Skip to content

Bishoy Goubran, MD on the Consequences of War on Children and Adolescents

2023-01-19

Author(s): Scott Douglas Jacobsen

Publication (Outlet/Website): The Good Men Project

Publication Date (yyyy/mm/dd): 2023/01/18

Scott Doulas Jacobsen: Trauma is a terrible consequence of war and conflict zones. As noted by numerous human rights documents, in war and conflict zones, the major non-combatant victims are women and children. Those can come with long-term trauma, PTSD, CPTSD, etc. Your specialty is in child and adolescent psychiatry. What issues arise for children who undergo the trauma of conflict zones and war?

Bishoy Goubran, MD: The brain is born with neural algorithms optimized for learning. However, in a war zone, the child’s brain quickly learns that the world is full of threats. The basic safety needs are not met. Physiological, metabolic, and circadian necessities are disrupted. Under these precarious circumstances, the neural program switches to a survival mode, descending to the lowest tier of Maslow’s hierarchy of needs. This shift in focus negates the children’s innate proclivity towards creativity, collaboration, and self-actualization, and instead, they are left in a state of defense. This can become incapacitating as the child’s cognition becomes hypercautious in an attempt to avoid further trauma, pain, or betrayal.

Trauma directs the child’s ontology moving forwards towards hypervigilance, paranoia, and anxiety. The world is no longer seen as a safe place. In a war zone, children may experience trauma by witnessing the violent death or injury of loved ones, being attacked, or sexually assaulted themselves, or their homes being destroyed. Not to mention that in some conflict areas, children themselves are recruited to fight. All of which creates an increased risk of experiencing traumatic events of different thresholds. Trauma transcends time and space, taking hold over bodily functions for many years and sometimes a lifetime after its inception. It affects the brain, hormones, and has a multisystemic effect on bodily functions. It not only acts on neurological and psychological levels. it also becomes so embedded in the system that it acts epigenetically to shape, unmask, and instigate other Psychosomatic and psychiatric illnesses.

Trauma not only leads to Post Traumatic Stress Disorder (PTSD) but also mood disorders such as depression and bipolar disorder can be instigated by trauma, as can psychotic disorders like schizophrenia. Traumatized children may engage in self-harming behaviors in an attempt to alleviate psychological pain and bring it under their control. When faced with chaos, a phobia of disempowerment and a phobia of unpredictability may become central in their sense-making. Other maladaptive coping mechanisms may include substance abuse and dissociation from reality.

The consequences of trauma on children can be severe and can affect Children’s development, learning, and general functioning in the long term. There is a study published in the Journal of the American Medical Association, that shows that adults who experienced trauma during childhood are more prone to developing chronic conditions such as heart disease, diabetes, and obesity. Also when it comes to academic performance, a study conducted in war-affected regions of Afghanistan elucidated that children who experienced trauma had lower academic achievement and were more likely to repeat grades compared to non-traumatized peers.

Also, direct trauma aside, the sensory experience of war — the loudness of war machinery, sounds of gunshots, explosions, demolitions, bombardment — can be very overwhelming for children and drastically worsen their mental well-being. Especially children with sensory integration and processing difficulties where their senses often exaggerate vibrations and acoustic frequencies. We see that often in patients within the Autism Spectrum and those with Attention Deficit Hyperactivity Disorder.

Jacobsen: Can you tell us more about dissociative experiences?

Goubran: Well, dissociative experiences involve a disconnection between a person’s thoughts, emotions, and sense of self. You can think about it as a defense mechanism, if the brain feels that the pain is too much, and escape is difficult, it “ejects” the sense of self like a pilot ejects themselves from a fighter jet when its destruction seems inevitable.  Dissociation can appear as depersonalization, where the child no longer feels they exist within their body. It can also appear as Derealization, where the conscious experience of reality as real diminishes or changes.

Rarely following chronic, early trauma, a complete disruption of the identity can happen. A disorder known as Dissociative Identity Disorder (DID), colloquially known as multiple personalities or split personalities. It is a disorder characterized by the disruption of identity into more than two distinct personality states. Memories of the trauma are compartmentalized and repressed.  One of these “alters” or “identities” may be the “trauma holder,” hiding in the recesses of the subconscious, holding the pain of the trauma and emerging only at certain times to deal with perceived threats. The other identities may serve different functions and allow the individual to adapt to life despite the trauma they have experienced. The result is a disruption of a sense of continuity and agency over the self, as each personality state seems to take over the individual.

Jacobsen: How does PTSD appear in children? 

Goubran: There is something very somatic and visceral about PTSD and its responses. It affects the limbic system which is the system responsible for emotional processing. It also creates ripples affecting multiple brain networks. We know it alters the hippocampus, amygdala, and fear-processing centers in the brain. Disrupting the emotional and reflex pathways and creating micro behaviors that short-circuit the volitional part of the brain. It also affects the insula, changing the way the body calibrates its responses to the external environment.

