Former child soldiers’ acute war experiences have long-term consequences, but the nature and extent of these consequences are influenced by post-conflict risk and protective factors. In our sample, injuring/killing others was associated with increasing externalizing problems and decreasing levels of adaptive/prosocial behaviors while being raped predicted higher baseline levels of internalizing problems (anxiety/depression). However, most of the associations between these war experiences and longitudinal outcomes were not statistically significant in models that accounted for post-conflict factors. The relationships between acute war trauma, internalizing and externalizing problems, and positive psychosocial adjustment were therefore significantly shaped by post-conflict experiences.
Our results also suggest that different forms of trauma have differing degrees and types of long-term mental health impact. General witnessing of war violence, for example, was not associated with changes in mental health, while being raped was predictive of higher levels of internalizing problems but not of increased externalizing problems or decreased prosocial behavior. Our findings - particularly the associations we observed between perpetration of violence, increases in externalizing problems, and decreases in adaptive/prosocial behaviors - are consistent with relationships observed in other studies of former child soldiers3, 5
and adult war veterans.32
Our findings point to a number of important post-conflict factors that influence long-term wellbeing and that may represent appropriate targets for intervention. Youth who remained in school and those who experienced higher levels of community acceptance had higher baseline levels of adaptive/prosocial behaviors adjusting for all other factors. In addition, decreases in adaptive/prosocial behaviors were associated with higher levels of stigma, while increases were associated with social support and school attendance. Most promisingly, in the presence of increasing community acceptance, youth demonstrated significant improvements in all outcomes investigated.
Taken together, these findings highlight the potential of post-conflict intervention programs that address community dynamics such as acceptance and stigma and that bolster strengths at the individual level through social support. In Sierra Leone, thoughtful attention was given to promoting community acceptance of former child soldiers immediately following the war.14
Community sensitization campaigns assisted the initial phases of reintegration but did not continue over the long-term.33
The nationwide sensitization efforts were particularly strong before the creation of the Sierra Leone Truth & Reconciliation Commission, which was meant to coordinate mass campaigns. Given the long-term positive effects of improved community acceptance on former child soldiers’ mental health, interventions aimed at bolstering and maintaining this protective process may strengthen and sustain the impact of initial efforts.
Our findings underscore aspects of community-based intervention features - including efforts to reduce stigma, increase community acceptance and increase school attendance – that are crucial to the mental well-being of war-affected youth. However, despite how our findings support broad, community-based approaches, we do not disregard the possible beneficial effects of targeting interventions at individual child soldiers. Without specific comparison groups (i.e. a sample of non-war-exposed children with behavioral problems), there is not sufficient evidence to rule out war-related factors as ultimately etiological and influential in subsequent post-conflict adjustment.
Study limitations include moderate retention rates given the challenging field conditions and early termination of the T2 data collection, use of self-reports and a lack of information on pre-war levels of mental health problems in Sierra Leone, which limit our ability to interpret the magnitude of the mental health problems observed. Furthermore, although our measure of mental health outcomes was developed and validated for use in Sierra Leone, clinical cut points are unavailable for this context. Additionally, we cannot make strong claims about causality in these data since war-related experiences were reported retrospectively. Our findings are also limited in their general application to the country as a whole, as our sample comprises youth who originated from 5 out of 14 districts in Sierra Leone (Kono, Bo, Kenema, Pujehun, and Moyamba) demobilized over a specified time period; this design was necessitated in part by the significant ethical and logistical difficulties involved in obtaining a country-level representative sample of former child soldiers. However, we have no reason to believe that the children we interviewed are very different from either the children in their own districts or other districts that were served via the DDR process. Finally, without a comparison group of self-reintegrated youth or youth never associated with armed groups, we cannot broadly generalize our findings to comment on other groups of war-affected youth.
Study strengths include the use of dimensional assessments capturing a broad range of mental health indicators in a culturally sensitive manner as opposed to a narrow focus on trauma-related disorders. Moreover, by including multiple types of outcome measures, including positive/adaptive outcomes, we were able to identify different patterns of sensitivity. For example, all outcomes were associated with community acceptance, but rape was more associated with internalizing problems while killing/injuring others was more associated with externalizing problems and deficits in prosocial/adaptive behaviors. While stigma influenced both internalizing and externalizing problems, internalizing problems were additionally influenced by daily hardships and age of involvement with armed groups. Adaptive/prosocial behavior, meanwhile, was most sensitive to school access and social support.
Overall, this prospective study contributes to the literature on the processes that influence mental health in former child soldiers over time. By examining post-conflict variables, we identified broader processes that work to shape the long-term psychosocial adjustment and well being of children associated with armed forces and armed groups; in short, we found that mental health in this group is influenced by much more than past war experiences. Although our general finding may apply broadly, the specific processes that influence risk and resilience are likely to be shaped by culture and context.34
Although stigma and discrimination may be seen as universally detrimental human experiences, the social meaning of being a former child soldier may differ, for example, in a context where youth involvement in conflict is focused on joining together to fight a common enemy compared to situations where forced abduction plays a significant role. Similarly, although the experience of being raped may be considered universally harmful, the implications of this experience certainly interact with gender and culture to influence adverse outcomes.10
In Sierra Leone, other research has observed that, although both boys and girls reported rape, stigma against girls more commonly included insinuations of sexual impropriety that are particularly damaging to the social prospects of females.13, 35
In this manner, the nature of both war experiences and post-conflict experiences must be examined carefully across settings.
Based on our findings, we suggest that post-conflict adversities and resources must be given closer attention in both research and service delivery. Such understanding of the impact of multiple war-related and post-conflict factors is important for identifying appropriate intervention targets. The results of this study emphasize the importance of investing in longer-term (i.e., beyond the immediate post-conflict period) approaches to monitoring and supporting the wellbeing of war-affected youth.