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date: 09 July 2020

Children and Armed Conflict

Abstract and Keywords

The United Nations has defined six grave violations that occur in war that impact children: killing or maiming of children, recruitment or use of children as soldiers, sexual violence against children, attacks against schools or hospitals, denial of humanitarian access for children, and abduction of children. These violations have a myriad of negative impacts on children, including biological, psychological, and social effects. Culturally appropriate support and care provided at the micro, mezzo, and macro levels can help alleviate these impacts and help children recover from these experiences.

Keywords: armed conflict, children, child soldiers

The twentieth century saw a shift from most wars being between nations to being within a nation, between its ruling government and an insurgent force, causing a change in the location of battles. Conflict no longer occurs on isolated battlefields, but in everyday locations such as towns and villages. This change has caused a dramatic increase in the impact of war on civilians, including children. In addition, the negative impact of living in a violent neighborhood has been recognized as having similar impacts to that of living in a declared war zone. According to the United Nations (UN) (n.d.), there are six “grave violations” that occur in armed conflict that negatively affect children: killing or maiming of children, recruitment or use of children as soldiers, sexual violence against children, attacks against schools or hospitals, denial of humanitarian access for children, and abduction of children.

Killing and Maiming of Children: Denial of Humanitarian Access for Children

In part because of the shift in location of battles, children are at high risk of death during armed conflict from guns, airstrikes, and explosive devices. Leila Zerrougui, the UN Special Representative of the Secretary-General for Children and Armed Conflict (2012), noted the increasing use of explosive devices in populated areas as a growing trend of concern. She states that thousands of children have been killed in this manner in countries such as Afghanistan, Iraq, Libya, Somalia, Sudan, and Syria. In some cases, children themselves have been the ones to carry the explosive device to the area for detonation.

It should not be assumed that only children living in areas with a declared conflict are exposed to high levels of violence. A large number of children who live in countries with no declared conflict in their borders are affected by these issues; they are impacted by the continual violence that occurs around them. In the United States in 2010, 4,828 youth ages 10–24 were victims of homicide, and almost three quarters of a million were treated in the emergency room for injuries sustained from violence (Centers for Disease Control, 2012). As in other conflicts around the world, those of minority races and ethnic groups and of lower socioeconomic status are disproportionately affected. In the 10- to 24-year age range, homicide is the leading cause of death for African Americans and the second leading cause of death for Hispanics (Centers for Disease Control, 2012).

Youth living in the inner city in the United States are more likely to have witnessed or experienced community violence, with studies finding up to 43% having witnessed a murder, 11% having been shot at, and 3% having been shot. Almost 80% had witnessed a beating. This was true even for the youngest children. One study found that in a group of 3 to 4 year olds attending a Head Start program in Washington, DC, 78% had been exposed to at least one incident of community violence (Stein, Jaycox, Kataoka, Rhodes, & Vestal, 2003). In Guyana, it was found that 85% of children in Georgetown had heard gunshots, and over a third had seen people shooting at each other. Although only 3% had seen someone being killed, over one third had seen the body of a murder victim where they were killed (Cabral & Speek-Warnery, 2005). Research in Cape Town, South Africa, found that over 90% of children between 8 and 13 years old had witnessed violence and almost 50% stated they had witnessed a murder. Over 80% had also heard about acts of violence (Barbarin, Richter, & de Wet, 2001). In recognition of the impact of urban violence, humanitarian agencies such as the International Committee of the Red Cross and Médecins Sans Frontières have started providing aid there (“Urban violence,” 2013).

However, the majority of deaths that occur as a result of armed conflict are not from violence, but rather result primarily from the conditions created by wartime, such as malnutrition and an increase in communicable disease, to which children are particularly vulnerable. Thus, children under 5 years of age have the highest mortality rates in areas affected by conflict (Zwi et al., 2006). The infant mortality rate has been found to increase 10% in countries with conflict (Gates, Hegre, Nygård, & Strand, 2012) and is exacerbated by the forced displacement of children from their homes. Children are estimated to make up almost half (47%) of the world’s 33.9 million refugees or internally displaced persons (UN High Commissioner for Refugees, 2011). In camps for those who have fled the violence, communicable diseases can run rampant because of crowded conditions combined with poor sanitary conditions. Malnourishment is a frequent reason why they are unable to fight these illnesses (Machel, 2001). Additionally, access to safe drinking water is a major issue for those who have been displaced by violence (Risser, 2007). Its lack can both cause illness and inhibit recovery.

These lacks are linked to another grave violation—denial of humanitarian access. In some areas, combatants will refuse to allow resources such as food or medicine to reach civilians affected by the conflict, exacerbating the situation. As one example, in a region of Somalia, a blockage of humanitarian access by rebels affected 3.5 million people who were also dealing with famine. In Syria, hospitals were attacked by government forces and medical workers were threatened for suspicion of having provided medical care to the opposition (UN Security Council, 2012a).

Landmines and Cluster Munitions

Landmines and cluster munitions have been identified as a special risk to the killing and maiming of children because these ordnance often remain as a threat long after the end of a conflict. Currently, an average of 4,000 civilians die each year from landmines, almost half of whom are children. In some affected countries, however, the percentage is markedly higher. In Afghanistan, the most affected country, 61% of deaths were children (International Campaign to Ban Landmines, 2012). In addition, these numbers do not include the high number of civilians who are maimed, but not killed.

These ordnance remain in place long after battle because of the time, expertise, and money it takes to clear them. It takes approximately 100 times longer to clear a mine than to place it, and although the initial cost of landmines is about U.S.$3 each, they can cost up to U.S.$1,000 to clear. Children are at special risk for being landmine victims because they are less able to read warning signs and less likely to be aware of the dangers of landmines. Children in poor families are at particular risk because these children are more likely to be in mined areas when scavenging for firewood, fetching water, cultivating their crops, or herding animals (Machel, 2001). Additionally, some landmines are brightly colored and can appear as toys to a child. The “butterfly” mine, once common in Afghanistan, came in several colors and had a “wing,” creating an attraction for young children (Machel, 2001).

