Threat in the life of Iraqi children

Given the magnitude of the possible exposure and duration of distress evidenced by Iraqi children, there is strong reason to expect that this, in combination with malnutrition and reduced school attendance, will dramatically reduce their learning potential. 6 Threat in the life of Iraqi children Atle Dyregrov, Magne Raundalen following the 1991 Gulf War we were part of what was called The International Study Team, documenting the effects of the war and the United Nations sanctions on the Iraqi civilian population. In a study following a group of ninety-three children in Baghdad over the two years after the war, we found that children continued to experience sadness and remained afraid of losing their families. Trauma scores continued to be high, indicating that symptoms persisted, with somewhat diminished intensity over time. It was concluded that the psychological impact of war on children is not over when the fighting ceases.1 For the past year, and increasingly over the last months before the outbreak of war in Iraq, the threat was very high in Iraq. There is some indication that threat to survival is especially important for the development of posttraumatic symptoms in both adults2 and children.3 In a study we carried out following the massacres in Rwanda in 1994,4 threat to one’s life was the factor that evidenced the strongest influence on two debilitating traumatic stress reactions, NEW DIRECTIONS FOR YOUTH DEVELOPMENT, NO. 98, SUMMER 2003 © WILEY PERIODICALS, INC. 111 112 YOUTH FACING THREAT AND TERROR intrusion of negative sensory memories and avoidance of any experience that might remind the child of the threat. In January 2003, some members of the original International Study Team, supplemented by other experts, carried out a new mission to Iraq to look at the consequences of a new war on Iraqi children. We were responsible for the child mental well-being part of this mission. Effects of the threat of war on Iraq children Iraqi families have lived with sanctions and the results of massive bombing for more than ten years. This has led to poverty, malnutrition, and death; economic depression; and problems with sanitation, electricity, and water. Regarding young Iraqi children, a UNICEF report states: Exhausted parents who can hardly meet the family’s basic needs are naturally less sensitive and caring towards their children, and deprived children often add through their consequent difficult behaviour to parents’ distress. Families whose resources for loving care are depleted through long-term multiple stressors can no longer provide their children with a sense of belonging, which is necessary to promote young children’s curiosity, exploratory activities and tolerance for unfamiliar situations. Finally, the home environment of many young children has become depleted of essential commodities, toys, books and other opportunities for self-directed learning and achievement.5 Although not as high a level of threat as in 2002 and 2003, the threat of a war has been constant in the lives of the Iraqi children over the last eight years. Many children do not know any other reality; they have lived with this threat all their life. Clinically, we know that living with uncertainty takes its toll. Over time it depletes energy, with tiredness and exhaustion often more acutely felt when the danger is over. Little is known about the ways children experience the threat of a possible war. To our knowledge no one has ever studied this. Will children adapt “naturally” and therefore give little thought to the threat? Will they seek out information to try to cope, or will they try to reduce their exposure to news and information to maintain as normal a situation as possible? THREAT IN THE LIFE OF IRAQI CHILDREN 113 These were some of the questions we wanted to learn more about by talking to children directly.6 What did we do? In the fourth week of January 2003 we visited twenty-one families and had in-depth interviews with eighty-five children and youngsters from the ages of four to eighteen years. The families were recruited from different areas of Baghdad and Basra by door-todoor knocking, without any previous appointment. In addition, we visited two schools and collected 232 questionnaires from schoolchildren aged ten to sixteen years (M = 12.7). The three-page questionnaire consisted of the Iraqi Child & Adolescent Questionnaire, the Impact of the Threat Questionnaire, and the Birleson Depression Inventory, all soliciting information about the mental consequences resulting from the children’s present situation. Visiting families Our interviews of the children were constructed to get an in-depth impression of how children in different age groups experienced the war threat. We had access to the families without any government interference and were able to go from door to door in different neighborhoods. All the families welcomed us and cooperated in a very friendly and open manner. Parents understood and respected our wish to talk to children alone when we explained that it was our experience that children were more open and talkative without the parents present. For some families we did not find this appropriate, for example, when we needed