Past horrors, present struggles: The role of stigma in the association between war experiences and psychosocial adjustment among former child soldiers in Sierra Leone

Abstract

Upon returning to their communities, children formerly associated with armed forces and armed groups--commonly referred to as child soldiers--often confront significant community stigma. Much research on the reintegration and rehabilitation of child soldiers has focused on exposure to past war-related violence and mental health outcomes, yet no empirical work has yet examined the role that post-conflict stigma plays in shaping long-term psychosocial adjustment. Two waves of data are used in this paper from the first prospective study of male and female former child soldiers in Sierra Leone. We examined the role of stigma (manifest in discrimination as well as lower levels of community and family acceptance) in the relationship between war-related experiences and psychosocial adjustment (depression, anxiety, hostility and adaptive behaviors). Former child soldiers differ from one another with regard to their post-war experiences, and these differences profoundly shape their psychosocial adjustment over time. Consistent with social stress theory, we observed that post-conflict factors such as stigma can play an important role in shaping psychosocial adjustment in former child soldiers. We found that discrimination was inversely associated with family and community acceptance. Additionally, higher levels of family acceptance were associated with decreased hostility, while improvements in community acceptance were associated with adaptive attitudes and behaviors. We found that post-conflict experiences of discrimination largely explained the relationship between past involvement in wounding/killing others and subsequent increases in hostility. Stigma similarly mediated the relationship between surviving rape and depression. However, surviving rape continued to demonstrate independent effects on increases in anxiety, hostility and adaptive/prosocial behaviors after adjusting for other variables. These findings point to the complexity of psychosocial adjustment and community reintegration in these youth and have a number of programmatic and policy implications.

Introduction

Of the many horrors of war, the phenomenon of children associated with armed forces and armed groups is of increasing international concern (CSUCS, 2008, UNICEF, 2007). At present, it is estimated that as many as 300,000 children under the age of 18 currently serve in government forces or armed rebel or militia groups around the world (CSUCS, 2008). A number of recent studies have documented high rates of mental health problems among children formerly associated with armed forces and armed groups (CAAFAG), commonly referred to as “child soldiers” (we will use the term “child soldiers” throughout this paper for ease of readability with the caveat that it implies the broader view encompassed by the acronym CAAFAG). Upon returning to their communities, former child soldiers may face significant stigma due to community perceptions that these youth are immoral or dangerous. Stigma for a variety of reasons, from HIV to mental illness, has been robustly linked to poor health outcomes (Collins et al., 2008, Rao et al., 2007, Williams et al., 2008). Although much attention has been paid to the negative impact of the violence that child soldiers endure, little is known about how stigma associated with such experiences may influence the psychosocial adjustment and social reintegration of former child soldiers in the post-conflict environment.

A number of studies in recent years have documented increased risk of mental health problems, including symptoms of posttraumatic stress disorder (PTSD), other anxiety disorders, and depression, among former child soldiers. For instance, Kohrt et al. (2008) found that 55.3% of Nepalese former child soldiers met standard diagnostic criteria for PTSD, 53.2% met criteria for depression and 46.1% for anxiety disorder. In northern Uganda, a study by Derluyn, Broekaert, Schuyten, and De Temmerman (2004) evaluated 71 former child soldiers, and found extremely high rates (97%) of posttraumatic stress reactions. This study, although critiqued for its recruitment methods (McKay & Wessells, 2004) speaks to the scale of distress in this sample. Bayer, Klasen, and Adam (2007) studied 169 former child soldiers in rehabilitation centers in Uganda and the Democratic Republic of the Congo (DRC) and documented that over a third of their sample (34.9%) met clinical symptom thresholds for PTSD.

Several studies illustrate risk for poor mental health outcomes among former child soldiers, however the substantial variability in these outcomes across different settings suggests that long-term psychosocial adjustment is influenced not only by past war experiences, but also by post-conflict factors, which may vary widely. For example, in Nepal, Kohrt et al. (2008) observed that poor mental health outcomes persisted in former child soldiers compared to matched controls even upon adjusting for exposure to violence. They speculated that other processes such as experiences of discrimination and stigma might likely account for these differences.

