Running head: CHILD MENTAL HEALTH ON CONFLICT-AFFECTED COUNTRIES 1

Child Mental Health on Conflict-Affected Countries: A Literature Review of The Case and

Future Implications for Governmental Entities

Nazrin Abdullazada

ADA University
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Child Mental Health on Conflict-Affected Countries

17-year-old Samia became the winner of the World Health Day Art Competition

organized by the Afghanistan Ministry of Public Health and the WHO in 2017. Samia’s drawing,

"Depression" illustrated a person saving a friend on the dark side. She got the inspiration for her

drawing from her sister who suffered from depression. Samia said, "For a long time, she just

wanted to stay in her dark room without talking to anyone. My mother and I talked to her a lot,

and she got better." Samia’s sister was lucky, unlike other children who suffer from war-

generated mental disorders. Save the Children (2019) reports 142 million children settling in

conflict areas, and about 24 million children need mental aid. According to Muthanna et al.

(2020), children in armed conflict zones raise the predominance of mental illnesses, such as

PTSD (the post-traumatic stress disorder), behavioral difficulties, and depression. Consequently,

children with war and post-war traumas are more likely to experience the risk of suicidal

thoughts, hypervigilance (extremely sensitiveness to unreal danger), stereotypical behaviors, and

educational challenges, which affect them negatively in the next stage of their lives. (Muthanna,

2020) A systematic qualitative study conducted by interviewing 1011 children and caregivers

from Bamyan, Kabul, and Mazar-e-Sharif discovered a frequency of 22.2 percent probable

psychiatric disorders across 1011 kids aged 11 to 16. (Panter-Brick et al., 2009). Afghan child

mental health outcomes derive from two dominant factors: The macro-level direct war traumas

as primary derivatives and the daily experiences deriving from war indirectly (Ventevogel,

2013). Even if the Afghan government concern child psychological well-being and adopt

intervention programs addressing basic needs (health, education, safety access), the outcome of

the study suspected the effectiveness of the interventions to repair war-related mental disorders.

Scarce data and unavailability of convenient conditions limit a detailed insight and effective
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interventions. This paper reviews the previous findings on the variables of child mental health in

Afghanistan and other war-affected countries, which own extensive data and similar economic,

cultural, and social context. Also, paper contributes to the discussion of preceding interventions

for the solution.

Literature Review

The solution to the child mental problems in low-income countries is important to

increase the overall well-being of citizens to have a more productive and sustainable future

generation. Determining the underlying factors to change the Afghan government’s unsuccessful

intervention strategy by paying attention to the Afghan children’s daily experiences is the main

objective. The derivatives, gender-specific approaches, and coping techniques are the main

debatable aspects of the problem and are still investigated.

Derivatives of child mental disorders

An important factor on Afghan children’s war-related mental disorders is debate over the

derivatives. Conducted studies to find the main determinants in and post-war stage, since the

Taliban, determined two main paths for the derivatives of psychological disorders stem from the

war: direct (exposure to Taliban violence, loss, bombs), and indirect (outcomes of the war on the

social environment: poverty, unsafe family variables so-called daily stressors). (Miller &

Jordans, 2016) A paradigm that represented the "war exposure" concept shaped almost all the

initial studies in which military exposure was dominant, and little importance was attached to the

effects of daily stressors, the insistently mentally taxing everyday life circumstances caused by

armed conflict. However, Khamis’s study proved that everyday stressors have indeed been

observed to mediate the impact of military confrontation on child mental wellbeing substantially

or completely (Khamis, 2014), and even have regularly exceeded direct war experiences in terms
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of their effects on distress. (Panter-Brick et al., 2011) The great prominence of conflict violence,

including military troops' rocket strikes, deadly bombardments, physical and sexual violence

make it more likely to underestimate the aggression that children often face in private settings.

(Panter-Brick et al., 2014) The current findings indicate that children in war settings don't only

deal with violence and loss that derived from war, they also deal with the obstacles to their

quality of life while dealing with limited social resources and coping with the stresses of regular

life. (Masten & Narayan, 2012)

