Violent childhood experiences - Consequences on mental health and approaches to intervention

Abstract

In order to develop in a healthy manner, a child requires a secure environment and a steady bond with a close caregiver (Johnson, Browne, & Hamilton-Giachritsis, 2006). However, experiences of violence may interfere with this process of healthy development. The present thesis examined the consequences of exposure to family, institutional and organized violence on the mental health of children in Sub-Saharan Africa, living either in institutional care or being associated with armed forces. Subsequently, intervention approaches to reduce psychological suffering and to prevent children from further exposure to violence were developed and evaluated.Children in Sub-Saharan Africa are exposed to high rates of corporal punishment within their families and schools (UNICEF, 2010, 2011). Studies from other settings have found that family violence is strongly related to mental health problems, including trauma spectrum disorders as well as internalizing and externalizing psychological problems (e.g. Catani, Jacob, Schauer, Kohila, & Neuner, 2008; Elbert et al., 2009; Gámez-Guadix, Straus, Carrobles, Muñoz-Rivas, & Almendros, 2010). In Sub-Saharan Africa, institutional care is part of the support system for orphans and vulnerable children (McCall, 2013; Wolff & Fesseha, 1998). The few existing studies investigating these contexts have indicated that the quality of caregiving in such institutions is poor and that the caregivers are often undereducated and overburdened (e.g. Espié et al., 2011; Levin & Haines, 2007; Wolff & Fesseha, 1999). To date, little is known about the occurrence of violence toward children in institutional care in Sub-Saharan Africa. Interventions in institutional care worldwide have successfully improved the quality of caregiving (e.g. Levin & Haines, 2007; St. Petersburg-USA Orphanage Research Team, 2008; Wolff & Fesseha, 1999), yet none of them specifically targeted violence in institutional care. In regions of war and conflict, children are exposed to additional stressors in form of organized violence. This is especially true if they are recruited as child soldiers, during which time they experience and perpetrate massive amounts of violence (Schauer & Elbert, 2010) and suffer heavily from the consequences resulting in trauma spectrum disorders and aggressive behavior (Maclure & Denov, 2006; Schauer & Elbert, 2010; Stott, 2009). These mental health problems can pose challenges to the reintegration process (Betancourt et al., 2010; Boyden, 2003). It is therefore important to support the reintegration process by addressing individual psychological suffering (Stott, 2009).The present thesis focused on family and institutional violence in Tanzania and on organized violence in the Democratic Republic of the Congo (DRC). The first article investigated corporal punishment and its consequences on Tanzanian primary school children and found alarmingly high rates: More than 95% of the children reported experiencing corporal punishment in the family and at school. More than half of the children reported incidents of corporal punishment in the family within the last year. Experiences of corporal punishment were related to externalizing problems, such as aggression and hyperactivity. The findings were in line with reports from UNICEF (2011) and research from other countries (Ani & Grantham-McGregor, 1998; Schilling, Aseltine, & Gore, 2007). The second and the third article revealed that corporal punishment and violence were equally common in institutional care. Experiences of violence in institutional care were more strongly related to mental health problems than were experiences in the family of origin. The most affected children were institutionalized at a very young age. Thus, adverse experiences in institutional care compounded with adverse experiences in the family of origin and distant and unresponsive caregiving in institutional care (Johnson et al., 2006; McCall, 2013). Subsequently, a two-component intervention was developed in the third article that addressed individual psychological suffering as well as prevention from further exposure to violence. Children suffering from traumatic stress were treated with KIDNET (Ruf et al., 2007). To reduce further exposure to violence and to improve caregiving all caregivers were trained in parenting skills and nonviolent discipline strategies. A six-month follow-up demonstrated this intervention’s feasibility and showed initial positive outcomes. Traumatic stress and experiences of violence in institutional care substantially decreased post treatment.The fourth article shifted the focus from family violence to organized violence in the DRC and examined the experiences of violence and mental health of former child soldiers. Results revealed that child soldiers experienced and perpetrated higher amounts of violence compared to adult combatants. Additionally, they suffered more from the consequences of being both victim and perpetrator, resulting in higher rates of traumatic stress and aggression. In accordance with the literature (Betancourt et al., 2010), aggressive behavior was linked to failed integration attempts. Based on these findings, the fifth article described the development and evaluation of a two-component intervention, addressing mental health problems as well as aiming to reduce exposure to further violence by supporting the integration of former child soldiers into civil society. The intervention was embedded within a reintegration program offering vocational training and social support and was tested in a randomized-controlled trial against treatment as usual. An advanced version of NET (Schauer, Neuner, & Elbert, 2011) focusing on traumatic experiences as well as perpetrated violence was implemented. Individual sessions were followed by a group session, which dealt with the role change from combatant to civilian. A six-month follow-up confirmed feasibility and found initial positive outcomes. Traumatic stress decreased substantially in the treatment group, whereas aggression decreased in both groups. Closeness to combatants was used as an inverse index of integration and this index showed a specific decline as a result of the intervention.The present thesis showed that exposure to violence, namely violence in families and institutions as well as organized and perpetrated violence in armed conflict, has detrimental consequences for children’s mental health. Consequently, the present thesis developed and successfully tested two interventions designed to reduce the children’s psychological suffering as well as to protect them from further exposure to violence. The interventions targeted children in institutional care and former child soldiers in reintegration programs. Thus, the present thesis showed that intervention approaches focusing on both individual psychological support and prevention of further exposure to violence promise to support affected children in overcoming their psychological suffering, providing them the opportunity to grow up in a secure and supportive environment.