VMH0007

Written evidence submitted by Child Soldiers International

Summary

1. The British army currently enlists approximately 1,800 minors (aged 16–17 years) annually. Child Soldiers International[1] (CSI) is concerned that the mental health vulnerabilities of these adolescents have been overlooked in existing research. CSI encourages the Defence Committee to examine the mental health effects of armed forces employment on adolescents as a specific category.

2. CSI acknowledges the advances in mental health research since the King’s Centre for Military Health Research (KCMHR) was established. However, this submission presents evidence of critical gaps in the research thus far. In particular:

• Current mental health research is not usually carried out in anonymous conditions, which is known to lead to the under-reporting of disorders;
• Current research does not adequately disaggregate relevant demographic data, particularly age and socio-economic background, which obscures these important risk factors and leads to over-generalisation in the conclusions drawn;
• The research, in focusing mainly on deployment, has not yet examined the effects of military employment as a whole on mental health, particularly the influence of military training and culture;
• Adolescents are psychologically and neurologically more vulnerable than adults to developing, or suffering a deterioration of, mental illness in conditions of high stress; and
• Negative mental health outcomes are more common in armed forces personnel and veterans who enlisted as minors.

3. CSI concludes by calling for the minimum enlistment age to be raised to 18 years, to avoid unnecessary and potentially long-lasting harm to adolescent recruits.

4. CSI would like to give further evidence to the Committee orally, if permitted.

1. To what extent do current statistics accurately reflect the level of mental health issues in serving armed forces personnel and veterans, including PTSD?

The effect of non-anonymous conditions on reporting PTSD

5. British studies of PTSD in military groups are carried out in confidential, but not anonymous, conditions.[2] Obtaining identifying information from study participants facilitates longitudinal (follow-on) research afterwards, but leads to under-reporting of the true prevalence of mental health problems.[3] When KCMHR carried out a study on the effect of anonymity on reporting PTSD, the anonymous respondents were three times as likely to report the symptoms as those who had provided identifying information confidentially.[4] The study was small (600 participants) but its findings were statistically significant, and similar findings have been made in the US.[5] It indicates that the current estimates of PTSD prevalence in the armed forces, may substantially under-represent the problem.

2. What are the challenges to accurately assessing the extent of mental health issues in serving armed forces personnel and veterans and how could government improve its understanding of those issues?

No segmentation of minors in the data collected

6. Studies in the UK and have found that mental health problems are most prevalent in the youngest age group.[6] For this reason, mental health studies routinely treat the age of participants and other demographic characteristics as confounders – variables that interfere with the analysis. It is becoming increasingly clear from psychosocial and neurological research that age, as a statistical indicator of psychological maturity, is itself a risk factor for mental health problems in high-stress environments.[7]

7. The age bands used in KMCHR studies are wide; the youngest age group is ‘under 25’, so does not distinguish minors from adults.

Imprecise data on socioeconomic background

8. The current research does not routinely incorporate sufficiently detailed, disaggregated data analysis concerning recruits’ socio-economic background. The elevated developmental vulnerability of young people, particularly during adolescence, is compounded by factors associated with background of deprivation (common among the youngest army personnel)[8], but this too is often treated as a confounding variable rather than a risk factor.[9]

No data collected on age at enlistment

9. Evidence is growing that enlisting at a very young age is associated with a wide range of negative outcomes, including poor retention,[10] poor long-term socio-economic prospects,[11] and a very high prevalence of mental health problems among those who leave shortly after joining.[12] These outcomes point to early enlistment as a risk factor for mental health, but KMCHR does not collect data on age at enlistment.

Effects of military training

10. CSI is also concerned that UK research has not investigated the effects of training or other aspects of military employment outside of deployment on operations. International research has shown that military training has a major and long-lasting psychological impact on recruits. For example, US research has found that between 2004 and 2009, the peak rate of attempted suicide among recruits during basic training was four times higher than the peak rate of attempted suicide during deployment to Iraq or Afghanistan.[13] British infantry veterans interviewed by CSI have stated that they found their initial training more traumatic than deployment and believe this is the root cause of the psychological difficulties they subsequently faced adjusting to civilian life.[14]

11. The lack of research into the effect of military training is particularly significant for the 31 percent of recruits who enlist as minors but drop out of training,[15] or who are otherwise discharged from the armed forces before reaching deployable age. Early Service Leavers (ESLs) report a high prevalence of mental health problems; 20 percent report the symptoms of PTSD, for example.[16] In view of their high trainee drop-out rate,[17] enlisted minors are over-represented among ESLs. This evidence strongly suggests that many recruits who enlist as minors and are not deployed suffer significant negative mental health consequences from their military employment.

