PTSD in Sri Lankan Children

The facts of life are that a child who has seen war cannot be compared with a child who doesn't know what war is except from television.” - Sophia Loren

By Dr Ruwan M Jayatunge M.D.

(March 09, Ontario, Sri Lanka Guardian) Children are susceptible to PTSD reactions, which is a complex health condition that can develop in response to a traumatic experience - a life-threatening or extremely distressing situation that causes a child to feel intense fear, horror or a sense of helplessness. Children exposed to the traumatic events such as sexual assault/abuse, war, natural disasters, terrorist incidents, serious accidents, or violent personal assaults can develop PTSD. Posttraumatic Stress Disorder can develop in children without any predisposing conditions, especially if the traumatic event is extreme. PTSD contributes to difficulties with behavior, relationships, mental health, attention, concentration and memory tasks; PTSD has also been linked to school failure.

Many studies have shown that there is a connection between children’s exposure to traumatic events and psychological problems. These include not only full-scale PTSD, but also problems with:

* peer relationships
* relationships within the family
* self-esteem
* school activities and performance
* sexual behaviour (in cases of sexual abuse)
* emotional development
* depression and anger
* physical health
* substance abuse
* fears
* anger
* guilt
* feeling ashamed

There are several factors that would increase the risk of developing PTSD in children. These factors include the severity of the traumatic event, the parental reaction to the traumatic event, and the physical proximity to the traumatic event. Goodman (2002) states that trauma-exposed children are most at risk if they have:

1) Physical injuries as a result of the event (e.g. physical abuse)

2) Personally witnessed the event

3) Pre-existing mental health issues or learning difficulties

4) A limited support network

5) Someone close to them who is missing, hurt, or dead

6) Caregivers who are experiencing emotional difficulty

7) Previous loss or trauma experiences

Gender also appears to be a risk factor; several studies suggest girls are more likely than boys to develop PTSD (Hamblen, 1999).

Sri Lanka Children of the War Zone

Children in war-torn areas are often direct or indirect victims of violence, and witnesses to various horrors associated with war. According to the United Nations Children’s Agency, UNICEF the conflict in Sri Lanka had killed hundreds of children and left many more injured. Children who are a vulnerable group have suffered severe traumatic events during the there decade long Sri Lankan conflict. Children of the North as well as of the South have experienced many anxiety related conditions due to the war. They are traumatized children and have various behavioral problems. They are at a high risk of developing numerous psychological ailments especially PTSD.

Exposure to war-related traumatic events contributes to subsequent mental health distress, and in some cases, longer-term psychopathology in children and adolescents. As Ana Freud & Burlingham stated in 1943 Children are always the most vulnerable and generally more exposed citizens in countries where declared and undeclared wars rage. Exposure to war traumas can deleteriously affect children’s social, emotional, and cognitive development and pose significant problems into adulthood if left untreated. Exposure to war situations children lose predictability in their lives. They become far a way from daily routine and daily habits, which provide security for them. It affects their psychosocial development negatively.

Children who have experienced or been exposed to war trauma may have numerous symptoms including trauma based behavior. They often have anxieties and insecurities that can cause them to perceive every aspect of the world as being unsafe and frightening. The grow up with a generalized fear and hostility which affects their future lives. Trauma is often associated with intense feelings of humiliation, self-blame, shame and guilt, which result from the sense of powerlessness and may lead to a sense of alienation and avoidance. Therefore, the initial trauma could become a vicious cycle.

Children lived in war-torn environments had experienced a tremendous amount of stresses that could be classified as beyond usual human experiences. Children’s vulnerability lies in the substantial claim that severe early stress produces a cascade of events that have the potential to alter brain development. (Pushpa Kanagaratnam- Rehabilitation of children psychologically affected by armed conflict in Northeast Sri Lanka ) Sri Lanka's rising child mental health problems have caused by the prolonged armed conflict.

War trauma had devastated effects on the Northern Part of Sri Lanka. A large number of children in the North experienced the devastating consequence of the war. The magnitude of psychological damage was shown in the statistical reports presented by Professor Daya somasundaram. According to Professor Somasundaram Child admissions at the district hospital Tellipallai, were 8% in 1994 and in 2002 , 12.6% of admissions at the outpatient psychiatric clinic at the General Hospital Jaffna were children under 18 years.

