Mental health of children from a war affected border village: a cross sectional comparative study

Background Sri Lankan government had a war against terrorism for thirty years in North and East of Sri Lanka. There were villages in the North-East bordering to the LTTE held territory and the community lived in those villages faced to frequent attacks during that three decades. The present study was conducted to compare the mental health of children in a war affected border village, with the mental health of same aged children from a village not directly affected by the war.


Background
Since independence from British rule, Sri Lanka had been experiencing an ethnic conflict that has slowly escalated into full scale war in 1983, between the Sri Lankan government and a group of Tamil separatist terrorists, Liberation Tigers of Tamil Eelam (LTTE). Thereafter, over three decades, the violence resulted in the deaths of tens of thousands of Sri Lankans of all ethnicities (1). Through a combination of terrorist tactics and conventional forces, the LTTE carried out massacres of innocent civilians, attacked economic targets and vital infrastructure and created a fear psychosis that crippled everyday life for at least three generations of Sri Lankans (1). Over the course of the conflict, the LTTE frequently exchanged control of territory in the North and East of Sri Lanka with the government military, with the two sides engaging in fierce military confrontations, which has devastating effects on the daily activates of the residential communities within and bordering the territory, irrespective of their ethnicity.
The adverse effects of war extend to the whole community especially including the most vulnerable members of society, such as children (2). In addition to the ways that war affects adults, it affects children in different ways (3). Studies have shown that exposure to war and terror leads to severe stress reactions and anxiety in children (4,5). In addition higher rates of post-traumatic stress disorder and depressive disorder has been found among affected children (3). Some studies conducted in Sri Lanka were suggested an association between mental health of children and exposure to conflicts (6)and internal displacement (7). However, evidence on interventions are limited (8).
This study was planned to achieve two main objectives: (1) to describe the war related trauma exposure of children in a war affected border village, and, (2) to compare the mental health of children in a war affected border village, with the mental health of same aged children from a village not affected by the war.

Study setting
Padaviya is a rural agricultural area located in Anuradhapura District of Sri Lanka. It has 240 Km² of land area and 24,185 population (9). It was bordering to the territory captured by the LTTE for more than one and half decades, until the end of the war in 2009. The community lived in the area faced to frequent and brutal attacks during the three decades of war (1).

Sample and sampling
The study was conducted about two and half years after the civil war, in September 2011. Sample was selected from grade 8 and 9 students in a government school (1C category) in Padaviya (n=148). Comparison group (n=138) was selected from an 1C category government school in Anuradhapura, an area which is socioeconomically similar but not affected by the war as a border village.

Study Instruments
Demographic details, degree of exposure to the conflicts, life-experiences and perception regarding the effect of war on their lives were collected through a pre-tested self-administered questionnaire. The validated self-report Sinhalese version of the Strengths and Difficulties Questionnaire (SDQ) was used to assess mental health. SDQ ask about 25 attributes, some positive and others negative. These 25 items are divided between 5 scales; (1) Emotional symptoms, (2) Conduct problems, (3) Hyperactivity/inattention, (4) Peer relationship problems, and, (5) Prosocial behaviour. First four scales added together to generate a total difficulties score. (10). Scores were categorized in to three categories depending on clinical importance; (1) a score close to average -clinically significant problems in the particular area are unlikely, (2) a slightly raised score-may reflect clinically significant problems, and, (3) a high score -substantial risk of clinically significant problems in the particular area. However, score represented 2 nd and 3 rd categories were considered as having a risk of clinically significant problems for the analysis.

Data Collection and Statistical Analysis
Both the groups were complete same questionnaires at the school during the school time. War-trauma exposures were describe by calculating percentage of exposure. Prevalence of mental illnesses were calculated and both groups were compared through calculation of odds ratio (OR) and chi-square test.
War-trauma exposure Majority (n=85, 57.0%) of children living in a border village were experienced some kind of an extremely terrifying incident related to the war. Only 17% (n=24) children in comparison group experienced an extremely terrifying incident related to the war. Nearly one third (n=45, 30.4%) of the children living in a border village were experienced an invasion by the terrorists. Bodily injuries to themselves and bodily injuries to a family member due terrorists attack was reported by 14.2% (n=21) and 27% (n=40) of children living in the border village respectively. Nearly one fifth (n=26, 17.6%), who are living in the border village, had lost at least one immediate family member due to terrorist attacks.   (6). A study investigated the mental health impact of prolonged forced displacement in 2012 showed that the prevalence of somatoform disorder and major depression were considerably higher than national estimates (7).
The sample of the present study is not a representative sample of the border villages, as it was selected from one government school. Therefore, in depth analysis with more representative sample is important for confirmation. Moreover, effect of the time, formal and informal interventions can be assessed through such a study.

Conclusions
Majority of children living in border village reported different exposures related to the civil war that can cause considerable and long-lasting psychological impact. Children from the border village had a significantly higher risk of showing borderline abnormal values on the SDQ, compared to children not from a border village. It is probable that this is due to the effect of war and it's impact on the mental health of the children of the border village.