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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 4
| Issue : 2 | Page : 63-68 |
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Mental Health Disparities of Ukrainian Children Exposed to War: A Narrative Review
Aida Mihajlovic1, Lara Segalite2, Allison Lawler3
1 Adult Outpatient Psychiatry, Union Health Services; Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
2 Psychiatry Residency Faculty, Advocate Lutheran General Hospital, Park Ridge, IL, USA
3 Chief Resident of Psychiatry, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| Date of Submission | 29-Jun-2022 |
| Date of Decision | 29-Jun-2022 |
| Date of Acceptance | 30-Jun-2022 |
| Date of Web Publication | 22-Aug-2022 |
Correspondence Address:
Dr. Aida Mihajlovic
Adult Outpatient Psychiatry, Union Health Services, W Polk Street, Chicago, IL 60612
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_20_22
Although there has been a lot of research focused on the effect of war on child refugees, along with those impacted directly, there are no recent studies comparing these two groups side-by-side. In this paper, we review psychiatric comorbidities associated with children (defined as 17-year-olds and younger) exposed to war, with an additional emphasis on approaches to treatment. In addition, we aim to understand these children's thoughts and insights into their situation(s). We will do so by presenting narratives given by close relatives of (1) two children currently in Ukraine in the midst of the war, (2) another young Ukrainian child war refugee who was able to recently leave the country, and (3) an adult and his experiences of being a war refugee and then resettling in the United States as a child. We never know when or where a war will begin. It is important that we have mental health professionals that can help children through the current and unexpected adversities that arise with war and displacement. These children need assistance with their uncertainties about the future and the risk of disruption of peace or comfort. Moreover, mental health disparities are substantial amongst children exposed to the traumas associated with war, and treatment is limited. We share this research to encourage mental health professionals to seek understanding of the impact the current war is having on Ukrainian youth. It is our hope that, with presenting these narrative accounts, mental health providers will gain a deeper understanding of what these children are encountering and will become prepared to support them and their mental health.
Keywords: Mental health disparities, posttraumatic stress disorder, trauma, Ukrainian children
How to cite this article:
Mihajlovic A, Segalite L, Lawler A. Mental Health Disparities of Ukrainian Children Exposed to War: A Narrative Review. World Soc Psychiatry 2022;4:63-8 |
| Introduction | |  |
The current war in Ukraine is leading to many children being directly subjected to a war environment and even more being displaced as refugees. Unicef reports that, as of March 2022, half of the Ukrainian refugees are children, causing 60% of all Ukrainian youth to seek refuge away from their home country.[1] Exposure to war and military aggression can be considered a violation of the basic human rights of children.[2] As these children seek refuge in other countries, and potential resettlement in the United States, it is imperative that we gain an understanding of both the mental health of child refugees as a whole, along with the unique circumstances of the refugees from the current war in Ukraine.
The prevalence of mental health disparities in children exposed to war is substantially higher than that of the general population.[3],[4] The effect of war and displacement can be detrimental to youth, as this is a critical time in their physical, mental, and neural development.[5],[6] Due to this unique developmental period, war refugee children are at a higher risk of developing psychological illness.[7] Moreover, trauma experiences and stressors may have an immense, lasting effect on children's overall physical and mental wellbeing.[5],[6] Although there is scarce literature on refugee youth resettling in “high-income” countries such as the United States, the available studies show an increased risk of poor psychological outcomes and psychiatric diagnoses.[5]
There is currently a lack of understanding about refugee youth and their psychological vulnerabilities, which suggests a need for improvement of mental health services and treatment effectiveness in this population.[8] It is important to gain direct insight from affected youth because understanding the child's perspective is a necessity for assessing the best interests of a child. However, while seeking refuge, children often experience mistreatment, which can reduce trust when it comes to sharing their stories. That being said, they are often more likely to be open and honest with someone they know and trust.[9] Obtaining information from close relatives is useful, as many child refugees may view family as the source of their protection against their unpredictable world.[10] Most studies involving youths are retrospective to trauma exposure, limiting the understanding of the correlation between the impact of trauma and developmental timing. Developmental timing of trauma exposure is a key determinant for developing psychopathology.[11] Thus, both children currently in a war zone and those that have already attained refuge are included in this study.