The process by which stigma and discrimination directed at former child soldiers may occur appears to vary greatly by context. In Sierra Leone, a survey of ex-combatants (which included adults and former child soldiers) conducted by Humphreys and Weinstein, 2004, Humphreys and Weinstein, 2007 found that higher rates of exposure to violence were associated with lower levels of community acceptance. The degree of acceptance encountered in families may also vary from that of the broader community. In northern Uganda for instance, Annan, Blattman, and Horton (2006) observed very high rates of family acceptance, with only 1% of returnees reporting that their families were unwelcoming or unhappy about their return. However, the researchers also noted that community acceptance was not as widespread, with nearly 25% reporting the presence of initial community stigma (usually expressed in the form of insults) upon return home. Blattman and Annan (2007) also noted that stigma tended to decrease over time with 94% of participants stating that they felt “very” or “somewhat” accepted by the community at the time of interview. These studies suggest a more nuanced relationship between past experiences of violence, community stigma and family support in contributing to the mental health of former child soldiers.

In Sierra Leone, the long term psychosocial adjustment and social reintegration of former child soldiers is of particular concern. Civil war ravaged the West African nation from 1991 to 2002. Children of all ages were involved in the national army, civilian defense forces (CDF) and, most notoriously, in the Revolutionary United Front (RUF). The RUF rebel group was responsible for brutal atrocities including terrorism directed at civilian populations, a campaign of amputations to suppress resistance and the large scale abduction of children (CSUCS, 2008). In the Sierra Leone conflict, official estimates indicate that some 5000–10,000 children were involved in the different warring factions (CSUCS, 2008), though other sources report estimates as high at 48,000 (McKay & Mazurana, 2004). The RUF, in particular, was known for forcing children to commit atrocities, including murder, against neighbors and loved ones in order to indoctrinate new recruits and sever community ties. During their years with the rebels, many of those children were also raped repeatedly and forced to take drugs to reduce inhibitions against committing violent acts (McKay & Mazurana, 2004).

At the war's end, short-term disarmament, demobilization, and reintegration (DDR) programs worked to prepare former child soldiers to return to their homes through services offered at interim care centers (ICCs) such as reunification with their remaining family members and communities. During the DDR process, many young people were given the explicit message that their involvement in the atrocities of the war was “not their fault.” Similar messages were an important part of the community sensitization campaigns carried out in the communities where these young people were returned (Betancourt et al., 2008, Betancourt and Khan, 2008, Stovel, 2008). Despite these external messages, however, the day-to-day interactions of these youth with others in their community reminded them that all was not forgotten. The initial response to their return was often one of fear and distrust (Betancourt, Simmons, et al., 2008). Females were frequently seen as sexually promiscuous or defiled, while many youth--male and female alike--were treated with apprehension (Burman and McKay, 2007, Denov, 2007).

Of the many aspects of the DDR process, reintegration and rehabilitation remain the longest and most complex. Successful reintegration and rehabilitation depends on a number of factors, including family and community acceptance (Annan et al., 2007, Betancourt et al., in press, Betancourt et al., 2008, Boothby, 2006), access to educational and training opportunities to help war-affected youth achieve self-sufficiency and maintain productive roles in the community (Betancourt et al., 2008, Wessells, 2009) as well as the behavior of the youth themselves. Thus, to understand the full impact of war experiences on former child soldiers it is important to explore the role of post-conflict factors which are gaining attention in research on war-affected youth (Annan et al., 2007, Ellis et al., 2008, Lykes, 1994, Miller et al., 2008).

