This document discusses the prevalence of post-traumatic stress disorder (PTSD) among children who have survived wars and conflicts. It begins by providing background on the impact of war on children, including their reactions, effects on military families, and social and economic consequences. It then discusses PTSD in depth, covering its pathophysiology, signs and symptoms, diagnosis, and medical and non-medical management. The document concludes by examining prevalence studies of PTSD among children in Iraq after experiencing war.

1. PREVALENCE OF POST TRAUMATIC
STRESS DISORDERS AMONG
SURVIVED CHILDREN FROM WAR
AND CONFLICTS
Hawler Medical University
College of Nursing
By:
Raveen Ismael Abdullah
B.Sc in Nursing
Supervised
By:
Assist. Prof. Dr. Norhan Z. Shaker
Assist. Prof .Dr. Shokir Saleem.I
2016-2017

2. Table of Contents
Introduction.............................................................................................................................................1
Objectives ...........................................................................................................................................1
Children Reaction to War ........................................................................................................................2
Children in Military FamilIies ...................................................................................................................3
The Social and Economic Impact of War on Children and Young People...................................................4
Posttraumatic Stress Disorder .................................................................................................................6
Pathophysiology......................................................................................................................................6
Signs and symptoms................................................................................................................................7
Diagnosis.................................................................................................................................................8
Medical management of PTSD................................................................................................................9
Non-medical management of PTSD .....................................................................................................10
Psycho-education and Peer Counseling..............................................................................................10
Trauma-focused Psychotherapy .........................................................................................................10
Cognitive-Behavioral Therapy...........................................................................................................10
Eye Movement Desensitization and Reprocessing (EMDR) ...............................................................10
Prevalence of PTSD among children in Iraq............................................................................................10
Conclusion.............................................................................................................................................12
References ............................................................................................................................................13

3. 1
Introduction
War is a state of armed conflict between societies. It is generally characterized by extreme aggression,
destruction, and mortality, using regular or irregular military forces. While some scholars see war as a
universal and ancestral aspect of human nature, others argue it is a result of specific socio-cultural or
ecological circumstances (1). Richard Smalley (2) identified war as the sixth (of ten) biggest problem
facing humanity for the next fifty years.
Through the history of humanity, many wars took place resulting in death of millions of civilians, leaving
endless number of injured and causing psychological traumas for survivals and soldiers (3). Women,
children, and elderly are always the first victim of war (4).
Iraq and Kurdistan had their part of war, they face many wars including; internal war, Iran war, Kuwait
war, Kurdistan revolution in 1991, Kurdistan internal war 1995, American war on Baghdad 2003 and
latest war of IS that is still ongoing (5).
Studies have showed that mental health consequences of war are not less damage than physical
consequences. Trauma, PTSD, and depression are always the major impact of any war. A study on 45
Kurdish families in two camps reported that PTSD was present in 87% of children and 60% of their
caregivers .A study on 84 Iraqi male refugees found that poor social support was a stronger predictor of
depressive morbidity than trauma factors (6).
Studding the mental consequence of war is of extreme importance, as Iraq and Kurdistan is about to
finish a very devastating war against IS, that lasted for 3 years. Causing large negative impact on the
psychological wellbeing’s of survivals. Identifying major mental impact of war will support healthcare
professionals in addressing the needs, and strategies of support for survivals.
Objectives
To identify the prevalence of PTSD among survived children from war.
To identify social and Economical impact of war on children