3. How does the level of mental health issues, services and outcomes in serving armed forces personnel and veterans:
   - compare both to the actual level in the general population and to public perceptions of mental health issues in armed forces personnel and veterans?
   - vary between different groups of serving and former personnel, including reservists, those who have been deployed on operations and early leavers?

Military-civilian comparisons and perceptions

12. As outlined above, existing research does not yet adequately differentiate sub-groups within the broad categories of serving personnel and veterans. Consequently, public perceptions are likely to both over- and under-estimate the extent of mental illness, depending on which sub-group is concerned. Nonetheless, the available research has shown that military employment increases several risks to mental health, with the youngest recruits most affected.

13. Relative to UK civilian rates, for example, anxiety/depression[18] and harmful drinking are at least twice as common in the armed forces.[19] Studies have found that PTSD is only slightly more common in the armed forces as a whole than in the general population (although it is likely to be under-reported, see above), but twice as common among infantry personnel, which is the major role group for the youngest recruits aged 16-17.[20] Although suicide is less common in the armed forces as whole than in the general population, this is not the case for the youngest recruits. The suicide rate among the youngest army recruits over the last two decades has exceeded that of same-age and sex civilians by 45 per cent.[21]

Violent behaviour

14. Contrary to a common assumption that joining the army reduces delinquent violent behaviour in young people, an analysis of the international research in 2017 found that military training and culture reinforce several known risk factors.[22] UK and US research in the last decade has found that violent offending became more prevalent after enlistment, even before personnel were sent to war;[23] and that violent offending was substantially more common among military personnel than among civilians.[24] Research by KCMHR further discovered that the rate of violent offending increased again once personnel were sent to war, after which the rate was double that found prior to enlistment.[25] It is not known why enlistment is accompanied by an increase in violent behaviour before personnel are deployed, but it is likely that initial training – which stimulates aggression – plays a role.

15. The studies show that younger recruits and those from poorer backgrounds are more likely than others to behave violently.[26] US and British studies have found that pre-existing problems, such as a history of anti-social behaviour, combine with military factors, such as being trained for a combat role, to drive up the prevalence of aggressive behaviour among personnel.[27] Since adolescent enlistees are less mature than their older counterparts, typically come from poorer backgrounds, and are over-represented in infantry jobs, they carry more of the major risk factors for violent behaviour.[28]

16. Psychological development in adolescence may also be a factor in increased violence among young recruits. The same brain development processes which incline adolescents towards risk-taking are also a risk factor for developing a fascination with violence.[29] According to evidence given to a German parliamentary committee by an expert psychologist: ‘[B]rain development in adolescence means that young people make more risky decisions and these risky decisions help to explain the risk factors in adolescence frequently described in research for both post-traumatic illnesses and aggressive behaviour.’[30]

Ex-forces personnel

17. The prevalence of mental health problems increases after veterans leave the forces. Personnel who were in the British armed forces in 2003 but had left by 2013 have been between two and three times as likely as the general population to have problems with anxiety/depression, harmful drinking, and PTSD. Over the same period, even ex-forces personnel who were not sent to Iraq or Afghanistan have been 2.5 times as likely as civilians to screen positive for PTSD.[31] The long-term suicide rate among male ex-forces personnel aged 16–19 was three times that for the same age group in the general population,[32] echoing a similar elevated suicide rate found among young personnel in other countries’ armed forces.[33] As noted above, the greatest prevalence of mental health problems is found among Early Service Leavers, in which the youngest enlistment age group is over-represented.[34]

4. What proportion of mental health issues in veterans is attributable to service in the Armed Forces and how well is this measured and understood?