parental cooperation to talk to the smallest children. After the interview we all gathered together, and we reiterated the aim of the study and reported on our interaction with the children. The interview was semistructured. In place of prewritten questions it identified specific issues to be covered. One issue was how the present situation and the threat of an 114 YOUTH FACING THREAT AND TERROR armed attack affected the children’s daily lives, including their psychological reactions, with special attention to fear, sadness, and anger. A second issue was communication about their thoughts and worries both at home and at school. Whom could the child talk to for updated information, explanation, and comfort? Alone with the fear With few exceptions the children reported that the imminent threat of war was influencing their daily lives. They thought about the threat every day and were very fearful about what could happen. At the same time there had been little communication with parents, teachers, or friends about the emotional aspects of the threat. Parents obviously had not found a good way to inform or comfort their children, and the children were not confronting the parents with penetrating questions. Children’s fear had a life of its own, seldom touched by communicating with others. They listened to news and watched TV but were often confused by what was reported or said. Watching the news increased their fear, but at the same time it was difficult not to listen to the news, either because they wanted to know what had happened or because rooming conditions made it impossible to refrain from listening and viewing. Yet some youth were very clear about not watching news: “I run away as soon as the news starts.” We understand that parents struggle with this and that their avoidance of communicating about threat and fear with their children is normal. It is not easy to transform one’s own fear and worry for the future into calming and comforting language to children. Even children as young as four and five had concepts of real physical threat from bombs and guns––destroying of houses, burning homes, and killing of people––and thought that in the end, referring to their own families, “we will all die.” The youngest children had some mental protection owing to their lack of understanding: one girl thought that she was protected when her sister put the blanket over her head, and another was comforted by the mere fact that her brother had a knife in his room. Parents were surprised to hear how much their preschoolers feared the situation THREAT IN THE LIFE OF IRAQI CHILDREN 115 (for these youngest children we had a parent present during our interviews). The fear most children felt concerned the death of family members and their fear for their own lives. In addition to their fear, the general life situation of the children often resulted in a state of fatigue, resignation, and sadness. They could discuss the prospect for peace and express hope for peace and even optimism for the future, but in the end they were often resigned and stated, “There will be a war.” They spoke about having adapted to the situation, but this adaptation had a resigned and depressive quality to it. Questionnaire data The responses to the questionnaire showed that almost all children were concerned about a possible war; they worried that they might not live to become adults and that something bad would happen to them or someone in their family. The high numbers of children that reported many or very many headaches (61 percent) reflected physical consequences of this constant threat and tension. More than 70 percent feared very much that something would happen to their family. Despite this they were optimistic and had hopes that things would improve for them, and they enjoyed playing and fun activities. Questionnaire data showed a high level of intrusive thinking about the threat. Although they did not want to think about it, the thoughts often came. This may partly explain that 35 percent often had attention and concentration difficulties (another 25 percent had this sometimes), but malnourishment and difficult living conditions may sustain or increase these problems. The threat often led to waves of strong feelings, including alertness and watchfulness when it was not necessary. When we used the Impact of Event Scale for children7 as many as 78.8 percent scored above the recommended cutoff point of 17. However, our use of this scale was a bit unorthodox, as the children were asked when filling in the thirteen items to think not of a specific event but about the threat of war. The Birleson Depression Inventory also reflected a group on which the situation was taking its toll. The recommended cutoff 116 YOUTH FACING THREAT AND TERROR score is 17, and 70.7 percent of the Iraqi children scored above this level. Again there should be some caution when interpreting these results, as the score may be inflated by lack of food and malnourishment (items on the inventory include “I get stomach aches” and “I enjoy my food”). But even after we took this possibility into account, the group was depressed, whether as a result of the economic sanctions or of the threat of war. Almost 40 percent of the children