RECLAIMING DREAMS

Prioritising the mental health and psychosocial wellbeing of children in conflict.

Boys playing in a War Child UK Child Friendly Space in northern Iraq. Photo: Arete/War Child UK

Boys playing in a War Child UK Child Friendly Space in northern Iraq. Photo: Arete/War Child UK

Escaping a war-zone is not like escaping a war.

Escaping a war-zone is not like escaping a war.

"The impact of war is real for me because I saw a lot of dead people and no spot to bury them in. Dead bodies that stayed out for days. One of my uncles, who I really loved, died, but I didn't cry, because I saw death a lot."

Dieudonne, 15, Central African Republic

Picture of Dieudonne, Central African Republic Picture of Dieudonne, Central African Republic

Photo: Arete/War Child UK

Photo: Arete/War Child UK

Huge efforts are made by the international humanitarian community to meet the physical needs of children, by providing shelter, food and water.

But their needs for mental health and psychosocial support are often not addressed.

Without this support children risk developing greater psychological, social and emotional problems later in life, severely limiting their ability, and that of their families and communities, to rebuild post-conflict.

Fighting and violence disrupts children’s lives. Children see their homes, schools and communities being destroyed. They see loved ones being killed. They are forced to flee with their families.

Those who stay at home risk being killed or injured, or being directly recruited to fight in the conflict.

These dangers have long-term mental and psychological repercussions that can devastate children’s ability to recover from conflict and communities’ capacities to rebuild.

Mental health and psychosocial support (MHPSS) is the humanitarian sector’s response to these less obvious needs.

In World War II, Anna Freud found that children in the Blitz who had a stable home life were more resilient to aerial bombardment than those whose family life was disrupted and whose parents were absent, violent or stressed.

Children of an eastern suburb of London, who have been made homeless waiting outside the wreckage of what was their home. Children of an eastern suburb of London, who have been made homeless waiting outside the wreckage of what was their home.

Credit: New York Times Paris Bureau Collection, National Archives (US)

Credit: New York Times Paris Bureau Collection, National Archives (US)

Eman's story, Syria

"When the conflict started I was doing my undergraduate degree. It affected me every day as I was trying to live my normal life in Aleppo.

"There was harassment in the street, and if you were mistaken for a protester they would take you, arrest you by mistake.

"I left Syria three years ago, but I still have all these feelings and I still get flashbacks. I don’t think I can cut out that period of my life.

"I have seen a change in my sister who was studying for her degree in Syria. Before, she used to be energetic, very optimistic. She was cheerful and had a lot of hobbies, but when I saw her last time I was shocked.

"Although she managed to finish her degree, she doesn’t have any hope. She locked herself in her room, crying and crying... I don’t know if it’s called depression, but locking yourself in your room for a whole week, not wanting to eat or be around anyone. That has really struck me … 

"Most of the doctors and psychologists have left the country, there’s only a few left. Those few cannot get so many people to come to them.

"All these organisations in Syria are only supporting shelter, maybe education, but they are not looking into people’s emotional wellbeing."

Central African Republic (CAR)

Central African Republic Central African Republic

Photo: Arete/War Child UK

Photo: Arete/War Child UK

The Central African Republic (CAR) has suffered prolonged conflict and political unrest since independence in 1960.

In 2013, a rebel coalition seized power in the capital, Bangui, leading to widespread violence, predominantly between the two main rebel coalitions: Ex-Seleka and Anti-Balaka.

Between 2015-2016 there has been extreme violence with increased clashes between armed groups and attacks on civilians.

Central African Republic ranks 188th on the Human Development Index—the lowest of any country on the list. The economy is weak and social services are severely limited.

War Child is one of only a few international child-focused humanitarian agencies now operating in Central African Republic.

UNICEF estimates that in total, 1.1 million children are affected.

Photo: Arete/War Child UK

Photo: Arete/War Child UK

"During that war, my uncle died. We didn't know where his dead body was. Some people told us that dead bodies were being sent to one area of the city. So we went there.

"I saw the hole where they bury the dead bodies. It is on our path to the farm.

"When I go farming and I see this grave, I don't feel good."
Pierre, 17, Bangui

Child soldiers

or Children Associated with Armed Forces and Groups

Child soldier Child soldier

Credit: Arete/War Child UK

Credit: Arete/War Child UK

The ongoing violence and instability in CAR has had a huge impact on the mental wellbeing of the population. 

An estimated 10,000 children associate with armed forces and groups.

Children's experiences in an armed group can lead to both internalising and externalising mental health problems, caused by various factors such as the nature of how they joined the armed group (forced or not), their age and gender, their exposure to armed violence, and type of role they perform in the armed group.

However, evidence suggests their psychosocial wellbeing improves once they leave the armed group and have community acceptance, social support and education or economic opportunities.

Upon returning to their communities, children associated with armed groups often face intense community stigma.

This plays out in discrimination and exclusion, bullying and shouldering the blame for community ills.

This can exacerbate the stigma that children face, affecting their health outcomes and shaping their psychosocial adjustment over time.