Using narratives as a means for evaluating mental health is invaluable, as Healthcare providers have described that a preferred approach to assessment is through narrative. Narratives allow providers to get to know their patients and their background, journey, cultural and religious practices, and experienced trauma. This allows providers to have more insight into the patient's mental health and to be able to employ a patient-centered and individualized approach.[12] Furthermore, the goal of obtaining a narrative should go beyond assessing and treating mental health disparities, and should “reclaim the social and psychological landscape of childhood” for these children.[13]
Due to the high prevalence of mental health disparities in child war refugees and the limited insight into their treatment, we aim to introduce narratives as a method of beginning an understanding of their journey and unique needs. We would like to present narratives, as dictated by close relatives, of youth currently in the war area who recently sought refuge, along with those who have been affected from the refugee process in the long-term.
In this article, we aim to perform a necessary task by providing historical narratives given by close relatives for four youths that were directly involved in, or attained refuge from war. We will use current literature to reflect on these children's experiences and to discuss currently available treatment modalities.
| Methods | | |
Due to the serious nature of the situation in Ukraine and urgency of this research initiative, we conducted a selective, succinct review of the available literature found currently in the PubMed database regarding youth affected by war or displacement. The purpose of this literature search was two-fold: To review current mental health disparities and available treatments for this population, and to conduct a needs assessment for the specific aforementioned aims of this paper.
The PubMed database was searched using keywords “refugee,” “war,” and “mental health or psychiatry” [Figure 1]. The search was then limited to the past 10 years and then the past 5 years. Each article was screened to determine a specific focus on youth and mental health disparities and/or treatment. If these criteria were met, the article was further reviewed and, if relevant, incorporated into this paper.
Additionally, four narratives were obtained from close family relatives of two children currently in Ukraine during this war, a child who recently sought refuge from Ukraine, and an adult who sought refuge from his home country of Russia in his youth. These narratives were summarized, scanned for themes, and correlated with the current literature.
| Results | | |
The PubMed search yielded a total of 706 articles. When limited to the past 10 years, this number decreased to 421 articles. When limited to the past 5 years, this number decreased to 282 articles. Of these 282 articles, when examined more thoroughly, less than a third (77) of the remaining articles focused specifically on youth. Of the remaining 77, less than half (34) had a specific focus on investigating the mental health disparities and/or treatment for youth refugees or youth exposed to war. These were analyzed, and the results were summarized below. Only 3 of the 34 remaining studies addressed war refugees that resettled in the United States.[5],[10] Additionally, only one of the final 34 articles focused on the youth involved in the current Ukraine war.
| Case Reports | | |
Girl A
A gentleman tells the story of his young niece – we shall call her Girl A – a 9-year-old girl currently living with her parents in Ukraine. The multi-family building they call home is still intact, but they must seek refuge in the building's basement, from dawn until dusk, along with 20 other families. Girl A's friends who have lost their homes due to destruction now seek refuge at train stations or under bridges, and she no longer sees them every day at online school. She is nervous every night when she ascends the stairs to her apartment after sunset to see if her home is still there. She longs to go out into the fresh air, but her parents will not allow her to, as she may get hurt or killed. She hears mothers discussing seeking refuge in another country, but they do not want to leave their husbands, who must stay to fight for the military. Elderly family members that are not well enough to travel would be left behind as well. Her father, the family's sole provider of basic necessities, must leave them every day to prepare to fight in the war. She worries that he will not return. Girl A feels uncomfortable talking about her worries to her mother, who is already overwhelmed. Also, girl A can no longer seek support from her friends, as many have stopped coming to school. She is unsure whether they are homeless, have left the country, or have been killed. She imagines that they are in another country – which she describes as paradise – as she sits in a crowded basement with minimal food and water. Girl A expresses that she copes by setting a schedule each day with a similar routine. This gives her a sense of control in her life while facing all of the unknowns regarding her future.
Girl B
A woman shares the story of her grand-niece – we shall call her Girl B – who is also currently in Ukraine during this war. As with Girl A, 7-year-old Girl B lives in the basement of her home with her mother and 2 younger sisters. However, girl B lives in a farmhouse, so her basement is a soil floored area of 3 m × 2 m. Her father is an oil engineer and cannot return to his family in Ukraine due to border closures; he is stuck in Turkmenistan. Girl B does not have access to online school and learns from her mother, but has trouble concentrating due to hunger. Girl B misses going to school, but is scared of being attacked; she has a friend who saw his parents get shot in front of him by a sniper. He was able to escape, but the bullet was so close to him that he could feel it pass him. She constantly sees soldiers with missing limbs, and this scares her. Girl B's constant fear and anxiety is only worsened by the bombings and sirens she hears every day and night. She asks her family to share any accurate updates about the war with her. Hearing conflicting things from her family and soldiers confuses her, causing her to feel disoriented, and thus more anxious. She feels unsafe and wants to seek help directly, but she and her family do not know where they can obtain it. Therefore, she turns to her grand-aunt, who shares her story.
