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When The State of the World's Children first went into print in 1980, 10 per cent of the children born that year died from preventable causes. By 2018, that number had declined to just 3 per cent. Thanks to milestones such as the adoption of the Convention on the Rights of the Child in 1989, children are now on global and national policy agendas in ways that were not possible.

Each State of the World's Children (SOWC) examines a key issue affecting children. These have ranged from children with disabilities, conflict and war, child labour, urbanization, early childhood development, and much more, making it the most comprehensive analysis of global trends that impact children.

The topics and recommendations provided in the SOWC also guide UNICEF's priorities, helping us design, calibrate and implement country programmes effectively and with an eye on the needs of the world's children.

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When The State of the World's Children first went into print in 1980, 10 per cent of the children born that year died from preventable causes. By 2018, that number had declined to just 3 per cent.

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Last Sunday in Iraq a young teenage boy was captured before he could detonate an explosive belt on behalf of ISIS. Linda Wertheimer talks to terrorism expert John Horgan about the group's recruitment.

LINDA WERTHEIMER, HOST:

ISIS is increasingly employing children to carry out acts of terrorism. Last Sunday in Iraq, a young teenage boy was captured before he could detonate an explosive belt. And authorities are still investigating whether another young teen was responsible for last weekend's wedding bombing in Turkey. While the use of children in warfare is not new, researchers say that ISIS has taken the notion of child soldiers to a new level, even bragging about employing children on their social media sites.

John Hogan is a psychologist at Georgia State University. He's been studying terrorist groups for 20 years. He joins us now from Atlanta. Welcome to the program.

JOHN HORGAN: Thank you so much for having me.

WERTHEIMER: Now, you are getting a lot of your information from ISIS websites. Tell us what you're seeing.

HORGAN: In contrast to, I suppose, most terrorist groups for whom allegations of child exploitation would be embarrassing, ISIS has very publicly embraced the use of children.

WERTHEIMER: So who are these children, and how do they find their way to ISIS? Is this part of the outreach?

HORGAN: It's part of the outreach. I mean, one of the extraordinarily effective ways in which the Islamic State has managed to recruit so many is because of that outreach. And they have, in the last 18 months, paid particular attention to targeting not just lone, disaffected male Muslims or male Muslim converts, they have reached out to entire families to say it's OK. There is a place for your spouse and your kids here, and this is a package deal. We will find a role for everybody.

WERTHEIMER: It sounds as though they must have set up some kind of system for where the children sleep, what they do, what - do they study?

HORGAN: We - one of the things that really struck us in trying to make sense of all of this imagery, and we've put all of this in a rather elaborate database, which we're going to publish soon, is just how how systematic and structured this entire process is, from - or through which, rather, they progress these children from being merely passive bystanders to fully fledged, fully committed, mobilized fighters.

WERTHEIMER: Could you just give us maybe a condensed version of that? You say that it starts off gently, perhaps with toys and treats attracting the children.

HORGAN: Toys and treats and it really is about trying to lessen any doubts or reduce fears that kids might have about what life in the Islamic State might be about. The next phase is schooling, and this is where kids are far more subject to intense indoctrination, which they don't really understand the ideology but they do parrot it. But it also brings the kids far closer to ISIS-specific personnel, so recruiters who are able to select kids out who might be showing aptitude for one activity or another. And this is where ISIS essentially creates prestige among these young kids at school. And they project the idea to them that greater things await should they be lucky enough to be accepted to go from the schools into a military training camp and stationed as part of the Islamic State's military activity.

WERTHEIMER: How do they move from taking the children, sort of encouraging them to go to school and giving them sweets and toys and all of that, how do they get from that to suicide bombing?

HORGAN: Suicide bombing is only one of many roles that these kids have fulfilled. I mean, by our estimates, we're looking at somewhere between 1,200 and 1,500 children who have been indoctrinated, trained and mobilized over the past two years. But they don't have to work hard to convince the children to become martyrs. I mean, this is very much a process of intense psychological dynamics where utter obedience and complete allegiance to the Islamic State is expected.

There are numerous accounts of children who failed at training or who miss their parents too much and decided that, you know, this really wasn't for them. In some cases, in many cases in fact, those children were severely beaten and, in some cases, even executed. This is really all about providing points of no return. The children at a point here really don't have a choice. And it is fundamentally - this entire activity is based on coercion.

WERTHEIMER: John Horrigan is the co-author of a forthcoming book "Small Arms: Children & Terrorism." Thank you very much for talking to us.

HORGAN: Thank you for having me.

Copyright © 2016 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

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ISIS Increasingly Recruiting Children To Carry Out Terrorist Acts

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Last Sunday in Iraq a young teenage boy was captured before he could detonate an explosive belt on behalf of ISIS. Linda Wertheimer talks to terrorism expert John Horgan about the group's recruitment. LINDA WERTHEIMER, HOST: ISIS is increasingly employing children to carry out acts of terrorism.

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Students aim to get top marks 'to get revenge on Americans'

The are taught to march in perfect unison and do taekwondo training

Former leader Kim Jong Il attended the academy during Korean War

Rare pictures show images of North Korea's future soldiers as children as young as 11 are taught combat training in a military academy.

New recruits with shaved heads are seen preparing for war in the grounds of Mangyongdae Revolutionary School in Pyongyang as they practise their taekwondo.

One pupil named Jo Chung Hyok said: 'Because of the present situation, I am trying to study harder.

'I really think that's how I can get my revenge on the American imperialists: by getting top marks in class.

'It's my revolutionary duty,' Jo said. 'I'm working extra hard to get top marks in military subjects like tactics and shooting.'

The government-run school, where former leader Kim Jong Il was educated during the Korean War, indoctrinates students with criticisms of America and South Korea.

Pupils chant in English: 'The respected Marshal Kim Jong Un is our father.'

Pupils dressed in military uniform are taught to march in perfect unison and are given rifles to hold as they prepare to become the 'core' of the Korean People's Army, according to biology teacher Ri Kyong Hui.

Students are also taught more ordinary academic subjects including biology, history and languages - but they have no access to the internet to assist their studies.

A cademy administrator Lieutenant Colonel Kim Hak Bin said: 'At the moment, the situation on the Korean Peninsula is tense, and America is being bad to us.

'But you can see that the students here look just as bright as usual, and life and classes are carrying on the same as before.

'Our students are ready to go to the front lines whenever a war breaks out, and they are now studying harder than usual,' he added.

The school, located near the birthplace of North Korea's first leader, Kim Il Sung, was created in 1947 to house, feed and educate the sons and daughters of soldiers killed while fighting the Japanese who occupied Korea from 1910 to 1945.

Today, the girls are housed in a separate academy named after Kim Il Sung's mother, the Kang Pan Sok Revolutionary School in the western port city of Nampho.

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North Korea's newest batch of future soldiers: Scrawny 11-year-olds with freshly shaved heads punch the air as they practice taekwondo

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Students aim to get top marks 'to get revenge on Americans' The are taught to march in perfect unison and do taekwondo training Former leader Kim Jong Il attended the academy during Korean War Rare pictures show images of North Korea's future soldiers as children as young as 11 are taught combat training in a military academy.

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By Siddharth Chatterjee

" Childhood should be carefree, playing in the sun; not living a nightmare in the darkness of the soul " - Dave Pelzer

The Kony 2012 video viewed by nearly 100 million people stunned the world and brought back into focus the egregious use of children as combatants. The blatant terror and savagery taking place in a moral vacuum of sorts, where thousands of children are maimed, raped, killed and abused is a microcosm of a problem afflicting many parts of the world. It even spurred some U.S. Senators to act upon the decades of crimes against humanity committed by the notorious Lord's Resistance Army in Northern Uganda.

Human Rights Watch confirmed reports of child soldiers being used extensively in recent weeks by the M 23 rebel group in the Congo. Young children continue to be recruited and used as soldiers, scarring them for life. Estimates suggest that as many as 300,000 child soldiers are active in conflicts around the world. 40% of armed forces (including national armies, militias, gangs, terrorist organizations and resistance forces) in the world use children.

Many erroneously believe that child soldiers are mostly boys. In fact, 30% of armed organizations that use children have girls. Girl soldiers aren't just at risk for long-lasting physical and psychological wounds, they are almost always at risk of often brutal sexual violence as well.

The other fallacy is that the issue of child soldiers is isolated to armed militias in parts of Africa. Child soldiers have been used by armed groups in recent and ongoing conflicts in South Asia, Southeast Asia, the Middle East and South America. Moreover, some governments also recruit and use children under the age of 18 in their armed forces.

Numerous factors influence the recruitment of young children into conflicts. Children are most vulnerable in areas where conflicts have raged over a long period of time. If children are born into and raised in a conflict zone, they are more likely to be de-sensitized to violence. They are also less likely to have been exposed to opportunities, such as education or jobs.

Besides forced recruitment, many children volunteer to fight as they have few other options for a livelihood outside of an armed organization. The military or militia is seen as a 'meal ticket' and a place for safety and security. Children are also easier to convince and control, and often require little or no payment, making them targets for terror groups and militias.

Society must also reflect on what war can do to the psyche of survivors. Child soldiers who have managed to be rehabilitated have told stories of becoming de-sensitized to killing others after having been recruited when they were as young as 9 or 10. Studies show that these children suffer from high rates of depression and anxiety. They are also victimized by the loss of a moral compass and social bonds. Due to the severe violence they mete out to others, they lose the ability to rationalize between wrong and right, causing long-lasting damage to their psyche.

Children exposed to long-term violence are also at risk for psycho-somatic symptoms such as insomnia and nightmares, as well as prone to addiction and aggressive behaviour. In Liberia, studies showed that 90% of child soldiers showed evidence of post-traumatic stress disorder (PTSD) and 65% displayed symptoms of a major depressive disorder. Many have thoughts of suicide.

What must be done about this? One option remains most urgently in front of society: Children already recruited into violent conflicts can be rescued and re-integrated into society. The international community does not need to wait for conflicts to end for children to be removed from armed organizations. UNICEF demonstrated this clearly in South Sudan in 2001, when, after protracted negotiations with all parties to the conflict, the organization and its partners removed thousands of child soldiers from the on-going conflict and re-integrated them into society. Many lives were saved as a result.

Disarmament, demobilization and reintegration (DDR) programs have been implemented in countries like Sierra Leone and Liberia. The most replicable and successful examples are when various actors partner with local authorities. For example, in Liberia, a range of partners acted in concert to re-integrate children, including UNICEF, World Food Program, World Health Organization (WHO), ActionAid, and the United Nations Development Program (UNDP).

The biggest challenge for most child soldiers comes in the 'R' part of DDR programs. Having been raised in hyper-violent situations, most children are unable to adjust to civilian life. There is often little recourse for effective mental health counselling in countries recovering from armed conflict. Many face stigma from other members of society.

Mental health counselling may prove to be a sine qua non to successfully re-integrating child soldiers into civilian life. In this regard, it may be critical to enlist the help of national psychiatric institutions from developed countries as well as international NGOs that provide health services.

Economic re-integration is already a part of DDR programs. Many of these children have only ever known a violent life; left without options and opportunities, they are doomed to repeat the same cycle of conflict they grew up in. Child soldiers can be trained in vocational, trade and business skills to enable them to participate in economic activities. Younger, pre-adolescent children can be sent to specialized schools where the focus is on learning life and basic education skills, rather than making them fit into regular schools where they have little in common with their peers.

Experts say that once conflicts end and many psychologically scarred former child soldiers (now young adults) are demobilized and returned to their communities, the peace is fragile and insecurity is amplified. This is because these children have not been properly reintegrated and their psycho-social needs unmet. Parts of Africa, Asia and South America risk long term instability as there is evidence of children moving from one armed group to another, or becoming part of criminal gangs.

Finally there is need for affirmative political action. The United States can play a pivotal role in this regard. To its credit, the United States has laws (the Child Soldier Prevention Act) that prevent military aid to countries and groups that employ child soldiers. However, parties have been exempt from these laws at the discretion of the American government. It is imperative that this is avoided at all costs. America's moral leadership and astute conviction is urgently needed to stop this highly egregious and tragic practice.

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For Child Soldiers, Every Day Is A Living Nightmare

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By Siddharth Chatterjee " Childhood should be carefree, playing in the sun; not living a nightmare in the darkness of the soul " - Dave Pelzer The Kony 2012 video viewed by nearly 100 million people stunned the world and brought back into focus the egregious use of children as combatants.

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In a tent in a refugee camp in Dohuk, at the base of ochre-colored mountains, Amir and Ahmed, 15 and 16, unroll their mats on the floor to forget the terrible memories. It's a cool autumn evening, and they prop themselves up with cushions and turn on the TV. The two brothers fled from their captivity at the hands of the Islamic State (IS) six months ago. Now all they want to do is watch some cartoons.

The brothers flip through the channels. IS also has its own propaganda station, which viewers can easily receive here, in Kurdish northern Iraq. Ahmed, holding the remote control in his hand, suddenly calls out: "There we are Amir! That's us!" The brothers recognize themselves on the screen: dressed in black outfits, their faces masked, with other child soldiers during combat training in Mosul.

It is now spring, and that evening spent in front of the television is a few months in the past. Ahmed and Amir, sitting close together, talk about it in the same small tent in the camp. Ahmed, the older of the two, speaks in a hoarse voice about their time with IS, while Amir stares at the floor. "They gave us drugs, and we believed everything after that," they say.

Ahmed and Amir were held hostage by IS for nine months, imprisoned in a military camp in Mosul, the IS stronghold in Iraq. There the terrorist organization used beatings and weapons to train them to become child soldiers, or "lion cubs of the caliphate," as IS puts it. The "lion cubs" blow themselves up to kill supposed infidels. They witness beheadings, to learn how they are done. They donate blood for injured adult fighters. And they turn in traitors.

It is difficult to determine how many child soldiers Islamic State is training. Experts estimate that about 1,500 boys are serving the terrorist group in Iraq and Syria. Some are born to the militants. In fact, more than 31,000 women are currently pregnant in IS-held territory. Other children arrive with their parents from abroad when the parents join the jihadist movement. In many cases, the "lion cubs" are also children of local fighters or orphans who join IS voluntarily. Others, like Ahmed and Amir, are kidnapped.

The brothers grew up in a village in the Sinjar region. They had a good life, they say, playing soccer, climbing mountains and catching chickens, until IS attacked their village in August 2014. The men drove into the village in pickup trucks, threatening the inhabitants until they ran away in fear -- but by then it was too late. They pulled the brothers onto a vehicle and drove them to a collection point in Tall Afar, where a decision was reached on how they would be used.

IS divided the boys into two groups. The younger, weaker ones were to remain in school to learn the Koran. The older boys were sent directly to military training in Mosul. Ahmed and Amir were taken to a training camp with 200 children. IS wanted them to forget that they were Yazidis. They kept their mouths shut, they say, too afraid to say anything.

Ever since IS began losing territory in Syria and Iraq due to increased military operations against it, the terror organization has beefed up its propaganda efforts aimed at children. Researchers with the Quilliam Foundation, a British think tank that analyzes IS propaganda, found that in 2015, significantly more children were being used to promote the terrorist organization in the media than in the past. The acts of brutality committed by children were also on the rise, with more and more documents surfacing that showed children serving or seeming to serve as executioners for IS. It was an attempt to demonstrate resistance against the air strikes in Syria, says Nikita Malik, who headed the study.

By depicting children, says Malik, IS wanted to show that it was relatively unimpressed by bombs. IS' message, she explains, is this: "No matter what you do, we are raising a radicalized generation here." Within the system, says Malik, the children's task was to spread IS ideology in the long term, and to infiltrate society so deeply and lastingly that supporters would continue to exist, even if territory was lost.

In the mornings before sunrise, Ahmed and Amir prayed. Then they learned the basic skills of a child soldier: How do you disassemble a Kalashnikov? How do you set an improvised explosive device? How do you detonate an explosive vest? IS men beat them with sticks and kicked them in the stomach -- to make them tougher, as the men put it. In the evenings, the brothers laid on mattresses filled with fleas. Their bodies felt dead, they say. Their thoughts revolved around their mother and father, who they had last seen waving to them as they were taken away on an IS truck.

IS gave them black Afghan outfits to wear and took them to the front, says Ahmed. They wanted them to see their enemies: the PKK, Yazidis, the Peshmerga. On one occasion, a militant beheaded a Yazidi before their eyes. "We will kill you, too, unless you convert," the men told them. It was during that time that Amir, the gentler of the two brothers, stopped talking.

IS also gave them pills, which they didn't want to swallow at first. But then they noticed that the adults who took them seemed more self-confident afterwards. "When we swallowed the pills, everything changed," says Amir. Their fear disappeared, and so did the stabbing sensation in their hearts. The brothers began to believe that Yazidis were inferior.

Every evening, after training, Ahmed slipped away to some bushes behind the dormitory. He had hidden a mobile phone there, on the ground under some branches, which he used to send messages to his mother: "Hello Mama, we're alive," or "I miss you."

When a guard caught him with the banned phone one evening, he says the man dragged him into a room, tore his shirt from his torso and beat him 250 times with the wooden section of a water pipe, breaking Ahmed's sternum. The bone grew back together crookedly, and today it protrudes from his T-shirt like a boil, a mark that will remind him of the evil of IS for the rest of his life. His eyes begin to flicker when he describes the incident.

Eventually they mustered the courage to flee the camp. Together with two children, they ran away at night when the guards weren't paying attention. They traveled for nine days, until they encountered some Peshmerga fighters. They slept under bushes during the day, and they had very little to drink. One of the boys in the group had already tried to escape once before. The IS militants shattered his foot with the butt of a rifle, and now the other boys had to carry him much of the way.

Former Iraqi dictator Saddam Hussein also abused children as soldiers. Starting in the mid-1990s, military summer camps were built in Iraq for thousands of boys. The regime sought to militarize them to gain better access to society. The unit of child soldiers that took shape after the Iran-Iraq War was called Saddam's Lion Cubs. It has been estimated that several thousand children fought in the Iraq war in 2003. IS later adopted term, as well as the basic elements of the training program for Hussein's "lion cubs."

Inside the camp, a small crowd gathers at the entrance to the tent where Ahmed and Amir are staying as they tell their story. Their mother, who is sitting with them, wants her sons to become children again. She brings them water when they cry at night. She gently places her hand on their mouths when they quote the Koran. And she hopes that the voices of people being tortured will begin to fade in her sons' heads as time passes.

The recruitment of children takes place in several phases, beginning with harmless socialization. Islamic State hosts events in which children are given sweets and little boys are allowed to hold an IS flag. Then they are shown videos filled with violence. Later, in the free schools IS uses to promote the movement, they learn Islamic knowledge and practice counting and arithmetic with books that use depictions of tanks. They practice beheading with blond dolls dressed in orange jumpsuits. With a new app developed by IS, they learn to sing songs that call upon people to engage in jihad.

In areas controlled by IS, there is no alternative to these schools. They are collection points for children that IS selects for its military camps. Scouts visit the classes and determine which pupils will become "lion cubs." Once children are caught within the system, it is difficult for them to extricate themselves from it.

It has been three days since Wahad, 11, successfully escaped from an IS Koran school in Tall Afar. Now he's sitting on a chair in the office of an aid organization in Dohuk, a slender boy with blue eyes, red hair and freckles. His Uncle Idriz, an imposing man with a thick moustache, brought him here. He too almost lost his life under IS.

Very little support is available for child soldiers who manage to escape. Mirza Dinnayi, an employee of Air Bridge Iraq, gathers their data in the hope that an aid project will be established for them one day. "But at the moment the authorities have enough on their hands with the women raped by IS," says Dinnayi. Nevertheless, he records Wahad's story.

Dinnayi has a page of questions he wants Wahad to answer. But Wahad can hardly concentrate. He can't stop thinking about a particular verse from the Koran. Dinnayi wants to know how far IS managed to pull Wahad onto its side, and the extent to which he was converted.

"Do you speak Arabic?" he asks in a friendly, eager tone.

"No," says Wahad.

"What do you speak?"

"Kurdish," says Wahad.

"And how do you read the Koran, since it's in Arabic?" Wahad is silent.

"Are you a Muslim or a Yazidi?"

Wahad looks at the floor, his cheeks flushed with shame. "Yazidi," he says, in barely a whisper. He can hardly bear the idea of having betrayed the Yazidis, and of being on the wrong side.

Wahad also stood in front of the school in Tall Afar when IS was sorting its hostages. He was one of the weak ones who were sent to the Koran school. IS locked him and 34 other boys into a bare room that became their prison for the next 20 months. Every morning before sunrise, a female IS teacher would come to the room to wake them up to pray. After that, they studied the Koran for seven hours. To encourage them to apply themselves, they were promised, as if they were in a fairy tale: "If you're good, you will be allowed to see your mothers."

Wahad did not become a soldier, and he didn't fight, and yet he is so traumatized that he hardly speaks anymore. Psychologists at the Mental Health Center in Dohuk work with children like him, "unless the parents themselves are too traumatized to bring them," psychiatrist Thikra Ahmed Muhammed says in a colorful play room. In the past, children who had experienced the trauma of car accidents or bed-wetters were the ones receiving therapy. Now many of the patients have depression, and some of them, even children younger than 10, have attempted to commit suicide.

A four-year-old child, the psychiatrist explains, tries out the things he has seen on his six-year-old sister: putting out cigarettes on her arm or tying a rope around her neck. A five-year-old boy wakes his mother in the dark and says: You have to pray. Muhammed paints pictures with the children. They often draw themselves, with large eyes and small mouths.

In the evening, Wahad is standing in front of one of the apartment buildings in Dohuk where he and his uncle are staying. Wahad watches the neighborhood children playing with marbles, but he keeps gazing off into the distance. His Uncle Idriz, sitting next to him on a bench, describes how IS killed a child that tried to escape and threw the body into the midst of the other children. Wahad says almost nothing, but when he speaks, his voice sounds like the chirping of a small bird.

His Uncle Idriz is also unable to forget the images from the past. When IS attacked his village, he and other Yazidis were forced to lie on the ground in a row. The IS militants walked down the line and shot and killed 380 men, but they missed Idriz. He played dead and survived after nomads found him. They fed him tomatoes and raw liver.

It is difficult for Idriz to accept that Wahad has become a silent child, and that Wahad probably will not be able to cope with the horrors as well as him. But Idriz does his best. He goes over to the children playing marbles, puts his hand on Wahad's shoulder and firmly massages his neck.

"I'll take you to the park tomorrow," he says. "You'll see normal life there. I will make you strong, Wahad." Idriz gives him a little push. Wahad, looking ashamed, picks up a few marbles, looks up at his uncle, leans his head against his stomach and, in his soft voice, says: "Yes, as strong as a warrior."

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Islamic State's Child Soldiers: First Come the Sweets, Then the Beheadings - SPIEGEL ONLINE - International

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In a tent in a refugee camp in Dohuk, at the base of ochre-colored mountains, Amir and Ahmed, 15 and 16, unroll their mats on the floor to forget the terrible memories. It's a cool autumn evening, and they prop themselves up with cushions and turn on the TV.

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Today, among the 87 war-torn countries in which data have been gathered, 300,000-500,000 children are involved with fighting forces as child soldiers.

Some, as young as seven, commit unspeakable atrocities: killing parents and siblings, assaulting neighbors, torching the villages they once called home. Some are forced to serve as sex slaves. Many are injected with drugs to curb their inhibitions against committing violence.

Once the killing ends, peace treaties are signed and emergency humanitarian missions pull out. But these children's sorrows persist.

Theresa Betancourt has made it her mission to understand how to promote their resilience-and ultimately, their healing.
From Child Soldier to Productive Citizen
Betancourt, ScD '03, directs the Research Program on Children and Global Adversity at the François-Xavier Bagnoud Center for Health and Human Rights at Harvard School of Public Health. For nine years, she has tracked the emotional fate of former child soldiers and explored how-and if-this war-scarred cohort can go on to lead meaningful and productive lives.

Using both surveys and one-on-one interviews, Betancourt has painted a psychic portrait of young people-coolly referred to in the academic literature as "children formerly associated with armed forces and armed groups"-who struggle to find a place in tattered postwar societies. She is now adapting and testing group interventions for troubled youth in Sierra Leone that have proven successful in other places riven by violence.
Dust Cloud-or Lasting Care
"We need to devise lasting systems of care, instead of leaving behind a dust cloud that disappears when the humanitarian actors leave," says Betancourt, who is also an assistant professor in the Department of Global Health and Population.

In Sierra Leone, assistance quickly evaporated after the African country's crisis was no longer in the news. Today, Sierra Leone ranks 11th from the bottom on the UN Human Development Index of 169 nations. Its district health officers are justifiably preoccupied with high rates of maternal and infant mortality. The country has one psychiatrist-who practices in the capital, Freetown, and is soon to retire.

Betancourt's research seeks to show how former child soldiers and other war-affected youth may be helped, despite such limited resources, to become contributing members of society as adults. She has disseminated her findings to hundreds of professionals from local and international NGOs and UN agencies working with Sierra Leone's former child soldiers.

She hopes that one day these accomplishments can be bolstered by a broader continuum of care-one that extends from everyday citizens who give troubled kids encouragement and guidance to frontline community health workers to psychologists and psychiatrists, who can manage cases needing a higher level of services. In an ideal world, grassroots mental health services would offer a place for sufferers to tell their stories, talk about their dreams and ambitions, and develop trusting relationships.

"The postconflict environment is where things break down, but also where we can help," she says. "We don't have time to waste."
From Alaska to Africa

Tragedy told by the numbers

Child recruits in the Sierra Leone civil war interviewed by Theresa Betancourt's research team had been severely traumatized by their experiences:
70% had witnessed beatings or torture.

63% had witnessed violent death.

77% saw stabbings, chopping, and shooting close-up.

62% had been beaten by armed forces.

52% witnessed large-scale massacres.

39% had been regularly forced to take drugs such as marijuana and cocaine.

45% of girls and 5 percent of boys had been raped by their captors.

27% had killed or injured others during the war.

Betancourt's path to Sierra Leone began in the Alaskan permafrost. She was born in a Native hospital in Bethel, a town near the state's west coast that then numbered about 3,000. Her parents, both Caucasian, imbued the family with a passion for other cultures. Her father was a math and science teacher who had joined the Peace Corps in the early 1960s, stationed in Ethiopia. Her mother worked in remote villages for the federal infant learning program.

In Bethel, where the majority of residents were Yup'ik, Betancourt acquired both an insider and outsider perspective. "My friends were Yup'ik. I had Yup'ik baby sitters. I spoke Yup'ik. We were outside the dominant culture-but we needed to understand that culture in order to live well."

Her father's passion for Ethiopia never waned. When friends came over for dinner, he would haul out his slide projector and display pictures from his Peace Corps days. "We were in small-town Alaska permafrost," Betancourt says, "but we always knew what Africa looked like."

Initially trained as a counselor using expressive arts in therapy with children, Betancourt started focusing in 1995 on children affected by war. First with the UN Office of the High Commissioner for Human Rights, then with the International Rescue Committee (IRC), a New York-based humanitarian organization, she worked with young refugees in Albania, Chechnya, and the Eritrea-Ethiopia border, organizing emergency education programs and eventually research initiatives.

In 2002, at the end of a bloody 11-year civil war, Betancourt made her initial trip to Sierra Leone to work with the boys and girls there. "The first time I met with former child soldiers, what struck me was that they looked really little, really young. They told me they were 13 and 14, but they looked eight. They were malnourished and wearing tattered clothes.

I couldn't fathom what they had seen."

Betancourt has now been tracking more than 500 former child soldiers, many of whom are growing into adulthood and starting their own families. Her main questions: What helps young people endure this experience and still thrive? What qualities of the individual, the family, and the environment shape resilience? How can effective interventions, resonant with the local culture, be delivered by community members who receive special training and routine supervision?
Groundbreaking Research Tells the Story
Betancourt believes both numbers and words are needed to take the measure of a child soldier's trauma. As a result, she relies on both quantitative and qualitative methods in her research efforts. In her longitudinal study, she uses a detailed questionnaire to elicit the boys' and girls' war and postconflict experiences. Her local staff conduct in-depth qualitative interviews of the children and their caregivers, along with focus groups in the community.

Much of the existing scholarship on intergenerational relationships in war-exposed populations is based on the experiences of Holocaust survivors. Betancourt's work is, therefore, groundbreaking. Her nine-year project following male and female child soldiers in Sierra Leone is Africa's first such prospective study.

And a 2007 study that Betancourt co-authored was one of the first randomized controlled trials of mental health interventions among African adolescents affected by war-and one of only a handful of trials of psychological treatments for depression conducted in a developing country. Among other things, she has shown that effective treatments-and clinical trials of these treatments-are feasible in poor, rural, illiterate, war-torn communities.
A Vicious Circle
In Sierra Leone and elsewhere, former child soldiers suffer nightmares, intense sadness, intrusive thoughts, and recurring violent images. Not surprisingly, those who committed extreme acts of violence, or were its victims, tend to suffer the most persistent mental health problems and need the most intensive care.

Frequently, these children have difficulty with community relationships after their release. They struggle with guilt and shame. They are labeled as different or untrustworthy, which, in a vicious circle, deepens their sense of isolation. In their home communities, they are blamed for having destroyed lives, homes, property, and society itself. Those who are socially isolated are especially vulnerable to addictions and abusive relationships.

Girls face a compound burden. They are more likely to suffer depression, anxiety, and post-traumatic stress disorder, compared with boys. Some have returned to their communities having had unwanted pregnancies during their times with rebel groups. At home, they face the double stigma of having participated in violence and being seen as "impure," regardless of their war experiences.
Hundreds Taught to Work with Former Child Soldiers

HSPH Fellowships

En route to earning her doctorate in 2003 at HSPH, Theresa Betancourt received crucial financial aid. In 1998 and 1999, she was awarded a Taplin Fellowship, which paid her expenses. In 1998, she held a Saltonstall Fellowship at the Harvard Center for Population and Development Studies, which helped launch her field research on the Chechnya conflict. In 2008 and 2009, she received the Julie Henry Junior Faculty Development Award, which supported Betancourt's Family Strengthening Intervention project in Rwanda, a pilot study to bolster resilience and prevent mental health problems among children in postgenocide Rwanda whose families are affected by HIV/AIDS; the research led to a National Institute of Mental Health grant.

To grapple with these problems, Betancourt and her colleagues have looked to existing evidence-based mental health interventions that help violence-affected youth manage their emotions and build interpersonal skills. The goal is to forge connections to families and communities, and give children the
wherewithal to negotiate the adversities they often encounter. Ideally, such approaches are linked to educational and job programs that restore civilian roles-since returning to school or securing a livelihood are prime sources of confidence and motivation in the children.

Betancourt emphasizes that direct, sustained treatment of war-affected children is the task of local partners. "I like to stay put in a place, develop relationships, and keep working at things over time," she says. Despite the oppressive content of her work, she is neither dour nor drawn to philosophical discussions about the nature of good and evil. As she puts it, "I'm very pragmatic." Married to a physician specializing in health inequities, and the mother of two young children, she has a noticeable lightness of spirit.
Distress Has a Local Meaning
Betancourt is planning pilot studies that use components of cognitive behavioral therapy and an approach known as group interpersonal psychotherapy that has proved successful in relieving depression among children-some former soldiers, some not-crowded in refugee camps in embattled northern Uganda. Group interpersonal therapy is based on the idea that the roots of depression, and the mechanisms for healing it, lie in people's relationships with others. Young people who have all experienced the same ordeal can share support, wisdom, and understanding.

In Betancourt's intervention, war-affected young people learn that they are not alone in their experiences and emotions.

"The key is being able to put a word to their feelings: sadness, worthlessness, hopelessness, loss of energy, the sense that life is not worth living," she says. "We spend a lot of time trying to learn local terms for emotional suffering. Once intervention and problem solving begins, these young people no longer feel alone. Their symptoms start to lift."

Betancourt and her team call their pilot model the Youth Readiness Intervention, because it builds readiness to succeed in critical aspects of life such as personal relationships, taking care of one's self, planning for the future, and achieving economic self-sufficiency. Meeting weekly for two months, the participants focus on the present: setting goals, curbing high-risk behaviors and substance use, reducing trauma-related distress, and boosting community involvement.
Complementing African Programs and Traditions

A Recipe for resilience

Former child soldiers are not a monolithic population of the emotionally wrecked. "When people think of child soldiers, they think of people who are terribly damaged in some way," Theresa Betancourt says. "But I've seen very much the opposite: tremendous stories of resilience, of acceptance, of love in families."

In her view, resilience springs from a complex ecology of individual traits and social forces. "In one sense, any child who made it through the war alive likely developed survival strategies to navigate a harsh and dangerous environment. Some of these young people, especially those who survived abuse, possess a sense of resourcefulness, which shows up in confidence and a sense that they can control their fate."

Another potent factor in resilience is family connectedness. When parents openly embrace their sons and daughters and bring them back into the fold, it not only sustains the child but also sends a signal to the larger community that the boy or girl is worthy of acceptance and care. Going to school, doing homework, and graduating likewise foster a sense of normalcy and regaining lost time.

How the wider culture draws meaning from the war and its aftermath also influences the fate of former child soldiers. During the postwar, government-led process, which has included sanctioned forgiveness and community sensitization campaigns, many young people received the explicit message that their involvement in the country's atrocities was not their fault.

"The groups fit well in collectivist cultures such as in Uganda or Sierra Leone," says Betancourt. "In northern Uganda, we saw very strong effects in girls, more so than in boys. That may be because in these crowded camps-where girls had a lot of responsibilities caring for people, cooking, gathering firewood, fetching water-they didn't have much in the way of supportive social contacts before meeting other girls in the same situation."

Betancourt's locally adapted models also complement what has been initiated in Sierra Leone and other nations, including "sensitization" campaigns that encourage communities to discuss the conflict and the dangers of excluding any stigmatized group. Traditional healing ceremonies-such as ritual washings and collective feasts-can also mark new beginnings for former child soldiers.

Such evidence-based interventions are far more effective than the once-popular technique in humanitarian assistance known as "psychological debriefing," in which Western practitioners briefly visit war zones, conduct therapies in which victims talk about their traumatic experiences, then leave.

According to Betancourt, "Flying in and asking someone to share their trauma in one or two sessions, without an ongoing, safe therapeutic relationship, can actually do more harm than good."
Not a "Lost Generation"
In the aftermath of chaotic civil wars, investments in psychosocial and mental health problems are typically phased out as the problem shifts to a postconflict and then a reconstruction phase. "Unfortunately, these children's needs do not follow a similar phasing-out process, particularly when they have been ill-addressed at the outset," says Betancourt. "There is real difficulty in getting funding for this work. Sierra Leone, in particular, is seen as a 'has been' conflict: no longer sexy."

What most worries her is that societies will write off former child soldiers as a "lost generation." The opposite could be true, she contends: The very qualities that helped these children survive a harrowing experience may also enable them to catalyze change in their shattered homelands.

And while Betancourt's research may seem specialized, many of her findings transcend culture. "When someone's a survivor, it means they are still here today, despite what they went through," she says. "It would be terrible if people who had been through events like this saw themselves as hopeless or as victims. A survivor orientation means being able to feel the strength of what it takes to make it through such horrendous experiences and still move forward in life."
Learn More
Register to hear Theresa Betancourt speak during our free HUBweek Panel, "Four Global Health Threats, Four Global Health Opportunities"

Madeline Drexler is editor of the Review.

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Life after death: Helping former child soldiers become whole again

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Today, among the 87 war-torn countries in which data have been gathered, 300,000-500,000 children are involved with fighting forces as child soldiers. Some, as young as seven, commit unspeakable atrocities: killing parents and siblings, assaulting neighbors, torching the villages they once called home. Some are forced to serve as sex slaves.

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In Central African Republic (CAR) we are strengthening the capacity of the government and others to end the exploitation of children by armed groups, and to enable children to return home.

We are supporting a central African organisation, Enfants Sans Frontières (Children Without Borders), to help prevent the recruitment and use of children in violent conflict, and to protect children from its impact. In 2016, we accompanied Enfants Sans Frontières to Geneva to make representations to the UN Committee on the Rights of the Child.

Enfants Sans Frontières has been trying to identify such opportunities for international advocacy for years. This meeting in Geneva is crucial. It is a big step forward for our organisation and we thank Child Soldiers International and its donors to enable us to attend.

(Brice Kakpayen, Enfants Sans Frontières Director)

The issue

As many as 10,000 children were used by armed groups involved in the latest conflict in CAR (2012-2015). Armed groups in the mainly Muslim "Séléka" coalition and predominantly Christian militias called "Anti-Balaka" both used children as young as eight as combatants, guards, human shields, porters, messengers, spies, cooks, and/or for sexual purposes.

Our impact

about the use of children in CAR's conflict has been used by the UN Committee on the Rights of the Child in Geneva and the UN Security Council Working Group on Children and Armed Conflict in New York to convey our concerns and recommendations to the CAR government and others working on the ground. This will support the work of our partner, Enfants Sans Frontières, and others, as they try to protect the rights of children.

We have worked with the government to support their September 2017 ratification of the OPAC treaty.

What we'll do next

In 2017-2018, we will work with national and international partners to improve assistance to former child soldiers, through community-based approaches.

We also plan to train government officials and Parliamentarians on children's rights and the prohibition of child recruitment.

We will work with Enfants Sans Frontières and similar organisations to produce awareness-raising materials, which will help to prevent recruitment in vulnerable communities.

Background

The use of children for military purposes in CAR has affected all parts of the country for a long time. Even before the latest conflict, virtually all armed groups and militias were known to have recruited and used children, even though some had made commitments to the UN not to do so. It can be particularly difficult to secure the release and reintegration of children involved in community-based militia, since their families and their former commanders all share the same community background.

Photo © Child Soldiers International

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In Central African Republic (CAR) we are strengthening the capacity of the government and others to end the exploitation of children by armed groups, and to enable children to return home. We are supporting a central African organisation, Enfants Sans Frontières (Children Without Borders), to help prevent the recruitment and use of children in violent conflict, and to protect children from its impact.

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SOS Children's Villages UK provides orphans and abandoned children in Sudan with a family environment, quality education and healthcare.

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Used

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How are child soldiers brought into wars and how are they affected?

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"Over the last ten years, two million children have been killed in conflict. Over one million have been orphaned, over six million have been seriously injured or permanently disabled and over ten million have been left with serious psychological trauma."

USED.

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You can help every child grow up with the love and support of a family

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Colin's Google doc about child soldiers.

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Colin's Google doc about child soldiers.

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Create a new document and edit with others at the same time -- from your computer, phone or tablet. Get stuff done with or without an internet connection. Use Docs to edit Word files. Free from Google.

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Thousands of children are serving as soldiers in armed conflicts around the world. These boys and girls, some as young as 8 years old, serve in government forces and armed opposition groups. They may fight on the front lines, participate in suicide missions, and act as spies, messengers, or lookouts.