggressively so, in testing and retesting the limits
of their new caretakers and new home. Many children did not remember their
exact names, birth dates, nationality, or religion. Sprengel wrote that these
children were
Displaced Children 109
completely without roots . . . They lack spontaneity and have no confidence in
others or in themselves. Their sense of insecurity is increased by having no mother
tongue and not knowing any language well. Their care calls for the utmost patience
and tact (UNESCO 1952:41).
More recent research into the effects of political conflict on children has
emerged from conditions as varied as Lebanon, Ireland, Cambodia, South Africa,
and Latin America. These studies also indicate that war-related traumas are
often diverse and multiple, and can occur repeatedly over a long period of time.
In Lebanon, Macksoud's (1988) distribution of a representative sample of
Lebanese children by types of war traumas showed that the most common war
experiences were bombardment, witnessing violent acts, and bereavement. On
average, a Lebanese child will experience five or six different types of traumatic
events during his or her lifetime.
In South Africa, psychologists also found that the chronicity of hostilities
has a direct impact on psychological distress among child victims of political
conflict in their country (Chikane 1986; Straker 1987; Gibson 1989). Under
apartheid, black South African children have grown up amidst continuous social,
economic, and political oppression. They have witnessed the murder of
community leaders, the petrol bombing of their homes and schools, and the
widespread detention of anti-apartheid leaders. Many have themselves suffered
exile, aiTest, detention, and assault. Straker (1987) has noted that under these
conditions, the term post-traumatic stress disorder has ceased to hold meaning
for the black South African child victims of political violence, who should rather
be seen as suffering from a continuous stress syndrome.
Another prominent feature of today's conflicts is the personal involvement
of civilians, so that children not only are victims of violence, but also are
participants in violent activities (Boothby 1988; Garbarino 1991). A recent
literature search of news publications (McGee 1990) identified 25 countries
where, in the past five years, children under the age of fifteen have comprised
significant percentages of national standing armies, guerrilla or liberation groups,
or both. Child involvement in violent activities often occurs within divided
communities where there is no front line, and where the enemy and enemy
territory are not well defined. It is also pronounced in societies marked by
political oppression, social prejudice, and economic discrimination. Many
children feel compelled to participate actively in their people's struggle. Other
child combatants are actively recruited through indoctrination programmes that
urge the call to duty through national or religious symbols and use slogans and
the media to glorify war. In other embattled countries, impoverished children
join national armies or guerilla groups in efforts to secure food, clothing, shelter,
and protection. Still other children are pressed into combat through forced
conscription or abduction.
In Mozambique, nearly all of the boy soldiers with whom we have worked
were abducted from their families by Renamo, taken to militarized base camps,
trained as combatants, and in many instances, encouraged to kill other human
110 Neil Boothby
beings. Here, three boys describe what our research identified as three distinct
phases of Renamo's attempts to transform boys from civilians into combatants
(Boothby, Upton and Sultan 1991). The first, a 12-year-old boy from Tete
Province, describes how Renamo forced children to witness human abuse
without outward displays of emotion:
Sometimes, just for their entertainment, Renamo forced children to fight each
other in front of them. I was considered a good fighter because I was strong and I
fought to survive. But one time they forced me to fight an adult and he beat me . . .
When one of us didn't perform a task the right way Renamo's punishment would
be to hang us upside down from a tree and beat us with sticks and their hands.
Renamo would gather all of us around and if any of us showed any sympathy
or fear they would make us go through the same punishment.
. . . Three different times people tried to escape the base camp and were caught
and brought back. Renamo gathered the children together, including me, to witness
their punishment. They told us we could not cry or we would be beaten too . . .
(Then) one of Renamo's soldiers struck the man who tried to escape on top of
the head with an axe. After splitting his head open he kept driving the axe down
until it went into the man's chest area (Boothby, Upton and Sultan 1991:21).
A second 12-year-old boy from Inhambane Province speaks about the ways
in which Renamo attempts to force children to become abusers themselves:
Renamo assigned otheT boys our age to watch over us. They were once part of
our group and also had been beaten. Now, they were put in charge and were even
worse. They enjoyed hurting us . . .
Renamo caught an old woman trying to escape. She was brought to the group
of us that was being trained. The Renamo leader pointed to Manual and told him
to kill her. He took his bayonet and stabbed her in the stomach. Then the leader
told Manual to cut off heT head. He did it and they saw that he was brave and
made him chief of our group (Boothby, Upton and Sultan 1991:21).
Finally, many children described how a set of formal rituals often follow a
child's first act of murder. These ceremonies appear to make the child's
transformation from civilian status into the inner circle of Renamo. There are
numerous variations on this rite of passage, according to the different testimonies
we heard. This one is offered by a 13-year-old boy from Gaza Province:
After the killing . . . Renamo brought a traditional healer to me . . . He called
forth demons and asked them to protect me against Frelimo's bullets. He said
the demons agreed to protect me. But he said I had to drink the blood of the next
three people I killed before I would be safe from the bullets. If I didn't, I would
be killed myself . . . (Then) there was a ceremony. The music and singing lasted
all night and everyone smoked marijuana (Boothby, Upton and Sultan 1991:22).
