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Caring for the Child Soldiers ofGuantanamoBrian Grady a & Norma G. Jones ba Department of Psychiatry , University of Maryland , Baltimore ,Maryland , USAb MSW Program, Army/Fayetteville State University , Fort SamHouston , Texas , USAPublished online: 19 Jun 2013.

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DOI: 10.1080/10911359.2013.795051

Caring for the Child Soldiers of Guantanamo

Brian Grady

Department of Psychiatry, University of Maryland, Baltimore, Maryland, USA

Norma G. Jones

MSW Program, Army/Fayetteville State University, Fort Sam Houston, Texas, USA

Military behavioral health personnel are confronted with unexpected opportunities to provide behav-

ioral health interventions during their course of duty. This article provides an in-depth discussion of

the treatment interventions that were designed around the concepts and techniques used in working

with children in institutional settings. Confronted with language barriers, the Afghani child soldiers at

Guantanamo responded to the supportive, therapeutic group and individual interactions in a manner

similar to that of American adolescent males in similar restricted settings. They were engaging and

used the interventions to problem solve, express feelings, and cope with their circumstances.

Keywords: Child soldiers, Guantanamo detainees, adolescent detainees, mental health treatment, in-

carcerated adolescents

U.S. military mental health providers are called upon to serve in a variety of domestic and

international situations. Military mental health professionals are also uniquely involved in serving

in or close to traditional or nontraditional war zones. As medical professionals, they are called on

not only to care for wounded U.S. uniformed personnel but to provide mental health services tocivilian contractors, the local civilian population (Burnett, Spinella, Azarow, & Callahan, 2008),

and captured military or enemy combatants. Unfortunately, child soldiers may be included in these

populations as they are often pressed into service unwillingly, join to avenge the loss of family

members, or may do so secondary to socioeconomic despair. These child soldiers are exposed toserious violence, and rates of posttraumatic stress disorder among child soldiers can be significant

(Ovuga, Oyok, & Moro, 2008). Betancourt noted that wounding or killing others and being a

victim of sexual assault particularly effected a child’s psychosocial adjustment (Betancourt et al.,2010). Africa has been primarily associated with the greatest inclusion of children in warring

factions, but children have also been impressed as soldiers in Europe, Asia, and the Western

hemisphere.

Child soldiers were also taken into custody during the global war on terrorism (GWOT). Threechildren, identified as child soldiers in Afghanistan, were transferred to the detention facility

located in Guantanamo Bay; they were detained in separate quarters known as the Iguana House.

This article describes the nature of the treatment for these youths during their detention. This

The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of the

Department of Defense or the U.S. government.

Address correspondence to Brian Grady, Department of Psychiatry, School of Medicine, University of Maryland, 701

W. Pratt St., Baltimore, MD 21201, USA. E-mail: bgrady@psych.umaryland.edu or grady@telepsychiatrist.com

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CARING FOR THE CHILD SOLDIERS OF GUANTANAMO 719

article will not address the care of adolescents held with adults as reported in the literature(Aggarwal & Pumariega, 2011) as these detainees were not identified as child soldiers to the

mental health treatment team. All detainees, regardless of age, receiving mental health care were

treated with the same respect and dignity by the mental health providers and staff of the detention

hospital as they would have received in any detention facility in the United States. The mentalhealth treatment team’s sole mission was to provide culturally competent mental health care to

detainees and was not connected in any way with the Behavioral Science Consultation Team or

interrogation mission. During intake and ongoing assessments of detainees, care was taken not to

request information beyond that needed for treatment.The purpose of the article is to explore care for child soldiers, one of many unusual situations

that military mental health providers may find themselves serving. As well as taking care of

the detained patient’s mental health, staff must also be aware of their concomitant mission to

monitor the health and well-being of the detention personnel and identify problem processes thatmay surface in the command. The military mental health professional working in the detention

environment should be well versed on the Stanford Prison Experiment (Haney, 1973); Milgram’s

obedience experiments (Milgram, 1974); BBC Prison Study (Reicher, 2006); Groupthink (Janis,

1972); and the Stockholm syndrome, (Namnyak, 2008). The purpose is not to profess the validityof outcomes of these researchers or their critics who purport alternative explanations for behavior

(Haslam, 2012) but rather appreciate the need for awareness of potential processes occurring

naturally or under duress. Mental health personnel must also be aware of the seductive nature,

and its effect on judgment, of working in a detention or classified environment. The military mentalhealth provider should also be familiar with the mission of the International Red Cross and tenets

of the Geneva Convention and Convention on the Rights of the Child. The military mental health

provider in charge should have access to the Task Force Surgeon and Commander in order tomake them aware of emerging concerns. The provider should also be aware of related detention

literature and various ethical views on such topics as hunger strikes (Wei & Brendel, 2010).