Based on 2000 May report by the UNICEF and Save the Children Fund (SCF), Out of an estimated 900,000 children in the North and the East an estimated 300,000 children have been displaced due to the war. In early May 2009, the UN estimated that some 7,000 civilians, including at least 1,000 children, had died and more than 10,000 had been injured since fighting intensified in mid-January. A recent United Nations Children's Fund (UNICEF) study concluded by UN agencies, found that one million Lankan children have been seriously affected by the war.

Little K whom I have met in 2002 at the Anbaham orphanage Mulangavill represent the naked reality of the modern day war affair. She was nine years old when she became a victim of a cross fire between the armed forces and Tamil militants in the North. She sustained a gun shot injury to her left arm. She underwent a traumatic amputation of the left hand. The doctors were compelled to perform this operation in order to save her life. She was lucky enough to be alive but gradually became another psychological victim of the Eelam war. She has fear feelings, night terror, bed-wetting, hyper arousal and alienation. Traumatized war- zone children like little K carry the psychological scars throughout their lives.

Air attacks in the Eelam War caused severe anxiety in children. Master P was terrified when air attacks took place in Jaffna. During this attack, his neighbor’s house was destroyed and some were critically injured. They were taken to the Jaffna hospital. Master P becomes anxious when he hears aircraft sounds. He has startling reactions, intrusive memories of the air attacks and sometimes nightmares.

Children of the endangered Villages

In the height of the Eelam war, the LTTE attacked Sinhalese villages in order to induce fear and terror. The Gonagala Massacre was an atrocity that occurred on September 18, 1999, in the small village of Gonagala in the Ampara District. According to reports, over 50 men, women and children were hacked to death in the middle of the night. According to the survivors of the Gonagala Massacre, nearly 80 LTTE cadres who took part in the killings and half of them were females.

Master G was 16 years old when he witnessed the brutal attack of his village by the LTTE in 1998. His father and uncle were hacked to death while they were working in their paddy field. He saw over 18 dead bodies of his relatives and neighbors. Their bodes were mutilated and Master 16 was hounded by the horrific scenery for a number of years. Out of fear and desperate his remaining family members abandoned the village and came to Meddavacchiya.

Master G had nightmares, intrusive memories and morbid fear after the attack and his life began to change. His studies were neglected and eventually to support the family he decided to join the army at that age of 18. While on training he developed a panic attack when he heard gun shots fired by his instructors. He had fear feelings and marked abnormal behaviour. Subsequently he was refereed to the Military Hospital Colombo and diagnosed as having PTSD.

Child Soldiers of the Sri Lankan Conflict

In over 18 countries in the world, child soldiers are being recruited and they have become the direct participants of war. In the Sri Lankan conflict, child soldiers were used in the war fronts by the LTTE. Child recruitment by the Tamil Tigers was to become institutionalised after 1990. Out of an estimated fighting force of 7000-10 000, as many as half may be women and 20-40% were children. (Unicef, SCF Coalition to stop the use of child soldiers. The use of children as soldiers in the Asia-Pacific region. London: Coalition to stop the use of child soldiers./ University Teachers for Human Rights. The sun god's children and the big lie. Colombo: UTHR-J; 2000.) But some reports say that the he LTTE first established the “Baby Brigade” for recruits under the age of 16 in 1984.

Based on CSUCS, Asia Report, July 2000, citing R. Gunaratna, "LTTE child combatants", Jane's Intelligence Review, (July 1998) indicates that at least 60% of the dead LTTE fighters were under 18, and of these, most are girls and boys aged 10-16 years. Most of the LTTE soldiers killed at the Weli Oya complex in July 1995 were children, and during an assault on the Wanni defences on 1 February 1998, at least 200 child fighters were killed. (CSUCS, Asia Report, July 2000)

Child soldiers are are at high risk for developing a range of different behavioural, psychological and neurobiological problems. Based on the research done by Kohrt and colleagues of Emory University found that 75 of the Nepali child soldiers (52.3%) met the symptom cutoff score for depression, 65 (46.1%) met the score for anxiety 78 (55.3%) met the criteria for PTSD, 55 (39%) met the criteria for general psychological difficulties, and 88 (62.4%) were functionally impaired. Statistically adjusting for traumatic exposures and other possibly confounding variables held that being a child soldier was significantly associated with depression and PTSD among girls (2.4 and 6.8 times higher odds, respectively) and PTSD among boys (3.8 times higher odds).