The Convention on the Prohibition of the Use, Stockpiling, Production, and Transfer of Anti-Personnel Mines, and on their Destruction, has been adopted by 161 countries. All countries in the North Atlantic Treaty Organization, with the exception of the United States, have signed it (International Campaign to Ban Landmines, n.d.). Since this convention, the global production of landmines has greatly decreased and there has been no intercountry trade of landmines since the 1990s. Although the death rate remains unacceptably high, it is approximately one third of what it was at the start of the twenty-first century (International Campaign to Ban Landmines, 2012). An international treaty to ban cluster munitions entered into force in August 2010 and currently has 111 state parties. Unfortunately, a number of the largest users, including Israel, the United States, China, and Russia, have not joined. However, the United States has put in place a moratorium on the export of cluster munitions (Cluster Munition Coalition, 2012).

Recruitment or Use of Children as Soldiers: Abduction of Children

Article 38 of the Convention on the Rights of the Child requires those taking a direct part in combat be at least 15 years old, and in 1998, the recruitment of child soldiers under the age of 15 years was declared a war crime (Fox, 2005). However, the weakness of this article is that the convention is only applicable to nations, not nonstate armed forces such as rebel forces (where the majority of child soldier usage currently occurs), and it only requires states to take “all feasible measures,” rather than all necessary measures to prevent it (Fox, 2005).

Based on these principles, an Optional Protocol to the Convention on the Rights of the Child on the involvement of children in armed conflict was ratified by the UN in 2000 to increase the protections afforded to children. This Optional Protocol raised the age of mandatory recruitment and involvement in combat to 18 years. It states that there will be no compulsory recruitment of children under 18 years of age, and voluntary recruitment must be truthful, genuinely voluntary, and only with the consent of parents or guardians. The Optional Protocol is also written to apply to all armed groups, regardless of whether they are the official armed group of the nation. As of this writing, 150 countries are parties to this Optional Protocol (UN High Commissioner for Human Rights, 2012).

The involvement of children in armed conflict is considered one of the worst forms of child labor, as well as a form of human trafficking. Armed forces find children to be effective fighters because they have been trained to follow the instructions of adults and are less likely to question orders. Children are not likely to demand payment, as would older soldiers, and are trained to become fearless in battle. This fearlessness is achieved in part through their less fully developed sense of mortality, as well as forced usage of drugs (Singer, 2005).

The UN Security Council (2012a) reports 18 countries where the use of child soldiers occurred in 2011—Afghanistan, the Central African Republic, Chad, Colombia, Côte d’Ivoire, Democratic Republic of the Congo, India, Iraq, Libya, Myanmar, Pakistan, the Philippines, Somalia, South Sudan, Sudan, Syria, Thailand, and Yemen. In addition, the Lord’s Resistance Army (LRA) operated throughout central Africa. Numbers are difficult to estimate because not only do armed forces using children not report this fact—never mind the numbers—but also the specific children involved are constantly changing as some children leave and new ones are recruited. In addition, the countries where use of child soldiers occur change as conflicts begin and end. For example, as the conflict in Mali grew in 2012, children were being recruited to serve with armed forces. Children are used by both governmental forces and forces fighting against them.

Although the stereotype of a child soldier is a boy with a gun, the reality is much broader. Children serve not only as combatants, but also as porters, cooks, messengers, and forced sexual partners. Additionally, it is estimated that approximately 40% of child soldiers worldwide are girls (Save the Children, 2005). The productive work of girls is often central to an armed force because females fulfill such traditional duties as cooking and cleaning (McKay, 2006). In fact, Denov (2007) calls the work that girls perform “fundamental” to the success of the armies’ efforts and states that this is exemplified by the fact that girls are typically the last to be released at the end of the conflict. Girls complete additional duties, including carrying goods, gathering information, or acting as sexual partners. However, this does not mean that girls do not fight; many girls also fight in armed combat.

Although the use of children in combat is not new, there has been a dramatic increase in numbers over the past decades for several reasons. One reason is the proliferation of light, inexpensive assault weapons that are easier for children to carry and use (Fonseka, 2001). Another is the change in wars to now being more likely to be fought between a rebel force and a government. Children are more likely to be used by rebel forces fighting against a government within a country, although they are used by government forces as well. Rebel groups have less access to men of fighting age and therefore need younger participants to increase their ranks.

The reasons why children are involved in armed conflict vary from the macro to the mezzo to the micro level. On the macro level, children are more likely to be involved in conflict in countries where there is a general lack of respect for human rights, where the government has been unstable, and where the armed conflict is of a long duration (Høiskar, 2001). This prolonged instability can lead to a lack of educational or vocational opportunities, making children more vulnerable to recruitment. Additionally, the conflict can cause children to become separated from their parents, again rendering them more vulnerable to recruitment. The UN has noted a linkage between recruitment of child soldiers and the displacement of families. Some families will become displaced in an effort to avoid armed groups recruiting their children, whereas other families will have their children forcibly recruited from camps for internally displaced persons (UN Security Council, 2007).

On the mezzo level, familial wealth plays an important role. Children from wealthy families are typically not at risk for involvement in armed conflict because their families are able to protect them through legal measures, bribes, or relocation. The children from poorer families are most at risk for recruitment (de Silva, Hobbs, & Hanks, 2001; Machel, 2001). This is even true in industrialized nations, such as the United Kingdom and the United States, where volunteers come disproportionately from families of lower socioeconomic families who join the armed forces, especially as enlisted soldiers rather than officers (Wessells, 2006).

In some cases, children voluntarily join the forces, whereas in others they are forcibly recruited. However, the UN Special Representative of the Secretary-General for Children and Armed Conflict successfully argued before the International Criminal Court that there should be no distinction made between these two recruitment methods. She stated that this “choice” is made in the context of poverty, familial loss, and lack of protection; therefore, it cannot truly be regarded as voluntary. The Court agreed, stating that, “children could not give ‘informed’ consent because they possessed limited understanding of the short-term and long-term consequences of their choice and actions and did not control or fully comprehend the structures and forces with which they were faced” (UN, 2012, p. 4).

These “voluntary” reasons may result from a search for stability in the upheaval generated by armed conflict. “Volunteering” may be the only manner in which to get daily food and some semblance of protection from harm. War and conflict, because of the instability they cause, often lead to increased poverty and hunger. Some child soldiers have said that they joined in the fighting to escape the poverty in their families (UNICEF, 2001). Parents may also offer their child for military service to earn the salary for the child’s work (Machel, 2001). Children may also opt to join because of the perceived power and excitement (Wessells, 2006). For some girls, joining the group may offer more opportunities than traditional life seems to offer, as well as an escape from a forced early marriage or sexual abuse (Denov, 2007; Wessells, 2006). In societies where honor and shame are important concepts, they may be motivating factors for children to join; children may wish to avenge the death of a family member (Singer, 2005).

