The armed conflict in Ukraine began in February, 2014 when Russia annexed Crimea, and escalated in February 2022 with a full-scale invasion of Ukraine. Several studies have shown a severe impact on the mental health of Ukrainian adolescents and children with an increase in psychological issues such as depression, anxiety, and post-traumatic stress disorder (PTSD) [15, 16]. Although several telephone surveys have been conducted, in-person prospective studies aimed at assessing the mental health of children in wartime are lacking. Additionally, the cumulative effect of prior burn injuries and current armed conflict on the mental health of children has not been described. We have successfully interviewed and conducted an assessment of the mental health, utilizing the Achenbach System of Empirically Based Assessment (ASEBA), of Ukrainian children during a surgical burn and reconstructive surgical mission. This appears to be the most thorough evaluation of children in war-time Ukraine performed for the purpose of assessing the disease burden. We also performed simultaneous mental health assessment of the children’s caretakers.
Treatment of burn injuries can be a complex and arduous process that is focused on restoring both function and form. These treatments can span over the course of years or decades, particularly in the pediatric population where burned tissues do not grow in turn with uninjured tissue. This creates the need for frequent scar revisions and other procedures to reduce contracture and restore function. While the reconstructive procedures are constantly evolving, they remain well-described in burn literature. Procedures such as skin grafting, and various local tissue rearrangements have become the mainstay of treatment and are performed around the world. However, only recently have the psychological effects of burn injury been explored. Treatments for psychological trauma experienced due to burn injury remain as an afterthought when compared to the traditional medical and surgical treatment, which can potentially cause increased psychological morbidity. Studies have shown that burn survivors are at risk to suffer from anxiety, depression, and post-traumatic stress disorder, as well as frequent disturbances in sleep and frequent nightmares [17, 18]. Much like other trauma, the prevalence of psychological disturbances does tend to decrease over time [19]. Studies have identified factors that reduce the long-term psychiatric consequences of burns, including positive coping strategies, social support, mindfulness, and altruism [20, 21, 22]. It is unclear if these coping mechanisms learned at an early age could reduce the psychological impact of further adversity, such as that experienced during wartime. It is difficult to draw conclusions in a smaller sample size such as this, however it is an interesting thought to consider possible protective factors from the development of coping mechanisms in children with burn injuries living in a war zone.
Our psychosocial wellbeing assessment shows that there is a heavy mental health disease burden within our study population with evidence of clinically significant pathology. Some children need thorough examination and treatment in connection with the risk of Depressive, Obsessive-Compulsive, Oppositional Defiant and Attention Deficit Problems. These results show relatively good agreement between child self-assessment and parental assessment of the children, which is typically not the case in this patient population. Prior studies have shown that there is only a low to moderate correspondence between child and parent reports of mental health problems [23]. However, some agreement with prior studies was seen in that, children typically self-report greater levels of internalizing problems compared to parents, which was seen within our population [24].
It is important to note the limitations in our study. Most notably our analysis is conducted on a small sample of a relatively distinct population of children in Ukraine with prior traumatic burn injury. Given that a history of burn injuries in children is an independent risk factor for post-traumatic stress disorder, anxiety, and other forms of psychopathology, the effects of the war cannot be directly inferred given history of burn trauma [3, 4] Within our study, the children were removed temporarily from conflicted regions during the time of the reconstructive mission and as such were interviewed after the immediate risk of injury to them or loved ones was minimized during the questionnaire period. Our population was not limited to any specific geographical region and as such some individuals had greatly varying proximity to the frontlines of the war.
An important aspect of our initial evaluation is conducting psychological assessment at the time of a surgical reconstructive mission. The concept of treatment and evaluation of mental health during war has been described as early as the Roman empire but likely is as old as the act of war itself [25]. Modern texts arising from the time of World War I describe evaluation and treatment of PTSD on the field and during return and integration to society [26]. Therefore, evaluation of mental health during reconstructive missions for burns or trauma warrants examination. Our reconstructive team, paired with a clinical psychiatrist were able to successfully evaluate surgical patients who have undergone prior trauma. Additionally, the current war in Ukraine increases the relevance of such evaluation. Though we were teamed with a clinical psychiatrist, the surveys can be distributed during any surgical mission and later evaluated by a mental health professional. Later directing these patients to appropriate mental health providers would allow for a more complete treatment, rather than solely focusing on surgically treatable burn and trauma disease.