In 1998 the Secretary General's Special Representative for Children and Armed Conflict, Mr. Olara Otunnu visited Sri Lanka and urged LTTE to free the child solders. In his speech Mr Olara Otunnu stated that

Children who become soldiers lose their innocence. Part of the reason why the fighting groups will tend to reach out to children is because, of course, the adults may become disillusioned, they maybe killed off, they may run away, so they reach the children who are less able to defend themselves. But there's a more cynical reason: that children, because they are innocent, can be moulded into the most unquestioning, ruthless tools of warfare, into suicide.commandos, into committing the worst atrocities.

In his researched article Child soldiers: understanding the context Professor Daya Somasundaram of Department of Psychiatry, Faculty of Medicine, University of Jaffna defined the push and pull factors for Northern children to become child soldiers. As Professor somasundaram points out in Northern Sri Lanka extensive epidemiological surveys in 1993 of 12 cluster schools in Vaddukoddai and of adolescents in Jaffna and Killinochchi schools showed widespread war stresses and the effect of the war on these children's development and the resulting brutalisation, is to make them more likely to become child soldiers. Many of the child soldiers seem to have a whole range of conditions from neurotic conditions like somatisation, depression, post-traumatic stress disorder to more severe reactive psychosis.

SE was 11 years old when he was forcibly abducted from his parents and recruited as a child soldier by the LTTE. During the training period, he was beaten and threatened to be killed if he did not obey the orders. He never had the opportunity of going to school after he became a child soldier. Instead of books, he carried AK 47 and grenades. SE and other children underwent physical training and political indoctrination. Little SE witnessed a number of horrific events which changed his psychological makeup drastically. He was forced to observe torture, then forced to induce it on victims. At the initiation, he received a vial of cyanide on a string necklace and instructed to bite down upon in the event of capture.

SE witnessed numerous atrocities. Once he saw a killing of a rival member by the adult members. Along with other children, he had to take part in a number of attacks against the Sri Lankan Army. They were called the members of the Baby Brigade. The Baby Brigade was a support team for the adult fighters. SE the child soldier saw the deaths of some of his mates following mortar fire.

Today SE is in a rehabilitation center but his horrendous psychological scars have not left him completely. He has intense rage, suicidal urge and alienation. Once a bright and innocent student now has become a child victim of the Eelam War.

Major A of the Sri Lanka Army was shattered when the LTTE used child soldiers to attack an Army camp in the North. He described his heartrending experience thus….

…… A large number of LTTE carders came to attack our camp. There were a large number of child soldiers. Some of them were carrying RPG. The first wave mostly consisted of child soldiers. They destroyed two bunkers. We had no option and we too opened fire. The attack went for about five hours and finally we were able to resist the attack. There were hundreds of dead bodies around the outer perimeter of the camp. I saw the horror and the inhuman side of the war. The innocent children turned in to child solders who possessed hate and brutality. Some dead children had no pubic hair probably they were ten or eleven years old. They were in their final sleep with AK 47 tightly held to their hands. Who could turn these innocent minds to monsters of killing machines? On that day I realized that the God does not exist……

According to UNICEF data, there were 6,183 cases of child recruitment by the LTTE in five years after the February 2002 CFA. Out of this, 3,732 were boys and 2,451 were girls. After the victory over LTTE in March 2009, the Government of Sri Lanka launched a rehabilitation program to integrate former child soldiers to the society. At present 273 former child combatants are attending the Ratmalana Hindu College and more training centres have been established in several parts of the country. The war-affected children receive education and vocational training.

PTSD in Sri Lankan Children after the Tsunami Disaster

On 26 Dec 2004, earthquake occurred off the west coast of northern Sumatra, Indonesia, which generated a massive tsunami wave that swept across the Indian Ocean within hours. The first Tsunami wave began to impact Sri lanka at about 8.40 am. Nearly 37, 000 people in Sri Lanka lost their lives and over 100, 000 houses had been destroyed and 516,150 people became displaced. More than a third of all those killed in the 2004 tsunami were children. The tsunami disaster in Sri Lanka affected the mental health of thousands of child survivors. A large number of child survivors lost their parents, siblings, and friends. Many experienced posttraumatic stress reactions soon after the disaster.

Following any traumatic event children will experience some persisting emotional, behavioral, cognitive and physiological signs and symptoms related to the, sometimes temporary, shifts in their internal physiological homeostasis. As the experts, point out children's reaction to a trauma will involve not only the impact of the catastrophe on their lives but a sense of crisis over their parent’s reactions.

