Addressing the mental health needs and burdens of children fleeing war: a field update from ongoing mental health and psychosocial support efforts at the Ukrainian border.

Background: The ongoing horrors of the war in Ukraine have led to enormous consequences: loss of life, severe injuries, and mass movements of civilians. Exposure to war, living in conflict zones, and forced displacement increase the risk of experiencing a broad spectrum of direct and indirect burdens towards physical and mental health, in particular among children. Objective: This letter to the editor aims to provide multiple clinical and 'mental health and psychosocial support' (MHPSS) systems' perspectives by experts working in ongoing aid efforts to bridge and disseminate their current observations towards child and adolescent mental health services involved in the mental health response to the current war in Ukraine. Results and Discussion: The diverse perspectives from three mental health professionals involved in the MHPSS response highlight the different burdens and needs of children being confronted with situations of an existential nature. Children live through transformed social situations, deteriorated life conditions, general uncertainty, and encounter numerous losses. As such, war is the ultimate non-normative and existential stressor. The four perspectives highlight the need to: (1) adjust help toward the needs of the beneficiary, (2) understand help efforts as intersubjective human encounters and enable parents and caregivers in these encounters, (3) recognise losses and embrace finding ways to facilitate grief, and (4) continue to address these needs in a coordinated way that follows inter-agency guidelines.
Conclusion: Better understanding the needs of refugee children underlines the importance of investing in their future by providing resources for humanitarian aid and psychosocial interventions during sustained emergencies. The perspectives presented in this letter emphasise that psychosocial care is deeply rooted in intersubjective help-encounters and, therefore, a professionalisation of interventions should co-occur with their humanisation and be adapted to subjective needs, varying sociocultural backgrounds, and the individuals themselves with the goal of reducing suffering and fostering well-being. HIGHLIGHTS: The three expert humanitarian aid perspectives highlight the need to: adjust help toward the needs of the beneficiary,understand help efforts as intersubjective human encounters and enable parents and caregivers in these encounters,recognise losses and embrace finding ways to facilitate grief, andcontinue to address these needs in a coordinated way that follows inter-agency guidelines.

Background and introduction

The ongoing atrocities of the war in Ukraine have led to enormous consequences: loss of life and severe injuries, as well as mass movements of the civilian population throughout the country and to neighbouring countries (United Nations Office for the Coordination of Humanitarian Affairs [OCHA], 2022). At the beginning of May 2022, an estimated number of more than 15 million people were affected by the war and, as a result, in need of humanitarian assistance. More than 12 million were considered in need of humanitarian health care (Health Cluster Ukraine, 2022). This war is swiftly becoming one of the greatest refugee crises since World War II, with more than 5.7 million people already having fled Ukraine (UNHCR, 2022, as of 5 May 2022). Most of these people, many of whom are women and children, are finding shelter in other European countries. They often initially arrive in Poland, which is now providing refuge to over three million Ukrainians fleeing the country (UNHCR, 2022, as of 5 May 2022). Other European nations are expecting to take in hundreds of thousands of refugees from Ukraine. This is likely to be a challenge, as the global pandemic has already put immense strain on psychosocial and mental support services within many national health systems (Manchia et al., 2022).