4. 2
Children Reaction to War
It is impossible for children to go through upheavals of this kind without showing their effect in difficult
behaviour and in variations from normality. Infantile nature has certain means at its disposal to deal with
shocks, deprivations and upsets in life.
Outlet in speech is often delayed and after months had elapsed since the occurrence of some gruesome
devastating incident that has been witnessed by the child. Such incidents include death of parents as well.
The children who lost their fathers in air raids never mentioned anything of their experience for many
months.
Their mothers were convinced that they had forgotten all about it. Then after a year, two of them at least
told the complete story with no details left out. The child begins to talk about the incident when the
feelings which were aroused by it have been dealt with in some other manner.Children often imitate
whatever they see in their play, with toy houses being bombed by marbles. There was a lot of excitement
among the children while involved in such games.
In case of a boy who for long refused to accept his father’s death, it got reflected in his games. In his war
games, the inhabitants of the bombed houses were always saved in time. Since the denial was never
Completely successful, the play had to be repeated incessantly it became Compulsive. Often children
clung on possessively to something that they managed to save at the time of separation. Strange
behaviour, sometimes destructive often related to regression (returning to infantile modes of behaviour) is
seen in slightly older children.
Early education involves socializing by gaining control over the selfish instincts. It had its own rewards
which lost their value on separation at this stage. They find no reason to be good, unselfish or clean.
There were many other associated effects such as bed wetting, thumb sucking, greed and aggression.
In some children, abnormal withdrawal from the world has been noted.
Some become emotionless like an automaton. Some emotional outbreaks of hysterical type have also
been reported. However, in general, sooner or later the child returns to good relations with the outer
world.

5. 3
The recovery time depends on a lot of factors like extent of damage, treatment in post-traumatic period,
the coping capabilities of the child which is further dependent on the age of the child. War-related
traumas vary enormously in their intensity, from exposure to brutal death and witnessing of explosive-
violent acts, to the derivative effects of war such as displacement, relocation, sickness, loss of loved ones,
and starvation. Among those children exposed to war-related stressors for a longer period, it is generally
estimated that the prevalence of posttraumatic stress symptomatology varies from 10 to 90%, manifested
by anxiety disorders such as posttraumatic stress disorder and other psychiatric morbidities including
depression, disruptive behaviors, and somatic symptoms (7).
Children in Military Families
In addition to direct effects there is a cost of war that creates a major side effect related with children
from military families who also experience serious problems and situations that may stigmatize and
determine their later life.
The war has profound effects on both military personnel and their families. The psychological burden of
war extends beyond the military themselves, to their spouses and their children. Studies have shown a
strong correlation between military spouses and high stress levels that can potentially lead to mental
health problems.
The stress and inconvenience caused by the involvement of a family member in a war extends beyond the
militants, to their families. The separation during operations often leads to burdening the parent left
behind with new additional roles, disrupting family routine and creating feelings of insecurity, anxiety
about the member who is away and difficulty in making plans for the future(8). When the militant parent
returns, their reintegration in the family can be difficult because there is a need for roles redefinition.
However, only a few studies have carried out in this field. More than 2 million children in the U.S. are
affected by the tenure of their parents in Iraq and Afghanistan, and 40% of these children are younger
than 5 years old. According to a survey of Chartrand et al (2008) in children of militants involved in
Operation “Desert Storm” during the period between August 1990 and February 1991, girls were more
emotional and demonstrated sadness and withdrawal, while the boys had discipline problems. Younger
children were more susceptible to these symptoms(9).

6. 4
The teens mostly showed somatic symptoms such as increased heart rate and elevated levels of stress.
They also stated increased fear of loss and feelings of uncertainty .It also seems that military families who
experience long periods of absence are more likely to be involved in incidents of child abuse and neglect
.Many children have problems in their relationships at school, in groups of peers and in their relations
with other family members, drop in school performance, sleep disorders and increased feelings of anxiety
and stress.
Another issue that may arise is when a parent returns from the field suffering himself from PTSD.
Research has shown that children of soldiers suffering from PTSD present with increased behavioral
disorders, problems with authority, depression, anger, aggression, hyperactivity or apathy and learning
difficulties compared to children of militants without PTSD.
It has been shown that children respond with more sensitivity and empathy in the psychological
problems of their parents than in situations of actual risk. Thus, living with a parent who suffers from
PTSD may cause secondary trauma significantly affecting their ability to cope with stressful situations in
the future.
In many cases it seems that the presence of members extended family environment may reduce
symptoms, because the children feel more secure or because the parent who stays behind is been relieved
to some extend and is able to respond best to the roles undertaken. However, it is necessary to create
programs that help militants’ families in order to avoid compromising the mental health of children and
jeopardize their future (10).
The Social and Economic Impact of War on Children and Young People (11)
Children and young people are highly vulnerable to the effects of war, for multiple reasons. For instance,
children are in many ways dependent on adults for their survival needs, such as food and water, and
child-parent separation is a real danger during situations of armed conflict. Children and young people are
still developing physically and psychologically.
The consequences of war, such as mental trauma and physical injury, can thus have a very long-term
impact on their development and growth into adulthood.