Dr. Tull - Clinical Psychologist from the University of Massachusetts Boston of the view that the 3 to 4 weeks after the tsunami, 14% to 39% of Sri Lankan children who were exposed to Tsunami disaster had PTSD.

Following case studies disclose the psychological consequences faced by Sri Lankan children after the Tsunami disaster.

Miss K is a 12 year old Tsunami survivor. On the 26th of December 2004 she went on a pilgrimage with her family members and unexpectedly met with a gigantic tidal wave in Mathara (A southern Sri Lankan town).They were traveling in a bus and all of a sudden massive waves came to the main road destroying houses. The sea water came through broken windows and passengers panicked. Miss K was extremely frightened. She thought that everybody was going to die. Fortunately her father opened the escape hatch on the roof of the bus and people managed to escape. After the sea water level dropped, passengers got down from the roof. On her way back Miss K saw a large number of dead bodies, destroyed houses and vehicles. The roads were destroyed and traveling has come to a stand still. With much difficulty her parents brought miss K home safely. Once they came home they thought the troubles are over. But it was just the beginning. After this life threatening event Miss K’s behavior gradually changed. She had fear feelings, nightmares and bed-wetting. She became isolated and refused to go to school. Her school was situated near the sea. She had a fear feeling that the Tsunami would come again.

Miss. H is a 14 year old girl who witnessed Tsunami events and her sister getting injured as a result of a collapsed wall. Her sister sustained a fractured thigh bone and was later admitted to the hospital. Miss. H became terrified and felt helpless. After three months of Tsunami tragedy, she became depressed and would give a startled reaction to sudden sounds. Many times, she saw Tsunami waves in her dreams and the gigantic waves taking her sister to the sea destroying houses and killing people. She could not concentrate at school. Her education performance started to fall. In addition, she had increased irritability with physical complaints such as headaches, and numbness of the arms.

Master L (9Y) was in the Negombo beach on the day that the Tsunami hit Sri Lanka. The Negombo beach is an attractive place where the tourists from Europe and North America come often. That day he was walking near the sea shore with his father. Suddenly the sea water level started receding. They could see several hundred meters of the sea bed now without water. Overjoyed crowds went to the sea and started collecting corals. Within ten or fifteen minutes, a huge wall of water came towards the seashore. Terrified people started running. Master L ran with his father towards an elevation. While he was running he saw people being washed away by the waves. He was scared and crying. When they came home, he was still distressed. Master L saw TV programs on Tsunami. There he saw terrible scenes. He was worried about his grandmother who lived several hundred miters away from the sea. Although he came to know that his grandmother was safe his distress was not subsiding. He became frightened, alienated from people and developed a fear of darkness. He could not see the TV, which carried Tsunami news. Every time he insisted his parents to switch off the TV.

Master N (age 9 Y) was another child survivor of the Tsunami disaster who witnessed the devastating events at Matara town. Several weeks after the disaster he had ruminations about the tsunami. He became impulsive and distractibility and attention problems became more prominent. He had marked sleep disturbances, emotional numbing social avoidance and regressive behaviour.

Child Abuse and PTSD

According to the WHO ( World Health Organization) general definition child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.

The mental health impact of child abuse is clearly a serious public health problem. It has been suggested that physical and emotional abuse in childhood may increase an individual's vulnerability to PTSD. In a recent study, women who reported childhood sexual abuse were five times more likely to be diagnosed with PTSD compared to nonvictims (Coid et al., 2003). Another study showed that the lifetime rate of a PTSD diagnosis was over three times greater among women who were raped in childhood compared to nonvictimized women (Saunders et al., 1999).

An average of 4000 complaints of child abuse, are reported annually according to the Child Protection Authority (NCPA). According to Professor Harendra De Silva - former Chairman of the Child Protection Authority 20 % of boys and 10 % of girls have been sexually abused annually. 10,000 to 12,000 children from rural areas are trafficked and prostituted to pedophiles by organized crime groups. (CATW Fact Book, citing "Sri Lankan children for sale on the Internet", Julian West, New Delhi, London Telegraph, 26 October 1997). There are an estimated 30,000 child prostitutes. The numbers are expected to increase to 44,000 by the year 2000. (ILO-IPEC, Mainstreaming Gender in IPEC Activities, 1999)