Exposure to war, living in a conflict zone, and forced displacement are all creating or increasing the risk of experiencing numerous detrimental direct and indirect physical and mental health burdens, particularly for children (Bürgin et al., 2022; Charlson et al., 2019; World Health Organization, 2018; Yule, 2003). War deprives children of critical developmental opportunities and violates their rights to develop in safe and nurturing environments and child friendly places (Bürgin et al., 2022). Thus, the current situation calls for action and engagement to mitigate risks, as well as to prevent and reduce harm toward children while fostering and scaling up support for all who are involved with emergency responses and long-term aid and care-efforts. Mental Health and Psychosocial Support (MHPSS) is currently being employed by international organizations, mental health services in European countries, Ukrainian mental health professionals themselves experiencing displacement, and collective civil engagement. Such aid efforts, if implemented systematically, should follow agreed upon guidelines and standards of operation as set out in the ‘Guidelines on Mental Health and Psychosocial Support in Emergency Settings’ by the Inter-Agency Standing Committee [IASC] (2007). Current assessments by international humanitarian organizations highlight the immediate need for such inter-agency collaboration to implement MHPSS with the goal of treating the social and mental health problems of conflict-affected individuals with a multi-layered approach to care and interventions, inclusive of basic services and family and community support, as well as specialised psychological interventions (Health Cluster Ukraine, 2022; International Medical Corps, 2022; UNICEF, 2022).

Addressing the mental health needs and strains of conflict-affected children requires insight into, and an understanding of, existing MHPSS interventions and their efficacy and sustainability in the specific context of Ukraine’s volatile climate. Accordingly, this letter to the editor provides different clinical perspectives on MHPSS systems and the ongoing humanitarian aid and intervention efforts. It discusses both these efforts and their implications for (European) psychiatric and mental health services.

The following perspectives and reflections presented are contributed by mental health and MHPSS professionals with longstanding experience working within different crises around the world and reflecting their current observations in their work with Ukrainian Refugees in Poland (see bio sketches enclosed).

Clinical and help-systems perspectives and observations of ongoing MHPSS efforts

Clinical perspective: Lyla Schwartz on the needs and strains of children from clinical observations within Polish shelters

Resulting from observations across Polish shelters, more general responses to mental health and psychological conditions for Ukrainian refugees in Poland have largely been a version of basic psychosocial support rather than targeted care efforts. Care providers are often working to collectively respond to large numbers of people, but, through this, are unable to adapt their care to the individual needs of the beneficiary. This observed one-size-fits-all care is often less effective when the resources and guidance are unavailable to individualised and contextualised aid efforts to make them more circumstantial. Likewise, psychological resources need to be contextualised and culturally adapted – not merely translated. From clinical observations, women and children residing in shelters are experiencing vicarious and continuing traumatic experiences, stressors, and anguish. With the separation from male family members and an overall lack of information regarding their own situations, this existential uncertainty is causing ongoing anxiety for a growing number. Two topics are particularly relevant:

First, the specific socio-religious context of this displacement should be considered as it may be impacting the outcomes of MHPSS. For instance, we are seeing a growing number within this population looking to pharmaceutical medicine as the ultimate solution to psychological symptoms such as insomnia, grief, and anxiety. Therefore, group or individual counselling, resilience building, and other psychological interventions are being brushed over in favour of medicine and drugs. Stigma also seems to exist around mental health and labelling. As a result, there is a lack of inclusion for children experiencing behavioural challenges. Further, those with mental health needs due to crisis-induced trauma are often offered only faith-based solutions (such as being told to pray), rather than with informed and specialised care. Thus, destigmatising stress reactions and psychological symptoms and syndromes is vital for help efforts addressing the needs and burdens of children.

Second, there appears to be a scarcity of caregivers’ perspectives featured in existing reports. This viewpoint is critical in understanding why and how the needs of Ukrainian children during and after their flight can be met. Some families who have stayed in shelters in Poland have returned to Ukraine, only to then return once more to Poland. Expectations and plans of returning should be managed and supported according to the individual circumstances. This seems to be important in being able to provide consistent care and foster stability. Next to this, there appears to be a significant proportion of parents having difficulty effectively communicating with their children. In some instances, parents are telling their children that they are on holiday. Their exposure to conflict is obvious, but parents are struggling to explain the war to their children and justify why they are now residing in shelters. This noncommunication further exacerbates the feelings of confusion and uncertainty some children are experiencing. As such, there is an urgent need for accessible guidance for parents and caregivers to ensure stable care and quality interaction integrated into daily parenting. Supporting parents in finding ways to productively talk to their children about the current situation is also urgently needed.