However, in most situations, the children are forcibly recruited in some manner, especially girls (Save the Children, 2005; Singer, 2005). For example, in Nepal children were kidnapped—individually or in groups—into the Maoist rebel forces. In both Nepal and Sri Lanka, the rebels had a “one family, one child” policy in which each family was expected to provide a recruit or face severe punishment (Human Rights Watch, 2004; Shakya, 2011). Some forces will abduct children from places where they gather, such as schools, churches, or orphanages. Street children can be particularly vulnerable to recruitment, in part because of their poverty and isolation.

One of the most infamous users of child soldiers has been the Lord’s Resistance Army LRA, a rebel group that has been operating since 1986. The LRA is known for its widespread forcible kidnapping of Ugandan children and brutal violence, which they both used against the children and forced them to perpetrate. Approximately 300,000 children were abducted from their schools, from their homes, and from the roads (“Peace restored,” 2013). The LRA specifically abducted educated girls in some cases so they could be forced to serve as interpreters and intelligence officers (“Bleak future,” 2011). The child soldiers experienced violence in multiple forms and methods. Violence occurred not only in combat, but also as a disciplinary technique. To force the children to remain with the army, harsh violence was used against those who revolted in any manner. It was more difficult for girls than boys to escape. Because girls were less likely to be involved in conflict, they had fewer chances to escape or for protection workers to find them because they were typically limited to staying at the base camp. If they had borne a child, this also inhibited their ability to escape. Additionally, they were less likely to feel they could return to their home village because of the stigmatization they would face for bearing a child out of wedlock.

Although the LRA has not been active in Uganda since 2006 and currently has no more than 500 soldiers, they continue to terrorize neighboring countries such as the Central African Republic and the Democratic Republic of the Congo. In the Democratic Republic of the Congo, they are repeating their tactics of forcible recruitment and continuing to force children to kill their families or other children. In the Central African Republic, they have developed the new tactic of kidnapping people for ransom in the form of food, clothing, or other goods (UN Security Council, 2012b).

The use of children by armed groups is widespread in Colombia. Although the government has used children for intelligence gathering, the vast majority are fighting for rebel groups—the Revolutionary Armed Forces of Colombia (FARC) and the National Liberation Army (ELN) (UN Security Council, 2012a). Children as young as 8 years old are recruited by FARC, typically by force, and face severe punishment if they attempt to return home. The guerrilla groups have a relatively high use of females, with one quarter to one half of their soldiers being females (Human Rights Watch, 2003). Related to “voluntary” recruitment, the rebel force offers girls a chance to break out of the passive role allotted to females (Care International, 2008).

In Sri Lanka, the conflict between the government of Sri Lanka and the rebel group known as the Liberation Tigers of Tamil Eelam, more commonly referred to as the Tamil Tigers or LTTE, lasted until 2009. The Tamil Tigers received international condemnation for the regular use of child soldiers, with approximately 40 to 60% of their forces under the age of 18 years, most of them recruited when they were between 10 and 16 years old. The Tamil Tigers were particularly known for their use of girls in direct fighting; about half of the soldiers are female (Singer, 2005). Children were often forcibly recruited. The Tigers visited the homes of families in the area of the conflict and informed them that they must provide a child to the group. Those families who resisted were threatened and harassed (Human Rights Watch, 2004). Other children were simply abducted off the street while walking home or participating in festivals (UN Security Council, 2006). The children who joined were treated harshly; they were allowed no contact with their families and were beaten if they tried to escape or made a mistake (Human Rights Watch, 2004).

Myanmar has been the country with the largest use of children by government forces, although they are used by rebel groups there as well. However, in 2012, in conjunction with the UN, they created an 18-month plan to release and reintegrate the children currently in their armed forces. Additionally, the plan included methods to prevent future recruitment. While this is an ambitious goal, there is a set timetable for actions to occur and methods to determine whether the goals are being reached (“No more child soldiers,” 2012).

Attacks Against Schools or Hospitals

War and armed conflict also disrupt children’s education; an estimated 28 million children were out of school because of conflict in 2011—42% of the total (UNICEF, 2012a). War diverts funds from education and the average length of a conflict in a poor nation is 12 years. In countries with conflict, only about 80% of youth are literate compared with 93% in other poor countries (UNESCO, 2011). Children who are involved with armed groups or who are displaced from their homes by the violence are especially likely to be out of school. The impact of conflict on education is starkly clear when looking at the example of Somalia. Lacking a functioning national government since 1991 and beset by warring regional factions, Somalia’s educational attendance is extremely low—only 42% of children are enrolled in primary school, 36% of whom are girls (UNICEF, 2012b). Whereas one study noted that war’s impact on education is often offset by humanitarian aid and can stem from preexisting conditions (Human Security Report Project, 2012), another notes that impacts of conflict on education are not limited to that nation, but affect its neighbors, who do not receive such aid (Gates et al., 2012).

Even children who are not combatants or displaced because of the conflict often have their educations affected. During times of violence, parents are more apt to keep children home to protect them. Children can be at risk of becoming targets of violence during their journey to school. They also fear being accused of giving aid to the “other” side during their travels or being forced to help one side or the other (IBON Foundation, 2006). Although schools should be a safe place for children, isolated from the conflict, this is too often not the case. In Nepal, schools were a “recruitment centre and a battleground” (Shakya, 2011, p. 560). Children gave recruitment speeches to recruit other children and the walls were painted with Maoist propaganda (Shakya, 2011). The trauma the children have witnessed and the state of fear can inhibit them from concentrating and learning, and malnutrition can impact their cognitive development and thus their ability to learn (Kohli & Mather, 2003; Machel, 2001). Teachers in the Gaza Strip of the occupied Palestinian territory note that students often cannot learn because of hunger and fear (O’Loughlin, 2007).