Gender differences

Another significant aspect of the issue that is worth attention is gender in child mental

experiences. Gender discrimination, social inequity, and marital challenges are frequently

identified as variables contributing to child psychosocial and mental disorders. According to the

study, Afghan girls are 2.5 times much more predisposed to mental abnormalities compared to

the male participants. (Panter-Brick and colleagues, 2009). The increasing suicide efforts are the

evidence of the depression that most of Afghan girls experience when seeking to integrate a ‘new

generation' gender identification with ‘conventional' Afghan female responsibilities created

during Taliban regime and war. (Billaud, 2013). As contrasted to males, Afghan teenage females

may seek resolution on self-injury (Ventevogel, 2013). “Purdah” is one of the notions that

emerged during the Taliban war, and affects to the girls’ mental health negatively by separating

the masculine domain from the tightly restricted female sphere. It was considered a vital aspect

of a man's honor to "guard" a girl against external impacts. Excessive seclusion of girls during

the war time, particularly those in cities who were restricted to tiny houses that they might not

leave, caused significant emotional stress and suffering (Dupree, 2004). However, this ‘purdah-

related depressed mood' is entrenched in Afghan society, continues to exist even after the war,
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and is the cause of psychological discomfort. In recent years, the new government adopted a plan

to strengthen girls' social liberties and psychological well-being, which possess a significant

influence in the female children’s mental health, but the initiatives directly concern familial

aggression, psychiatric problems, promoting their rights essentially fostered the issue, and had

counter-effect. (Ventevogel, 2013) The reason of this counter-effect is the cultural variable.

Males frequently refuse to acknowledge the stress derived from purdah as a probable

determinant of female children’s mental difficulties, which means the culture factor should be

considered, and any interventions opposite to culture should be implemented in a careful manner,

otherwise, the outcomes of such interventions will be undesirable. In another research of children

in Afghanistan's four north areas, surprisingly, male respondents reported greater levels of mental

sensitivity in contrast to common sense (Ventevogel, 2013). The unexpected result that male

children and adolescents reported more issues than females may be accounted with males' higher

vulnerability to environmental stress factors, more independence of movement, are dominantly

engaged in working settings that may subject them to maltreatment, while female children were

more reserved. Several opponents claim that boys are more eager to articulate their mental

displeasure, whilst girls are timid because of cultural context. However, it seems that male

children also aren’t open about their problems due to Afghan culture’s male role expectations. In

Afghanistan, males have cultural hinders like an “obligation” to be “strong”, and a perception of

“A man doesn’t cry”, which lead to the underestimation of male children’s mental challenges and

demonstrate the female children more vulnerable to psychological disturbance.

Children’s coping ways with mental risks

One of the widespread study questions that attract most researchers, is how war-affected

children deal with war and post-war-generated mental disorders. Despite common sense, not all
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children with war-related traumas display long-run impacts, and even several amounts of them

adapt to traumas by demonstrating a minor pathology. (Fuaad, 2015) This finding led to the

emergence of further concepts on the variation of coping strategies and raised the question why

some children’s psychological defenses easily adapt to stressful situations, while the

overwhelming percentage of the children exhibited psychological symptoms, (Ventevogel, 2013)

and experience long-term mental consequences. According to Fuaad, there are some mental

defensive strategies, which protect the war-affected children from failing to serious mental

disorders: self-originated methods and external supplements. The children's ability to operate

anxiety, to detect and mitigate the mental risks, to commit themselves to a future goal, so-called

“hope” in cultural context (Ventevogel, 2013), and finally to build trustable relationships with

their caregivers to use their protection factor are among self-originated methods. As an example,

from Afghan children's perspectives, persistence is required to attain a goal, and dedication and

heavy effort (koshesh in culture) may help them advance their quality of life, which is the most

used coping technique (Panther-Brick, 2010). On the other hand, external social elements like the

attachment to a social group (united beliefs), the social and familial level of cohesiveness also
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should be considered mediating factors in the war-affected children’s coping techniques. The

significance of external factors stems from the fact that stress is transmitted collectively rather

than individually. The mental state of a person is easily affected from the psychological condition

and support of the community. As a result, the investigation of children’s coping ways with the

psychopathology are taken as a model and basis to implement effective future interventions and

plays the role of a guide for sustainable development programs on the issue.

Retrieved from https://doi.org/10.1007/978-1-4614-6375-7_5

Discussion

The study purposes to demonstrate how war-generated daily factors foster mental issues

in Afghan children by reviewing the previous research findings. While a considerable amount of

previous research evidence points to the direct war exposure (military attacks, child soldiers,

abuse, and so on) as the main derivative, the adopted research approach mainly supports the idea

of indirect war outcomes becoming the influential in the emerging child psychopathology.

War-generated daily factors as the derivative

Panter-Brick’s evidence proves the correlation between children’s psychiatric

abnormalities and stressful exposure to lifetime violence. The everyday adversities emerging

within family and society deriving from post-war-generated political and socio-economic

pressures are slightly dominant in the occurrence of mental challenges (Panter-Brick, 2011).

