The impact of war and refugee status on children and teens

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.. Children in the middle of a war experience a persistent threat to their physical and mental health, and there may be long-term consequences for their development as well.

I'll talk about the impact of trauma and a forced displacement and what can be done about it with Dr. Nayla Khoury. She's a child and adolescent psychiatrist at Upstate. Welcome back to "The Informed Patient," Dr. Khoury.

Nayla Khoury, MD: Thank you so much.

Host Amber Smith: We always hear about how resilient children supposedly are, but how strong and how long must that resiliency be to survive a military invasion or a war, like what's happening in Ukraine?

Nayla Khoury, MD: That's a really good question. First of all, war is an awful experience for anyone to live through: children, families, entire communities; it upends daily life. I've fortunately not lived directly through war, but I'm interested in this topic in part, because of my family's experience, living through decades of civil war and immigrating here to the U.S.

With the current situation in Ukraine, we know that more than 3 million Ukrainians have lost their homes, and it's estimated that more than half or at least half are children. And we know that many more are impacted indirectly. Children and families in neighboring countries and around the world are watching the war, potentially reliving their own experiences of trauma and may be living in states of fear.

So in terms of resiliency, this is an important and really complicated question. We think about resiliency as the ability to rebound after adversity and even to thrive, to transform in meaningful ways, and so it depends on prewar factors like poverty and previous experience with trauma and violence.

It depends on the young person's unique experience of the war itself and on what happens afterwards in terms of how families land, where they land, and how the community responds to where they are in terms of welcoming them or discriminating against them. And in general, resiliency depends on the family's ability to maintain a sense of normalcy during very abnormal times.

Nayla Khoury, MD: We also know from a lot of research on trauma and resilience that one of the most important factors for a young person to support resiliency is the emotional and physical presence of at least one supportive adult or caregiver, and that this can mediate or moderate a lot of the biologic and emotional effects of stress.

Host Amber Smith: So in the heat of the moment when things start, and you're fleeing this, you know, fight or flight response that comes on, how long does that stay on before it's damaging? Because I guess, initially, fight or flight is what saves us or helps us save ourselves. But at some point it's dangerous -- right? -- to have a constant state?

Nayla Khoury, MD: Fight or flight response, the stress system in our body, is a normal way of adapting to stress, and war or the experience of war or abnormal times, when that sense of stress can go on for long periods of time. But I do want to say there are lots of young people who live in perpetual states of high stress response because of community violence or violence in the home, and war is another potential time. So there's no exact time answer in terms of how long is too long. I do have to say, we know that many young people are quite resilient. So even in the face of a lot of fight or flight stress for hours, days, weeks, months, young people can bounce back. But a lot of it has to do with what support systems they have to help them make meaning of the stressful experience, so it's complicated.

Host Amber Smith: In Ukraine, those children who are fortunate enough to escape and become refugees are likely not going to be living predictable lives for a while. What type of kid is best able to roll with it in those circumstances?

Nayla Khoury, MD: You're asking in some ways about the predictors of resiliency. And so there are individual characteristics that can predict resiliency, such as a young person's maturity, their flexibility of mind, their ability to be mindful, sense of self-efficacy and hope. There's also a lot of family factors in terms of positive relationships and attachment, terms of caregivers.

And then in terms of communities, the sense of belonging and identity is hugely important in terms of predicting which communities will be resilient in the face of forced displacement.

Host Amber Smith: What about the infants, the little babies that are less than a year old that are in Ukraine. Now, will they have memories of the war or sheltering in the basements or any long-term effects, or are they too young?

Nayla Khoury, MD: It's hard to predict the long-term effects of war and trauma on an infant, and it depends in large part on the caregivers around them. So an infant's first task in the first year of life, besides mere survival, is learning about safety in the world in the context of their primary caregiver relationship.

So, do they have verbal memories of sheltering in basements? No. Most infants don't have verbal memories before they can speak or have language. Might they have visceral memories associated with intense anxiety? They might, so it depends a lot on the ability of their caregiver to maintain a sense of regulation or safety, no matter where they are.

Host Amber Smith: Well, the scenes of destruction that children and adolescents see and the experiences they have while fleeing for their lives, are those memories that are likely going to stay with them forever or does severe trauma mess up someone's ability to remember traumatic things accurately?

Nayla Khoury, MD: Trauma and stress does a lot of things to our stress hormone system, our immune system and things like memory, learning and regulations. So it can impact how a young person organizes their life or their narrative. But some of what we focus on in trauma-informed therapy is helping kids and adults and families put together the narrative of traumatic events with the emotions in a way that helps them make meaning and grow from it.

So, I guess it's to say that memories themselves don't have to be haunting and can even be growth promoting, but certainly we can imagine there's lots of destruction that will impact many kids and many families in significant ways.

Host Amber Smith: Are they likely to have nightmares and trouble sleeping?

Nayla Khoury, MD: Nightmares and sleep disturbances are one potential symptom of trauma and are classic symptoms of post-traumatic stress disorder, which we diagnose if symptoms have persisted after at least a month. And that's duein part to the fight-flight response that has a hard time calming down. Other reactions could involve more physical or somatic complaints like headaches or stomachaches or other types of anxiety and dysregulation.

Host Amber Smith: Many kids have lost their homes, perhaps their parents, other people they loved. And these are things that would be challenging to cope with under normal circumstances. Does the fact that they happened during war or as the result of war complicate the trauma and healing?

Nayla Khoury, MD: It certainly may complicate the trauma, and I think it depends on a young person's narrative and how they make meaning of war. War is devastating, and it can also sometimes bring communities together in terms of having a shared sense of ideology, mission or purpose, which can sometimes help, even in the face of intense and immense grief, anger, and so much loss.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with psychiatrist, Dr. Nayla Khoury about the impact of forced displacement on children and adolescents.