7. 5
Armed conflict currently occurs most often in those regions that include very poor and low-income
countries, such as in Africa, Asia, and Latin America. In most poor countries where war is not present,
children and young people
already experience difficulty in accessing schooling and health care and in receiving adequate nutrition.
They may be required to work to earn income to help support their families and may be charged with
carrying out domestic tasks to keep their households running, such as fetching water and caring for
younger siblings.
When a war breaks out, the situation for young people generally becomes much worse, as the
overwhelming majority of victims of current conflicts are civilians and the targets of various armed
groups whether government or opposition forces are all too often civilian infrastructure, such as schools,
hospitals, and houses. Thus, young people may be forced from their homes and deprived of access to the
services and resources that help them to develop, while at the same time they are exposed to extreme
levels of violence and intimidation. Armed conflict has a significant effect on the foundations and
structure of society, the economy, and the state. It is generally a period of great social, economic, and
cultural disruption.
The social order can be heavily disturbed as family members are killed, injured, or separated, and can
even be turned upside down when friends become enemies or armed children command their former
teachers or village authorities. The norms of society are broken and the rule of law is often absent, with
people of all ages and walks of life committing acts of violence for which they may never be punished.
Yet, war can also offer opportunities for young people that did not exist prior to the outbreak of a
conflict, and can be an opportunity for positive changes to occur. This happens when, for instance, young
people have the opportunity to access education for the first time in their lives while living in refugee
camps, or when local and international nongovernmental organizations advocate for and facilitate the
implementation of children’s rights.
It is important to realize that war does not have the same impact on all children and young people, as
young people are not a homogenous category. War affects different groups of young people in different
ways, depending on a wide variety of characteristics, such as the dynamics of the conflict (that is, the way
in which the war is fought and where the fighting takes place) and the social and economic position of

8. 6
different groups of young people in society. Often, armed conflict affects girls differently from boys; this
is the gendered impact of conflict. War can also affect younger children differently than those who are
older, as well as those from urban areas versus rural areas. To fully understand the effects of armed
conflict on children and young people, this chapter will explore the social and economic impacts of war
on different groups of young people and in different armed conflicts around the world.
Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) in children and adolescents occurs as a result of a child’s exposure
to one or more traumatic events: actual or threatened death, serious injury, or sexual violence. The victim
may experience the event, witness it, learn about it from close family members or friends, or experience
repeated or extreme exposure to aversive details of the event. Potentially traumatic events include
physical or sexual assaults, natural disasters, and accidents(12).
Pathophysiology
The immediate physiologic response to trauma can be significant and may set the stage for persistent PTSD
symptoms. Alterations in the noradrenergic and dopaminergic neurotransmitter systems and the stress
response of the hypothalamic-pituitary-adrenal axis are well documented. The effects of these responses in
the central nervous system (CNS) can affect later neurophysiologic responses(12).
The impact of single-incident trauma (such as a car accident or being beaten up) is different from that of
chronic trauma such as ongoing child abuse. In addition to the symptoms of PTSD, sexual assaults have
widespread impacts on the victim's psychological functioning and development. Abuse by a caretaker
also creates special problems.
The impact of traumatic events on children is often more far reaching than trauma on adults, not simply
because the child has fewer emotional and intellectual resources to cope, but because the child's
development is adversely affected.
If an adult suffers trauma and deterioration in functioning, after time when the person heals, he can
generally go back to his previous state of functioning, assuming that he has not done serious damage to