In El Salvador, psychologists have become so concerned with the degree of
civilian involvement in that political conflict that they have begun to question
the efficacy of traditional concepts of mental health (Martin-Baro 1982; Martir
Hidalgo 1990; Aparicio 1990). They suggest that political violence in their
country has existed for so long that it has become institutionalized in most
Displaced Children 111
sectors of society. As a result, the dynamic between the individual and society
has been altered to such an1 extent that there now exists a sharp state of
polarization, increasing militarization of civil society, self-regulated behaviour
on a wide scale, and emotional numbness. Salvadoran society has, in their words,
reached a point where the 'abnormal (war, violence, loss, fear) has become
normal'. Under these conditions, they find the traditional definitions of 'mental
health* (acceptance of and adaptation to societal norms and values) and 'mental
illness' (deviation from that norm) to be inadequate, as it is the dynamic between
the individual and the society which displays signs of 'illness', not just the
individual him/herself.
In sum, the conditions and tragedies faced by children in countries embroiled
in political conflict or war vary considerably. On a continuum, they can range
from exposure to a singular trauma (e.g. World War II bombardments of English
cities) on the less harmful end, to exposure to diverse traumas which occur
repeatedly over extended periods of time (e.g. Renamo's abduction of
Mozambican children), on the more harmful end. In addition, many children
exposed to violence associated with today's political conflicts also live in
impoverished communities or refugee camps that lack physical safety and other
basic social and psychological necessities for life. Some of these settings may
be so damaging that no child remains unscathed, although there may be
variations in the form and severity of a child's reaction. Thus, psychological
and developmental risk can be related to direct threats or insults to the child
(exposure to violence), to environmental deprivation (the absence of opportunities
for physical, cognitive and emotional development), or to both. Since there were
not any multifactorial and integrated conceptual models that guided previous
research efforts, caution needs to be exercised in applying past findings and
their implications for mental health initiatives to present war or political
conflict contexts.
A Clinical Perspective: Acute and Chronic Trauma
Clinical observations, however, do provide basic insight into the impact of war
conditions and traumas on children's psychological and developmental wellbeing. These observations indicate that there is a difference between the effects
of exposure to acute and chronic trauma. An acute stress reaction represents
a normal shock reaction which follows exposure to a highly stressful event (Freud
1967; Janis 1969; Farberow and Gordon 1981; Garmezy and Rutter 1985). It
generally lasts only for a few days and is marked by features of severe anxiety.
If the trauma is intense enough, it may lead to permanent psychological scarring,
especially when children lose their parents and/or extended families. However,
when the trauma is sporadic and experienced in the presence of parents, extended
family, or other familiar community members, the fear and anxiety that most
children do manifest appears to subside fairly rapidly (Garmezy 1983).
Chronic reactions, on the other hand, are those which endure beyond this
brief time span and include a persistence of often debilitating symptoms. This
112 Neil Boothby
chronic reaction is marked by features of PTSD (including a persistent
re-experiencing of the trauma, reduced responsiveness and involvement with
the environment, and diminished expectations for the future), as well as by more
diversified, age-related, symptoms of stress. Profound alterations in personality,
behaviour, and moral development also have been noted among child victims
of chronic political violence, human abuse, and impoverishment (Freud and
Dann 1951; Langmeier and Matejcek 1963; Kinzie et al. 1986; Boothby, Upton
and Sultan 1991; Garbarino 1991).
Garbarino's (1990, 1991) inclusion of the role of children's cognition in the
discourse on war-associated trauma is illuminating. He states that 'acute
incidents of danger often require situational adjustment by normal children
leading normal lives—fitting the traumatic events into the child's understanding
of his or her situation'. This observation is consistent with the main
conclusion of the study by Freud and Burlingham of English children exposed
to air raids:
If these bombing incidents occur when small children are in the care of their own
mothers or a familiar mother substitute, they do not seem to be particularly affected
by them. Their experience remains an accident in line with other accidents of
childhood [emphasis added] (Freud and Burlingham 1943:21-22).
In other words, when the trauma is short-lived and the child's primary
relationships are not disrupted, he/she is better able to assimilate or 'fit' the
traumatic event into his/her existing world view. The clinical picture is different,
however, for children exposed to political conflicts characterized by chronic
strife, high personal involvement, poor definition of threat, and political, social
and economic oppression. Garbarino states:
Chronic danger imposes a requirement for developmental adjustment [author's
emphasis]. Children may appear to 'get used to it', but chronic danger is likely
to produce far reaching effects upon the child. These include persistent Post
Traumatic Distress Syndrome, alterations of personality, and major changes in
patterns of behaviors and beliefs to make some sense of ongoing danger. This
process is most likely to take place when the danger comes from social factors
that overthrow day-to-day social reality, as happens during war or when a child's
neighborhood is taken over by chronic violence, most notably civil war or
insurrection (Garbarino 1990:11).