School buildings themselves can also be targets for attack, either for physical destruction or for recruitment of child soldiers (Kilpatrick & Leitch, 2004; Machel, 1996; Risser, 2007; Shakya, 2011). Schools are often attacked both by rebel groups and by official state forces. For example, in Palestine, schools have been attacked and occupied by both the Israel Defense Forces and the Palestinian armed groups. The Israel Defense Forces have stormed schools using tear gas, whereas Palestinian militants have destroyed schools when rockets they fired at Israel fell short (UN Security Council, 2012a). In countries such as Afghanistan, Colombia, Iraq, and Somalia, schools and teachers have been a repeated target of rebel groups. Schools have been bombed, burned, and forced to closed, and teachers were intimidated, kidnapped, or killed (UN Security Council, 2012a). Teachers can be a target for armed forces because of their high status in the community or their strong political views. Teachers in Sri Lanka who tried to protect the children from forced recruitment by armed forces were targeted by guerrillas, whereas in Colombia, schools are regularly attacked or occupied by armed factions and schoolteachers are threatened or killed (Coalition to Stop the Use of Child Soldiers, 2007; Machel, 2001; UN Security Council, 2012a).

Sexual Violence Against Children

During conflict, the risk of sexual violence increases, both for civilians and for those involved with armed groups. During most of the world’s recent conflicts, such as in the Central African Republic, Sierra Leone, and Sudan, reports of sexual assault and sexual violence have spiked (Doctors Without Borders/Médecins Sans Frontières, 2005; Special Representative on Sexual Violence in Conflict, 2012; UNICEF, 2005). Both males and females are at risk of this crime, although the vast majority of reported cases have been by females. Males who have been victimized typically do not report it because of cultural shame and stigma (Christian, Safari, Ramazani, Burnham, & Glass, 2011). Rape has been recognized as a war crime for its tactical use to inspire fear and humiliation in a population. Even in camps for those who have fled the violence, the risk of sexual assault remains high. This is in part because these criminals are aware that there is a high percentage of women living there unprotected, not even by a front door (Ali, 2013; “Sexual violence continues,” 2008).

In the Democratic Republic of the Congo, sexual assault has become extremely widespread. Although it is committed by all sides in the conflict, the vast majority recently has been by government forces, apparently to punish community members for suspected collaboration (UN Security Council, 2012a, 2012c). In addition, the situation in this nation exemplifies how conflict can help tear down societal norms and the rule of law as sexual violence perpetrated by civilians has also increased markedly (Bartels et al., 2012; Nelson et al., 2011). However, this may be caused in part by the demobilization; those who were soldiers are now in civilian clothes rather than a uniform (UN Security Council, 2012c). Children were more likely than adults to have been assaulted by civilians; additionally, they were more likely to be assaulted by multiple perpetrators at once (Nelson et al., 2011).

For children involved with armed groups, rates of sexual abuse have ranged from 30 to 81% (Betancourt et al., 2013). In most armed groups, girls are routinely gang raped until a high-ranking officer claims them as his property (Denov, 2007). In some groups such as the LRA, a girl may be given to a commanding officer as a “wife,” and she is then bound in sexual slavery. In Colombia, sexual violence by nongovernment armed forces has been called “habitual, extensive [and] systematic” (UN Security Council, 2012c, p. 5). In FARC in Colombia, girls may be forced to have sex with an officer, forced to use contraception that can be both inadequate and harmful, and, if they became pregnant, forced to have an abortion (UN Security Council, 2012a, 2012c). This can be additionally traumatizing because Colombia is a predominantly Catholic country.

Impacts of Armed Conflict

The six grave violations can have numerous impacts on children. Article 39 of the Convention on the Rights of the Child states that children should receive assistance necessary to promote “physical and psychological recovery and social reintegration” following armed conflict. Using a biopsychosocial approach can be a useful tool for examining these impacts. Biologically, children may have been injured. Children are often not able to access the medical treatment they need to recover (“Children wounded,” 2010; Santacruz & Arana, 2002). Thus, physically, they may encounter difficulties. Socially, children affected by conflict may encounter difficulties in education because they are typically substantially older than other schoolchildren at their level because of their lack of educational opportunities, especially if they were displaced or involved with an armed group. If so, they may experience shame at being behind younger children and become easily frustrated (Care International, 2008). Social reintegration (discussed in more detail later), if not done well, can create difficulties. Blattman (2006) suggests that the largest cost of child soldiering is not in its impact on mental health, but on human capital. His longitudinal study found that the impact of lost education resulting from involvement in the conflict, together with the risk of injury, had a long-term result of lower income by nearly a third.

Psychologically, numerous impacts have been documented. Although not all children who are exposed to violence and trauma develop severe reactions, the majority of children will show some behavioral impacts. These impacts can range from heightened anxiety, particularly in situations that resemble the original, to severe aggression or dissociation. The witnessing of violence, even on television, can cause long-term problems. Living in a state of fear can create permanent trauma for children if it is not addressed. Children living in conflict areas have been found to score high on assessments of psychological difficulty, including depression, anxiety disorders, and Post-Traumatic Stress Disorder (PTSD; Attanayake et al., 2009).

Both the type of trauma and the number of traumatic events have been found to impact the development of psychological difficulties such as PTSD (Thabet, Abed, & Vostanis, 2004; Thabet & Vostanis, 1999). As one example, children in Palestine experiencing bombardment or home demolition were found to have higher levels of PTSD and fear than children living in the same area who experienced other forms of political violence (Thabet, Abed, & Vostanis, 2002). Children who have been displaced by conflict are likely to have more severe mental health issues than children who have been affected by the war but not displaced (Elbedour, Onwuegbuzie, Ghannam, Whitcome, & Hein, 2007; Živčić, 1993). This result may be caused by the additional burden of living in a refugee camp, where both the ability to meet basic needs and the availability of community support are typically lower (Elbedour et al., 2007).

Displacement can result in children having to move to a new country, which can create social and psychological issues. Some children may be sent without their parents or other caregivers to third countries for a number of reasons: in a bid to keep them safe, because they were separated from their family during the conflict, or because their caregivers may have died in the conflict (Mitchell, 2003). However, the arrival of children as unaccompanied minors in a third country creates additional issues, including the lack of adult support to seek asylum in these countries.