9. 7
his relationships, studies, and work. A child, however, will be knocked off of his developmental path and
after healing from the trauma will be out of step with his peers and school demands. He will therefore
suffer ongoing frustration and disappointments even when he has healed from the trauma.
Many individuals who suffer traumatic events develop depressive or anxiety symptoms other than PTSD.
An individual who has some symptoms of PTSD but not enough to fulfill the diagnostic criteria is still
adversely affected. The diagnosis of Unspecified Trauma- and Stressor-Related Disorder should be
considered(12).
Signs and symptoms
The most common symptoms of PTSD include the following(12):
1. Reexperiencing the trauma (nightmares, intrusive recollections, flashbacks, traumatic play)
2. Avoidance of traumatic triggers, memories and situations that remind the child of the traumatic
event
3. Exaggerated negative beliefs about onself and the world arising from the event
4. Persisitent negative emotional state or inability to experience positive emotions
5. Feelings of detachment from people
6. Marked loss of interest in or participation in significant activities
7. Inability to remember part of the traumatic event
8. Sleep problems
9. Irritability
10. Reckless or self-destructive behavior
11. Hypervigilence
12. Exaggerated startle
13. Concentration problems

10. 8
Children may reexperience traumatic events in various ways, such as the following:
1. Flashbacks and memories
2. Behavioral reenactment
3. Reenactment through play
No specific physical signs of PTSD exist; however, various physical findings have been noted in children
with PTSD, including the following:
1. Smaller hippocampal volume
2. Altered metabolism in areas of the brain involved in threat perception (eg, amygdala)
3. Decreased activity of the anterior cingulate
4. Low basal cortisol levels
5. Increased cortisol response to dexamethasone
6. Increased concentration of glucocorticoid receptors and, possibly, glucocorticoid receptor activity
in the hippocampus
Diagnosis
The American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), lists
the following diagnostic criteria for PTSD in adults, adolescents, and children older than 6 years(13):
1. Exposure to actual or threatened death, serious injury, or sexual violence (any undesired sexual
activity is sexual violence.
2. Presence of one or more specified intrusion symptoms in association with the traumatic event(s)
3. Persistent avoidance of stimuli associated with the traumatic event(s)
4. Negative alterations in cognitions and mood associated with the traumatic event(s)
5. Marked alterations in arousal and reactivity associated with the traumatic events(s)
6. Duration of the disturbance exceeding 1 month
7. Clinically significant distress or impairment in important areas of functioning
8. Inability to attribute the disturbance to the physiologic effects of a substance or another medical
condition

11. 9
There are no specific laboratory studies or specific imaging studies that establish the diagnosis of PTSD.
Several psychological tests may be helpful in PTSD, including the following(12):
1. Child and Adolescent Psychiatric Assessment: Life Events Section and PTSD Module (CAPA-
PTSD)
2. Children’s PTSD Inventory (CPTSDI)
3. Child PTSD Symptom Scale (CPSS)
4. Abbreviated UCLA PTSD Reaction Index
5. Trauma Symptom Checklist for Children (TSCC)
6. Impact of Events Scale
7. Screen for Child Anxiety Related Disorders (SCARED)
8. Beck Depression Inventory
9. Mississippi Scale for Combat-Related PTSD
Medical management of PTSD(14)
The medications prescribed for treating PTSD symptoms act upon neurotransmitters related to the fear
and anxiety circuitry of the brain including serotonin, norepinephrine, gamma-aminobutyric acid
(GABA), excitatory amino acids such as N-methyl-D-aspartate (NMDA), and dopamine, among many
others. There is great interest in developing agents with novel and more specific mechanisms of action
than are currently available to target the PTSD symptoms described earlier while also minimizing
potential side effects.
Mirtazapine (Remeron) 7.5 mg to 45 mg daily
Venlafaxine (Effexor) 75 mg to 300 mg daily