In the U.S. juvenile detention system, youths usually fall into one of three categories: detained

awaiting adjudication (serious charges or probation violations); detained pending placement (grouphome, foster care, etc.); and post adjudication (Kaliebe, Heneghan, & Kim, 2011). Post-adjudicated

juveniles found to be delinquent related to serious crimes may be remanded to detention facilities

with locked cell capabilities until the age of 21; these detention centers might be located a

significant distance from their homes. Regardless of their status or category, the goals are the same:education, treatment of any physical or mental health issues, physical exercise, and providing a

safe and structured environment. Due to the regional nature of detention facilities for juveniles

and distance from their homes, parent involvement may be limited. This is especially true for

youth from lower socioeconomic homes whose parents may not be able to afford to travel to thedetention facility. Military mental health providers working with detained child soldiers may need

to be prepared to attend to the youths’ mental health needs for varying lengths of time.

The specific histories and past experiences of the three individual child soldiers are purposefully

limited or generalized so as not to release protected health information. During their detainment, anemphasis was placed on education (Betancourt, 2008), thought to help in maintaining or instilling

confidence, preventing isolation when returning to their communities, and enabling child soldiers

to bridge an educational gap inherent when access to schools is absent and thus improving futurejob/career opportunities. Physical well-being, individual therapy, group therapy, and consistent

therapeutic caring relationships were core to treatment of these children. While they did not

experience the protective function of family, significant healthy adult relationships were provided

by the children’s educators and therapists. Regularly scheduled activities and routine were providedto help keep the children grounded and offered a predictable environment similar to that which is

recommended for larger internal displacement camps (Betancourt, 2005). One obvious limitation

was the lack of social peer interaction beyond the three identified child soldiers.

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720 B. GRADY AND N. G. JONES

Taking care of detained individuals, whether child or adult, begins with developing operatingprocedures, educating the guard force on various behaviors of detained individuals, understanding

guard force behavior in the detention environment, ensuring adequate mental health support for the

guard force, and training the guard force on identifying mental health needs and safety issues of

detained individuals. Mental health staff experience significant stress in the detention environmentand a weekly process group was established for mutual support and resolving challenges. The

health and welfare of the interpreters was also a focus of an intermittent process group as they

played an instrumental role in communication between mental health staff and detainess.

Within months of the operation, a mental health educational program for guards was initiatedprior to deployment. The guards were trained military police. Internment and resettlement comprise

one of five main functions of military police. In addition to their basic military occupational

specialty training and pre-deployment detention training, guards were provided with daylong

mental health in the detention environment training at their mobilization site. The trainers includedthe lead psychiatrist and psychiatric nursing and corpsman staff. The following topics were

included in the training of all guards whether working with adults or the child soldiers:

� general background on the GWOT and the multilingual and multicultural nature of thedetained population;

� cultural awareness of the detainee population;� mental health illness signs, symptoms, and epidemiology of persons in detention;� suicide prevention in the detention environment;� concepts of detainee–guard interpersonal behavior in the detention environment, including

topics such as the Stockholm syndrome, hunger strikes, etc.;� detainee manipulation of the guard force and prevention;� buddy care, combat stress team, and additional available mental health resources for guards;

and� outcomes for self-referral or command referral for mental health services for guards.

Guards working with the child soldiers were screened by their chain of command but also

interviewed by the lead psychiatric nurse for appropriateness in working with an adolescent

population.

