Person:

Betancourt, Theresa

Objectives: To compare the risks of admission to hospital for any type of psychiatric disorder and for four specific psychiatric disorders among adults who as children were evacuated to Swedish foster families during the second world war and their non-evacuated siblings, and to evaluate whether these risks differ between the sexes. Design: Cohort study. Setting: National child evacuation scheme in Finland during the second world war. Participants: Children born in Finland between 1933 and 1944 who were later included in a 10% sample of the 1950 Finnish census ascertained in 1997 (n=45 463; women: n=22 021; men: n=23 442). Evacuees in the sample were identified from war time government records. Main outcome measure Adults admitted to hospital for psychiatric disorders recorded between 1971 and 2011 in the Finnish hospital discharge register. Methods: We used Cox proportional hazards models to estimate the association between evacuation to temporary foster care in Sweden during the second world war and admission to hospital for a psychiatric disorder between ages 38 and 78 years. Fixed effects methods were employed to control for all unobserved social and genetic characteristics shared among siblings. Results: Among men and women combined, the risk of admission to hospital for a psychiatric disorder did not differ between Finnish adults evacuated to Swedish foster families and their non-evacuated siblings (hazard ratio 0.89, 95% confidence interval 0.64 to 1.26). Evidence suggested a lower risk of admission for any mental disorder (0.67, 0.44 to 1.03) among evacuated men, whereas for women there was no association between evacuation and the overall risk of admission for a psychiatric disorder (1.21, 0.80 to 1.83). When admissions for individual psychiatric disorders were analyzed, evacuated girls were significantly more likely than their non-evacuated sisters to be admitted to hospital for a mood disorder as an adult (2.19, 1.10 to 4.33). Conclusions: The Finnish evacuation policy was not associated with an increased overall risk of admission to hospital for a psychiatric disorder in adulthood among former evacuees. In fact, evacuation was associated with a marginally reduced risk of admission for any psychiatric disorder among men. Among women who had been evacuated, however, the risk of being admitted to hospital for a mood disorder was increased.

Objective To investigate the longitudinal course of internalizing and externalizing problems and adaptive/prosocial behaviors among Sierra Leonean former child soldiers and whether post-conflict factors contribute to adverse or resilient mental health outcomes. Method Male and female former child soldiers (N=260, ages 10–17 at baseline) were recruited from the roster of an NGO-run Interim Care Center in Kono District and interviewed in 2002, 2004 and 2008. The retention rate was 69%. Linear growth models were used to investigate trends related to war and post-conflict experiences. Results The long-term mental health of former child soldiers was associated with war experiences and post-conflict risk factors, which were partly mitigated by post-conflict protective factors. Increases in externalizing behavior were associated with killing/injuring others during the war and post-conflict stigma while increased community acceptance was associated with decreases in externalizing problems (B=−1.09). High baseline levels of internalizing problems were associated with surviving rape while increases were associated with younger involvement in armed groups and social and economic hardships. Improvements in internalizing problems were associated with higher levels of community acceptance and increases in community acceptance (B=−0.86). Decreases in adaptive/prosocial behaviors were associated with killing/injuring others during the war and post-conflict stigma, but partially mitigated by social support, being in school and increased community acceptance (B=1.93). Conclusions Psychosocial interventions for former child soldiers may be more effective if they account for post-conflict factors in addition to war exposures. Youth with accumulated risk factors, lack of protective factors, and persistent distress should be identified; sustainable services to promote community acceptance, reduce stigma, and expand social supports and educational access are recommended.

This is the first prospective study to investigate psychosocial adjustment in male and female former child soldiers (n=156, 12% female). The study began in Sierra Leone in 2002 and was designed to examine both risk and protective factors in psychosocial adjustment. Over the two-year period of follow up, youth who had wounded or killed others during the war demonstrated increases in hostility. Youth who survived rape had higher levels of anxiety and hostility, but also demonstrated greater confidence and prosocial attitudes at follow up. Of the potential protective resources examined, improved community acceptance was associated with reduced depression at follow up and improved confidence and prosocial attitudes regardless of levels of violence exposure. Retention in school was also associated with greater prosocial attitudes.

Upon returning to their communities, children formerly associated with armed forces and armed groups–commonly referred to as child soldiers–often confront significant community stigma. Much research on the reintegration and rehabilitation of child soldiers has focused on exposure to past war-related violence and mental health outcomes, yet no empirical work has yet examined the role that post-conflict stigma plays in shaping long-term psychosocial adjustment. Two waves of data are used in this paper from the first prospective study of male and female former child soldiers in Sierra Leone. We examined the role of stigma (manifest in discrimination as well as lower levels of community and family acceptance) in the relationship between war-related experiences and psychosocial adjustment (depression, anxiety, hostility and adaptive behaviors). Former child soldiers differ from one another with regard to their post-war experiences, and these differences profoundly shape their psychosocial adjustment over time. Consistent with social stress theory, we observed that post-conflict factors such as stigma can play an important role in shaping psychosocial adjustment in former child soldiers. We found that discrimination was inversely associated with family and community acceptance. Additionally, higher levels of family acceptance were associated with decreased hostility, while improvements in community acceptance were associated with adaptive attitudes and behaviors. We found that post-conflict experiences of discrimination largely explained the relationship between past involvement in wounding/killing others and subsequent increases in hostility. Stigma similarly mediated the relationship between surviving rape and depression. However, surviving rape continued to demonstrate independent effects on increases in anxiety, hostility and adaptive/prosocial behaviors after adjusting for other variables. These findings point to the complexity of psychosocial adjustment and community reintegration in these youth and have a number of programmatic and policy implications.