Stateless Iraqi Kurdish children and adolescents’ mental health: A scoping review


 Kurdistan is one of the largest stateless nations in the world. Due to its geographical location, straddled between four major nation-states often in conflict with one another, Kurds face a disproportional level of conflict. Research has shown that there are significant mental health consequences as a result of living in conflict zones. It is suspected that the experience of statelessness in Kurdistan differs from the experience of individuals in neighbouring states, regardless of similar conflicts (Iraq, Iran, Syria, and Turkey). This could be due to the compounding effects of a sense of ‘not belonging’, as well as having barriers to accessing mental healthcare as a stateless individual. The current paper seeks to highlight the present literature on the understanding of conflict-related mental health consequences specifically affecting Iraqi Kurdish children and adolescents and to outline gaps in knowledge through a scoping review.


Introduction
While there have been numerous studies on the topics of war and conflict, children, and mental health, some of which focus on regions in the Middle East, there appears to be an absence of studies which exist in the intersection of these topics, specifically for the stateless Kurdish children of Iraq. This specific population has experienced a disproportionate level of conflict in neighbouring countries have worked in tandem on various occasions to stifle resistance by Kurds in any one state. Consequently, the Kurds of greater Kurdistan are in a worse situation than many other stateless ethnic minorities around the world existing within the borders of a single nation.
When considering the history of Kurdistan, a broader lens needs to be applied which looks at the history of the Middle East as a whole and the conflicts that stem from international relations with superpowers in the Global North, chiefly the United States of America. In Faath & Mattes' (2014) paper on migration from the Middle East and North Africa (MENA) countries to Europe, they highlight four unique forms of conflict that are relevant to the MENA as a result of the Cold War after the 1950s: "1. Attempts to reinstate one's sovereignty over national territory or to reclaim such territory 2. Conflicts arising because of imprecise or disputed border demarcation stemming from colonial times 3. Conflicts concerning maritime borders or the exact course of borders for the purpose of offshore utilization, in particular in the Mediterranean Sea 4. Conflicts arising because of shortages of natural resources such as water or soil" (Faath & Mattes, 2014, p. 164-166).
Apart from one of these reasons, due to Greater Kurdistan being landlocked within four nations and not having any maritime borders, all of the other reasons for conflict render Kurds acutely vulnerable to the consequences of war as a stateless nation with unestablished borders and a lack of central governance. Of the four regions within Greater Kurdistan, the fall of Saddam Hussein in up an estimated 15% to 20% of Iraq's population (BBC, 2019 (Montgomery, 1998). This resulted in the horrific event known as the Halabja Massacre whereby a chemical attack was carried out against the Kurdish people. This attack killed between 3,200 to 5,000 people and injured nearly 10,000 more, most of whom were innocent civilians (The Times, 2010). This also resulted in half a million Kurds being displaced (Montgomery, 1998). This chemical warfare disproportionally affected pregnant women and unborn children who showed an increase in birth defects years after the incident (Hilmas, E., & Hilmas, C. J., 2015). When Iraq was defeated in the 1991 Gulf War, Barzani's son Massoud and Jalal Talabani of the rival Patriotic Union of Kurdistan (PUK) led a Kurdish rebellion (BBC, 2019). The U.S. and its allies imposed a no-fly zone in Northern Iraq at this time and this propelled the two political parties, the KDP and the PUK, to begin negotiations around sharing power within the Iraqi Kurdish region (BBC, 2019). This did not last long and tension began to rise which resulted in a four-year civil war from 1994 and 1998.