12. 10
Non-medical management of PTSD (15)
Psycho-education and Peer Counseling
The role of both psycho-education and peer counseling is to help clients understand their experiences and
their reactions in the wake of traumatic events. Clients are given information on how to avoid secondary
exposure to the event, how to reduce stress responses, and where to go if they need ongoing support. By
understanding that their reactions are predictable after traumatic events, clients are less likely to blame
themselves and are more likely to comply with treatment.
Trauma-focused Psychotherapy
The two most effective therapies for PTSD and trauma symptoms are cognitive behavioral therapy and
EMDR. As non-drug treatments, they are both safe for pregnancy and breastfeeding.
Cognitive-Behavioral Therapy
The focus of cognitive therapy, in general, is to help clients identify faulty ways of thinking that increase
the risk of depression, and challenging those beliefs with more accurate cognitions. In trauma treatment,
this same approach targets distortions in clients’ threat appraisal processes, and helps to desensitize them
to trauma-related triggers. CBT is a highly effective approach and variants to this approach include
exposure therapy and stress-inoculation training.
Eye Movement Desensitization and Reprocessing (EMDR)
In EMDR the client is instructed to focus on the image, negative thought, and body sensations while
simultaneously moving his/her eyes back and forth following the therapist’s fingers as they briefly move
across his/her field of vision. Eye movements are the most commonly used external stimulus. But
therapists often use auditory tones, tapping, or other types of tactile stimulation. Clients can simply think
about their traumatic experiences, rather than having to verbalize them. This technique has proven highly
effective in reducing symptoms after a few sessions, and has been approved by the American Psychiatric
Association and the U.S. Veterans Administration for treating PTSD. Certified practitioners of EMDR
are available in many parts of the world.
Prevalence of PTSD among children in Iraq
Iraq has been at war at numerous times in history: a series of coups in the 1960s, the Iran-Iraq war (1980-
1988), the anti-Kurdish Al-Anfal campaign within the country (1986-1989), the Iraqi invasion of Kuwait
resulting in the Gulf war (1991), and the conflict starting in 2003. The UN-imposed economic sanctions

13. 11
following the Gulf war have had a profound impact on the health of Iraqis. The human rights abuses have
also been recorded (16).
There are few studies on the impact of these conflicts on mental health. A study on 45 Kurdish families in
two camps reported that PTSD was present in 87% of children and 60% of their caregivers (17). A study
on 84 Iraqi male refugees found that poor social support was a stronger predictor of depressive morbidity
than trauma factors (18). During the last three years of occupation by foreign forces, there have been
many news reports about the mental health of the population, but no systematic study.
Clinicians identified 20.3% of active and 42.4% of reserve component soldiers as requiring mental health
treatment. Concerns about interpersonal conflict increased 4-fold. Soldiers frequently reported alcohol
concerns, yet very few were referred to alcohol treatment.
Most soldiers who used mental health services had not been referred, even though the majority accessed
care within 30 days following the screening. Although soldiers were much more likely to report PTSD
symptoms on the PDHRA than on the PDHA, 49% to 59% of those who had PTSD symptoms identified
on the PDHA improved by the time they took the PDHRA. There was no direct relationship of referral or
treatment with symptom improvement (19).

14. 12
Conclusion
The consequences of war and armed conflicts are repugnant for the entire population, but especially when
it comes to children, are even worse because the damage caused is long-term.
Children are more vulnerable to many diseases and risks arising from the war, thus they tend to be
affected the most. The displacement, orphan hood, hunger, interruption of their education is just some of
the problems encountered during armed conflict.
The psychological effects of war are those that continue to afflict the children in the period after the war.
The feeling of insecurity, the appearance of PTSD, depression, mental disorders a child may experience
after the termination of the war are a load that may affect a country even for several generations.
Unfortunately, just a few studies have been carried out and few interventions have been developed which
aim to reduce the damages caused by war. Clearly, there is great need for greater attention to this
important issue of rehabilitation of a country.

15. 13
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