Most medical literature regarding child soldiers involves the epidemiology, child experiences,and reintegration efforts of child soldiers who were coerced or impressed into service (Derluyn,

Broekaert, Schuyten, & De Temmerman, 2004; Corbin, 2008; Ertl, Pfeiffer, Schauer, Elbert, &

Neuner, 2011). They are often located in displacement camps under the control of their government

for the reintegration process (Corbin, 2008). Generally, there are two areas specifically targeted fortreatment for child soldiers: education and reintegration in the community. Education is needed

to provide job/career opportunities that may decrease susceptibility to manipulation or illegal

activities. Reintegration is needed because most child soldiers were involved in civil or guerilla

warfare in their communities. Child soldiers are often impressed to fight the very people of thecommunities from which they were abducted; reintegrating them back into these communities

is very challenging. The situation with the child soldiers of Guantanamo Bay was both similar

and different when compared to the activities of typical reintegration camps. Education remained

a priority. Reintegration, however, was not the same. The GWOT was not an Afghan civil warbut was viewed by coalition forces as a war on al-Qaeda, an enemy residing in Afghanistan.

Recruitment or impression of child soldiers by al-Qaeda generally did not put them in direct

conflict with their communities but with coalition forces. Reintegration into their communities

was anticipated to be less contentious than that routinely experienced, for example, in Africansettlement or reunification camps. There was no literature on caring for insurgent or non-civil war

child soldier casualties.

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CARING FOR THE CHILD SOLDIERS OF GUANTANAMO 721

The three child soldiers were all Afghan males. The lead psychiatrist responsible for careprovision was a European American male, and the lead detention psychiatric nurse was a European

female. The psychiatrist enlisted the partnership of the base mental health social worker, an

African American female, to form the mental health treatment team for the adolescents. It was

felt important that the mental health team include both a male and a female therapist who workedclosely together, symbolically providing traditional parental roles. While not deemed necessary,

the team was fortuitous that the social worker was also an African American with skin tone similar

to the child soldiers. The psychiatrist and social worker visited the adolescents at least twice a

week, sometimes together as a team, and other times they might present for treatment individually.

BEHAVIORAL HEALTH INTERVENTIONS

The three Afghan males, based on physical examinations and appearances, were determined

to be somewhere in the age range between 11 to 14 years. Following their initial medical

examination, psychological evaluations, and screenings, the boys were moved to Camp Iguana,

located separately and out of visual range of the adult detainees, for their safety and care. Theyspent their remaining time in Guantanamo at Camp Iguana, in a small duplex cottage. The cottage

consisted of two living areas that were connected. Each separate cottage area had a bedroom,

shower, toilet facility, and living room/group room area. The cottage overlooked the ocean and was

surrounded by a privacy fence that was visually less restrictive and harsh than those surroundingthe adult detention areas. The common sitting area in one cottage was used for daily activities,

group therapy, games, and educational activities. The other half of the duplex provided additional

rooms for medical sessions advising and individual therapy and quarters for security. The boys

were allowed outside for fresh air, exercise, and games. Their favorite was playing soccer. Thesoldiers who served as their security staff/teachers and care providers assisted in implementing

their daily schedules. The schedules included educational classes, outside sports and recreation,

spiritual or prayer sessions, meals, health and hygiene, and caring for their rooms and living areas.The 24-hour staff consisted of soldiers who had experience and a background in criminal justice,

adolescent counseling, juvenile detention, or teaching and education. The setting was somewhat

similar to what can be found in some areas in the United States, for housing and treatment and

care of adolescent juveniles in a small group home–type environment.Programs were developed to provide the boys with comprehensive health care and education

in a culturally sensitive, therapeutic, caring, and safe environment. All interactions with the boys

focused on managing their emotional and psychological adjustment to a new foreign environment,

group confinement, and normal adolescent development, in a safe, culturally sensitive, and ther-apeutic setting. Interventions were provided, knowing that they could be returned to Afghanistan

at any time, with the goal of being able to implement smooth and calm reintegration.

The primary behavioral health interventions consisted of twice-weekly group therapy, individual

therapy as needed, and interactive therapeutic games. As mentioned earlier, the therapists, aEuropean male and an African American female, were the primary mental health providers.

The boys met the male therapist shortly after their arrival and related well to him. They were

responsive, polite, and cooperative. The female therapist joined the group about 6 to 8 weeks

later. Initially, they appeared somewhat shy at the female’s joining the group. Both therapistswere in uniform, as were all of the military members involved with the detainees. There was a

very similar skin tone and facial feature (not by design) of the female therapist, with whom one

of the younger boys identified and expressed warmth and connection early on. It appeared that

the therapist combination was a positive one that aided in the boys’ connecting and cooperatingwith and participating in the group and individual sessions. Both therapists, by nature, were warm

and nurturing, contributing to a natural relationship process.