Many children learn to cope or survive in these dangerous circumstances. But
their survival is not without cost.
Children exposed to the stress of extreme violence and deprivation also may
reveal mental health disturbance years after the immediate experience is over.
A follow-up study of Cambodian children who survived the physical and
psychological devastation of the Khmer Rouge regime (1974-1979) revealed 50%
developed PTSD four years after leaving Cambodia (Kinsie et al. 1986). To what
extent these psychological struggles were linked to exposure to previous violence
or horrors, or to the resettlement experience itself, is not clear. Of particular
interest, however, is the finding that those children who did not reside with a
Displaced Children 113
family member after resettlement were more likely to show PTSD and other
psychiatric symptoms.
Child Participants
Are there differences between children who witness violence and children who
participate in violence? Little is known about children who actively participate
in political violence and armed conflicts. Given the dehumanizing aspects of
violence, common sense would suggest the likelihood of a moral breakdown
in response to this involvement. However, this does not always appear to be
the case. In Northern Ireland, McWhirter (1983) found that children's social
and moral concepts have proved to be quite resilient, a finding linked to the
persisting strength of family bonds and religious values. Similar findings emerged
from studies undertaken in South Africa (Chikane 1986; Straker 1987; Gibson
1989). Many South African children spend considerable amounts of time
planning how to out-fox security forces and sometimes are directly involved
in violent confrontations with police or members of rival communities. None
the less, many of these same children appear to be capable of maintaining an
essential moral distinction between violence for a just cause and violence that
is seen as unjust, although in recent years psychologists have noted an increasing
tendency toward gang-like activities and violence. Coles (1986), in his study of
how children form political beliefs, also stressed the role of social crisis in
stimulating a precocious moral development in some children in some settings.
Other research, however, has noted a kind of 'truncated' moral development
among child participants, especially those involved with groups whose concern
for heritage, religion or nation has elevated participation in the 'struggle' to
a 'rite of passage' (Fields 1977; Garbarino 1990; Macksoud, Dyregrov and
Raundalen, in press).
Punamaki (1983, 1987, 1990) has examined the impact of participation in
political activities among children growing up in the occupied West Bank and
the Gaza Strip. She found that the Palestinian rejection of the Israeli military
occupation and a desire for their own homeland has led many children to
take part in demonstrations, stone throwing and sit-ins. Participation in
anti-occupation and pro-Palestinian activities has also meant that many
children have been detained for interrogation, their schools closed, their
houses destroyed, and hundreds have been killed or injured by occupying
forces. In this context, Punamaki found that exposure to political hardships
was correlated positively with active coping on the cognitive level and (what
she has termed) 'courageous' coping on the emotional level. Ideology, in other
words, serves as a psychological counter-force to the political hardships and
violence children witness and experience in the occupied West Bank and Gaza
Strip. At the same time, Punamaki found that neither active nor courageous
coping were effective in protecting children's mental health from the negative
effects of political hardships. Child participation in social-political activities
involves initiating actual deeds to change the military and political status quo,
114 Neil Boothby
deeds which are treated as serious offences and are severely punished by
military authorities.
Punamaki's work indicates that ideology is an important as well as a
paradoxical resource that must be taken into account when attempting to
understand the dynamics between political violence and psychological processes.
On the one hand, ideology can provide purpose and meaning to political struggle,
thereby bolstering, supporting, or even enhancing children's (and their parents')
capacities to cope effectively in the midst of difficult circumstances. On the other
hand, allegiance to an ideology may prolong and intensify the political struggle
and in the long run increase the challenges and dangers to which children and
their parents must respond. What leads to effective coping, in other words, also
leads children into danger. The use of active coping modes that are regarded
as effective and healthy by traditional psychology can result in mental health
problems for children because of the nature of the political situation.
If Palestinian children drew strength from identification with their people's
cause, Mozambican boy soldiers drew strength from their efforts to resist
identification with Renamo. These boys responded to abduction and forced
participation in violence by adopting a passive, 'do what you are told', exterior
posture, while at the same time actively struggling to maintain an inner
connection to traditional values and beliefs. Hopes of escape, prayers to
ancestors, reveries of better times spent with families and friends, silent recitals
of village songs, and other inner fantasies were some of the tools they employed
to resist identification with their aggressors. How did they fare? Our clinical
work with 42 former boy soldiers (between six and sixteen years of age) at the
Lhanguene Centre in Maputo indicated that the length of time spent in Renamo
base camp, more than personal involvement in violence per se, was associated
with the boys' varied capacities to later act upon their traditional concepts of
right and wrong. In general, the 35 boys who had spent less than six months
in Renamo camps appeared to emerge from these experiences with their sense
of basic trust in traditional values more or less intact. Even though some had
committed acts of violence, they continued to define themselves as victims, rather
than as members, of Renamo. After liberation, the majority of these boys did
display aggressive behaviour and feelings and were indeed distrustful of adults.