Pre-enlistment stress and the stress of initial training: a hazardous combination

18. It is sometimes suggested that an adverse childhood background – and not military employment – accounts for the psychological, social and economic problems found among young recruits and veterans. Research in the UK and US confirms that pre-existing vulnerabilities associated with a troubled childhood are common in recruits who enlist as minors. However, the same research shows that the stress and intensity of initial training exacerbates these pre-existing risk factors, strongly contributing to mental ill-health among the youngest recruits.[35]

19. Military training uses sustained stress and often harsh discipline to prepare recruits for the demands of military employment. The use of stressors such as the denial of sleep and comfort, and strenuous physical exercise to the point of exhaustion, is a standard component of Phase 1 training. For recruits training for future frontline combat roles in particular – of which minors constitute a disproportionate number – Phase 1 training includes repeated stimulation of adrenalized aggression (e.g. during bayonet training).[36]

Effects of chronic stress on adolescent mental health and neurological development

20. A measure of stress in adolescence is healthy, but a high-stress environment becomes harmful.[37] Relative to adults, adolescents are temperamentally more anxious, and more likely to experience depressed mood and emotionally volatility.[38] Crucially, they are also more reactive to stressors.[39] That is, adolescents react to stressors with a greater anxiety and then remain anxious for longer.[40] Accordingly, under stress they experience greater strain and are more likely than adults to be overwhelmed.[41] Under stress, adolescents are also more likely than adults to develop anxiety-related mental health problems, such as depression.[42] A high stress environment can even disrupt the development of the brain, which during adolescence is sensitive to repeated or prolonged stress. Under chronic stress, the brain’s transition to full maturation is compromised, particularly systems involved in the regulation of emotions.[43] There is some evidence that this can lead to lasting problems with anxiety in adulthood.[44]

21. While adult recruits can also be affected by the same risks, the neuroscientific research indicates that the brain changes so rapidly in mid-adolescence that the reduction in vulnerability between the ages of 16 and 18 is typically critical.[45]

5. To what extent does the military environment for serving armed forces personnel mitigate against the development of mental health issues?

Resettlement of enlisted minors

22. Whilst there is no evidence to support the claim that enlistment has a positive impact on young recruits’ mental health, research does show that exit from the military community across the age range is marked by a loss of social support networks and fewer social activities, which are important buffers for stress.[46] This is likely to account in part for the greater prevalence of stress-related mental health problems among veterans.[47]

23. There are several reasons why the youngest enlistees are likely to struggle more than older recruits after leaving the armed forces. Those who enlist as minors will not experience adulthood as civilians until they do leave, typically in their mid-twenties (if they did not drop out of training). An early entry into the military environment truncates the opportunity to build mature, supportive social networks in civilian life, meaning that enlisted minors have a more limited support structure to return to when they leave the forces. Having joined young and typically with few qualifications, they are also more likely than adult recruits to join army roles that offer the least continuing, transferabl education and training and carry the highest risks of physical and psychiatric trauma in war, particularly the infantry.[48] For these reasons, the youngest recruits are less likely than adult recruits to resettle well in civilian life.

Unemployment

24. The link between employment and mental health is well established. It is therefore significant that veterans are substantially more likely than non-veterans to be unemployed. Recruits who enlist as minors are at higher risk of unemployment than their both their civilian peers and adult recruits. In financial year 2015/16, for example, 16 per cent of veterans from across the armed forces who had left before completing four years’ service were unemployed six months afterwards, which was three times the national unemployment rate and greater also than the 13 per cent unemployment rate for civilians aged 16-24.[49] A study in 2013 found that 30 per cent of infantry veterans – of which a disproportionate percentage enlisted as minors – who had left the army within four years of enlisting were not in work, education or training 18 months afterwards.[50] The national unemployment rate that year was 8 per cent (21 per cent for 16-24-year-olds).[51]

Conclusion and Recommendations

25. Research has begun to shed some light on the extent of mental health problems among young personnel in the British armed forces, but under-represents the problems. It also does not yet assess the youngest and most susceptible enlistees, namely minors, particularly those from a background of deprivation.

26. CSI urges the Committee to call on the Ministry of Defence to:

• Raise the minimum enlistment age to at least 18 years, in recognition of the greater psychological vulnerability of minors compared to adults;
• Fund research that collects data on age at enlistment, more precise data on the age of participants, and better data on socio-economic background, and which disaggregates the results accordingly;
• Commission and publish research into the mental health effects of initial military training and other aspects of military employment other than deployment on operations.

1 March 2018