Boy C
Another gentleman tells us about his young nephew – we shall call him Boy C – who is a 6-year-old boy now living in Italy with his mother. Boy C sought refuge from the war in Ukraine with his mother about 2 weeks before his story was shared. On the day he and his mother left Ukraine, Boy C knew something was wrong by the way his parents interacted, and he has not seen or heard from his father since. Boy C often asks his mother about where his father is, and is frustrated by the silence. [Note from Boy C's mother: Boy C's father needed to stay in Ukraine to prepare to serve in the military, as all men of a certain age are required to do so. His mother frequently changes the subject, as she is unsure of whether she should be honest or lie to her son.] Boy C constantly feels demoralized while comparing himself to the Italian children who have nice clothes, bicycles, toys, and long-term friends. He is struggling in school, as he does not understand the local language or culture. This leads to poor academic performance and bullying from his peers. He used to turn to his mother for help with assignments, but can no longer do so, as she also does not understand the language either. In fact, Boy C finds it difficult to even see his mother, and she is constantly out working in order to make sure that she and her son can stay sheltered and fed. To cope, Boy C picks up sticks and pretends to shoot people, although he is unable to share what about this brings him comfort. His mom speculates he is imitating his father in the military, but is concerned that he is emulating the war he was exposed to in Ukraine.
Boy C requests honesty from his mother. He understands that the truth may be difficult to handle, so he asks that things are shared gently. However, he would still prefer to know the truth so that he can focus on acceptance. Like Girl A and Girl B, Boy C needs someone to support him, so he turns to his uncle, who shares his anecdote for mental health providers to understand the disparities of recent refugee youth.
Boy D
A woman shares a story about her son – we shall call him Boy D – who is currently an adult that sought refuge from Russia due to war at age 4. Boy D's journey to the United States involved significant turmoil. He and his parents first sought refuge in Austria, where generations of their family were living in a single room. As the family was previously well off in their home country, they had great difficulty adjusting to their new circumstances. This led to abundant internal conflict within the family, which Boy D still vividly recalls. The family then traveled to Italy, where Boy D witnessed his grandmother die due to the stresses of travel and lack of resources. Around this time, he began to have trouble sleeping. When he finally arrived in the United States, he received a scholarship for a good school, which gave him hope. However, he was constantly teased at school for having a different culture. His parents began to argue more, his grades were poor due to the language barrier, and he was constantly worried about the stability of his future. Due to all of this, his mental health started to decline. He would often ask his parents if they were going to move again, and would shake and cry at the site of a suitcase. He no longer had support from his parents, as they constantly worked to support the family. Hen they were home, they often argued, creating a distance between each other and their son. Possibly due to all of these psychosocial stressors, along with a family history of cluster A personality disorders and limited support, Boy D developed schizophrenia at the young age of 10. His symptoms continued to worsen, eventually leading to a disabled state by the age of 18.
Literature review
A total of 35 articles were found to be focused on refugee children exposed to war. These articles were reviewed and scanned for mental health diagnoses commonly found in refugee children and treatment recommendations for this population. The results were combined into common findings and themes.
Mental health findings
In the United States specifically, a high prevalence of anxiety and posttraumatic stress disorder (PTSD) was shown to be present in youth, specifically 2 years after resettling in the United States. It is imperative for refugees resettling to the United States to get appropriate mental health screening.[10] In addition to the stress of war and leaving their hometown, the mental health of refugees is further affected by the need to adapt to a new language, culture, and complicated legal and public service systems. Youths have an additional stressor of needing to catch up academically after likely having spent long periods of time away from school.[5] All of the aforementioned are amplified by the children having expectations of a more positive life experience in the new country and feeling disappointment after encountering these new psychosocial stressors.[14]
Regarding literature based outside of the United States, there were many studies about mental health disparities in child refugees, many of which had overlapping findings. The most prevalent diagnoses amongst a majority of the studies reviewed included PTSD, anxiety disorders, and depressive disorders.[15],[16],[17],[18] Two studies discussed the higher prevalence of specific anxiety disorders, including social[19] and separation anxiety.[10] Another common mental health disparity mentioned was behavioral issues, including anger and conduct disorder.[6],[20],[21] Less commonly noted were hyperactivity disorders,[14],[22] psychosis,[3],[8],[23] somatization,[24],[25] and substance use disorders.[26] Other mental health symptoms that were commonly seen in child refugees were elimination disorders, and insomnia.[7],[27] Less common symptoms included neurocognitive issues,[22] dissociation, and violent play.[2],[4] The most severe findings in child refugees were self-harm[8] and suicidal thoughts/behavior.[3],[4],[28],[29] Many of these mental health disparities worsened with increasing trauma related adversities, including exposure to violence or killing, death of a loved-one, being threatened or abused, lack of basic needs such as a home or food,[30] or with resettlement.[31]
Treatment recommendations
Both refugee resettlement organizations and mental health professionals can more effectively understand and deliver care for children if they know about the children's life experiences and needs.[9] Several aforementioned studies recommended treatment modalities for the mental health disparities commonly found in young child refugees.