It can cause mental health problems for individual children (anxiety, depression, traumatic stress reactions) or lead to a cycle of aggression and disunity with the community.

In post-conflict settings where armed violence is normalised, reported rates of sexual violence and male aggression are significantly higher.

Gender dimensions shape the stigma that these children are exposed to.

Girls will usually have experienced greater levels of sexual violence than boys in armed groups, although boys are less likely to report sexual violence. Once reintegrated girls face greater stigma because they are seen as sexually promiscuous or defiled.

Girls subjected to sexual violence in an armed group were found to adjust differently to boys once reintegrated into their community, and the experience of rape in particular was found to have a sustained impact on their mental health and psychosocial wellbeing.

This level of stigma reduces children's access to those very protective resources—their support networks—that can improve their psychosocial outcomes.

Disarmament, demobilisation and reintegration (DDR) programmes support children to leave militia forces safely and to reintegrate into their communities.

The economic and political rationale for DDR programmes is well established: DDR programmes that include economic opportunities for ex-combatants provide a realistic alternative to armed violence.

The social value of DDR programmes, however, is less well examined. Addressing social aspects and community relationships is as valuable as providing economic opportunity to reduce stigma.

Jordan

"When you live in a country that is not yours, you
live under pressure and humiliation."

Abdul, refugee camp, Jordan

... have fled to Jordan, escaping from violence, destruction and death. 

Life for refugees in Jordan

In both camps and urban settings, living conditions for refugees are difficult. 

The majority of Syrians who live outside of camps live below the Jordanian poverty line.

Families report difficulties finding sufficient food and water and in winter, heating is a problem.

Living conditions are cramped, with multiple family members in two or three rooms or tents with limited personal space.

There are few job opportunities and refugees exist on handouts from humanitarian agencies to survive. 80% of refugees identified cash for rent as their family's first priority, followed by food (74%) and cash (73%).

Access to health care is limited and children are often not in education because they cannot afford the materials, instead working to supplement their family's income.

In the camps, it is often younger (smaller) children who work as it is easier for them to leave and re-enter the camp without being seen by camp authorities.

Left without income and having exhausted their savings, families are increasingly unable to meet their children's basic needs.

"People are always angry and upset and that's because of poverty and because of the surrounding circumstances."
Adolescent Syrian boy, refugee camp, Jordan

Children uprooted

Children are psychologically, socially and materially impacted by their status as refugees.

Their mental wellbeing is affected by a mixture of their emotions, interpersonal relationships and physical environment.

War Child found that refugee children were angry, sad, worried and felt helpless and isolated.

Their parents were stressed and had trouble communicating with their children. Many parents demonstrated a lack of awareness of their children's problems.

"Parents behaviour with their kids changed, some parents are becoming angry and sometimes hitting their kids."
Adolescent Syrian boy, refugee camp, Jordan

All of these challenges place children at greater risk of developing mental health problems.

Ahmad's experience in Za'atari Camp

Ahmad, his wife and their two daughters fled from Syria in 2012. Since then they have lived in Za’atari camp, northern Jordan.

At the beginning they lived in tents, which didn’t protect them from the harsh desert climate, the summer heat or the bitter cold in winter. The overcrowded conditions in the camp and having only access to public bathrooms caused further stress to him and his family. They had lost everything, and with no work, were solely dependent on aid deliveries from international NGOs.

Ahmad says that the simple, small daily consequences had a very big impact on him and his family. No electricity meant the children couldn’t watch TV, or read after dark. The dust in the camp made the walk to school difficult during summer, but the mud in winter made the trip near impossible. Ahmad asks:

“With my daughters thinking about HOW to get to school, how can I expect them to focus on being good AT school?”
Ahmad

He says that every stone that got accidentally flicked against metal caused a little panic, the trauma of the war in Syria, the sounds of shooting still being present on his daughters’ minds.

For him the loss of income and loss of his social network were the biggest causes of stress. Before, in Syria, the children and parents both had a big social life, meeting with extended family members, neighbours and friends. After fleeing from Syria all of that was gone.

“We never imagined ending up in a life like this—in a camp."
Ahmad

Some things slowly changed. The camp was further developed and the family moved from tents into more stable caravans. Three years ago, his son, Rami, was born, and since last year Ahmad finally started working as a teacher again.

However, his difficulties and stress were deeply engrained and have been hard to overcome.

He and his wife signed up to War Child’s positive parenting sessions in Za’atari that runs over three months.

The Positive Parenting methodology takes participants through several sessions and teaches children’s development, effects of trauma, coping and healing strategies and practical tips on setting rules and recreating a safe and nurturing environment.

“We remembered again what it meant to be a parent. We started to focus on our children’s mental development and deal with issues in a more productive way. We started with little things, like spending some money we have to buy them toys and games,” said Ahmad.

“The course gave us space to deal with our children again and see what is happening with them—without anger.”
Yasmin, Ahmad's wife

The family’s daughters are also enrolled in War Child courses. The 14-year-old is attending one of War Child’s life skills courses, and the younger daughter takes part in theatre workshops.

“For Rami, I built a swing in our house.” When he hears his name, Rami’s eyes light up. He sits gleefully in the swing waiting patiently for his dad to give him a soft push.

Psychosocial support

Psychosocial support (PSS) normalises the feelings that children have.

It provides them with space to develop coping mechanisms and vent their frustration.

School-based interventions provide a safe space for children to learn, develop peer relationships and help to build positive adult relationships with teachers. They also provide routine for children and give parents their own space.

Education programmes do not usually address the ongoing stressors in a child's home environment.

The family's socio-economic situation, access to health and other services, and community integration and cohesion, are all important predictors of mental health in refugee settings.

The hardship that families face in Jordan increases the likelihood of physical and emotional abuse in the family home.

These are clear triggers for children developing mental health and psychosocial problems.

How War Child helps

We developed the Time to be a Child programme, integrating family PSS into early childhood education in six urban and camp settings in Jordan for Syrian children aged between three and six.

The programme also supports parents and caregivers. This helps families to create safe and nurturing home environments and to build stronger relationships with their children.

In the first year (2016), "Time to be a Child" reached 2,018 boys, 1,966 girls, 1,400 parents and caregivers.

From the first-year survey of children and parents/caregivers enrolled in the programme, 65% of children reported improved psychosocial wellbeing and 85% of parents reported the improved psychosocial wellbeing of their children.

In addition, 87% of parents reported an improved ability to cope with their own stress and 65% parents use positive parenting techniques, including positive discipline, at home.

occupied Palestinian territory

Gaza photo Gaza photo

Photo: Reuters/Yannis Behrakis

Photo: Reuters/Yannis Behrakis

"The last war caused trauma for me and my children. We felt disappointed, hopeless and very frightened of the possibility of being killed by an air strike."
Nafissa, mother of three, Gaza

Children in the occupied Palestinian territory (oPt) live under a constant threat of violence. In Gaza, there is a desperate housing crisis with children living in dilapidated buildings and caravans.

Generations of families have lived and continue to live under intense stress. Dysfunctional family relationships have been highlighted as one consequence of this chronic stress.

Levels of domestic violence are high with women and children affected by physical and psychological maltreatment by men in the household.

War Child response

Caregivers support programme

Palestinian children at a War Child space Palestinian children at a War Child space

Our pilot programme enables parents and caregivers to strengthen their own mental health and psychosocial wellbeing.

Over a series of eight sessions parents and caregivers address their anger, frustration and sadness and learn strategies to better cope with negative feelings and manage stress.

The second half of the intervention focuses directly on strengthening parenting under conditions of adversity, with a particular emphasis on knowledge and skills related to positive parenting.

It is a subtle but important distinction from other parenting programmes available in that it emphasises the parent/caregiver as an individual person rather than primarily their role as a parent/caregiver.

Separate sessions are run for men and women. In early sessions, staff found that fathers would place the emphasis on mothers to support their children’s wellbeing, but over time they understood their own impact on their children. 

Staff have seen meaningful changes in male caregivers in focus group discussions and signs of improved relationships between husbands and wives, and parents and children.

What we want

Report conclusions

Children skipping at a War Child space in the Central African Republic Children skipping at a War Child space in the Central African Republic

Photo: Arete/War Child UK

Photo: Arete/War Child UK

  • MHPSS interventions that are delivered in isolation will not address the wider social issues that affect a child’s mental health and psychosocial wellbeing.
  • A systems-based approach in which PSS is embedded into education, protection, health care and wider community mechanisms should be adopted to provide sustained support to children, their families and communities. Such an approach addresses the daily stressors present in communities affected by conflict.
  • MHPSS interventions need to be accessible, community-based and adapted to local understandings to be effective.
  • War Child’s Care System Approach, currently in development, utilises research to inform and analyse the functioning and effectiveness of such an integrated approach to MHPSS.

What we're calling for

The delivery of holistic responses like this at scale requires commitment from the humanitarian sector—I/NGOs, academia and donors—to rally behind promoting MHPSS as a priority for children affected by conflict worldwide and for increased funding to deliver this vital work.

We believe that Governments and donors should take the following actions:

  • Prioritise MHPSS in humanitarian funding and crisis response. In a sector where funding is short-term (sometimes only six months), commitment to ring-fencing even 1% of aid for MHPSS would make a significant difference.
  • Redress the imbalance of MHPSS funding available for countries and protracted/immediate crises in the Middle East and in Africa.
  • Collect and systematise data on MHPSS funding: where is it allocated, through which programmatic interventions (commonly education, protection and health) and the longer-term impact of these interventions.
  • Seek political solutions to end armed conflict. An end to violence will alleviate the stressors on children living through armed conflict and improve their mental health and psychosocial wellbeing.

To see our full recommendations please download the report.

What can you do?

Instead of asking what difference one person can make, ask what difference you can make to one person.

Photo: Arete/War Child UK

Photo: Arete/War Child UK

No child should face the horror of war alone.

Our teams are on the ground in 9 countries, supporting children and their families with psychosocial support after war has ripped their lives apart.

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