NOTES 80643 Child & Youth Development Youth and employment in post-conflict countries: The psycho-social dimension Youth in at-conflict countries have often been involved both as victims and perpetrators of violence, responding to war and its effects in different ways. Not all individuals directly affected by conflict will develop long-term stress-related symptoms. However, those who do may be greatly and possibly even permanently affected, which limits the ability to find and keep a job. In turn, productive employment may contribute to the recovery of affected individuals and reduce the likelihood of their being drawn into future violence, thereby contributing to stability and peace building. Post-conflict development policy must address not only the reconstruction of physical capital, but also the reconstruction of psychological and social (psychosocial) capacities of those who have lived through violent conflict. There are over 3 billion people under the age of 24 in the world today, comprising 47% of the world’s population. Nearly 90% live in developing countries and the challenges they face - poor health, low quality education, lack of marketable skills, high rates of unemployment, early pregnancy, social exclusion, and the highest rates of new HIV/AIDS infections - are costly to themselves and to society at large. Client demand for policy advice on how to tap the enormous potential of the world’s children and youth is large and growing. This series aims to share research findings and lessons from the field to address these Volume IV, Number 2 important cross-sectoral topics. September 2010 www.worldbank.org/childrenandyouth Many of the factors exacerbating psychosocial distress – including absenteeism, poor job performance, and difficulties in performing economic deprivation, the rupture of social networks and lack mental and interpersonal tasks. Furthermore, studies in Europe of sense of belonging due to displacement – are mitigated when and Central Asia describe not only individuals’ limited ability to war-affected individuals are integrated into society through develop self-reliance after displacement due to violence, but also employment(1). However, research in conflict-specific contexts depression, demoralization, and feelings of worthlessness(6). finds that distress, depression, and Post-Traumatic Stress Disorder (PTSD) reduce the likelihood of working(2). Hence, Unemployment has been found to be widespread among ex- the need for well directed intervention to assist youth whose combatants, especially youth. Post-conflict, former child soldiers psychosocial health has been affected by conflict to prevent their have had higher levels of unemployment than demobilized adults, further marginalization and exclusion. perhaps attributable to adults’ education and work experience and stronger social and economic identities established before This note discusses the under-explored phenomenon of the the onset of the war. One study found that the poor long-term relationship among conflict and violence, psycho-social economic prospects of many former child soldiers in Uganda wellbeing and youth employment and the implications for policy were explained by their productivity loss due to missed education and intervention. and work experience during the time they spent in armed groups. While formerly abducted youth were as likely to be employed How do conflict and violence affect as non-ex-combatants, they were half as likely to be engaged in skilled work and earned a third less(7). the psychosocial well-being of youth? Former combatants who are given the chance to integrate into The persistence of severe stress-related symptoms from both the labor force seem to have greater difficulties than those who war itself and the daily stressors associated with post-conflict had less traumatic war experiences. Odenwald et al.(8) find that environments can impair the psychosocial well-being of ex-combatants in Somalia suffering from high levels of distress conflictaffected youth, impacting their health, cognitive and or from substance abuse problems were less likely to reintegrate social development and capacities to work and function socially. successfully through employment and vocational training A small literature documents traumatic symptoms and poor programs than other former soldiers. Preliminary results of a psychosocial outcomes among war-affected children and youth. post-war survey in Burundi show that trauma symptoms such For example, a comparative study found that war-exposed as experiencing headaches or pains when thinking about war Sudanese children age 7-12 living in northern Uganda had a experiences were associated with lower levels of income(9). In higher incidence of PTSD-like complains, behavioral problems, Uganda, however, evidence suggested that loss of education, and depressive symptoms than did Ugandan children who were rather than trauma, influenced economic outcomes(10). not affected by war. In addition to being exposed to a higher level of violent events, the refugee children were more exposed to daily How does employment affect stressors such as hunger, poor medical and sanitary conditions, psychosocial well-being? lack of clothes, and shortage of school materials, increasing the children’s anxiety for their own future and that of their siblings(3). The relationship between psychosocial well-being and employment is a complex and reciprocal one: poor psychosocial health may A more recent approach has stressed the resilience of youth, who, inhibit the ability to seek out and maintain employment, and although suffering profound traumatic symptoms and exposure meaningful work may be an important aspect of psychological to substantial risk, can often attain “desirable social outcomes recovery from conflict-induced