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722 B. GRADY AND N. G. JONES

The therapists engaged in their assignments to work with the children soldiers and to providethe best care possible from an ethical and professional perspective. They were warm, caring, and

culturally sensitive to the children’s needs at all times. The children were cooperative and got

along quite well living together.

The group therapy sessions provided an opportunity for continuous evaluation of the boyssafety, mental status and daily coping with their detention. This approach is somewhat similar to

what is used in some juvenile treatment settings in the United States. It allows for monitoring

of any changes; safety; emotional, medical, and physical care; and the provision of training and

education in preparation for the future.The boys were seen as resilient, with the capacity for connecting and developing relationships,

even though they each presented with distinct personalities and different levels of maturity. They

organized themselves by age and maturity in their group relationship to siblings with the oldest,

middle, and youngest. The two youngest of the three were more playful and interactive, whereasthe older boy appeared more serious and behaved somewhat as an older sibling following rules

and providing some oversight of the two younger boys. Cultural values were always considered

such as their training in contact with females. They were approached with respect, allowing them

to gradually develop an understanding and comfort of interacting with the female therapist. AsReverend Father R. C. Obol describes, our interactions and activities were designed to “promote

peace, reconciliation, unity and love amongst the participating children” (Obol, 2012).

The work with the children focused on (1) assisting them with adjusting, coping, safety, and

daily life skills while detained in a foreign group setting; (2) evaluating their individual physicaland mental health needs and awareness of any changes or symptoms that may surface from the

isolation and separation from family and familiar surroundings, and (3) planning discharge and

repatriation, which, as mentioned earlier, began with the initial contact. Their education consistedof individually developed reading, math, and language lessons that would assist each of them

in developing basic skills to become involved in educational and training programs that may be

offered to them once they were repatriated. This approach was similar to what has been used for

children soldiers in other countries (Birman, 2005). This was basically a group home for threeadolescent males who would be living together for an undetermined amount of time. The activities

included math, reading, language, group therapy, recreation, prayer (scheduled but not forced),

sports, and guidance in independent self-care skills.

The focus was on their personal, psychological, and physical adjustment. Establishing routinesand learning how to self-care using modern showers, toilets, and unfamiliar resources were the

beginning of this process. Once they had adjusted to the physical environment and were involved

in a routine, group therapy and their schedule activities were implemented.

The male therapist received orders for a change-in-duty station after nearly a year of co-facilitating the groups. It was decided that the social worker would continue the sessions without

adding a new co-therapist. It was anticipated that reintegration may take place soon. The group and

individual sessions continued until their departure. Consideration for culture, power differential,

prior existing relationships among the boys, and an undetermined length of time with theminfluenced treatment choices and interventions.

Documentation of group sessions were recorded and monitored any changes in their mental

status, physical health, and behavior or overall coping from session to session. Medications weremonitored and regulated by the psychiatrist who also served as co-therapist.

GROUP SESSIONS

Initially the group sessions (twice weekly, time limit: 45–90 minutes) consisted of having the

boys take turns in describing how they were feeling, encouraging them to discuss any adjustment

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CARING FOR THE CHILD SOLDIERS OF GUANTANAMO 723

or problems in the group home. This included how they were getting along with one another,their adjusting to living together as a group, their adjusting to their diets (which included regional

foods they were accustomed to), and how they were feeling physically. They were encouraged to

use group to discuss interactions in the group home, their feelings and working out solutions to

problems that would arise. Problem solving within the context of their current environment wasdiscussed and taught. Their recreational and outside game followed group therapy, which seemed

to have developed into a “reward” following group. They generally participated well in group

and looked forward to their outside time. Sometimes, it appeared that they would identify minor

issues to discuss to speed the group discussion along for their outside activities. Several dialectswere shared among the boys, initially requiring an interpreter. As their use of English improved,

the interpreter was phased out. They appeared to enjoy a sense of language freedom, speaking

independently in the group. There was an eagerness to demonstrate their use of English as well

as other languages that they were learning in their lessons.Richard Gardner’s interactive therapeutic game, The Talking, Feeling, and Doing Game, was

introduced into the group as they spoke English more freely. (Garner, 1986). This is a board

game (in English) that was developed initially to assist children with communicating in group