PTSD can occur immediately following the trauma or may be delayed. It presents with a constellation of symptoms and a set of criteria. One of the darkest PTSD symptoms in my opinion is avoidance. Victims may avoid talking about or recalling the trauma. As well as avoiding anything that reminds them of the traumatic event, such as a specific location, type of noise, scent, picture, or a visual reminder. This avoidance can become almost addictive, as it provides temporary relief from triggers. The alleviation of tensions by avoiding potential triggers lights up the brain’s reward system. If a brain gets conditioned and addicted to avoidance, imagine the debilitating repercussions this can have on a child. At times, avoidance grows more pathological, and the child’s avoidance list starts to become broader, more symbolic, and encompassing more elements as it becomes more generalized. Triggers expand to include even innocuous stimuli with a very distant association with the actual trauma, almost to the point of avoiding life itself. At best, avoidance drastically hinders the Child’s ability to explore and engage with the world.

PTSD also comes with “intrusion symptoms” such as distressing intrusive memories of the traumatic event. Children often call them “sticky thoughts” because they are difficult to get rid of once they arise. Other symptoms could be recurrent nightmares, which may render going to sleep a dreadful event for some of our patients.  Sometimes children experience dissociative flashbacks, where they almost relive the trauma, acting and feeling as if it is actually happening again. We also know that children may sometimes try to re-enact the trauma during play which can give us clues about the nature of the trauma. Sometimes we use that as a tool during play therapy to explore, understand and treat the child’s perspective of the traumatic event. PTSD can be so elusive, and aside from typical symptoms, it can also appear as distractibility, and mood disturbances. It can present with fatigue and low motivation. Children may struggle to go to school, and their brains may grow resistant to the process of learning.

Jacobsen: What are the types of treatments that help with Children suffering PTSD in conflict zones? 

Goubran: Systems have been put in place to provide targeted support to children in conflict zones. These programs focus on increasing the resilience and adaptive capabilities of children, as well as providing community and family support. Global health approach to the problem can be preventative and also curative by mitigating the risk factors as well. However, the effectiveness of these programs is contingent on funding, logistics, and accessibility. All of which, can be greatly affected in conflict zones.

When it comes to individual treatment however, the two main pillars are therapy and psychopharmacology. Therapy plays a central role in treating PTSD. Two of the highly effective, evidence-based form of therapy are Cognitive Processing Therapy (CPT) and trauma-focused Cognitive Behavioral Therapy (CBT). These approaches generally aim to help patients understand and process their trauma and to change the way they think about and perceive the event. It also involves cognitive restructuring by guiding the child to re-experience safety and trust in everyday life. Learning how to activate fear extinction and regain control over the memories stored in the body. By doing so, individuals can begin to untangle the effects of trauma and create a new narrative for their lives post-conflict. Other therapeutic tools include prolonged exposure therapy, eye movement desensitization and reprocessing, psychodynamic and psychoanalytic therapy, and biofeedback techniques such as breathing exercises can also be utilized.  Also, another therapeutic aspect is that parents can act as an external container to hold, process, and sort of transmute their children’s fears, and instill a sense of safety, structure, and predictability. Therefore, family and parental therapy is an important angle when designing the treatment.

As for medication, there are psychopharmacological tools that target PTSD symptoms depending on the presentation. We often use medications from the antidepressant class as it seems that Serotonin disruption plays a major role in PTSD psychopathology. We can also help mitigate symptoms such as sympathetic hypervigilance by medications that help soothe the autonomic hyperarousal or treat nightmares using psychopharmacological tools that alter the sleep architecture thus interfering with the sleep phases conducive to nightmares. Medications can be utilized to treat the underlying depression or mood disorder. It is definitely very individual presentation based and there is no one size fits all treatment.  Depending on the severity of the case, typically, a combined approach comprised of therapy and a tailored medication regimen is effective.

Ultimately It is in the art of psychiatry to really absorb the multifaceted experience of the patient’s reality and craft an approach to treatment based on that very nuanced impression. Hence, it’s personalized medicine, while, of course, adhering to evidence-based guidelines. I also want to end this interview, on a positive note, that with treatment and therapy, there is big hope. Traumatized children can gradually heal, be liberated from the effects of trauma, and lead beautiful, healthy, and fulfilling lives. Finally, if you or anyone you know have been a victim of any type of trauma, I definitely recommend you seek medical attention and connect with a psychiatrist and a therapist so you can accelerate your recovery and healing journey.

Bishoy Goubran, MD, is a board-certified psychiatrist specializing in Child and Adolescent Psychiatry. He received postdoctoral research training in Behavioral and Cardiovascular medicine. Dr. Goubran’s research interest is in psychosomatic medicine. 

License

In-Sight Publishing by Scott Douglas Jacobsen is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Based on a work at www.in-sightpublishing.com.

Copyright

© Scott Douglas Jacobsen and In-Sight Publishing 2012-Present. Unauthorized use and/or duplication of this material without express and written permission from this site’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Scott Douglas Jacobsen and In-Sight Publishing with appropriate and specific direction to the original content. All interviewees and authors co-copyright their material and may disseminate for their independent purposes.

Leave a Comment

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: