Child neurodevelopmental disorders in armed conflict country, case of DR Congo: long-term trauma impact on brain development in childhood: review

Abstract

Neurodevelopmental disorders are a group of disorders that begin during the developmental period. They typically manifest early in development, sometimes even before the child enters primary school, and are defined by developmental deficits leading to impaired personal, social, academic, and/or occupational performance1. The Democratic Republic of Congo (DR Congo) is a country plagued by repeated conflicts involving different local armed groups and instability in the management of public affairs2. But in spite of this, the country is also a victim of aggression by foreign armies, particularly from certain neighboring countries. These traumatic and/or stressful events to which the Congolese population is subjected are constituent elements of disorders that may include reactive attachment disorder, disinhibition of social contact, post-traumatic stress disorder, acute stress disorder, and adjustment disorders as defined by the DSM-5 manual1. Globally, resource-poor countries are at high risk of falling behind in 4 fields of development, with disability rates of around 20.4% (3.1%–45.2%) in any one of these fields3,4; some authors also reveal that language disorders are the most frequent, followed by motor, cognitive and sensory disorders3,4. In the DR Congo, according to UNICEF criteria, only 66% of children aged 36–59 months are on track for development (Early Development Index score) in at least 3 of the following areas: literacy/calculus, physical, emotional, and/or learning5. Risk factors for neurodevelopmental disorders Studies around the world show that low-resource countries are at high risk of delays in 4 developmental domains, with handicap rates ~20.4% and ranging from 3.1% to 45.2% in any one of these domains; these studies reveal that language impairment is the most common, followed by motor, cognitive, and sensory disorders3,4. However, in neurodevelopmental disorders, cognitive developmental disorders, language delays, and stereotypies frequently go together with reactive attachment disorder1. The presence of severe social negligence is a requirement for the diagnosis of Reactive Attachment Disorder and is the only known risk factor for it1. In DR Congo, without going back over the importance of these factors in the occurrence of neurodevelopmental disorders, these risk factors described are sometimes observed in the children’s guardians and/or parents, who react in their turn and sometimes leave the children to abandon. Hence the issue of “street children,” which does not promote a suitable environment for normal development and should involve all political and social actors, to return to the normal social order and bring these children back into an environment that allows them to blossom and consequently develop normally, this involves building schools and hospitals, improving the social status of the population, etc., a responsibility that falls mainly to the government. Some medical ailments, such as severe malnutrition, which is a scourge and challenge of the health system in a low-resource country like DR Congo, may accompany some signs of the disorder1,2. The armed conflicts that continue to be a daily occurrence in DR Congo increase the poverty rate6 and the risk of malnutrition, especially among the most vulnerable children, which are associated factors with neurodevelopmental disorders in an already fragile population. Impact of armed conflict on child neurodevelopment in DR Congo Armed conflicts provide a permanent stress exposure. It is well established that exposure to the traumatic event and its characteristics constitute the essential determinant of post-traumatic stress disorders in children. These disorders can become chronic in half of the cases, continue into adulthood, and be complicated by the occurrence of other mental disorders (in particular, depressive syndromes) or behavioral and personality disorders. This is not without consequences for neurodevelopment, as it results in psychosocial complications that can alter exchanges between the child and his or her environment and have repercussions on the child’s neurodevelopment7. The persistence of armed conflicts maintains the risk factors for neurodevelopmental disorders, the displacement of populations favoring changes in the living environment of the growing child, the change in nutritional regimes linked to displacement are both nutritional and environmental consequences of these armed conflicts, which can maintain neurodevelopmental disorders; sexual violence, sometimes against minors, used as a weapon of war in the DR Congo, and the recruitment of child soldiers into armed groups, remain a challenge for the defense and political system, which for nearly 3 decades has not been able to control the situation in the interior of the country, which remains disrupted by the presence of armed groups. All these factors have direct consequences on neurodevelopment and deserve special attention. Joint efforts to monitor child neurodevelopment in DR Congo Despite the long-running armed conflicts in DR Congo, some nongovernmental organizations (NGOs) or solidarity associations are taking the trouble and acting on a national or international scale, and are now, in many areas, partners of states, donors or funders and populations, particularly those who have the most difficulty in being heard by the community and its representatives, as is the case in the DR Congo. They are very present in the field of education, in extremely varied forms. For the monitoring of neurodevelopment, these organizations are usually involved in this area, especially as it is difficult to cover all aspects of neurodevelopment and education is the key to suspecting other neurodevelopmental disorders, as they may manifest themselves as school failure8,9. The NGO Afia Shuleni in South Kivu provides preventive health care and health education to school-age children in the DR Congo, specifically in the province of South Kivu, in order to improve their physical and mental health10 and to identify possible developmental disorders and thus maintain an environment suitable for the child’s healthy development. The NGO Afia Shuleni in South Kivu provides preventive health care and health education to school-age children in DR Congo, specifically in the province of South Kivu, in order to improve their physical and mental health and to identify possible developmental disorders and thus maintain an environment suitable for good child development. However, in response to the growing complexity of humanitarian crises in DR Congo and around the world, UNHCR has expanded the number and type of organizations it works with. The refugee agency has long worked with “sister” agencies in the UN family whose mandates complement or converge with its own. Among the most important of these are the World Food Programmed (WFP), the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), the United Nations Development Program (UNDP), the Office for the Coordination of Humanitarian Affairs (OCHA), the Office of the High Commissioner for Human Rights (OHCHR) and the Joint United Nations Program on HIV/AIDS (UNAIDS)11. These organizations converge their actions to allow the child to blossom and therefore develop normally and are all present on Congolese soil. Conclusion and recommendations Armed conflicts in DR Congo have evolved over the last 3 decades with a multiplicity of rebellions and aggressions on Congolese territory by foreign armies. These unfortunate events, which plunge DR Congo into mourning every day, unfortunately, do not go unnoticed, and the consequences of war on neurodevelopment are multiple. Some NGOs are acting locally to alleviate the consequences of this trauma in all aspects of life, but there is still a great deal of work to be done: eradicating armed groups, defending the country against all forms of aggression, integrating school medicine into the health system, identifying potential cases of neurodevelopmental disorder and treating them if necessary; conducting large-scale studies to take stock of the issue of neurodevelopmental disorder in DR Congo and drawing up guidelines for treatment. Ethical approval None. Sources of funding This research did not receive any specific grant from funding commercial, or not for profit sectors. Author contribution K.M.: conception, administrative support. B.G.: design. K.M., M.M., and T.M.: literature search. K.M. and B.G.: manuscript preparation. K.M., B.G., and T.M.: manuscript editing. K.M., M.B., B.A., and W.O.: manuscript review. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Kitoga Muke is the guarantor of this study and accept full responsibility for the work and the conduct of the study, has access to the data, and controlled the decision to publish. Consent None.