However, these actions and attitudes subsided quickly, and their early recovery
efforts were marked more by symptoms of PTSD (including appropriate feelings
of remorse over previous acts of violence), than by antisocial behaviour.
The seven boys, on the other hand, who had spent between one and two years
in Renamo camps, appeared to have crossed a kind of identity threshold in which
their own self-concepts had become more solidly entwined with their captors.
The conditions were so adverse and Renamo's indoctrination programme so
persistent that all these boys had come to view themselves as members of
Renamo. As one 15-year-old boy put it: 'I was reborn in that base camp. Even
if I could have escaped, I never could have gone home again. Not after what
I had seen and done.' Despite their ability to articulate the belief that the
generalized use of violence was 'wrong', most of these boys continued to use
Displaced Children 115
violence and other aggressive behaviour as a principal means of exerting social
control and social influence. One 13-year-old, for example, told me that Renamo
was not concerned about people's well-being; instead, they used them 'like
animals' to achieve their objectives. He stated that he thought this was wrong.
The next afternoon, however, I had to stop this same boy from brutally beating
a smaller child because this child refused to steal food and other goods for him.
He knew the difference between right and wrong; nevertheless, he continued
to use force and intimidation to manipulate others.
Only after three months at the Lhanguene Centre, did we begin to observe
signs of remorse over previous acts of violence among these boys, and recurrent
anxiety connected to reminders of other traumatic events. These symptoms began
to occur at about the same time the boys started to show increased attachment
behaviour and more positive feelings towards their new adult caretakers; a
'softening', so to speak, that also was accompanied by an increased interest
in social activities outside the centre. The behaviour and adjustments of these
former boy soldiers parallel accounts of the adjustment of Jewish children who
survived concentration camps (Freud and Dann 1951), and contrasted with
accounts of Palestinian (Punamaki 1987, 1990), black South African (Straker
1987) and Irish (McWhirter 1983) child participants.
Implications for Mental Health Care
Several treatment approaches (behavioural, psychoanalytic, crisis-intervention)
have been suggested by practitioners and researchers working with children
exposed to acute traumas followed by conditions of relative social stability.
Pynoos and Eth (1984) describe a one-to-one interview format that aims to offer
immediate relief for the child who has witnessed the death of a parent. The
authors use projective drawing and story telling to help the child relive the
traumatic experience, describe its 'worst moment', and gain a measure of control
over the troubling event. Galante and Foa (1986) discuss the advantages of group
sessions in the case involving larger numbers of children exposed to the same
traumatic event. Group sessions involved drawing, storytelling, role playing,
and other activities that encourage the free expression of fears and facihtate
trauma resolution. The goal of both approaches is to restore the affected children
to a pre-trauma level of functioning through structured opportunities to discuss
and better understand their fears and experiences. As Garbarino puts it: 'The
therapy of choice is reassurance: "you are safe again, things are back to
normal'" (1990:10).
However, for children who live in displaced communities and refugee camps
which lack safety and other basic necessities of life, a PTSD approach is not
sufficient. Instead, the intervention goal is to create a more positive social reality
for the child through broader assistance efforts that help to support or to
re-establish the child's primary relationships to parents, famines, communities
and, in some cases, larger ethnic groups (Ressler, Boothby and Steinbock 1988;
Garbarino 1991). The timely provision of food, material, or cash-generating
116 Neil Boothby
forms of assistance can assist vulnerable families in their own efforts to maintain
a regular income and to continue supporting themselves and their children. Such
actions have prevented separations from occurring in the first place, ensured
better care for children in the context of family and community, and promoted
family reunifications when separations had already occurred.
Assisting communities to devise strategies to shield their children from the
most serious psychological effects of war also is important. This can begin by
helping parents, teachers, and other community members to understand how
their own emotions, attitudes and actions are often directly linked to children's
responses to danger (Farberow and Gordon 1981; Galante and Foa 1986; Rigamer
1986; Ressler, Boothby and Steinbock 1988; Garbarino, Dubrow and Kostelny
1989). It also may include culturally appropriate programmes that help children
to process their experiences and feelings in a positive way. The fact that the initial
recovery efforts of children already exposed to sustained trauma are often
associated with aggressive behaviour and feelings has been problematic for
parents, teachers, and other caretakers (Pinsky 1949; Freud and Dann 1951;
Sprengel 1952). These individuals sometimes require assistance in understanding
that the child's initial aggressive behaviour is often an effort to re-establish limits
or boundaries and trust in others. In this way, they may be better able to tolerate
what can be the constructive use of aggression (Solnit 1966). In situations where
child combatants have been exposed to severe trauma or abuse, parents, teachers
and other community members involved with their rehabilitation also may benefit
from outside support to establish the kinds of daily routines and programmatic
initiatives that can enable these children to reorganize aspects of their mental,
emotional, social, and moral lives in a more coherent and adaptive manner.