reported that they felt life was not worth living most of the time, and an additional 17 percent sometimes felt that way. Nearly half of them felt very lonely most of the time. About one-quarter of them never slept well, and a similar number sometimes slept well. Many suffered from bad dreams that further jeopardized their sleep. Conclusion Given the duration of distress evidenced by Iraqi children before the war, and the exposure to a variety of war stressors during the war, there is strong reason to expect that this, in combination with unforeseeable consequences of malnutrition and reduced school attendance can dramatically reduce the learning potential of youth, especially among the poor. The mental resources of Iraqi parents have been depleted over a long period of time, and in combination with other negative health effects this may have a catastrophic effect on children’s mental health. With the history of sanctions, the long-standing threat, and the exposure to war stressors, rapid access to nutritious food, clean water and electricity, and improved security will be important to restore children’s physical well-being. This, together with a rapid return to normal schooling, will also be a good remedial for lessening children’s fear. However, with the large number of children exposed to traumatic stressors such as bombing, shelling, and loss of loved ones, our findings from the last Gulf war and from before the recent war started imply that many children will suffer from sadness anxiety and posttraumatic reactions. There is an imminent need for the government, UNICEF, and other NGOs to instigate programs that may contain and mitigate the situation. Information THREAT IN THE LIFE OF IRAQI CHILDREN 117 must be provided for parents on how they can communicate with and help their children in relation to the war. Unfortunately, many children are left with their own fear and fantasies, with little adult communication or understanding. In addition to advising parents about the need for talking more directly with their children about how they feel, parents can be made more conscious about the effect of news on children, and about how overhearing adults talk about the news strongly affects the child. Open communication, where children can express their thoughts (and fantasies) to listening adults, can in itself alleviate some reactions, but this will require adults who can be calm, reflective, and listening. Programs need to be put in place by the government, UNICEF, and NGOs to assist children in kindergartens and schools that take into account how the long period of threat is a contributing influence on reactions to the war. With a child population already run down by years of sanctions and threat, the challenges for good psychosocial interventions in the wake of the war are formidable. Unfortunately, little is known about the interplay between prewar mental exhaustion and exposure to trauma during war. Although all children can receive normalizing information and help to continue normal development through outreach school programs, more seriously traumatized children can be screened in order to enter groups where they can learn strategies helpful in reducing posttraumatic distress. One such model that has shown great promise is the manual developed under the auspices of the Children and War Foundation.8 Notes 1. Dyregrov, A., Gjestad, R., & Raundalen, M. (2002). Children exposed to warfare: A longitudinal study. Journal of Traumatic Stress, 15, 59–68. 2. Fontana, A., Rosenheck, R., & Brett, E. (1992). War zone traumas and posttraumatic stress disorder symptomatology. Journal of Nervous and Mental Disease, 180, 748–755; Hauff, E., & Vaglum, P. (1993). Vietnamese boat refugees: The influence of war and flight traumatization on mental health on arrival in the country of resettlement. Acta Psychiatrica Scandinavica, 88, 162–168. 3. Carlson, E. B., & Rosser-Hogan, R. (1994). Cross-cultural response to trauma: A study of traumatic experiences and posttraumatic symptoms in Cambodian refugees. Journal of Traumatic Stress, 7, 43–58. 118 YOUTH FACING THREAT AND TERROR 4. Dyregrov, A., Gupta, L., Gjestad, R., & Mukanoheli, E. (2000). Trauma exposure and psychological reactions to genocide among Rwandan children. Journal of Traumatic Stress, 13, 3–21. 5. UNICEF and Iraq Ministry of Health. (1999, July). Child and Maternal Mortality Survey 1999 (Preliminary Report). New York: UNICEF. 6. The entire report on the consequences of a possible war on children is available on-line at http://www.warchild.ca/report.asp 7. Smith, P., Perrin, S., Dyregrov, A., & Yule, W. (2003). Principal components analysis of the Impact of Event Scale with children in war. Personality and Individual Differences, 34, 315–322. 8. Smith, P., Dyregrov, A., & Yule, W. (1998). Children and war: Teaching recovery techniques. Bergen: Children and War Foundation. atle dyregrov is a clinical and research psychologist and is the founding director of the Center for Crisis Psychology in Bergen, Norway. magne raundalen is a child psychologist who has over twenty years experience working with children affected by war. Former president of UNICEF Norway, he now heads a national program for traumatized refugees in Norway.