Psychosocial research with children in Iraq: current health practice and policy in a context of armed conflict.

There is a need to show how psychosocial issues affect children in conflict areas like Iraq. Raising knowledge and awareness of children's mental health status in Iraq has been difficult and the knowledge base has been limited by the shortage of resources, international sanctions and the isolation of Iraqi scholars. Many obstacles to research in Iraq exist but an agenda should be developed emphasising the need for high-quality contextualised psychosocial research. Health researchers in the country need to clarify basic population parameters and to provide culturally appropriate, evidence-based interventions for practitioners.

Much attention has been paid to researching children affected by war and violent conflicts. Major areas of study explore the impact of war on children’s health, including the relationship between experiences of conflict and mental health. People in conflict situations experience many psychosocial problems (e.g. personal isolation, interpersonal stress). However, communities rarely have capacity (e.g. mental health resources) to counteract such adverse circumstances. Research can aid in the evaluation of intervention programmes and influence both policy development and future practice, but logistics, methodological and ethical issues, as well as difficulties in measuring intervention effectiveness, present ongoing challenges for researchers in conflict zones. These issues are particularly concerning when researching children (Sondheimer & Rey, 2012).

Recent social and political instability in Iraq presents a particular dilemma for scholars and investigators. War, economic sanctions and the departure of health professionals during the dictatorship destroyed the country’s social service infrastructure. Moreover, after the 2003 war, direct death threats made against those with higher education, perceived as either powerful or wealthy, or both, has reduced the availability of teachers in tertiary education in particular, contributing to the collapse of research activity. This has led to the loss of the scientific research base for social studies in the community, particularly the evidence base for children’s health and education services. The psychosocial status of Iraqi children and adolescents is substantially affected by the current environment, which undermines best practice and evidence-based interventions. The need remains to show how psychosocial issues affect health practices and policies involving children in conflict areas like Iraq.

Children’s psychosocial issues as a research arena in Iraq

Various factors contribute to child development and psychosocial well-being (e.g. socioeconomic status, educational attainment). Investigation of these issues is a challenge in both peaceful and conflict areas. Globally, child and adolescent mental health problems present high demands on care services in the face of diminishing resources (Belfer, 2008).

Raising knowledge and awareness of children’s mental health status in Iraq has been difficult due to unsystematic coverage of the topic in the literature. While there is some interest in scientific exploration, its scope is limited. For example, it is difficult to source publications targeting childhood mental health prior to 2003. Factors like the shortage of resources, international sanctions and the isolation of Iraqi scholars from the rest of the world have limited scientific studies in general, including research involving children’s welfare issues. However, there are exceptions worth noting.

During 1991, a study was conducted by members of an international team from the Centre for Crisis Psychology in Norway. This team assessed the impact of the 1991 Gulf War on Iraqi children using the Impact of Event Scale (IES) with 94 Iraqi children (Dyregrov et al, 2002). Using this work, the United Nations Children’s Fund (UNICEF) presented guidelines for child protection policy and programmes to assist Iraqi children who suffered in the war (UNICEF, 2003).

In 1998, a study on the prevalence of symptoms of post-traumatic stress investigated a sample of displaced children living on the Iraqi–Turkish border in Kurdistan (northern Iraq) in the aftermath of the 1991 Gulf War. It found that 20% of the sample was affected by post-traumatic stress disorder (PTSD) (Ahmad et al, 1998).

In 1999, a study in Baghdad estimated the prevalence of attention-deficit hyperactivity disorder (ADHD) among primary schoolchildren at 11% (Al-Obaidi & Ali, 2009).

Since 2003, a number of studies and articles conducted by Iraqi and non-Iraqi researchers have been published in international peer-reviewed journals. Only 2% of all health research in Iraq conducted between 2000 and 2005 tackled mental health issues (World Health Organization & Iraqi Ministry of Health, 2006). One of the main themes was the post-war impact of violence on the mental and psychological well-being of Iraqi children. Some studies have estimated the prevalence of mental disorders among samples of Iraqi children. In Mosul (a large city in the north of Iraq), mental disorders were found in 37% of children attending primary healthcare (Al-Jawadi & Abdul-Rahman, 2007). Among a clinical sample of children in Baghdad, 22% had diagnoses of anxiety disorders and 18% behavioural disorders (Al-Obaidi et al, 2010a).

A small number of research efforts have led to proposals for the development of child protection programmes and the building and promotion of a child-centred mental health system in Iraq. Also required is the development of curricula for training front-line paediatricians in children’s psychosocial issues, and supporting inclusive education for children with physical and mental disabilities (Al-Obaidi et al, 2009, 2010b, 2012, 2013; Al-Obaidi & Budosan, 2011).

The main obstacles confronting researchers in Iraq include: shortage of human resources to conduct studies; lack of funding; lack of appropriate research tools and research training of local professionals; low priority of data collection by state agencies; poor awareness of child mental health issues; and threats related to the safety of research teams in insecure areas. In spite of the abovementioned studies, the paucity of published data makes it difficult to obtain precise numbers on the prevalence and severity of childhood psychological problems in a country where child mental health services are almost non-existent (Al-Obaidi et al, 2010b). This complicates the framing of evidence-based treatments, programme planning and the establishment of policy benefiting Iraqi children.

Child psychosocial research: health practice and policy

Research outcomes contribute to helping practitioners develop effective interventions (Hart & Tyrer, 2006). Research on childhood psychosocial issues in the context of war and conflict has a direct and an indirect impact on policy and practice (Boyden, 2003). Children need stable, continuous and predictable programmes, focusing on treatment, rehabilitation, family and social reintegration. Children’s responses to adversities or catastrophes are universal, and family support in times of crises is of proven benefit (Boyden, 2003). Such attention has led to a shift in intervention programme priorities, from the supply of physical aid, to integrating mental health provisions within intervention programmes (e.g. in Kosovo, Bosnia, Rwanda, Afghanistan and Iraq).

Many obstacles to research in Iraq exist but an agenda should be developed emphasising the need for high-quality contextualised psychosocial research. Health researchers in the country need to clarify basic population parameters and to provide culturally appropriate, evidence-based interventions. Locally based research should avoid possible mistakes from poorly conceived intervention programmes. Iraq presents a good climate for research and a regrowth of the country’s academic community is being seen. The assistance of outside agencies in collaboration with Iraqi colleagues can be a joint learning exercise benefiting both parties and the population in the development of context-specific practices.