through mutual shared storytelling. The selection of cards and taking turns to tell their storywere accompanied with a reward token system embraced by the boys immediately. Within their

third or fourth session using the board game, they would shuffle through the cards and search

for faces that they would identify as their sister or mother, which would lead to their stories of

missing family and activities with their families. They sometimes would express concern aboutthe person’s safety or state that they missed them and looked forward to seeing them. However,

most of the time, they seemed to cope well and to avoid feelings that would take them away

from interacting and staying connected to their current surroundings. This interactive board gameprovided a playful, stress-reducing way for the boys to talk about home and family. It provided

an opportunity to begin the reintegration process This game was used throughout the remaining

time of their detention. They were not allowed any current event exposure such as television,

magazines, or newspapers. All educational materials were pre-approved to avoid any exposureto current political events in the world. They were shown pre-approved movies appropriate for

adolescents.

On occasion, one of the boys would request individual time to talk privately. They were given

the time when requested. They usually discussed dreams of going home and happy memories. Theywere quite skilled at staying with positive thoughts and memories that helped them to maintain a

rather stable emotional state. They would experience periods of horseplay or conflict among them,

which were addressed with time-outs and discussions. They would bring these events to group and

use the time to problem-solve and resolve feelings. Often, the caretakers had spent time providingthem with alternative ways to resolve conflict among them. The therapy sessions were focused

on providing a supportive, problem-solving experience for the boys as well as an opportunity for

the staff and therapist to evaluate the boys’ coping abilities throughout their detention.

REINTEGRATION

Once it appeared that we could be getting closer to the boys’ returning to Afghanistan, discussionswere encouraged about their home, allowing them to explain to us what life was like there. To

move this process beyond the interactive storytelling board games, some Middle Eastern movies

were introduced into the group. “The Cyclist” (Makhmalbaf, 1989) and “Baran” (Majidi, 2001),

two Iranian films, were used. They both provided an opportunity for the boys to see familiarscenes, villages, faces, people of various ages dressed in native attire and within the context of a

familiar cultural frame of reference, as well as to hear familiar sounds, such as voices and music.

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724 B. GRADY AND N. G. JONES

They responded with excitement and laughter, somewhat in an adolescent, childlike manner asthey watched the movies. Sections of the movie would be shown, followed by discussion. They

were asked to share their thoughts and feelings as they watched and listened to these familiar

occurrences. They began to talk about what it would be like when they returned home and what

they wanted to do with their time. They were told about the International Red Cross and howthey assisted children with support and safety as they reintegrated to their parent countries. They

were not provided details of when they would return home, since the exact time and date would

be determined with short notice. The guard staff and other military personnel were trained and

prepared for the date of departure.It was evident from the course of treatment that the child soldiers developed a positive

relationship with the mental health providers as well as the guard force. The relationships seemed

genuine and not the result of Stockholm-type syndrome. They had a range of personalities that

seem to have been reflective of their socioeconomic class of origin and concomitant experiences.One adolescent was diagnosed with depression early on and, after being educated on his diagnosis

and treatment recommendations, assented to a trial of a serotonin reuptake inhibitor in addition

to individual and group psychotherapy. They generally appeared to be developmentally age-

appropriate upon arrival and departed in an equally age-appropriate developmental manner withoutevidence of significant interruption due to confinement.

SUMMARY

Military mental health providers, regardless of their country of affiliation, will always be faced

with unusual situations that will test their ingenuity but should never test their integrity. Ascare providers, we must provide humanitarian care to all, both friend and foe, and especially to

particularly vulnerable populations such as child soldiers. The lead psychiatrist and social worker

providing care to the identified child soldier detainees in Guantanamo Bay focused their attention

to meeting the age-appropriate needs of these adolescents, addressing mental health issues andpreventing delay in age-appropriate development. Through play therapy, media, group discussions,

individual sessions, medical treatment, and demonstrated mutual respect for one another as well

as the staff, the providers felt the adolescents continued to develop appropriately during their

detention.The female therapist, along with some of their familiar guard staff and other military personnel,

assisted in the return of the children to Afghanistan. They were provided consistent and familiar

faces from the time of their departure until their return to the Afghanistan government and the

other children advocacy organizations present at the transfer. This provided closure for all theproviders who cared and worked with the children during their detention in Guantanamo. This

also provided the children with consistency and support as they repatriated to their families and

country.

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