The world was aware that in 2014 the Yazidi community were targeted and dramatically attacked by a terrorist group in Iraq. I don’t think it’s important to name the terrorist group or the justification for their actions as what matters is the impact of the brutality on the communities. Yazidi boys had been captured and brutally trained to become child soldiers by this terrorist group in Iraq.

The research reviewed in this blog today looks at the impact on the mental health of some of those boys. The study comes out of the Institute of Psychotherapy and Psychotraumatology at the University of Duhok in Iraq.

In particular the researchers were looking to find out what percentage of the children had developed symptoms of post-traumatic stress disorder as well as other symptoms such as depression and low self-esteem. The researchers assert that the experiences of these group of children have not been specifically researched, however they do cite other studies that have analysed trauma symptoms of child soldiers in other conflict zones around the world.

Methods

The researchers are aware that children who live in conflict zones who haven’t become child soldiers will also inevitably develop symptoms of trauma and distress. So to find out if children who have become child soldiers suffer a different level of trauma they have studied both groups. The researchers used structured interviews and standardised questionnaires called psychometrics to measure the levels of Post Traumatic Stress Disorder, Depression and Self Esteem.

The measures used were The Event Scale, The Child PTSD Reaction Index, the Arabized Version of the Children’s Depression Inventory (CDI) and the Coopersmith Self-Esteem Inventory. Descriptive statistics and discriminate analysis was used to analyse the categories of age, gender, PTSD, depression, and self-esteem. Details about these measures can be found in the article itself for those who are interested. The researchers studied three groups of boys:

1. The first group were the primary target of the research and consisted of 81 Yazidi boys aged between 8 and 14 years old who were child soldiers in Iraq between 2014 and 2017 for a minimum of  6 months
2. Group two were a control group and consisted of 32 Yazidi boys of the same age who suffered the impact of war and conflict and who lived in the same region and the same refugee camp as the first group, but who had not become child soldiers
3. Lastly group 3 were also a control group and consisted of 31 boys of the same age who were Muslim and living in the refugee camp, but who were not Yazidi or former boy soldiers.

Results

The Event scale showed that all the children studied had been subject to a range of violent experiences, including rape and family deaths, as a result of horrific and brutal attacks and or captivity. In addition to this 15% of child soldiers said that they used a weapon to injure someone. The mean or average score on the Event scale for all the boys studied was 12.6 out of a maximum score of 15, illustrating the high level of distressing events experienced.

In the PTSD measure, the former boy soldier group had a mean score of 48.3 putting them in the high symptom range compared to the other two control groups who’s scores were 14.5 and 14.2 putting them in the low symptoms range. These results show that the former boy soldiers level of PTSD was statistically analysed as being significantly higher than the two control groups consisting of boys who hadn’t been child soldiers. The authors commented that these rates of PTSD fall within the range that has also been identified from 30% to 67% in other groups of child soldiers in countries like Rwanda, Uganda and Sudan. The former child soldiers studied also had statistically significantly worse than average scores for self esteem (24.61) than the other two group of boys studied (9.1 and 8.42).

The authors noted that all the former child soldiers specifically recalled the beginning, and in particular the suddenness of their captivity with accompanying intense horror, feelings of being petrified and unable to do anything to help themselves, with 74% suffering from continuing intrusive re-experiencing of the event.

Conclusions

Overall the authors concluded that compared to the control groups the children who were captured and did become soldiers had not only higher levels of PTSD but also  showed significantly higher levels of depressive disorders (45.6%), specific anxiety disorders (45.8%) and physical manifestations of psychological distress described as somatic disturbances (50.6%).

The authors also point out that even strong community identity found in groups such as the Yazidi cannot circumvent the impact of traumatic experiences and the development of significant mental health disorders.

Strengths and limitations

Entering the refugee camps, gaining consent, creating understanding about the research and managing the translation issues involved in carrying out this research was a task that the authors were brave to take on. It is of great value that the researchers had two control groups so that comparisons and significant differences in the results for all three groups could be measured.

The authors highlight some of the limitations of the study as coming from the need to translate the DIPS measurement tool and the relatively small number of boys studied that makes it hard to generalise about the prevalence of mental health disorders in all boy soldiers.

The authors acknowledged that due to the boys experiencing a range of traumatic experiences stemming from their witnessing and involvement in war and conflict zones, it is difficult to attribute the cause of their distress specifically and solely to their experiences of being child soldiers. With further interviewing, some of the specific impact of the boys experiences of being suddenly captured could have been further extrapolated and differentiated from the traumas developed as a result of other war and conflict experiences. An area that could be highlighted in future research, that the authors did touch upon, was the way the boy soldiers were brutally trained to dehumanise themselves and others so that they could perpetrate harm on others. I was left wondering if the boys had such severe levels of dissociation that PTSD symptoms had been buried or compartmentalised so much that the diagnostic measures for PTSD alone could not capture the level of complex trauma involved in these cases.

In my experience as a psychotherapist working with childhood trauma, the role that the defence of dissociation plays cannot be ignored. Examining the role that potential dissociative identity disorders play in the management of these boys distress may have given further enlightening information.

Implications for practice

These boys who have been particularly brutalised warrant more attention, care and treatment for two reasons:

• The first reason is obviously because they were helpless victims who had no choice but to adapt to their captors. This sublimation of their rage, disgust and fear would leave them even more than others entrenched in a state of perpetual horror.
• The second reason is that some of these children may go on in adulthood to act out their dissociated distress by perpetrating further atrocities on others in their communities, or onto those seen as the enemies of, or indeed creators of their captors, through generations of global political manipulations.

Conflicts of interest

No conflicts of interest.

Links

Primary paper

Kizilhan J, Noll-Hussong M. (2018) Post-traumatic stress disorder among former Islamic State child soldiers in northern Iraq. The British Journal of Psychiatry, 213(1), 425-429. doi: 10.1192/bjp.2018.88

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Photo credits

• Kurdishstruggle CC BY 2.0
• The US Army CC BY 2.0
• Ping News CC BY 2.0
• Muhammed Rehan CC BY 2.0