In 2003, the U.S. led the invasion and began the Iraq war to overpower Saddam Hussein's regime. The two parties cooperated with the U.S., and after the "success" of the war (i.e. the liberation of the people of Iraq from the dictatorial leader Hussein), KDP and PUK began governing Iraqi Kurdistan in conjunction with the Kurdistan Regional Government (KRG). In September 2017, a referendum on independence was held in both the Kurdistan Region and the disputed areas seized by the Peshmerga in 2014, including Kirkuk (BBC, 2019). The vote was opposed by the Iraqi central government (BBC, 2019). More than 90% of the 3.3 million people who voted supported secession. The loss of Kirkuk and its oil revenue was economically detrimental for Iraqi Kurds. Following this event and the resignation of the president there was a period of time in which there was no regional governance, leading to unrest amongst the people.
To add to the already unstable political climate in the Middle East, ISIS posed another threat to the wellbeing of the Kurdish people. In mid-2013, the jihadist group of the Islamic State (IS) turned its sights on three Kurdish enclaves that bordered territory under its control in Northern Syria. An IS advance in northern Iraq in June 2014 also drew Iraqi Kurds into conflict. In August 2014, the IS group launched a surprise offensive and the Peshmerga (the forces sent in by the Iraqi government to the Kurdish region) withdrew from several areas (BBC, 2019). Most notably, one of the areas was Sinjar where IS militants killed or captured thousands of Yazidis, a prominent religious minority of Iraqi Kurds. This caused the internal displacement of thousands.
Several key events occurred that resulted in the Syrian Democratic Forces (SDF) declaring the total elimination of ISIS in March of 2019. One such event was driving out ISIS troops from Kobane, Syria in 2015 and another was capturing the IS capital Raqqa and the neighbouring province of Deir Al-Zour which was believed to be the last IS invaded territory in Syria in 2017 (BBC, 2019). However, this is not the end of Middle Eastern conflict against ISIS as there is potential for the "jihadist" sleeper cells to regain power and to ignite the second rise of ISIS (Farooqi, Azhar, & Tashfeen, 2018).
The most recent threat to the safety of the Kurdish people happened in October 2019 when the U.S. troops pulled back from the border with Turkey after President Trump said it was about to launch an operation to set up a 32km deep "Safe-zone" to resettle up to two million Syrian refugees. Turkish troops and allied Syrian rebels immediately advanced into the unguarded lands in an offensive that displaced over 300,000 Syrian Kurds (UN News, 2019). These recent events emphasize the continuing struggle against conflicts in Kurdistan and how international, external forces and decisions can have detrimental effects on the Kurdish people.
Studies that have focused on this region have either neglected to recognize the unique identity as a stateless individual, which should not be undermined as they are not privy to any of the benefits that come from being a citizen of a state that is recognized by international institutions. The Kurdish children of the last two decades have existed in the unique intersection of various vulnerabilities which cannot be understood independently from one another. For the purpose of this review, children will be defined as individuals under the age of 18, based on the definition set out by the United Nations Convention of the Rights of the Child. This study addresses a unique population which has historically been neglected in research or bundled with other groups, such as refugees or internally displaced individuals. A summation of the existing literature surrounding this topic will better inform the direction of future research in the everchanging political climate that is the Kurdistan region. Those that did not fit the criteria of investigating the relationship between displaced individuals and mental health specifically in the Middle East were excluded. Those that included populations that have been resettled in a Global North country were also excluded. This resulted in only 10 eligible papers for review. None of these papers fit the criteria exactly, as outlined in the results table.