For war refugee children resettling in “high-income” countries such as the United States, protective factors for psychosocial health include perceived community acceptance and support (especially within schools), family support and connectedness, and continuation of cultural and religious practices of their country of origin.[32]
The common recommended treatment modalities found in research based outside of the United States included well-trained providers, quality interpreters,[33] trauma-informed care[34] and group-based interventions.[26],[32] Traditional interventions, such as cognitive behavioral therapy and eye movement desensitization and reprocessing also showed benefit. There was also a strong support for narrative exposure therapy, especially for PTSD symptoms.[17],[20],[35] Less traditional therapies, such as creative art therapy, were recommended in supplementation.[17],[32] Including facilitation of acculturation in these modalities was often recommended,[1],[3] as well as ensuring that humanitarian needs are met.[2] Involving the parents, schools, and communities of the young refugees was shown to be instrumental for treatment effectiveness.[32],[36] Both involving and treating parents was an important part of treatment, as “positive parenting” strongly improved mental health outcomes for the children.[26],[35] One article presented that using “symptom networks” can help gain insight into the symptoms to further guide treatment.[23] Pharmacologic therapy was also suggested when necessary,[8] and could be paired with electronic mental health visits if needed.[17] It was also noted in two articles that most refugees do not develop mental health disparities, so assessing for adaptive functioning and resilience should be the first step for preventive measures.[31] “A large proportion of children need only a few words of understanding, to help them turn to their own ability to heal wounds[37]” Focusing on children's self-esteem, emotional regulation,[16] and resilience were shown to be important preventive measures.[2],[31],[33],[38]
| Discussion | | |
Young children from Ukraine had their safety, security, and predictability challenged abruptly. In these times of deprivation, they are confused and need someone to turn to, especially when trying to understand the mature complexities of war. Parents are often not able to help due to feeling confused and insecure themselves, especially when the families are of blended Russian and Ukrainian heritage. Friends are also difficult to turn to, and many are no longer around. Children dream of taking refuge in another country, often to find a whole new set of difficulties while adjusting to their new homes.
The mental health disparities found in the literature can be seen in the children presented in the case reports above. Girl A and Girl B show high levels of anxiety, with Girl A's situation leading to her being constantly nervous about going upstairs, losing her home, or losing her father. Girl B is also displaying heightened anxiety after directly witnessing and hearing about traumatic war events. Boy C has demonstrated some depressed mood after not being able to understand the language of the country he now lives in, and is also displaying some morbid fantasy play. Boy D suffered from insomnia, nocturnal enuresis, PTSD symptoms, and eventually developed a psychotic illness.
Our review of the literature demonstrated a high prevalence of mental health disparities commonly associated with war-involved and refugee youth. Although knowledge of these is important in guiding mental health treatment practices, there must be caution with treating these diagnoses mechanically. Gaining deeper insight from the narratives of children allows us to deliver comprehensive and personalized care in order to better understand what each child has experienced to address their specific needs. As can be seen in the treatment recommendations, well-trained mental health providers with an understanding of the plights specific to child refugees is essential in giving these children the best care.[12]
Several studies presented narrative exposure therapy as an effective treatment for child refugees displaying mental health symptoms. Indeed, the first three children did feel that sharing their stories with their relatives helped them to lessen anxiety and strengthen resilience. They also felt supported that someone took the time to listen to them and will share their story to help improve care for all children. It is our hope that this introductory presentation of narratives will help to enlighten mental health providers and promote gaining insight into the impact of war and refuge on Ukrainian youth to better understand and assist in these children's time of need, while simultaneously giving a preliminary introduction into narrative exposure therapy.
What we present today is limited by our sample size of four. Another limitation is that, due to the nature of the location and environment surrounding these children, our methods of obtaining the narratives was through close relatives, as opposed to directly from the children. Due to the urgency of this endeavor, a more thorough review of the literature is also warranted for future studies. This further illustrates a need for continued research into narrative-based understanding and treatment of refugee youth.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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