Each of these mental health care responses assumes knowledge (or a least
a willingness to acquire this knowledge) of a given population's own perceptions
of the meaning of the conflict, their trauma, how they express psychological
and spiritual distress, as well as an understanding of the strategies they use to
overcome these adversities. Eisenbruch (1984) observed that in cross-cultural
settings, Western-trained mental health professionals trying to understand
displaced children's problems from the perspective of behaviour and symptoms
have nowhere else to start other than the presumed universal response to stress.
This leads them to focus on symptoms such as nightmares, sleep disorders or
startle reactions, which may be ameliorated with medications, for example, while
other symptoms, such as avoidance, shame, and decreased involvement with
other people, may be overlooked and even prolonged by medical intervention.
If culture is not taken into account, mental health responses will not focus on
meaning, and the essential therapeutic task of encouraging the child to integrate
war traumas into his/her world view will not be accomplished.
Questions of Implementation
i
How does one begin to implement mental health care initiatives such as these
in unstable and sometimes dangerous settings where, in addition to exposure
Displaced Children 117
to violence and broken family bonds, vital social services may be disrupted,
school and basic health care curtailed, harvests lost, business and trade
interrupted or destroyed, and where the standard of living may have plummeted
beneath the level of basic subsistence? Needless to say, it requires creative and
even courageous responses on the part of many groups, including local, national,
and international organizations. Such responses need to take into account the
structural nature of both the causes and consequences of war. Structural
injustice, the negation of even the most basic human rights, economic
inequalities, racial, ethnic, religious, and social discrimination are often essential
causes of war. An informed response requires some recognition of the colonial
and imperial histories of a given nation or region. The fact that the majorities
in certain countries are dealt an uneven hand by the very structure of the socioeconomic systems influences not only their perceptions of the political conflict,
but also their attitudes towards mental health initiatives.
In countries where the government is an oppressor of people, psychosocial
programmes need to be deinstitutionalized; otherwise, they could be used (or
at least perceived to be used by a majority of people) to maintain the already
unequal status quo. 'You can't work in my country the way you think you can
work in your country,' is how one psychologist from El Salvador put it to me.
'In my country, to talk to a boy about the death of his father, to help him to
understand how and why his father was killed, is threatening to the government.'
A similar refrain was sounded over a decade ago by American soldiers who
fought in Vietnam. Many were mistrustful of psychiatrists sent there because
treatment for PTSD (feigned and real) too often merely reassured them and
urged them as'soon as possible back into active duty (Lifton 1972).
Yet even in countries where the government has adopted a benevolent attitude
towards the people, a systemic, community-based approach is preferable, not
only because the problem is essentially a social one, but also because of the
severe lack of human and financial resources available for individual treatment.
Outside assistance thus needs to be based upon a careful examination of how
a given population is coping on its own with the fear, danger and extreme poverty
engendered by war. The introduction of new or socially discrepant structures
into societies affected by war should be avoided whenever possible, as it can
tilt the often precarious balance of survival away from community-based
solutions and towards less responsive centralized ones.
In Mozambique, we have been impressed by the ability of group and
community structures to continue to care for children. Despite widespread
physical destruction of communities and massive displacements of people, the
majority of the government-estimated 200,000 orphaned and unaccompanied
children have been absorbed by extended families, or by members of former
communities and tribal groups. We also found that where orphanages, children's
centres, or other child-care centres had been established, often by outside
interveners, they were filled with children. In Gaza province, for instance, a
narrow river separates two districts that are equally affected by war. On the
one side of the river the orphanage had acted as a magnet, so to speak, and
118 Neil Boothby
was stuffed full of children; on the other side, there was no orphanage and there
were no children living outside of families. Save the Children Federation and
the Department of Social Welfare in Mozambique have assisted communities
to close down the orphanages, including the Lhanguene Centre in Maputo,
through a nationwide family tracing and reunification programme, as well as
through broader assistance initiatives to support communities providing family
care for large numbers of unaccompanied or orphaned children.