Even if these children are granted refugee status, the difficulties for these children do not end once they receive that status because they face the stress of acclimating to a new country, a new culture, and often a new language. In some cases, symptoms of PTSD do not start developing until 8–10 months after resettlement as they become comfortable in their new surroundings and begin to process the trauma to which they have been subjected (Schmidt, 2005). In addition, they frequently have the stress of concern for those who have remained behind and are still in danger (Cambridge & Williams, 2004). Even youth who migrate with their families may have a difficult time adjusting. Although they have the support of their families, there may be tensions with their parents as they try to adapt to the new culture. These children may wish to fit in with their peers, yet their parents may desire that they maintain their native culture and values. Furthermore, there will often be financial difficulties in the new country because working parents are typically not able to obtain employment at their previous level from their home country. Parents can also be coping with their own trauma and adjustment issues and may not be available as a support for their children. Xenophobia in the new country may also be a barrier to successful adjustment.

Exposure to violence among urban children has been found to be associated with a host of negative effects similar to those found among children living in countries where war is occurring. Research has found that exposure to violence is associated with problems including PTSD (Lynch, 2003; Scarpa, Haden, & Hurley, 2006), substance abuse, anxiety, depression (Lynch, 2003), conduct disorder and externalizing behaviors (McCabe, Lucchini, Hough, Yeh, & Hazen, 2005; Thompson & Massat, 2005), sexually risky behaviors (Voisin, 2003), attention difficulties, aggression and anxiety/depression (Barbarin et al., 2001), lower scores on intelligence tests and standardized reading assessments (Delaney-Black et al., 2002), and lower academic achievement (Basch, 2011; Milam & Furr-Holden, 2010). Again reflective of war zones, exposure to trauma has been found to have a cumulative effect, with greater exposure resulting in more severe effects (Lynch, 2003).

Because of their intense exposure to violence, those who have served as child soldiers are at even higher risk of negative impacts (Derluyn, Broekaert, Schuyten, & De Tem, 2004; Kanagaratnam, Raundalen, & Asbjørnsen, 2005). The impact can also be culturally specific. Research in Uganda has documented spirit possession experiences in former child soldiers, over and above experiences of PTSD. Cen, a harmful spirit, typically that of a person who has been murdered, can possess the body of their murderer for revenge. Cen possession was found to be significantly more common among former child soldiers than among others and was highly correlated with experiences of PTSD (Neuner et al., 2012). This is not considered psychopathology within the local culture, but has culturally specific methods of remediation (see Corbin, 2012). However, the sample in the study conducted by Neuner et al. (2012) reported that these methods were not always successful.

In Mozambique and Angola, those who have engaged in conflict are considered “polluted” by the war and must be cleansed before they are accepted back into society. They are carriers of the spirits of the dead; if the former soldiers are not cleansed, they will carry the anger of the spirits back into the community. Any psychosocial issues experienced by the combatant are caused by the anger of those who have died (Green & Honwana, 1999; Honwana, 2006). Traditional healers may also be sought out to help individuals who are having a difficult time returning to community life. The healer will conduct a biopsychosocial assessment, looking not only at the individual, but also at their relationships with their family as well as the community. Rituals and healings will be conducted to help the individual, the nature of which will depend on the primary religious identification of the individual and how rural his or her village is (Honwana, 2006).

These psychological difficulties are tied to social difficulties. Once child soldiers have been released from the armed force with which they were fighting, it can be difficult for them to reintegrate into society. As Briggs (2005) states, although not every child will suffer from PTSD, most will need assistance in reentering society and moving past their experiences to resume their life. Longitudinal studies have found that most former child soldiers grow up to lead productive lives, but they continue to struggle with psychological distress caused by their experiences (Boothby, 2006; Santacruz & Arana, 2002). If reintegration is not carried out well, the children will be vulnerable to re-recruitment. A flare-up in fighting in the Democratic Republic of the Congo caused leaders of armed forces to seek out youth who had previously fought, but had failed to reintegrate back into their families and communities because of a lack of resources for education and programs (“Youth again forced to fight,” 2007).

Cheney (2005) notes that it can be difficult to reintegrate child soldiers not only because of their actions while with the rebels, but also because of the cultural taboos that have been violated. Traditional generational roles in Uganda provided that it was the elders in a clan who decided when to go to war; however, that was upset by Kony’s abduction of children and their forced participation in conflict (Singer, 2005). These children become socialized into committing horrific acts to survive. It is then difficult for the children to revert to obeying their elders when they return to the community. Adding to the difficulty is the fact that although they may have left the community when they were children, because of the length of the conflict, they may return as young adults. They will be lacking the education and socialization they need to integrate into the community as appropriate to this new role. Girls who return with children are visible reminders of the violations of cultural norms, including maintaining virginity until marriage, the importance of a child’s paternity, and community-sanctioned marriage (Denov, 2007).

UNICEF (2006) states that reintegration is particularly difficult for girls. Because of gender stereotyping, the needs of girls have traditionally been excluded from such programs and, thus, few girls have used the programs. One reason is that girls typically are not viewed as soldiers because they often do not participate in combat. For example, following the decade-long conflict in Sierra Leone, girls did not qualify for programs because they were registered as “camp followers” (Machel, 2001). In Mozambique, the girls received packages of goods that included men’s clothing (Machel, 2001). Health services for such problems as sexually transmitted diseases, fistulas, and genital injuries are often needed, but rarely provided (Denov, 2007). In addition, the girls could benefit from services to help with the sexual abuse they have suffered—a topic rarely discussed in a number of countries experiencing these conflicts. Thus, girls often do not receive the reintegration services that boys do, leaving their physical needs unmet and their psychological trauma unresolved, although girls experience greater psychological impacts than boys (Betancourt et al., 2013). The stigma faced by returning girls has been found to be even greater than that faced by boys and impacts their ability to get a job, return to school, or get married (“Bleak future,” 2011; “Fewer ‘I do’s,’” 2011).

The social and psychological impacts of conflict can last long past the physical impacts if intervention is not provided. Overcoming these impacts requires culturally sensitive care, including supportive caregivers and a secure community (Machel, 2001; Punamäki, 2001). Children who receive assistance earlier and for a longer duration have better adult outcomes (Punamäki, 2001).

One of the primary services that programs can offer is to identify the location of the child’s family. During conflict, families are often forced to flee their villages and family members may have been killed. Thus, locating family to whom the former soldier can return can be more difficult than it may initially seem. After the child is placed in the home, follow-up services to ensure that reunification is proceeding smoothly can be essential. Family, and the support they can provide, has been found to be an important factor in helping to reduce the impact of war on children (Betancourt et al., 2013; Summerfield, 2000).