Dominant theories of stigma and discrimination are useful for understanding the situation of former child soldiers in the post-conflict environment. Research on stigma and prejudice grew from the early work of leading sociologists (Goffman, 1963) and social psychologists (Allport, 1954). With time, theory and research on stigma and its health consequences cited the need to move from a focus on individual characteristics to understanding stigma in its social context (Crocker, 1999, Yang et al., 2007). Stigma exists when an individual is labeled, negatively stereotyped, categorized as separate, and experiences discrimination by someone who is in a position of relative power (Link and Phelan, 2001, Link and Phelan, 2006). Former child soldiers returning to their communities often experience stigma, though in differing degrees (Annan et al., 2007, Betancourt et al., 2008, Boothby, 2006, Williamson, 2006). In addition to poor mental health outcomes (Dovidio et al., 2008, Link et al., 2008, Mak et al., 2007, Meyer et al., 2008, Williams et al., 2008, Williams et al., 2008, Yang and Kleinman, 2008), stigma may also contribute to fewer positive opportunities and less access to protective resources such as community and family support (Link and Phelan, 2001, Link and Phelan, 2006).

Social stress theory (Aneshensel, 1992) posits that stress and resources act as mediators in the relationship between social structure and poor health outcomes. Two hypotheses are suggested by this model. First, that social structure patterns both stress and resources. Second, that stress due to one's status has a causal relationship to mental health outcomes, while resources (internal and external) serve to buffer this risk (Aneshensel & Phelan, 1999). Social stress theory can be adapted to illuminate the processes characterizing the relationship between war experiences, social stigma and psychosocial adjustment in former child soldiers. First, adding to the model of social stress (see Fig. 1), it is important to note that for many former child soldiers, traumatic war experiences may create internal guilt, anxiety and even traumatic stress reactions. Upon return to their communities, child soldiers then experience lowered social status as a result of the prejudices and fear from community members. This stigma in turn may lead to greater experiences of stress (in the form of discrimination) and reduced access to protective resources, which may combine with internal distress to influence poor mental health outcomes.

Building on social stress theory, Link and Phelan (2006) have proposed that stigma leads to experiencing ‘less of the good things and more of the bad’ in relation to health and adjustment (Link & Phelan, 2006). In this manner, not only does stigma increase stress, it may also impede a person's access to coping resources (Aneshensel, 1992). Both of these models draw attention to the importance of understanding the consequences of social responses to the stigmatized individual and point to the possibility that psychosocial adjustment in former child soldiers must consider the post-conflict environment and not solely past war-related experiences. Indeed, stigma may be an important aspect of understanding how past war experiences continue to exert influence on the psychosocial adjustment of former child soldiers long after the end of war.

There is a strong body of literature linking discrimination with poor psychosocial outcomes in young people (Fisher et al., 2000, Klonoff et al., 1999, Rumbaut, 1994), yet discrimination directed at former child soldiers has received very little attention. In their study, Annan et al. (2007) noted that the minority of child ex-combatants who had experienced poor community acceptance upon returning home were three times more likely to exhibit negative social behaviors and had higher levels of emotional distress. Such findings point to the need to examine the role of discrimination in the longer term psychosocial adjustment of these youth.

In terms of protective factors, community and family support can be important resources contributing to healthier long term outcomes in former child soldiers (Corbin, 2008). Betancourt et al. (in press) observed that although family support and improved community support were not able to completely mitigate the deleterious effects of wounding/killing and rape on psychosocial adjustment, they did reduce the risk of negative psychosocial outcomes such as hostility. Stigma may serve to impede or erode such protective processes, placing youth at further risk for psychosocial maladjustment.

To build on this prior research, the present study examines the role of stigma as a potential mediating (i.e., explanatory) factor in the relationship between exposure to war-related events and psychosocial outcomes. The present study draws on prospective data to examine the contributions of potentially stigmatizing war exposures (i.e. surviving rape and participating in wounding/killing) and more recent post-conflict experiences (i.e. perceived discrimination, access to education, and acceptance in the family and community) to psychosocial adjustment. The study set out to examine the following hypotheses: first, that perceived discrimination (as our indicator of stigma) would be associated with poorer access to protective resources such as family and community acceptance and school access. And second, that the relationship between potentially stigmatizing past war-related experiences (being raped and wounding/killing others) and poor psychosocial adjustment would be in part attributable to (i.e. mediated by) higher levels of perceived discrimination.