We also noted that certain differences among societal groups in Mozambique
influenced coping capacities among war-affected populations. In the relatively
few remaining ethnic societies structured along matrilineal lines, for example,
women usually have direct access (and by extension, children more direct access)
to food and material goods. The opposite is generally true for ethnic societies
structured along patrilineal lines, where men have first access to food and
material goods, and women and children come second. In times of extreme
scarcity, this usually means mothers and children get what is left over. Not
surprisingly, rates of malnutrition among children in matrilineal groups are lower
than among children in patrilineal ones. We also found that the incidence of
family separation is often lower among matrilineal groups, suggesting another
built-in structural advantage that enables mothers and other women to serve
as buffers between their children on one side, and psychological trauma on the
other. Unfortunately, centrally planned relief strategies often have failed to take
regional differences such as these into account, and emergency programmes in
some parts of the country, most notably food distribution, have not produced
their intended results.
In the same way, we began to devise our psychological outreach programme
for child soldiers by learning what we could about the ways in which
Mozambican communities might respond on their own to girls and boys who
had been victims, as well as victimizers. At the Lhanguene Centre, rehabilitation
efforts began by establishing daily routines and safe codes of behaviour. Once
these were in effect, oral storytelling, dance, and theatre or sociodrama,
identified by Mozambican leaders as traditional community activities most
readily adaptable for therapeutic purposes, were integrated into the children's
daily routines. Former boy soldiers also participated in re-establishing codes
of morals and behaviour. As useful as some of these activities were in
encouraging the boys to express and better come to terms with past traumas
and present fear, our observations indicated that the boys' efforts to re-enter
civilian life after their experiences in Renamo camps were facilitated less through
psychological intervention than through their day-to-day relationships with their
Mozambican Women's Organization caretakers at the Lhanguene Centre. It
appeared that the attitudes and behaviour of both boys and caretakers gradually
changed over time, from mutual fear to mother-child relationships. Once trust
was established, the boys were able to reorient various aspects of their mental,
emotional, social and moral development in more adaptive manners. By the
end of their first year at the centre, all had made substantial progress in school,
bearing witness to their basically unharmed capacity for cognitive learning. To
Displaced Children 119
an impressive degree, too, they learned to control their aggressive behaviour
towards outsiders. All showed at least the beginnings of more normal
relationships with adults and other children and were reunited with their
immediate or extended families through a nationwide tracing programme which
has returned more than 5000 children to their famines.
Finally, former Mozambican boy soldiers required more than adult care and
psychosocial support in order to re-enter community life. They needed to be
forgiven by society, sometimes by the very people who had been victimized by
their past actions. Much of the work in Mozambique thus has focused on helping
community members—political leaders, soldiers, police, teachers, and other
students—to understand that these boys were victims as well. On a national
level, the Mozambique government established a policy whereby children who
were forced to participate in Renamo's activities would be provided with
appropriate care and psychological treatment rather than being sent to military
prisons, as had happened before. Community cohesion, family care, and
psychosocial support services have all played a role. But it has been
Mozambique's policy of amnesty, a policy which institutionalizes forgiveness
rather than children, that has given at least some of these boy soldiers the
opportunity to return home to their families and friends.
Conclusion
Children often develop symptoms of PTSD as well as cognitive and social deficits
following exposure to traumatic events. The manifestation and severity of the
child's reaction appear to be related to the nature and degree of the violence,
its timing in the child's life, the presence or absence of personal injury, and
access to social and family support. The relationship between psychological
processes and political contexts also suggests that we need to move beyond simple
formulations of the parent and family 'buffering model' and include the
importance of the political context itself. One-dimensional stress models that
focus on individual determinants of children's coping do not provide an adequate
conceptual framework for understanding, investigation or action. The nature
of the conflict, how children understand it, and how they perceive their roles
in it, all affect psychological processes and mental health outcomes. We need
a two-dimensional model which considers the context of the crisis itself and
children's coping in relation to that context, rather than solely in abstract,
individualistic terms (Punamaki 1990).
On clinical grounds, two broadly different groups of war-affected, displaced
children can be distinguished. The first group involves children who have been
exposed to acute traumatic events followed by relatively stable parental, family
and communal care. Such a child is likely to experience the trauma as an
accident: that is, a terrifying or life threatening event that is outside the range
of normal life experiences. The child's task in such cases is to assimilate this
unusual event into an existing, stable world view. The treatment objective here
is to reassure the child that the danger indeed has passed and that the world
120 Neil Boothby
is again a safe place to be. This can be facilitated through individual, group
or family mental health initiatives undertaken in culturally sensitive ways.
In many political conflicts and wars, however, children who are exposed to
violence also suffer from additional traumas and adversities. They lose their
homes, their possessions, their friends, and frequently their parents, or siblings,
or other kin. For most children, the loss of a parent is an overwhelming event,
and normal grieving and effective coping—difficult for any child whose parent
or sibling has died—are particularly problematic for war and refugee children.
Severe deprivation in the form of insufficient food, lack of medical care, and
inadequate safety and shelter is often the unfortunate defining characteristic
of what it means to be a displaced child today. While the physical health
implications of deprivation may be more obvious than the mental health effects,
both occur. Children malnourished because of war have demonstrated both
physical and mental delays. While physical development is stunted and survival
questionable, cognitive and emotional impairments also occur.