trauma. and emotional adjustment�(4). The main lesson is that war does not inevitably destroy all that it touches, and that while war Unemployment has well-documented negative effects on causes many to become extremely vulnerable, vulnerability does psychosocial well-being,(11) particularly apparent in situations not in itself preclude ability(5). of post-traumatic stress. In a study conducted after the attacks of September 11th, in the U.S., Nandi et al. 2004, found that The resilience paradigm calls for more nuanced and rigorous unemployment predicted the persistence of PTSD in the sample studies of youth in areas of conflict, including attention to the a year after the event. Similarly, in studies of refugees and asylum context and social meaning of violence and reintegration. Conflict seekers, unemployment was also associated with the occurrence does affect the psychosocial well-being of youth; however, the of PTSD.(12) As observed by Wessells (2006), “Uncertainties about factors which determine the extent and nature of this impact are identity, jobs, and role are among the greatest life stresses for only now beginning to be explored. many former child soldiers, who want above all to be normal and like other children.�(13) How does psychosocial well-being Employment plays a vital role in promoting psychological affect employability and productivity? wellbeing: the economic autonomy which it provides is central The cognitive, emotional and behavioral effects of psychosocial to defining social status. Especially for young males, their social impairment can severely undermine social functioning and recognition as men may entail the ability to establish and support productivity. Studies of mental health impacts in post-conflict a family.(14) In its absence, youth may remain marginalized from and developing countries are very few, although a body of U.S. economic, social, cultural and institutional systems.(15) More research has shown that those with depression and other mental attention needs to be paid to the effects of employment on their illnesses show significantly higher rates of unemployment, identity and psychological well-being of both men and women. 2 Child & Youth Development Notes | September 2010 Figure 1: Psychosocial Health Intervention Applied to Post-Conflict Environments Curative Specialized Care Estimated Tertiary 1-3% of population Focused Care Estimated Secondary 30-40% of population Development Para-Professional Group Care Basic Community Estimated Care Primary 60% of population Poverty Reduction Peace & Security Education Health Source: Jordans et al. 2008; Baingana et al. 2005; Kalksma-Van Lith2007(17). Interventions to Support the n Small Group Therapy. This is a form of psychotherapy in which one or more therapists treat a small group of clients together as Psychosocial Wellbeing of Conflict a group. Affected Children and Youth n Creative Therapy. A type of group therapy that uses expressive Psychosocial health approaches may be classified into three and creative techniques. levels (see Figure 1). The tertiary level targets the 1 – 3 percent of the population with the most severe mental health problems. These interventions are necessarily very individualized – The secondary level targets the 30-40 percent of the conflict requiring focused care or, in the worst cases, specialized care affected population that may be at risk of developing mental (Figure 1) - since they aim to “rewire� the young person’s health problems, while the primary level is directed at the general attitudes, outlook, and decision-making strategies. Thus, they are population to promote adaptation and normalization in the quite costly. However, evidence from the US suggests that, if done post-conflict environment, through developing and restoring correctly, the high benefits greatly outweigh the costs of these livelihoods and access to services.(16) interventions. We can think of a continuum of interventions ranging from For the general population of children and youth or those who are developmental (primary level) to curative (tertiary level). Curative at a low-risk of developing mental health problems, developmental approaches are largely trauma-oriented and entail psychological approaches are most appropriate. These interventions are treatment of small groups. They include: preventative and focus on post-conflict social contexts and challenges rather than past experiences. Interventions include: n Psychotherapy. The treatment of mental and emotional disorders through the use of psychological techniques n Reintegration into Society. These interventions aim to designed to encourage communication of conflicts and normalize systems and structures, such as returning to insight into problems, with the goal being relief of symptoms, education, re-establishing cultural ceremonies, restoring social changes in behavior leading to improved social and vocational networks, re-establishing livelihoods, providing material and functioning, and personality growth. psychosocial support for parents, reuniting families.