When it's considered that war ended and the Taliban regime failed, the evidence on the

dominance of daily stressors in Afghan children's mental condition is much sounder. It’s been 20

years that the conflict ended, and the traumatized children of war turned to adults with

psychopathology. As a result, time-variable changes the scope and directs the research subject

from the children with war traumas to the children with daily trauma disorders caused by the
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adults who suffered from war-generated challenges. Even if the political violence still exists in a

less matter and creates insecurity issues in several regions, the outcomes of war violence don’t

appear in a great manner in the post-war-born children’s mental problems because they haven’t

directly exposed to war-violence (2001-2021). However, social, and familial issues resulting

from the war still have a negative impact on Afghan children’s psychological state. (Ventevogel,

2013) Based on the evidence, the correlation between Afghan children’s psychological well-

being and social and family context is inevitable. Afghan children with poor social relationships

and live with families struggling with indirect long-term war outcomes are more likely to face

early marriage, workload, sexual and household aggression to “save” their families from the

despaired situation, which have more destructive results on Afghan children’s psychology. The

conclusion made based on the last studies, Afghan children's mental distress must be examined,

and interventions should be implemented by considering the critical significance of daily

hardships rooted in social issues like poor financial condition rather than focusing on the direct

wartime impacts.

Research limitations to generate issue-focused interventions

Even if the research provided evidence for the new perspective on the issue and an

extensive source list, some aspects limit more efficient results. The first limitation is the lack of

original data. Researchers mostly use Panter-Brick’s data as secondary data and, there is no

attempt to generate original updated data since 2011, which prevents researchers from making

contemporary conclusions. The second limitation is the data gathering process. The data

collected in a limited number and areas doesn’t represent the whole segment of the targeted

group, so the results aren’t generalizable. The last limitation of studies on the issue is that the

researchers didn’t provide the interview questions that they used. To provide the qualitative
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questions and rationalize why the questions were asked usually increases the reliability of the

results. In this case, the researchers haven’t provided the questions, which put the readers under

suspicion about whether the questions were relevant to investigate the Afghan children’s mental

problems. Also, this limitation prevents future researchers to analyze the qualitative questions

and improve the upcoming results.

Research and intervention recommendations

Referring to the limitations, the research area and age range should be expanded. To

increase the samples (1000 children from each segment) will help the researchers to get an

objective picture. Furthermore, researchers are advised to generate updated original data instead

of sticking to the previous ones because variables change over time, it means the results that the

researchers get won’t necessarily reflect the current situation unless they generate new data.

Additionally, considering the reserved nature of Eastern countries, participatory action research

is recommended as a more appropriate data collection method because children are more open

about their experiences and desires about what measures should be taken in group conversations

with the ones sharing similar experiences rather than interviewed by an unknown person. In

terms of interventions, culture variable plays an important role, the interventions that threaten

society’s cultural believe worsen the issue rather than solving. As the example in “Gender

differences”, the intervention had counter-effect because of Western style approach. It’s

recommended to demonstrate people, how they’ll benefit from the women’s mental

empowerment, and policymakers use “hope for resilience” notion (widespread in Eastern

society) as the supplementer. Finally, governments should precisely estimate intervention quota

considering the war-generated diminishing economy. According to interventions pyramid, there

are 4 layers. It’s obvious that not each child will need all intervention layers. As it’s mentioned in
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the children’s coping ways, some children deal with mental challenges easily, meaning that basic

need interventions will be enough for them. The children experiencing higher mental disorders

surely will need the higher intervention styles. As a low-income country, wasting money on

unnecessary programs worsen the situation because poverty is the primary factor fostering daily

stressors and child mental problems as it’s in the evidence. For instance, if the interventions

target 10 million children, but only 5 million children need this program, so the government

waste their financial power. Wasted money means poorer and sadder families and more children

with mental disorders. Hence, the government should indicate the target child population of

interventions.

Conclusion

To conclude, child mental well-being is the significant governmental and social problem

creating an undesirable cycle. The evidence clearly defines that the psychopathology rate among

Afghan children exceeds normal rate (Panter-Brick, 2011), and indirect war outcomes like social

and financial challenges within society dominate the direct war exposure as the cause of

increasing psychopathology. (Ventevogel, 2013) The elimination of the limitations like scarce

data, research methodology, and transparency will raise objectivity and efficiency of the

upcoming studies. The findings’ practical implications make war-affected governments realize

the possible danger of psychopathological adults that stems from the war-traumatized children to

break the vicious cycle of mental problems in low-revenue countries. The main contribution of

the research is the demonstration of main problems and pathways to child mental disorders in the

Afghan government’s decision-making process on intervention strategies. Still conducting more

research by eliminating research mistakes is required to obtain more rational and updated

outcomes on the issue.

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Fuaad, M. F. (2015). Psychological effects of war and violence on children. Journal of

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