Uprooted children living within uprooted social groups are often forced to
alter their existing world views in order to make sense out of their new realities.
The longer they live in the midst of danger and adversity, the more likely it
is that their personalities, behaviour, and moral sensibilities will become altered
in the process. They require more than reassurance. Instead, mental health care
initiatives in these contexts need to mobilize available human and financial
resources to support community efforts to create a more positive social reality
for children. Strengthening and reestablishing children's primary relationships
with parents, families, communities, and, in some cases, their larger ethnic
groups, is a priority. While individual approaches may be useful in these contexts
as well, the major thrust of primary mental health initiatives needs to be oriented
towards the family and the community, rather than the individual child perse.
APARICIO, J. J. (1990) Experienca Psicologica Desarrollada en un Centra de Ninas Huerjanos
Victimas del Conflicto Armado en El Salvador, 1985-1990, unpublished paper.
ARROYO, W. and ETH, S. (1984) 'Children Traumatized by Central American Warfare', in Eth, S.
and Pynoos, R. (eds.) Post-traumatic Stress Disorder in Children, Washington, D.C., American
Psychiatric Press.
BOOTHBY, N. UPTON, P. and SULTAN, A. (1991) Children ofMozambique: the Cost of Survival,
U.S. Committee for Refugees, Washington, D.C.
BOOTHBY, N. (1988) 'Without Moral Restraint: Children in the Midst of War', Social Health
Review, Spring.
BURBURY, W. M. (1941) 'The Effects of Evacuation and of Air Raids on City Children', British
Medical Journal, 2: 640.
BURT, C. (1943) War Neurosis in British Children, Nervous Child, 2: 324.
CHKANE, F. (1986) 'Children in-Turmoil: the Effects of Unrest on Township Children', in
Burnatn, S. and Reynolds, P. (eds.) Growing Up in a Divided Society, Johannesburg, Raven Press.
COLES, R. (1986) The Political Life of Children, New York: Houghton Mifflin.
EISENBRUCH, M. (1984) 'Cross-cultural Aspects of Bereavement, 0: Ethnic and Cultural Varations
in the Development of Bereavement Practices', Cultural Medicine and Psychiatry, 8: 315-347.
FARBEROW, N. L. and GORDON, N. S. (1981) Manual for Child Health Workers in Major
Disasters, U.S. Department for Health and Human Services, Washington, D.C.
FIELDS, R. (1977) Society Under Siege: A Psychology of Northern Ireland, Philadelphia, Temple
University Press.
FREUD, A. and BURLEVGHAM, D. (1943) Children and War, New York, Medical War Books.
Displaced Children 121
FREUD, A. and DANN, S. (1951) 'An Experiment in Group Upbringing', Psychoanalytic Study
of the Child, 6: 127.
FREUD, A. (1967) 'Comments on trauma', in Furst, S. (ed.)Psychic Trauma, New York, Bask Books.
GALANTE, R. and FOA, D. (1986) 'An Epidemiological Study of Psychic Trauma and Treatment
Effectiveness for Children after a Natural Disaster', Journal of the American Academy of Child
Psychiatry, 25, 3:3 57.
GARBARINO, J. « al. (1991) No Place to be a Child: Growing up in a War Zone. Lexington,
Massachusetts, Lexington Books.
GARBARINO, J. (1990) 'Children and Youth in War Zones; Coping with the Consequences'.
Testimony prepared for the U.S. Senate Committee on Human Resources.
GARBARINO, J., DUBROW, N. and KOSTELNY, K. (1989) What Children Can Tell Us,
San Francisco, Jossey-Bass Publishers.
GARMEZY, N-. (1982) 'Stressors of Childhood', in Garmezy, N. and Rutter, M. (eds.) Stress, Coping
and Development in Children, New York, McGraw Hill.
GARMEZY, N. and RUTTER, M. (1985) 'Acute Reactions to Stress', in Rutter, M. and Hersov, L.
(eds.) Child and Adolescent Psychiatry, Oxford, Blackwell Scientific.
GIBSON, K. (1989) 'Children in Political Violence', Social Science Medicine, 28, 7: 659.
ISAACS, S. (1941) The Cambridge Survey, London, Methuen.
JANIS, I. L. (1969) Personality: Dynamics, Development and Assessment, New York, Harcourt,
Brace and World.
HNZBE, J. D., SACK, W. H., ANGEIX, R. H., MANSON, S. and RATH, B. (1986) The Psychic
Effects of Massive Trauma on Cambodian Children', Journal of the American Academy of Child
Psychiatry, 25, 3: 370.
LANGMHER, J. and MATEJCEK, Z. (1963) Psychological Deprivation in Childhood, New York,
Halsted Press Books.