How is this likely to impact the long-term development? I wanted to ask you that question as it relates to preschoolers and also teenagers.

Nayla Khoury, MD: It depends a lot on the kids' and young person's experience, you know, whether they end up in a refugee camp or as immigrants in other countries. So there's a lot of different factors in terms of the migration experience that might impact how safe and how stable and how supportive a young person's environment is, going forward. So when it comes to learning about mental health and behavioral health of refugees, there are few studies that actually look at young people living in refugee camps, but the few studies that are out there show that up to 80% can experience symptoms like depression, anxiety, post-traumatic stress and behavioral challenges, particularly under 8 years of age. Among adolescents, there is more concern for risky behaviors and exploitation in terms of trafficking, as well as substance use, acting-out behaviors, things that might be just riskier behaviors, in adolescents.

Host Amber Smith: Now survivors are going to grow up knowing or learning that (Russian) President Putin ordered the invasion and some of them have Russian friends and family members. So is this bound to complicate those relationships?

Nayla Khoury, MD: I don't know how many people believe that President Putin speaks for all Russians or that all Russians are behind this war. And in fact, I think people are able to see the differences there. But I am aware that the amount of misinformation, particularly in Russia, may absolutely complicate relationships in terms of how people are able to understand or empathize (with) what's happening in Ukraine and how that may be impacting relationships.

Host Amber Smith: We've talked mostly about the children and adolescents who find themselves in the middle of this war. I wonder, though, since we turn on the television and we see footage, it almost feels like we're on the front line in real time, whether there's any significant impact on the kids here who view the news coverage?

Nayla Khoury, MD: Absolutely. There can be. So there's a lot of helpful guidance out there for families in terms of how to talk to their children about what's going on in Ukraine and in the war and how much to limit media exposure. So especially among the youngest children, watching that direct TV, if it can be helped, may not be necessary, but of course, some families might feel the need to know what's going on as much as possible.

So trying to limit exposure and then, especially with school-aged kids and adolescents, finding ways to talk about what's happening so that families and parents can be there to support their young people, their kids, as they make sense of what's going on.

Host Amber Smith: Being so far away from what is happening can lead to feelings of helplessness.

Do you have any suggestions for how to lessen that feeling?

Nayla Khoury, MD: I think helplessness is a great word that many people are experiencing as they watch what's happening. And for many who are from Ukraine as well, who may not be able to go back and help fight the war, I do know that there are lots of ways to help and hold hope from afar.

Some of that is just contributing financially. Some of that is contributing and being involved in nonprofit organizations that are doing work. And some of it is continuing to focus on your work of everyday life to connect to a sense of mission and purpose.

Host Amber Smith: Many of the people who are leaving Ukraine are finding refuge in adjacent countries. I believe the U.S. is going to be accepting refugees from Ukraine as well. What can be done to help promote healing and resilience among the kids who were displaced and will find themselves in a new country for their new home?

Nayla Khoury, MD: First and foremost, the basic triangle of survival is making sure that kids do have home, shelter, food, access to education.

So all of that is vitally important. And then the climate that kids and families find themselves in, in terms of being welcomed or being seen as other or discriminated against, also has a huge impact on a young person's wellness or well-being. So it's about connection and belonging and helping to create infrastructure for supporting those things no matter where these Ukrainians end up living.

Host Amber Smith: Once the children are out of danger, once they have a safe place to call their home, maybe once they're back in a school setting of some sort, what issues are likely to surface within them?

Nayla Khoury, MD: Well, it could be all sorts of things. And I think some of what we try to tell parents and adults is really to allow any expression of feeling to be present.

I mean, it could be anxiety and fear that we see. It could be acting-out behaviors or regressive behaviors, like a kid who used to be able to toilet themselves and is now unable to do that. There's all sorts of different ways kids can express stress. And so being open and aware that all of it is possible, and anger -- anger can come out in all sorts of scary ways.

So some of the guidance we give to parents is thinking about safety first. So how to let your young child know -- and this is, I think, true of our kids who are not even directly affected by the war -- letting them know that they're safe, having predictable routines, then allowing expressions of feeling, following our child's lead in terms of what they might need, enabling them to tell a story of their experience when they're ready to, and that can be verbally, it can be done using pictures, and then connecting with community in whatever way that might be, whether it's through song or other rituals. So those are some of the practices that I think can be helpful.

Host Amber Smith: I was going to ask how important it is for playtime and recreation, which, you might not think about that necessarily when you're running for your life, but once a child has safety and they're out of danger, do they still need to have play time in their day?

Nayla Khoury, MD: Absolutely. Play is how a child learns about the world. And I think some of the impacts of trauma, of all different sources, is that young people often don't get a chance to play. They're so worried about survival that their play is restricted. And so yes, ample space for play is vitally important.

Host Amber Smith: I know you've done research in trauma, but I wonder: Is the trauma of war different from the trauma of a fire or a hurricane that forces someone out of their home without warning?

Nayla Khoury, MD: Yeah, it can be. And I don't have a great answer for this. I've looked at trauma from natural disaster, trauma from war trauma, from terrorism. There are a lot of similarities. We do see some more what we call "externalizing behaviors" sometimes in war, armed conflict, kids who've experienced that, so kids who may then go on to have more aggressive behaviors than other types of trauma. But I think there are just so many factors that go into predicting how a young person's going to respond. It is very hard to know.

Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Khoury.

Nayla Khoury, MD: You're so welcome. Thanks for having me.

Host Amber Smith: My guest has been Dr. Nayla Khoury, a child and adolescent psychiatrist at Upstate Medical University. "The Informed Patient" is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

I'm your host, Amber Smith, thanking you for listening.