Millions of children are caught up in conflicts, in which they are not merely bystanders but targets. According to Machel (1996), 90% of war victims in wars all over the world are civilians and half of them are children. In cases where children are not directly injured or killed, they often experience extreme degrees of psychological stress, e.g. in cases where they witness killings, witness or experience rapes or other forms of violence. All over the world, children are more and more directly involved in wars, or even recruited as soldiers. The stress they experience can lead to trauma, resulting in severe psychological consequences such as post-traumatic stress disorder, depression and anxiety.
These phenomena have become important also in countries not directly involved in war because of the refugees who seek help in peaceful countries. Because of this, the consequences of traumas have become important topics for the communities in these countries. Trauma itself is not only a consequence of war, but also of other experiences such as rape, child abuse, and accidents or catastrophes.
Speaking of traumatized children, doctors are very often the first persons to contact. Therefore, we believe it is important for us, as future physicians, to have good knowledge about trauma and reactions to trauma.
Trauma
Traumatic experience can be characterized as follows: it happens suddenly, it is unpredictable and outside of the normal life experience. The person is unprepared and extreme feeling of helplessness can evoke.
Due to impact of the event some traumas cannot be managed successfully. Traumas cause fear even as memories and therefore all confrontation in similar situations is usually avoided. For example, traumatized children are not able to finish trauma dreams since they wake up in the middle of them. Normally dreams are a good method of managing stressful experience. When they cannot finish their dreams this can be fatal because in this way children stay vulnerable for a longer time. Usually, speaking about traumas is avoided since adults often believe that they should not speak about the traumatic experience with children. If a successful management cannot be achieved, consequences of the trauma can become chronic: appearance of illnesses, addictions, suicidal behavior, psychiatric diseases or - a typical reaction to trauma -
PTSD.
In situations where children are exposed to ongoing stress, such as being under siege for months, being afraid of continual or sporadic sniping or of suffering starvation, symptoms of intrusive images can appear as well as thoughts and the avoidance of thoughts, feelings and situations related to the stressful experience.
Children and trauma
Children are often more vulnerable and sensitive. Events that are normal for adults can be traumatic for children. Often, problems of children have been underestimated by adults who do not want to talk about traumatic experiences with their children - especially if they themselves experienced such traumas. In war situations, different problems often add to the actual traumas such as family divisions, children often get new, more responsible, roles in their families.
Children are generally more flexible than grown-ups, they can adapt to new situations more easily. At the same time they are more vulnerable, new stressful experience can lead to refreshing of the wounds and to similar or even more severe psychological problems than the trauma itself. Therefore the period after the trauma - e.g. life as a refugee or life in post war period - is crucial to the well being of children (as shown in a study by
Keilson, 1979). Since doctors play important roles for all these children, they can have essential impact on them - in bringing their lives into normality.
The manifestation of post-traumatic stress
Generally, children experience typical forms of PTSD less frequently - symptoms such as psychosomatic problems, behavioral problems or higher levels of aggression are prevalent. Girls show more signs of depressive symptoms whereas boys show more aggressive behavior. Especially frequent are anxiety symptoms. Psychosomatic reactions are more typical for children than for adults. The most important of these are headaches, stomachaches, breathing problems, circulatory trouble or secondary incontinence.
Even among adult refugee population there is a great tendency to somatize. A survey by Lin and Kleinman has showed that 43% of refugees treated for somatic symptoms were suffering from psychological causes (in contrast to 26% from an ethnical comparable non-refugee immigrant population). If somatic symptoms are treated by physicians who do not know about psychological traumas and their consequences, there is a danger of missing potential causes and means of treating the problems. We see a need to know more about trauma, especially about treatment of refugees and victims of war.
Implications for medical students
We, as medical students, believe that we should promote the knowledge about trauma and its consequences among other medical students - future physicians - and in broader society. Because of our age we are more flexible. On the one hand we can find different forms of working with traumatized children, doing this we can help doctors by finding a different approach to these children. On the other hand we are in a period of our lives in which we can ourselves learn more and faster especially about working with people practically. These skills are something we will need as doctors for the rest of our professional lives.
Finally, the knowledge about trauma is in itself important for medical doctors. They are often the first contact for children and traumatized grown-ups and are not able to speak about it openly. If a well-trained doctor is able to recognize the symptoms of trauma and treat these, or refer the patient accordingly,
(s)he can ease great amounts of mental or somatic pain and save much (also financial) trouble for the patient but also for the greater society.