Results
The results of the studies revealed that to date, no study has been done specifically on stateless Iraqi Kurdish children's mental health. To support the importance of pushing forward this research agenda to better understand the unique lived experiences of that specific population, ten papers will be analyzed. Although these papers do not completely align with the interests of the research question, there are components in each which shed light on the current research question such as similar population of interests (refugee, children, or internally displaced individuals) or within similar geographical regions (within the Middle East).

Summary of each paper's findings
The policy paper "Islamic State, Disputed Territory and Ethno-religious Diversity: An Opportunity for the Development of Iraq's National Policy on Displacement" (Louise, 2019) identified protection gaps within Iraq's response to displacement. The legacy and persisting existence of the Islamic State (IS) in Iraq significantly exacerbates an already challenging displacement context. Further complicating the situation is the conflict between the Government of Iraq (GoI) and the Kurdistan Regional Government (KRG) over the resource-rich "Disputed Territories". How the GoI and KRG respond to internally displaced populations (IDPs) who are perceived as IS-affiliates will have far-reaching, generational consequences. The most pressing concerns for these displaced groups are forced, premature, uniformed and obstructed returns, lack of civil documentation, severe movement restrictions in camps, and arbitrary detention. All of these challenges lead to dire consequences for the mental health of displaced populations.
Perceived IS-affiliates are at great risk of torture whilst detained, reporting experiences of or witnessing "electrical shocks, being hung by arms and feet, showered with boiling water, and deprived of meals" (Louise, 2019, p. 7). Additionally, due to institutional shortcomings, there is the potential for detained IDPs to fall through administrative cracks, without legal documentation and no rights in the eyes of internationally established institutions. This paper argues that perceived IS affiliates must all be offered the same protection as minorities and other vulnerable groups of IDPs.
"Refugee children from the middle east" by Montgomery (1998)  In "Discrimination, mental problems and social adaptation in young refugees", Montgomery & Foldspang (2008) showed that perceived discrimination among young refugees from the Middle East is associated with mental illnesses and social adaptation difficulties. There is not a directive relationship, rather it is many recursive interactions between mental health, discrimination, and social adaptation. This is the figure representing those relationships:  which is directly correlated to depression and other self-regulatory challenges. In addition, the degree to which the individual was involved in or engaged with the war affects their mental health consequences. Parent or caregiver stress, anxiety, or depression have been shown to predict the elevated internalized symptoms of their child or youth. The timing and duration of exposure to these contextual stressors can also affect developmental outcomes. For example, enduring chronic levels of stress for an extended period of time can have long term implications on health, development, and future mental health. Finally, there is convincing evidence that cumulative risk or prolonged multiple risks can affect the severity to which an individuals' mental health is affected; specifically, there is risk of increased mental illness severity for those who experience risk factors in early childhood rather than later in adolescence. Protective factors that impact a child or adolescents' ability to cope with migrative trauma include that of social support from peers, social inclusion, and community acceptance. Furthermore, for older adolescence, economic and employment opportunities are linked to positive outcomes and better mental health.
In the "Annual Research Review: Resilience and mental health in children and adolescents living in areas of armed conflict -a systematic review of findings in low-and middle-income countries", it was concluded that resilience is a complex dynamic, driven by time-and context-dependent variables, rather than the balance between risk-and protectivefactors with known impacts on mental health (Tol et al., 2013). This confirms that studies must be specified to a population and experiences cannot be generalized among different groups.
There is no universal model that may explain mental health across all contexts.
"Health needs and care seeking behaviours of Yazidis and other minority groups displaced by ISIS into the Kurdistan region of Iraq" Cetorelli et al. (2017), showed that the demand for health services was high among Yazidis and other minorities residing in camps.
Declines in the public sector funding further restricted access to camp clinics, stressing the need for alternative access strategies for health care.
In "Trauma and perceived social rejection among Yazidi women and girls who survived enslavement and genocide", the participants reported a high number of traumatic events-more than 80% of girls and women and almost all participants who were formerly enslaved, met the criteria for post-traumatic stress disorder (PTSD) diagnosis (Ibrahim et al., 2018). Furthermore, perceived social rejection in their community mediated the relationship between traumatic enslavement and depressive symptoms.
Finally, "A systematic review on the mental health of children and adolescents in areas of armed conflict in the Middle East" is the first paper of its kind to systematically review the literature on mental health of children living in areas of armed conflict in the Middle East including Iraq (Dimitry, 2012). The main findings are that children and adolescents living in these conflict zones are exposed to high levels of traumatic experiences and experience a prevalence of PTSD. Some of the main determining factors identified were levels and types of exposure, age, gender, socio-economic adversity, social support, and religiosity.

Discussion
To date, there are no studies specifically focused on the lived experiences and consequential mental health of stateless Iraqi Kurdish children and adolescents. Though this population has existed for nearly a century, been through numerous tragedies, wars, and conflicts, and been the subject of discrimination, they have been neglected in the literature.

Declarations
Ethics approval and consent to participate Not applicable.

Consent for publication
Not applicable.
Availability of data and materials Not applicable.

Competing interests
Not applicable.

Funding
Not applicable.
Authors' contributions EC contributed to the entire production of the paper.

Acknowledgement
A special thank you to Dr. Marshall Beier who graciously supervised the writing of this paper from its conception to completion. Your insights into this topic were tremendously helpful and your edits, invaluable. Thank you for your guidance and your continued support. This paper was inspired by my work in Kurdistan, Iraq in 2019 with Preemptive Love Coalition, without which, the paper would lack context and passion.

Authors' information
En Chi Chen, MSc.
Current Program Officer at Dahdaleh Institute for Global Health Research