Advocacy for a coordinated and safe response for the mental health and psychosocial needs of children affected by the conflict in Ukraine.

Introduction

The ongoing military actions in Ukraine pose an immediate and growing threat to the lives and well-being of at least 7.5 million children [1]. This situation creates further challenges for many children and adolescents already struggling after nearly 8 years of conflict in eastern Ukraine, which has had a devastating impact on their mental health and well-being [2]. Beyond the direct ones, there are also indirect effects associated with a profound and potentially long-lasting impact on the psychological well-being of an entire generation of children [3].

Following the Ukraine conflict, humanitarian needs are dramatically escalating and spreading. As of June 30, 2022, at least 343 children have been killed and more than 635 injured since the beginning of the armed conflict [4]. Furthermore, 12 million people have been displaced, with more than 6 million Ukrainian refugees, mainly women and children, who have fled across international borders [5]. Among those fleeing, many are unaccompanied asylum-seeking minors without parental care and protection, exposing them to a heightened risk of trafficking, abuse, exploitation and gender-based violence, even after being in the care of responsible authorities in the destination country [1].

Children in institutional care

A group of particular concern and risk is represented by institutionalized children across Ukraine. Even before the current conflict, Ukraine was one of the countries in Europe with the highest rate of child institutionalization [6], with an estimated 100,000 children—half of whom have disabilities—living in various forms of institutional care, including baby homes for children aged 0–4 [7]. Indeed, more than 90% of children deprived of parental care actually have at least one living parent but are placed in institutions because of disability or poverty or because their parents are considered unfit to care for them [8]. There is compelling evidence that early institutional deprivation can have a profound and long-lasting impairment and burden relevant to the mental health and well-being beyond adolescence and into adulthood and it is widely recognized among the international community as a violation of children’s rights [9]. Children with mental health conditions and disabilities are especially vulnerable and among those most likely to be excluded from social protection and be negatively affected by displacement, and their continued care is easily jeopardized in a time of crisis [8]. Moreover, it is expected that the number of children at risk of family separation and in need of alternative care will increase—both during the peak of the crisis and as a result of its long-term socio-economic impact on families’ capacity to care [10].

Children’s rights and legal context

The UN has identified six grave violations against children during times of armed conflict, namely: the recruitment and use of children as soldiers; the killing or maiming of children; sexual violence against children; the abduction and trafficking of children; attack against schools or health care; and the denial of humanitarian access [11]. The commission of any of these violations constitutes a breach of international humanitarian law and may constitute a war crime and a crime against humanity [11, 12].

We note here that Russia, as the occupying power, has the responsibility to respect, protect, and fulfill human rights in the occupying Ukrainian territories. Indeed, as the International Committee of the Red Cross (ICRC) points out [13], the occupying power must respect the laws in force in the occupied territory and take measures to ensure public health standards and provide medical care for the population under occupation, therefore, the Russian authorities have a role in the protection of children on Ukrainian territory.

Impact of war on European children’s mental health

In a survey about changes in children’s lives during the Ukraine war since April 2022, 50% of participating parents reported that their children’s mental health had deteriorated after the war started, compared to the pre-war period. The mental health status of children from areas most heavily impacted by the war was particularly disturbing [14]. The most common symptoms observed by parents were mood swings and increased anxiety (45% and 41%, respectively). Parental observations of sleep disorders, poor appetite, memory and attention impairment, aggression, and reduction/cessation of desire to communicate were also high, ranging from 29 to 13% [14].

While Ukrainian children are directly affected by the war, children beyond Eastern Europe could also be indirectly affected by the current crisis. Save the Children outlines three ripple effects of the Ukraine crisis on children across the world: (1) a global hunger crisis; (2) a climate crisis and energy poverty, and (3) a heightened mental health burden [15]. Through mass media, the war can indirectly impact children’s well-being by being exposed to news and images of war on television, newspapers, and social media, which can lead to insecurity, anxiety and worries [12].

The current war outbreak in Ukraine adds another layer of mental health burden on children following the COVID-19 pandemic, which has been accompanied by heightened levels of insecurity, increase mental health needs and reduced quality of life in both children and their caregivers, thus creating a scenario of double jeopardy [10, 12].

Coordinated child protection efforts

Institutionalization and armed conflict are significant social determinants of mental ill-health during childhood and adolescence and affect millions of children across many regions of the world [3, 9]. The current crisis will likely create further pressure on the already strained child and adolescent national care system and slow down the implementation of the reform of the child protection and care systems across Ukraine [8].

Thus, the conflict in Ukraine prompts governments, international and regional organizations and civil society to work together to ensure that children’s rights are fully promoted and protected and strengthen mechanisms for monitoring, reporting and prosecuting perpetrators of grave violations against children [11].

Immediate actions are needed to ensure the safety of institutionalized children in conflict areas where the breakdown of law-and-order leaves children vulnerable to neglect, exploitation and trafficking [6]. UNICEF and other international organizations have called on the authorities, both in Ukraine and in refugee-hosting countries, and legal guardians of children under institutional care, to keep children safe and protect their rights by: strengthening child protection systems; expanding the capacity of emergency care arrangements; following safety evacuation instructions; and cooperate with competent authorities to enable family tracing and reunification mechanisms with parents when in the child’s best interests and the provision of temporary, safe and appropriate care in the meantime [6].

Conclusions

In light of the growing psychosocial and mental health needs of children directly or indirectly exposed to the violence and trauma of war, an inter-agency collaboration between child protection, education, and mental health services should be adopted to prevent and reduce the harm and help youth and their caregivers cope with such adversity and build resilience. Thus, the current crisis calls for political action and collective engagement to design and develop programs targeting the specific challenges related to war and its consequences [12], entailing support to families in the care for their children to prioritize keeping children safe in family environments. Such support (e.g., reducing stressors, increasing parenting capabilities, along with mental health support) can enhance family resilience and help minimize the need for residential care. Specific training will need to be implemented among professionals in the field of child and adolescent mental health. It is incumbent on child and adolescent psychiatrists, pediatricians, allied child health care providers, health institutions, researchers, and policy makers to address the psychological impact of this ruthless war on children as a critical and priority issue.