Increasing family support has been shown to help ameliorate the effects of violence (Benhorin & McMahon, 2008; Ozer, 2005; Punamäki, 2001; Shields, Nadasen, & Pierce, 2008; Wallen & Rubin, 1997). It can be difficult for parents to offer support to their children when they themselves may be traumatized. This is especially true for a conflict of long standing, where the parents themselves did not have a childhood free of conflict. The mental health of children and the impact of war trauma on parents have been found to be correlated (Thabet, Abu Tawahina, El Sarraj, & Vostanis, 2008). Therefore, it is important for social-service providers to educate families about the effects of trauma, while understanding the potential impact of intergenerational transmission (Burrows & Keenan, 2004).

Additionally, if economic opportunities are provided to the children, they will not only help ease the reintegration, but also reduce the likelihood that the children will become re-involved with the conflict because of the reduction of poverty. In Colombia, it has been noted that demobilization programs must help youth become self-sufficient. According to the Coalition to Stop the Use of Child Soldiers (2007), “They come from military institutions in which you have to do and not think. Then they come to an institution that gives them benefits but not tools to enable them to be self-sufficient” (p. 11). Children who had been demobilized but lacked job skills were vulnerable to re-recruitment by the army (Coalition to Stop the Use of Child Soldiers, 2007). Vocational opportunities that were offered were typically gender stereotyped. Girls were offered training to be hairdressers, beauticians, or dressmakers (Care International, 2008). It has also been found that if proper supports and reintegration methods are not in place, children are prone to engage in activities that place them at risk for contracting HIV. These activities include injecting drugs and engaging in sex work because of the difficulties they faced in psychosocial healing, addictions acquired while serving in the conflict, and economic struggles resulting from the lack of job skills and community support (“Bleak future,” 2011; “Former child soldiers,” 2008).

All too often, reintegration programs ignore the vital role of community. The reintegration of child soldiers is eased with greater community acceptance (Betancourt et al., 2013; Boothby, 2006). If communities do not understand the nature of the experience of the returning children, they may not accept them. The Coalition to Stop the Use of Child Soldiers (2008) reported that former child soldiers often faced extensive stigmatization by their community and were constantly bullied at school. Working with the community and the local healers can help reduce the spiritual contamination of the children and make the community more willing to interact with them and them with the community. Save the Children (2005) found that one of the most commonly stated needs of returning girls was to help the community to understand that their involvement in the armed group was coerced. This is especially true if girls are returning with a child. Communities often need assistance in understanding that these relationships were forced and learning to provide support to the returning girls.

In summary, the six grave violations have numerous negative impacts on children and their biopsychosocial development. However, culturally appropriate support and care provided at the micro, mezzo, and macro levels can help alleviate these impacts and help children recover from these experiences.


Ali, L. (2013, January 14). Displaced women still vulnerable in Mogadishu. Al-Jazeera. Retrieved from

Attanayake, V., McKay, R., Joffres, M., Singh, S., Burkle, F., & Mills, E. (2009). Prevalence of mental disorders among children exposed to war: A systemic review of 7,290 children. Medicine, Conflict and Survival, 25(1), 4–19. doi:10.1080/13623690802568913Find this resource:

Barbarin, O. A., Richter, L., & de Wet, T. (2001). Exposure to violence, coping resources, and psychological adjustment of South African children. American Journal of Orthopsychiatry, 71(1), 16–25.Find this resource:

Bartels, S. A., Scott, J. A., Leaning, J., Kelly, J. T., Mukwege, D., Joyce, N. R., & VanRooyen, M. J. (2012). Sexual violence trends between 2004 and 2008 in South Kivu, Democratic Republic of Congo. Prehospital and Disaster Medicine, 26(6), 408–413. doi:10.1017/S1049023X12000179Find this resource:

Basch, C. E. (2011). Aggression and violence and the achievement gap among urban minority youth. Journal of School Health, 81(10), 619–625.Find this resource:

Benhorin, S., & McMahon, S. D. (2008). Exposure to violence and aggression: Protective roles of social support among urban African American youth. Journal of Community Psychology, 36(6), 723–743.Find this resource:

Betancourt, T., Borisova, I., Williams, T., Meyers-Ohki, S., Rubin-Smith, J., Annan, J., & Kohrt, B. (2013). Research review: Psychosocial adjustment and mental health in former child soldiers—A systematic review of the literature and recommendations for future research. Journal of Child Psychology & Psychiatry, 54(1), 17–36. doi:10.1111/j.1469-7610.2012.02620.xFind this resource:

Blattman, C. (2006). The consequences of child soldiering. Retrieved from

Bleak future for former female fighters. (2011, March 8). IRIN News. Retrieved from

Boothby, N. (2006). When former child soldiers grow up: The keys to reintegration and reconciliation. In N. Boothby, A. Strang, & M. Wessells (Eds.), A world turned upside down: Social ecological approaches to children in war zones (pp. 155–178). Bloomfield, CT: Kumarian Press.Find this resource:

Briggs, J. (2005). Innocents lost: When child soldiers go to war. New York, NY: Basic Books.Find this resource:

Burrows, R., & Keenan, B. (2004). Bearing witness: Supporting parents and children in the transition to peace. Child Care in Practice, 10(2), 107–125.Find this resource:

Cabral, C., & Speek-Warnery, V. (2005). Voices of children: Experiences with violence. Retrieved from

Cambridge, P., & Williams, L. (2004). Approaches to advocacy for refugees and asylum seekers: A developmental case study for a local support and advice service. Journal of Refugee Studies, 17(1), 97–113.Find this resource:

Care International. (2008). Overcoming lost childhoods: Lessons learned from the rehabilitation and reintegration of former child soldiers in Colombia. Retrieved from

Centers for Disease Control. (2012). Youth violence. Retrieved from

Cheney, K. E. (2005). “Our children have known only war”: Children’s experiences and the uses of childhood in northern Uganda. Children’s Geographies, 3(1), 23–45.Find this resource:

Children wounded in war missing out on treatment. (2010, June 28). IRIN News. Retrieved from

Christian, M., Safari, O., Ramazani, P., Burnham, G., & Glass, N. (2011). Sexual and gender based violence against men in the Democratic Republic of Congo: Effects on survivors, their families and the community. Medicine, Conflict and Survival, 27(4), 227–246. doi:10.1080/13623699.2011.645144Find this resource:

Cluster Munition Coalition. (2012). Cluster munition monitor 2012. Retrieved from

Coalition to Stop the Use of Child Soldiers. (2007). Frontiers: Childhood at the borderline. Retrieved from

Coalition to Stop the Use of Child Soldiers. (2008). Returning home: Children’s perspectives on reintegration. Retrieved from

Corbin, J. (2012). African approaches to healing children and families affected by armed conflict: Implications for Western practice. In J. Corbin (Ed.), Children and families affected by armed conflicts in Africa: Implications and strategies for helping professionals in the United States (pp. 169–184). Washington, DC: NASW Press.Find this resource:

Delaney-Black, V., Covington, C., Ondersma, S. J., Nordstrom-Klee, B., Templin, T., Ager, J., et al. (2002). Violence exposure, trauma, and IQ and/or reading deficits among urban children. Archives of Pediatrics and Adolescent Medicine, 156, 280–285.Find this resource:

Denov, M. (2007). Girls in fighting forces: Moving beyond victimhood. Retrieved from

Derluyn, I., Broekaert, E., Schuyten, G., & De Temmerman, E. (2004). Post-traumatic stress in former Ugandan child soldiers. The Lancet, 363, 861–863.Find this resource:

de Silva, H., Hobbs, C., & Hanks, H. (2001). Conscription of children in armed conflict—A form of child abuse. A study of 19 former child soldiers. Child Abuse Review, 10, 125–134.Find this resource:

Doctors Without Borders/Médecins Sans Frontières. (2005). The crushing burden of rape: Sexual violence in Darfur. Retrieved from

Elbedour, S., Onwuegbuzie, A. J., Ghannam, J., Whitcome, J. A., & Hein, F. A. (2007). Post-traumatic stress disorder, depression and anxiety among Gaza Strip adolescents in the wake of the second Uprising (Intifada). Child Abuse & Neglect, 31, 719–729.Find this resource:

Fewer “I do’s” for former female rebels. (2011, February 23). IRIN News. Retrieved from

Fonseka, B. (2001). The protection of child soldiers in international law. Asia-Pacific Journal on Human Rights and the Law, 2(2), 69–89.Find this resource:

Former child soldiers at risk of HIV. (2008, February 15). IRIN News. Retrieved from

Fox, M. (2005). Child soldiers and international law: Patchwork gains and conceptual debates. Human Rights Review, 7(1), 27–48.Find this resource:

Gates, S., Hegre, H., Nygård, H. M., & Strand, H. (2012). Development consequences of armed conflict. World Development, 40(9), 1713–1722. doi:10.1016/j.worlddev.2012.04.031Find this resource:

Green, E. C., & Honwana, A. (1999). Indigenous healing of war-affected children in Africa. IK Notes, 10, 1–4. Retrieved from

Høiskar, A. H. (2001). Underage and under fire: An enquiry into the use of child soldiers 1994–8. Childhood, 8(3), 340–360.Find this resource:

Honwana, A. (2006). Child soldiers in Africa. Philadelphia, PA: University of Pennsylvania Press.Find this resource:

Human Rights Watch. (2003). “You’ll learn not to cry”: Child combatants in Colombia. Retrieved from

Human Rights Watch. (2004). Living in fear: Child soldiers and the Tamil Tigers in Sri Lanka. Retrieved from

Human Security Report Project. (2012). Human security report 2012. Retrieved from

IBON Foundation. (2006). Uncounted lives: Children, women and conflict in the Philippines: A needs assessment of children and women affected by armed conflict. Retrieved from$file/Uncounted + Lives + -Oct + 2006.pdf

International Campaign to Ban Landmines. (2012). Landmine monitor 2012. Retrieved from

International Campaign to Ban Landmines. (n.d.). The treaty. Retrieved from

Kanagaratnam, P., Raundalen, M., & Asbjørnsen, A. E. (2005). Ideological commitment and posttraumatic stress in former Tamil child soldiers. Scandinavian Journal of Psychology, 46, 511–520.Find this resource:

Kilpatrick, R., & Leitch, R. (2004). Teachers’ and pupils’ educational experiences and school-based responses to the conflict in Northern Ireland. Journal of Social Issues, 60(3), 563–586.Find this resource:

Kohli, R., & Mather, R. (2003). Promoting psychosocial well-being in unaccompanied asylum seeking young people in the United Kingdom. Child & Family Social Work, 8(3), 201–212.Find this resource:

Lynch, M. (2003). Consequences of children’s exposure to community violence. Clinical Child and Family Psychology Review, 6(4), 265–274.Find this resource:

Machel, G. (1996). The impact of armed conflict on children. Retrieved from

Machel, G. (2001). The impact of war on children. New York, NY: Palgrave.Find this resource:

McCabe, K. M., Lucchini, S. E., Hough, R. L., Yeh, M., & Hazen, A. (2005). The relation between violence exposure and conduct problems among adolescents: A prospective study. American Journal of Orthopsychiatry, 75(4), 575–584.Find this resource:

McKay, S. (2006). Girlhoods stolen: The plight of girl soldiers during and after armed conflict. In N. Boothby, A. Strang, & M. Wessells (Eds.), A world turned upside down: Social ecological approaches to children in war zones (pp. 89–109). Bloomfield, CT: Kumarian Press.Find this resource:

Milam, A., & Furr-Holden, C. (2010). Perceived school and neighborhood safety, neighborhood violence and academic achievement in urban school children. Urban Review, 42(5), 458–467.Find this resource:

Mitchell, F. (2003). The social services response to unaccompanied children in England. Child and Family Social Work, 8, 179–189.Find this resource:

Nelson, B. D., Collins, L., Van Rooyen, M. J., Joyce, N., Mukwege, D., & Bartels, S. (2011). Impact of sexual violence on children in the Eastern Democratic Republic of Congo. Medicine, Conflict and Survival, 27(4), 211–225. doi:10.1080/13623699.2011.645148Find this resource:

Neuner, F., Pfeiffer, A., Schauer-Kaiser, E., Odenwald, M., Elbert, T., & Ertl, V. (2012). Haunted by ghosts: Prevalence, predictors and outcomes of spirit possession experiences among former child soldiers and war-affected civilians in Northern Uganda. Social Science & Medicine, 75, 548–554. doi:10.106/j.socscimed.2012.03.028Find this resource:

No more child soldiers. (2012). IRIN News. Retrieved from

O’Loughlin, T. (2007, December 12). Education suffers amidst political tension and conflict in Gaza. Retrieved from

Ozer, E. J. (2005). The impact of violence on urban adolescents: Longitudinal effects of perceived school connection and family support. Journal of Adolescent Research, 20(2), 167–192.Find this resource:

Peace restored, but northern children still struggle. (2013, January 9). IRIN News. Retrieved from

Punamäki, R. (2001). From childhood trauma to adult well-being through psychosocial assistance of Chilean families. Journal of Community Psychology, 29(3), 281–303.Find this resource:

Risser, G. (2007). Children caught in conflicts: The impact of armed conflict on children in Southeast Asia. Retrieved from

Santacruz, M. L., & Arana, R. E. (2002). Experiences and psychosocial impact of the El Salvador civil war on child soldiers. Retrieved from

Save the Children. (2005). Forgotten casualties of war: Girls in armed conflict. Retrieved from

Scarpa, A., Haden, S. C., & Hurley, J. (2006). Community violence victimization and symptoms of posttraumatic stress disorder. Journal of Interpersonal Violence, 21(4), 446–469.Find this resource:

Schmidt, S. (2005). Liberian refugees: Cultural considerations for social service providers. Retrieved from

Sexual violence continues in IDP camps. (2008, March 4). IRIN News. Retrieved from

Shakya, A. (2011). Experiences of children in armed conflict in Nepal. Children and Youth Services Review, 33, 557–563.Find this resource:

Shields, N., Nadasen, K., & Pierce, L. (2008). The effects of community violence on children in Cape Town, South Africa. Child Abuse & Neglect, 32, 589–601.Find this resource:

Singer, P. W. (2005). Children at war. New York, NY: Pantheon Books.Find this resource:

Special Representative on Sexual Violence in Conflict. (2012). Press conference by Secretary-General’s Special Representative on Sexual Violence in Conflict. Retrieved from

Stein, B. D., Jaycox, L. H., Kataoka, S., Rhodes, H. J., & Vestal, K. D. (2003). Prevalence of child and adolescent exposure to community violence. Clinical Child and Family Psychology Review, 6(4), 247–264.Find this resource:

Summerfield, D. (2000). Conflict and health: War and mental health: A brief overview. BMJ, 321, 232–235.Find this resource:

Thabet, A. A. M., Abed, Y., & Vostanis, P. (2002). Emotional problems in Palestinian children living in a war zone: a cross-sectional study, Lancet, 359(9320):1801-1804.Find this resource:

Thabet, A. A. M., Abed, Y., & Vostanis, P. (2004). Comorbidity of PTSD and depression among refugee children during war conflict. Journal of Child Psychology and Psychiatry, 45(3), 533–542.Find this resource:

Thabet, A. A., Abu Tawahina, A., El Sarraj, E., & Vostanis, P. (2008). Exposure to war trauma and PTSD among parents and children in the Gaza Strip. European Child & Adolescent Psychiatry, 17(4), 191–199. Retrieved from this resource:

Thabet, A. A. M., & Vostanis, P. (1999). Post-traumatic stress reactions in children of war. Journal of Child Psychology and Psychiatry, 40(3), 385–391.Find this resource:

Thompson, T., & Massat, C. R. (2005). Experiences of violence, post-traumatic stress, academic achievement and behavior problems of urban African-American children. Child and Adolescent Social Work Journal, 22(5–6), 367–393.Find this resource:

UNESCO. (2011). The hidden crisis: Armed conflict and education. Retrieved from

UNICEF. (2001). Adult wars, child soldiers. Retrieved from

UNICEF. (2005). The impact of conflict on women and girls in west and central Africa and the UNICEF response. Retrieved from

UNICEF. (2006). State of the world’s children 2006. Retrieved from

UNICEF. (2012a). Education in emergencies and post-crisis transition. Retrieved from

UNICEF. (2012b). Education in Somalia. Retrieved from

United Nations. (2012). Report of the Special Representative of the Secretary-General for Children and Armed Conflict. Retrieved from

United Nations. (n.d.). The six grave violations. Retrieved from

United Nations High Commissioner for Human Rights (2012). Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in armed conflict. Retrieved from

United Nations High Commissioner for Refugees. (2011). UNHCR statistical yearbook 2010 (10th ed.). Retrieved from

United Nations Security Council. (2006). Report of the Secretary-General on children and armed conflict in Sri Lanka. Retrieved from

United Nations Security Council. (2007). Report of the Secretary-General on children and armed conflict in Sri Lanka. Retrieved from

United Nations Security Council. (2012a). Children and armed conflict: Report of the Secretary-General. Retrieved from

United Nations Security Council. (2012b). Report of the Secretary-General on the situation of children and armed conflict affected by the Lord’s Resistance Army. Retrieved from

United Nations Security Council. (2012c). Conflict-related sexual violence: Report of the Secretary-General. Retrieved from

United Nations Special Representative of the Secretary-General for Children and Armed Conflict. (2012). Annual report of the Special Representative of the Secretary-General for Children and Armed Conflict. Retrieved from

Urban violence—New territory for aid workers. (2013, January 8). IRIN News. Retrieved from

Voisin, D. R. (2003). Victims of community violence and HIV sexual risk behaviors among African American adolescent males. Journal of HIV/AIDS Prevention & Education for Adolescents & Children, 5(3/4), 87–110.Find this resource:

Wallen, J., & Rubin, R. H. (1997). The role of the family in mediating the effects of community violence on children. Aggression and Violent Behavior, 2(1), 33–41.Find this resource:

Wessells, M. (2006). A living wage: The importance of livelihood in reintegrating former child soldiers. In N. Boothby, A. Strang, & M. Wessells (Eds.), A world turned upside down: Social ecological approaches to children in war zones (pp. 179–197). Bloomfield, CT: Kumarian Press.Find this resource:

Youth again forced to fight in Congo, aid group says. (2007, December 25). New York Times, p. A4.Find this resource:

Živčić, I. (1993). Emotional reactions of children to war stress in Croatia. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 709–713.Find this resource:

Zwi, A. B., Grove, N. J., Kelly, P., Gayer, M., Ramos-Jimenez, P., & Sommerfield, J. (2006). Child health in armed conflict: Time to think. The Lancet, 367, 1886–1888.Find this resource: