What Happens When Child Soldiers Return Home?
BC School of Social Work Professor Theresa Betancourt has spent nearly two decades following the life trajectories of children who were forced to fight in wars. What she and her collaborators are learning could help change the way we treat trauma in under-resourced regions of the world.
In 1991, a small band of rebels backed by the Liberian warlord Charles Taylor and Libyan dictator Muammar Gaddafi crossed into the west African nation of Sierra Leone and ignited a civil war that would rage for more than a decade. The rebels called themselves the Revolutionary United Front and claimed to lead a movement for the people of Sierra Leone. But the rebellion devolved into a campaign of terror characterized mostly by brutality against civilians. In a country of then fewer than 5 million, an estimated 70,000 people were killed, 2.6 million were displaced, and at least 4,000 suffered amputations of arms, hands, legs, ears, and even noses.
What made the war infamous, though, were the children: Over the course of eleven years, tens of thousands of them were made to participate in the war, many taken from their families and forced to become fighters, spies, porters, and sex slaves. They witnessed rapes, massacres, mutilations, arsons, and executions. Some were forced to commit these atrocities themselves, sometimes even against their loved ones. The war finally ended in 2002, but what remained was an open, urgent question: What would happen with these children? No one knew what the lives of former child soldiers might look like. Perhaps they would become “an entire lost generation,” as the prosecutor for the UN Special Court for Sierra Leone described them in 2004, “lost souls wallowing in a cesspool of physical and psychological torment.”
Instead, many of them returned to their families and went back to school. Some grew up to become doctors, teachers, or entrepreneurs. Some fell in love and started new families. Others, though, fell into lives of isolation, depression, and despair. We know all of this because for the past eighteen years, Theresa Betancourt, director of the Research Program on Children and Adversity (RPCA) at the Boston College School of Social Work, has returned to Sierra Leone again and again to follow a cohort of more than 500 war-affected youths, carefully documenting their life trajectories to determine what has accounted for the difference between those who struggle to this day and those who have thrived. It is the longest, most comprehensive examination of life after child soldiering that has ever been done, and it has revealed a complicated picture of resilience, where the fate of a child’s life may depend more on his or her postwar environment—community support, family—than on what was experienced during the war itself.
In 2017, Betancourt came to the School of Social Work as the Salem Professor in Global Practice to expand on this groundbreaking work. She and her team have taken the lessons they’ve learned in Sierra Leone and other nations and used them to build a range of programs that have been noteworthy for producing positive outcomes for children and families facing adversity in a variety of countries and cultures. “Resilience is not some inherent trait or capability that just some people have,” Betancourt told me recently. “It’s a process whereby the social ecology interacts with the individuals, and it’s at multiple levels.”
The experiences of war and other forms of trauma cannot be undone, but what Betancourt’s research has shown is that what happens afterward, and how it affects the way a child’s life unfolds, is something that can be influenced. Betancourt and her collaborators have dedicated their entire careers to doing just that.
JANUARY MARKS THE PEAK of the dry season in Freetown, Sierra Leone’s capital city. The harmattan winds blow south from the Sahara Desert, covering everything—the cars, the sidewalks, the metal roofs of the vendor stalls—with a layer of fine red dust. Even the long, flat leaves of the banana trees turn red.
The city juts into the Atlantic Ocean on the westernmost tip of Sierra Leone, a vibrant jumble of pedestrians, motorbikes, and three-wheeled kekehs. But as you head east, toward the Kono District on the other side of the country, the noise and commotion fall away, replaced by open fields of elephant grass, green mountains studded with palms, and mango trees that grow as tall and thick as ancient oaks. Locals call their country Salone or swit Salone—sweet Sierra Leone.
But there has been much sorrow here in Kono, too. This, for instance, is where Ishmeal Alfred Charles was captured for the first time by rebel soldiers. He was 12 then and his mother had sent him from Freetown to live with his father in Koidu Town, the capital of the Kono District. She thought he’d be safer there. Instead, rebels attacked Kono two weeks after Charles arrived. They tried to force him to fight for them, but he pretended to be too confused to understand the workings of a gun. So they made the boy a porter instead, piling him with heavy loads of stolen loot. He may have been spared the experience of committing atrocity, but not from witnessing it. “You’d see them take a girl and go into the room,” he told me, “and they come back out, three men, all sweating, and you heard the girl crying and shouting. Sometimes you just hear a gunshot, like bam.”
One day, Charles managed to escape, running into the bush in a moment when the fighters were distracted. He joined up with a small band of fellow refugees walking north toward the safety of the Guinea border. But as the group passed through a town along the way, a new troop of rebels appeared and recaptured them. This time, the soldiers lined Charles and the others into a single-file row. You want the long sleeve or the short sleeve? they asked. “That was when they started cutting the hands off people,” he said.
Charles was fortunate to be spared that fate, and he eventually was able to escape a second time. He was captured once more by local militias before being released. When he returned home, his mother embraced him. She told him that none of it was his fault, and sent him back to school. “She was,” he said, “the closest friend I’ve ever had.” It has been one of the war’s enduring tragedies that not every former child soldier was welcomed home so warmly.
The Team on the Ground
Photographs by Michael Duff
THERESA BETANCOURT CAME TO KONO for the first time in 2002, only months after the war had officially ended. Back then, the land was ravaged, most of the roads impassable. She had to fly in via a helicopter so loaded with aid supplies and workers that she’d barely been able to squeeze aboard.
She was a Harvard grad student at the time, a year away from finishing her doctorate in maternal and child health. Just a few years earlier, she’d been a school mental health specialist in Oregon, working with refugee and migrant students struggling to fit in and go to college. Then, in 1995, she signed up for a Spanish immersion program that sent her to a Costa Rica radio station. That year, as the United Nations held a landmark World Conference on Women to discuss issues especially concerning to women and girls—poverty, education, health, war—Betancourt, with her basic Spanish, helped the station’s journalists cover the meeting. “It opened my eyes to child rights globally,” she recalled, “and exposed me to this world of UN agencies, and the important work NGOs could do.”
Within a year, she was interning for the Office of the United Nations High Commissioner for Human Rights in New York, housesitting for friends and feeding pet rabbits in exchange for a place to stay. In 1998, she started her doctorate work, then began consulting for the UN, and later the International Rescue Committee (IRC). She was sent to Ethiopia, Albania, and the Russian Federation, where she worked with displaced Chechen youth, setting up emergency education interventions and running small studies to see if they helped. It was around this time that she met Marie de la Soudière, then the director of the IRC’s Children Affected by Armed Conflict Unit. The connection would change her life.
At the time, the state of research relating to conflict zones and resilience was in disarray. There was evidence suggesting the importance of social environment to a child’s recovery after, say, enduring the London Blitz or traumatic wildfires in Australia. But experts were only just beginning to realize how mental health problems such as anxiety and depression express themselves differently in different cultures. And almost no one at the time was conducting longitudinal studies to see how war-affected children fared as they resumed their lives, tracking what helped them and what didn’t.
Psychologists and aid providers back then tended to default to PTSD-focused talk therapy. “It was totally a Western model, which was not developed for a traumatic environment,” de la Soudière told me. As the war wound down in Sierra Leone, however, she saw an opportunity. Many child soldiers were being sent to Interim Care Centers, or ICCs, several of which used programming designed largely by de la Soudière. The children would receive physical and psychological care at these ICCs for a few weeks while staff tracked down their families and conducted village-wide “sensitization” campaigns so that, hopefully, when the children returned home, they would be accepted.
Because of funding challenges, there was limited money to conduct follow-up visits to see how these children were faring after returning to their communities. But de la Soudière, convinced that much more of this kind of study was necessary, managed to scrape up a few years’ worth of extra funds—just enough to kick off the first stages of a new project to follow these youths for the long haul and discover what really mattered to their future success. She chose Theresa Betancourt to lead the project.
The Sierra Leonean civil war ended in 2002, but what remained was an urgent question: What would happen to the children forced to fight in it? No one knew how the lives of former child soldiers might unfold.
KONO, WHICH IS HOME TO MANY of Sierra Leone’s diamond mines, suffered mightily during the war. Upward of 90 percent of all buildings in the district are estimated to have been destroyed or damaged during the fighting. When Betancourt arrived in 2002 to begin her work for de la Soudière, the ICC had been set up in an abandoned school made of cinder blocks painted yellow, a grim building riddled with bullet holes. The teens there slept on dirty yellow foam mattresses, but their artwork from the time depicts the facility as a cheerful, colorful place—a place of reprieve.
Betancourt’s plan was simple. She would work out of the ICC, creating a list of children who’d passed through the program before returning home after the war. She assembled a collection of culturally adapted questionnaires to tease out how the children were feeling and what their wartime experiences had been. If all went well, she would continue to check in with these same children through the years in “waves” of follow-up surveys, keeping track of how they fared over time.
Betancourt camped in the house of a former warlord. She was an outsider, and she understood that the success of her study would lie in her ability to collaborate closely with local people and organizations. It was then that she was introduced to Moses Zombo. A native of the Sierra Leonean city of Kenema, Zombo was a former linguistics student who’d helped people forced to flee their homes during the war. He had a knack for in-depth interviewing, and found Betancourt’s project compelling. Over time, he would become one of Betancourt’s closest colleagues, an essential link to the children she hoped to learn from.
With no electricity, Zombo and Betancourt worked by flashlight late into the night. He gathered a team of local research assistants—former teachers and social workers—and Betancourt trained them on how to obtain informed consent and conduct interviews. Over time, they recruited a total of 529 children for the study. Most had been taken by rebels at around age 10, though some had been as young as two. They’d been held for three to four years on average. Most had been beaten, sometimes daily. Nearly half of the girls and about 5 percent of the boys reported that they’d been raped. About a quarter of the children said they’d killed or injured others.
The team completed the initial research wave in 2002, and then conducted its first follow-up in 2004. Then de la Soudière’s IRC funding dried up. But Betancourt found enough money to keep the project going. By 2006, she’d become an assistant professor at the Harvard T.H. Chan School of Public Health, and with funds gathered from sources such as USAID, she was able to conduct additional follow-up waves in both 2008 and 2016, each time adding to the research detailing how the lives of these former child soldiers were unfolding.
Nearly all of the children initially showed high rates of mental distress—anxiety, depression, hostility. But by the first follow-up wave, when the children had been home for two years, it was already clear that their suffering was not purely a product of their past experiences. Children who, after returning home, were taunted and stigmatized within their community or family, or who struggled to earn enough to survive, tended to spiral. Those who found acceptance, however, reported better recovery, regardless of their wartime experiences.
Zombo was blown away by the data. He thought of one boy who had struggled early on with visible scarring on his face and shame, but began thriving later, with a good job and a supportive wife and son. “And I’m talking to Theresa, and then we look at the data and this guy’s name is at the top of the positives list,” he said. “I told her, ‘You know? I think there is something to this thing we are doing.’”
By the fourth wave of assessments, in 2016, the data had revealed three clear groups. There were the “socially protected” youths, who’d endured relatively lighter wartime experiences, then gone home to families and villages that welcomed them. The other two groups both comprised children who’d endured greater horrors—higher rates of rape and violence. Both went home to stigma and alienation. But one, the “improving social integration” group, changed. Over time, the children in this group found acceptance. Many of them were girls who’d been raped. Returning home, they’d exhibited very high anxiety and hostility to others. But their communities and families eventually rallied around them and, fifteen years later, their life outcomes looked almost identical to those who’d been welcomed home immediately. In contrast was the “socially vulnerable” group. The smallest of the groups, it had the greatest number of boys who’d been forced to kill and injure. They came back hostile and angry, and they never managed to fully reintegrate with their peers or families. They were twice as likely as the other groups to still suffer symptoms of anxiety and trauma, more than four times as likely to have gotten into trouble with police, and three times more likely to have attempted suicide.
THERESA BETANCOURT (NÉE STICHICK) grew up in Bethel, Alaska, where her family settled following her father’s Peace Corps service in the 1960s. Bethel was a remote community with a population of around 3,000 back then. Many homes—including the log cabin she grew up in—didn’t have indoor plumbing, and most of the roads were unpaved. But Betancourt thrived in the conditions. She caught fish in a coffee can and learned to dogsled. In the summer, she would spend long afternoons on the lake behind the house, pushing herself on a raft her father had fashioned for her out of an old door. She learned early to respect and learn from the culture of Bethel’s majority native Alaskan Yup’ik population. She learned native stories and dance in school, and her babysitter taught her the Yup’ik language. “To me, it was just free and amazing and fascinating,” she told me.
Moses Zombo marveled at Betancourt’s adaptability in Sierra Leone, her effortless embrace of a life of bucket baths and meals of rice and dried fish eaten off a communal plate. “You couldn't be coming from Boston and like this!” he recalled thinking. But to Betancourt, it was like coming home. “I was ready for that,” she said, alluding to her upbringing in Alaska. “I’d already had the cold version.”
She was ready for something else she found in Sierra Leone, too: the way that a child’s life can be shaped by his or her upbringing. When Betancourt was growing up, her mother worked in early child development. “And I remember,” she said, “seeing what happened with a child with encephalitis or fetal alcohol syndrome or Down’s syndrome that wasn’t being picked up and given the family connection and care that it needed.”
IT NO LONGER REQURIES A HELICOPTER to get to Kono, a testament to Sierra Leone’s rebuilding efforts in recent years. In January, I made the six-hour drive from Freetown with Mahmoud Feika, the data manager at Caritas Freetown—an important local partner organization that works closely with Betancourt in Sierra Leone—and our driver, Peter French. As we neared Koidu, a green sign by the side of the road identified the way to the “Amputee Lodge.”
The war may be over, but life is still hard in Sierra Leone. It’s among the poorest countries in the world. Many households do not have access to clean water, and outside of the city, most also do not have reliable electricity. Life expectancy is just 54 years, more than 40 percent of the population lives on less than $2 a day, and 70 percent of youths are unemployed or underemployed. Sierra Leone’s economy was actually humming along, with a 20 percent growth rate in GDP by 2013, but then came the Ebola crisis, which resulted in nearly 4,000 deaths. A year after the epidemic ended, a mountain on the edge of Freetown collapsed in a rainstorm, resulting in nearly 1,200 deaths and 3,000 people left homeless.
I asked Abdul Jalloh, who directs the Sierra Leone Psychiatric Teaching Hospital, about the toll that all of this has taken on the country. “The war, now the poverty, the unemployment, all those things,” he said. “It has created a huge impact on the mental well-being of Sierra Leone.” Jalloh is one of just two psychiatrists in the country, to go with one psychiatric hospital and nineteen mental health nurses. The treatment gap for severe mental illness in the country is estimated to be 98 percent. Most sufferers, Jalloh said, are simply on the street undiagnosed.
Depression, anxiety, and trauma are widespread, and as Betancourt found in her research, these disorders can undermine the very thing that can keep an at-risk person afloat: community support and acceptance. Children who are unable to remain calm and be their best self when confronted with negative and stressful social situations “get into these patterns,” Betancourt said. “They have blowouts with people, and that leads to more blowouts, and then you’re blamed for everything and pretty soon you’re labeled a bad kid.”
Betancourt and her team are working to help children break that destructive pattern. I learned how in the Kono village of Ngaiya, from Tamba James Mafinda, the town chief, and Tamba Ellie, the local youth chairman, which is a sort of government position that advocates for local teens and children. Last year, they told me, Sierra Leoneans trained by Freetown researchers had conducted sessions to help area youths learn the skills of emotion regulation, problem solving, and goal setting. The effects, Mafinda and Ellie said, have been nothing short of astonishing. Those who finished the program have begun to behave, listen to their elders, and communicate their troubles before resorting to violence or theft. “They just calm down and obey,” Mafinda said. “They give respect to the chief.”
The sessions they spoke of were part of the Youth Readiness Intervention, or YRI, a course that Betancourt and her collaborators have spent the past decade devising and testing. It grew out of the team’s conviction that its work should be about more than simply documenting trauma. “It’s one thing to do observational research,” Betancourt told me, “but it’s really important, ethically, to not just watch a train wreck happen, and not try to think about, are there ways you could move up the tracks and try improving them?”
So Betancourt’s team decided to take the lessons they’d learned from their research and create the YRI to help create positive outcomes for Sierra Leonean youths. The program began to take shape in 2010, when Betancourt teamed up with the crew of US and Sierra Leonean researchers at Caritas Freetown, a local outpost of the Catholic Church’s development and aid-delivery arm. The team consulted with village leaders, imams and priests, government agencies, and experts from NGOs. They solicited input from parents and neighbors, local police and teachers, and the youths themselves. “And they all said almost the same thing,” recalled Musu Moigua, the Caritas project manager who conducted many of these conversations. “That the youth still do not know what they’re doing, they still are not focused, they cannot cope, they’re still having challenges.”
Meanwhile, Betancourt was digging into the literature. She found inspiration from experts in adolescent psychotherapy, such as John Weisz at Harvard University, and from pioneers in global mental health, like Vikram Patel, also at Harvard. Also influential was Paul Bolton, an old collaborator of Betancourt’s at Johns Hopkins University, who has shown that culturally sensitive, community-led interventions can be effective in low-resource settings. The idea is to rely on trained lay workers instead of impossibly scarce mental health professionals.
The result of all these efforts was the YRI’s twelve-module group intervention, which combines simple cognitive-behavioral and interpersonal therapy techniques. “It was designed with the ‘Do No Harm’ principle,” Betancourt said. “Rather than focusing on heavy trauma processing, [it] focuses on skills and stabilization in a way that can raise up all boats, and help benefit kids from a range of different challenges.” The group sessions are led by trained Sierra Leonean lay workers and are designed to be delivered orally, which is important in communities with lower rates of literacy. Heavy on parables and cultural references, the exercises focus on how to first recognize emotions, including poil at (sadness), yagba (worry), and gladi (happy), and how to focus on the positive. Other modules cover bereavement and coping with loss, goal making and strategizing, and how to recognize when you’re about to lose control.
CARITAS FREETOWN, housed in a small complex of concrete buildings painted dark green and bright turquoise, is located not far from Freetown’s famous Cotton Tree where, it’s said, the freed slaves who helped found the city in the eighteenth century rested upon their arrival. The organization first partnered with Betancourt’s research team on YRI a decade ago. Helping to seal the relationship was Ishmeal Charles, the former child soldier who’d escaped and been recaptured multiple times. Charles had gone on to graduate from university and he began working with Caritas in 2009. The youth intervention project immediately appealed to him. “When I saw what the YRI was, I said, ‘Oh thank God, this is exactly something that I want to work with,’” Charles told me. “We always say they disarmed the people in this country with the guns, but we didn’t disarm the minds of the people.”
The research team at Caritas today consists of nineteen Sierra Leonean research assistants—eleven of whom work on YRI—plus several expats who are part of Betancourt’s RPCA program. Among this latter group when I visited was Ryan Borg, one of Betancourt’s Sierra Leone Program Managers, who is from Connecticut and had been living in Freetown for the past two years.
Borg led me to a work room where her team sat at long tables, transcribing and translating YRI field interviews. When I asked what it was like to work on the intervention, the stories of transformation tumbled out. There were the youths who learned to stay cool in the face of taunting, and also the young women who de-escalated arguments with their husbands with a “Please, don’t make my pot boil!”
Unisa Jalloh, a YRI supervisor and lead consultant at Caritas, explained that it can come as a revelation to the young people he’s worked with that they can have control over their feelings. “They’ve not thought about that,” he says. “They say, ‘Wow, so human beings, we have the power to change.’” The intervention courses are so effective that those who’ve taken them often pass along the lessons to friends and family—so much so that when the team goes back, they often find that the youths’ caregivers display a statistically measurable improvement in their own emotional well-being.
In 2014, Betancourt and her team published a paper that documented the effects of the youth intervention. The researchers looked at two groups of students enrolled in an NGO-led education program. One of the groups, made up of 222 struggling Freetown youths, received the YRI before enrolling. The other group, consisting of 214 similarly challenged students, did not. The students who took the program demonstrated better behavior and had better school attendance than their peers who did not, and, eight months later, they were six times as likely to still be in school.
BASED ON THESE RESULTS, Betancourt and her YRI collaborator Nathan Hansen, at the University of Georgia, secured a grant in 2016 of almost $3 million from the National Institute of Mental Health to launch a YRI scale-up study. The idea is to determine whether the intervention and the skills it imparts can be made sustainable. “Millions of dollars have gone into putting programs in place in the developing world,” Hansen told me, “and once the program ends, you go back a few years later, and there’s no evidence to find it was ever there to begin with.”
The researchers are now in the middle of a new study called Youth Forward that tests expanded reach of the YRI research among 1,200 participants in an entrepreneurship program—some of these youths will receive the intervention and some will not. The study will assess not just whether the intervention benefits the young Sierra Leoneans who receive it, but also whether any of these benefits remain a year later. Betancourt and her colleagues will also test the strategy they use to deliver the intervention—relying on local facilitators trained and supervised by members of the original Caritas YRI team. In essence, Betancourt and her colleagues are trying to franchise the model in new locations and cultures, and studying how to support quality improvement even as they spread the concept of the YRI and the resilience it may foster.
The quest for these kinds of sustainable solutions is a growing focus at the Boston College School of Social Work, where Dean Gautam N. Yadama made Betancourt one of his first hires after arriving at BC in 2016. “It is very much in line with what a Jesuit university is talking about—this calling to have an impact on the world,” Yadama told me.
You can hear echoes of that sentiment in something Betancourt often repeats: “If you can do things here, you can do them anywhere.” That is, if you can develop solutions in a place with the challenges of Sierra Leone, you can adapt them to anywhere in the world. It’s a powerful saying—because the need is enormous. According to the global humanitarian organization Save the Children, 415 million children currently live in conflict zones, an increase of 34 percent in the past decade. At the same time, the UN reports that record numbers of refugees are fleeing violence, poverty, natural disasters, and the effects of climate change. The international community has not kept up: As a 2018 Lancet Commission on Global Mental Health observed, the burden of mental health disorders has risen all across the world over the past decade. Betancourt’s hope is that programs modeled on YRI strategies can help. But, she cautioned, that will take commitment and resources. “These are simple intervention packages that could be slotted into systems,” she said. “But if you don’t have a workforce, the policy, the financing, the leadership from government, a one-off intervention won’t save the world.”
Also crucial, Betancourt explained, is structuring efforts so that they are collaborations with the communities where the work happens, and that they have the goal of promoting a country’s own research capacity. The Caritas partnership is one example of that, but there are others. The research team partnered with the University of Sierra Leone and the University of Liberia on the Youth Forward project, providing seminars on data management and workshops on writing CVs and grant applications. Betancourt has also developed close ties with government officials in Sierra Leone, and for the past few years has hosted a conference in Freetown that brings together the country’s mental healthcare community.
FOR A LONG TIME, there were no recorded COVID-19 infections in Sierra Leone. But the country, scarred by the recent memory of Ebola, declared a year-long state of emergency on March 24 anyway, shutting down its airport, then its borders with Guinea and Liberia. The first case appeared a few days after that, on March 31. Not long after, the Sierra Leonean government declared a three-day national shutdown and banned inter-district travel.
Like universities across the United States, Boston College closed its campuses in March and recalled its international staff. Betancourt and much of her RPCA have remained in the States ever since. But the Youth Forward project was, by luck, in a relatively good position when the pandemic hit. The team had already gathered most of its initial data. But the fate of a crucial follow-up study, slated to begin this fall, is uncertain. Still, Betancourt is already thinking about how the effects of the pandemic should be incorporated into future work her team does with YRI participants. “Because Youth Forward is looking at this nexus between mental health, functioning, and employment,” she said, the recent “massive job loss and caving of economies is a potential confounder in the study.”
And speaking of mental health, change is happening in Sierra Leone. In 2012, the government released the country’s first-ever mental health policy and strategic plan, and later established a new Directorate for Noncommunicable Diseases and Mental Health. When the government official Aiah Gbakima spoke at Betancourt’s Youth Forward Conference in January, he summed up the country’s emerging consensus this way: “We emphasize today that investment in evidence-based programs to confront trauma, depression, and other mental health issues are likewise an investment in human capital and prosperity for all Sierra Leoneans.”
For his part, Ishmeal Charles believes that the nation is better prepared to respond to the mental health challenges of a pandemic than it was during Ebola. “Before, a lot of people would say, We are a very strong people, so we are not worried about psychosocial support. We don’t care, we don’t worry. But now, a lot of people are seeing that, yes, psychosocial help is obviously needed, and it is crucial that we take it seriously.”
As the pandemic grinds on, meanwhile, there has been plenty of work for everyone. Betancourt and Moses Zombo are working together on a book about the longitudinal study, and, of course, there are data to analyze, papers to organize and digitize, and plans to make. And despite the distance, the RPCA remains in close contact with colleagues in Sierra Leone. “I think our team really didn’t miss a beat,” Betancourt said.