(18) Narrative Exposure Therapy. A form of therapy for clients n n Child-Centered Group Interventions. These interventions with PTSD which encourages them to tell their detailed life restore normality and offer youth opportunities to come history chronologically to someone who helps them integrate together through community-based events, like sports, fragmented traumatic memories into a coherent narrative. cultural programs, and clubs Individual Therapy. This involves working on a one-to-one n These interventions are less expensive on a per unit basis than basis with a therapist to prepare a plan to create positive the curative approaches, but they cover a larger share of the changes in one’s life. population. Again, though, the benefits outweigh the costs. Child & Youth Development Notes | September 2010 3 The overall package of programming for any population, of conflict-affected youth, particularly those who have been therefore, needs to involve comprehensive, culturally sensitive, traumatized, must not only include the provision of skills and multi-level interventions, providing services both to children and employment but also the counseling to help them manage their youth who need social support and those who need curative care. past trauma. This intervention is central to both short- and Engaging youth themselves in the planning and implementation longterm employment growth and responses to conflict. of programs will improve their design and relevance. Our evidence base needs to grow, though. While poverty has been Conclusions shown to be an important factor in determining psychosocial well-being, the implications for employment, employability While addressing the psychosocial impact of trauma is clearly and productivity, especially among youth, have yet to be well critical in general, the effects of psychosocial interventions on examined. Given the limited documentation of experience to employment (and vice versa) are vital, especially in postconflict date, there is a need to test, cost, and evaluate the range of current developing countries. In addition, employment is a key element intervention approaches. in psychosocial wellbeing. Thus, employment preparation References and Recommended Reading (1) Evans, J. and J. Repper. 2000. “Employment, social inclusion and mental health.� Journal of Psychiatric & Mental Health Nursing, 7(1): 15-24; Hamilton, V. H., et al. 1997. “Down and out: estimating the relationship between mental health and unemployment.� Health Economics 6(4): 397-406 (2) According to the American Psychiatric Association, post-traumatic stress disorder (PTSD) “is a psychiatric disorder that can occur in people who have experienced or witnessed life-threatening events such as natural disasters, serious accidents, terrorist incidents, war, or violent personal assaults like rape. People who suffer from PTSD often relive the experience through flashbacks or nightmares, have difficulty sleeping, and feel detached or estranged.� See http://www.healthyminds.org/multimedia/ptsd.pdf (3) Paardekiiper, B., J. T. V. M. de Jong, and J. M. A. Hermanns. 1999. “The Psychological Impact of War and Refugee Situation on South Sudanese Children in Refugee Camps in Northern Uganda: An Exploratory Study� Journal of Child Psychology and Psychiatry 40(4): 529:536. (4) Betancourt, T. S., & Khan, K. T. 2008. “The mental health of children affected by armed conflict: Protective processes and pathways to resilience.� International Review of Psychiatry, 20(3): 317-328. (5) Boyden, J. and J. de Berry, Eds. 2004. Children and Youth on the Front Line: Ethnography, Armed Conflict and Displacement. Studies in Forced Migration. New York, Berghahn Books. (6) Holtzman S. B. and T Nezam. 2004. Living in Limbo: Conflict-Induced Displacement in Europe and Central Asia. Washington, DC : World Bank (7) Blattman, C. and J. Annan. 2007. “Child combatants in northern Uganda: Reintegration myths and realities.� Published in Robert Muggah, ed. 2008. Security and Post-Conflict Reconstruction: Dealing with Fighters in the Aftermath of War. New York, Rutledge. 103–126. (8) Odenwald, M., et al, 2007. “The consumption of khat and other drugs in Somali combatants: A cross-sectional study.� PLoS Med 4: 341. (9) Mvukiyehe, E., et al, 2006. “Wartime and Post-conflict Experiences in Burundi.� Columbia University, paper presented at the APSA Conference, September 2006. (10) Blattman, C. and J. Annan. 2007 (11) Much of the research on the negative mental health consequences of unemployment are based on studies carried out as a result of the decline in the heavy manufacturing industry that occurred in the 1970s and 1980s in North American and Europe. Unfortunately, no specific literature on the issue in Sub-Saharan Africa exists, although research on youth highlights the frustration that this population experiences due to poor access to jobs. (12) Nandi, A., et al, 2004. Post traumatic stress disorder in Manhattan, New York city after September 11 terrorist attacks. Journal of Urban Health 79:340-353. (13) Wessells M. 2006 Child soldiers: from violence to protection. Cambridge, MA: Harvard University Press (14) Bannon, I. and Correia, M., eds. 2006. The Other Half of Gender: Men’s Issues in Development. Washington, DC: The World Bank. (15) Ibid (16) See, for example, Inter-Agency Standing Committee (IASC). 2007. IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: Inter-Agency Standing Committee. (17) Jordans, M. J. D., et al. 2008. “Development and validation of the child psychosocial distress screener in Burundi.� American Journal of Orthopsychiatry, 78(3), 290–299. ; Baingana, F., et al. (2005). “Mental health and conflicts: Conceptual framework and approaches.� Washington, D.C: The World Bank (18) Kalksma-Van Lith, B. (2007). “Psychosocial interventions for children in war-affected areas: the state of the art.� Intervention, 5(1): 3-17 Children & Youth Unit, Human Development Network, The World Bank www.worldbank.org/childrenandyouth This note draws on the fuller report by Paula A.Rossiasco, Fionnuala O’Neil, Amy Richardson and Paul Francis: ‘Youth, Conflict, Psychosocial Well-being and Employment: Evidence and Implications’ (Draft). World Bank, 2009. The authors are grateful for the comments of Mattias Lundberg, Chris Blattman, Jeannie Annan, and Atieno Fisher. Photo credit: Scott Wallace. The views expressed in this note are those of authors only and do not necessarily reflect 4 the view of the World Bank. Child & Youth Development Notes | September 2010