LEYENS, J. P. and MAHJOUB, A. (1989) cited in: 'The Mental Health of Refugee Children
Exposed to Violent Environments', an unpublished project proposal by the Refugee Studies
Programme, Oxford University.
'
LIFTON, R. (1972) 'Home from the War: the Psychology of Survival', The Atlantic, November.
LYONS, H. A. (1971) 'Psychiatric sequelae of the Belfast riots', British Journal of Psychiatry,
118: 265.
MACKSOUD, M., DYREGROV, A. and RAUNDALEN M. fm press) 'Traumatic War Experiences
and their Effects on Children'. Draft to appear in Wilson, J. and Raphael, B. (eds.) International
Handbook of Traumatic Stress Syndrome, New York, Plenum Press.
MARTIN-BARO, I. (?) 'El Papel del Psicologo Social ante la Guerra Civil en El Salvador". Boleti'n
de Psicologfa, 17, Ano IV, vol 3: 99.
MARTIN-BARO, I. (1982) 'Un Psicologo Social ante la Guerra Civil en El Salvador', Revista del
la Asociacidn Latinoamericana de Psicologfa Social, 2, 1: 91.
MARTIR HIDALGO, J. G. (1990) Guerray Despersonalizacidn: Efecto Psicosocial del Conflicto
Armado en los sectores Populares de El Salvador. Asociaci6n de Capacitaci6n y Investigaci6n
Para La Salud Mental (ACISAM), San Salvador.
McGEE, K. (1990) 'The Use of Children as Combatants'. Unpublished paper, Institute of Policy
Sciences and Public Affairs, Duke University.
McWHIRTER, L. (1983) 'Growing up in Northern Ireland from aggression to troubles', in
Goldstein, A. and Segall, M. (eds.) Aggression in Global Perspectives, New York, Pergamon Press.
PINSKY, L. (1949) 'The Effects of War on Displaced Children'. Unpublished materials in the World
Federation for Mental Health Files, and summarized in the booklet: Basic Materials Used by
Working Groups, National Committee for Mental Hygiene, Second World Mental Health
Assembly, New York.
PUNAMAKI, R. L. (1983) 'Psychological Reactions of Palestinian and Israeli children to War
and Violence', in Children and War: Proceedings of the Symposium, Finland, Sluntio Baths.
PUNAMAKI, R. L. (1987) 'Psychological Stress Responses to Palestinian Mothers and their Children
in Conditions of Military Occupation and Political Violence', The Quarterly Newsletter of the
Laboratory of Comparative Human Cognition, No. 2, April, pp. 76-84.
PUNAMAKI, R. L. and SULEIMAN, R. (1990) 'Predictors and Effectiveness of Coping with
Political Violence among Palestinian Children', British Journal of Social Psychology, No. 29,
pp.67-77.
PYNOOS, R. and ETH, S. (1984) 'Children Traumatized by Witnessing Acts of Personal Violence:
Homicide, Rape or Suicide Behavior', in Eth, S. and Pynoos, R. (eds.) Post-traumatic Stress
Disorder in Children, American Psychiatric Press, Washington, D.C.
122 Neil Boothby
PYNOOS, R., FREDERICK, C , NADER, K., ARROYO, W., STEINBERG, A., ETH, S.,
NUNEZ, F. and FAIRBANKS, L. (1987) 'Life Threat and Post-traumatic Stress in School Age
Children', Archives of General Psychiatry, 44: 1057.
RESSLER, E., BOOTHBY, N. and STEINBOCK, D. (1988) Unaccompanied Children: Care and
Protection in Wars, Natural Disasters and Mass Population Movements, New York, Oxford
University Press.
R1GAMER, E. (1986) 'Psychological Management of Children in a Natural Crisis', Journal oj
the American Academy of Child Psychiatry, 25, 3: 364.
SOLNTT, A. J. (1966) 'Some Adaptive Function of Aggressive Behavior', in Loewenstein, R. M.,
Newman, L. M., Shur, M. and Solnit, A. J. (eds.) Psychoanalysis—General Psychology,
International Universities Press, New York.
STRAKER, G. (1987) "The Continuous Traumatic Stress Syndrome; the Single Therapeutic
Interview', Psychol. Soc., 8: 48.
UNESCO (1952) The Psychological and Social Adjustment of Refugee and Displaced Children in
Europe, Geneva, UNESCO.
VERNEZ, G. (1991) 'Current Global Refugee Situations and International Public Policy1, American
Psychologist, 46, pp. 631-672.
WIDGREN, J. (1988) 'The Uprooted within a Global Contort', in Miserez, D. (ed.), Refugees— The
Trauma of Exile, The Netherlands, Martinus Nijhoff Publishers.
WOLF, K. M. (1945) *Evacuation of Children in Wartime', Psychoanalytic Study of the Child, 1: 389.
MS received September 1991; revised MS received January 1992