Psychological perspective: Mariia Nakonechna on intersubjective aspects of providing psychological help to refugee children

The challenges faced by children and their mothers fleeing from war include transformed social situations, deteriorated life conditions, and general uncertainty. Based on conceptualising resilience as an individual's ability to keep their own normal functioning in the face of adversities, we can further consider war as the ultimate non-normative experience and thus stressor facing every affected person with very existential issues.

The first things refugees need include both personal and interpersonal safety. The focus on safety improves children’s lives, even though some aspects of their wellbeing might have decreased. Safety can be developed in interaction with others who demonstrate that different reactions are normal in times of war being an abnormal situation. In the concepts of L.S. Vygotsky’s cultural-historical theory (Zavershneva & van der Veer, 2018), refugees are creating new interfunctional psychological systems, insofar as they are now living in new social developmental situations. It is important to help them build new dynamic and functional systems of meaning, which would be useful in these difficult times. For instance, children seemingly like to listen to patriotic Ukrainian music. They find it inspiring or relaxing in different contexts. New resilient autobiographic experiences can be built through reflecting and discussing the music content. The development of higher mental functions in Vygotsky’s sense is a psychological means to live in new life situations with resilience and self-compassion. Within intersubjective situations, children can build dynamic systems of meaning and engage in dialogues that are mutually beneficial for themselves and others.

Another important feature of children’s life transformation is subjectivity and intersubjectivity. Children can be either reactive and passive or proactive and subjective. While interacting with others, they can show activity, reflexivity, and creativity and thus ensure mutual enrichment in the process of communication. Psychological interventions such as counselling, training, and support groups are therefore interconnected in intersubjective relationships. They are rooted in social developmental situations and are determinants of inner growth and an increase of a personality’s resources.

Children’s aspirations are often connected with Ukraine’s victory. They draw pictures, talk about it, and watch videos. Of course, they wish to return home. Perhaps they currently do not realise that they cannot return to the exact lives they had before the war, but they nevertheless have the potential to overcome this existential threat towards posttraumatic growth rather than posttraumatic stress. This gives room for hope in psychological and social ways.

Better understanding loss: Georgina Campbell on a perspective drawing from clinicians working in the humanitarian response

We as the MHPSS team in International Medical Corps have and continue to train and supervise non-specialist workers to listen without judgment and bear witness to peoples’ experiences of conflict. Oftentimes non-specialist workers (people involved in health and social care, community care, pastoral carers, and teachers who have no training or qualifications in mental health) have encountered and lived through similar experiences as those they support, heightening the stress they have already faced. However, in supervision and understanding the experience of conflict through their lens and interpretation, a theme repeatedly occurs; loss and interrupted grief. As people flee conflicts to be labelled as internally displaced or refugees, these feelings are often reinterpreted or pathologized into depression, anxiety, or PTSD when they come to seek help and support in safe and stable settings—to the point that the losses they experience may never be given the time to be fully understood nor grieved. This interrupted grief can be damaging to mental wellbeing and the impacts can be felt for years. In a recent International Medical Corps MHPSS needs assessment report from Ukraine (International Medical Corps, 2022), participants in focus group discussions described loss as one of the most talked about experiences: loss of loved ones; loss of life; loss of homes; loss of jobs, education and opportunities; loss of language; loss of financial support; loss of belongings; loss of safety; and so on. Conflict then interrupts the mourning process with people describing instances of keeping the bodies of deceased loved ones in their homes for several days, as they were too afraid to venture outside to properly bury them; or for bodies of loved ones found in mass graves, facing the challenging process of reburying them in a dignified manner. In these situations, the mourning ritual was lost

When developing care and support to people fleeing conflict and disaster, recognise the losses they are experiencing as individuals and as a population. Hear them and what they mean to the person, but also embrace finding ways to create socially and culturally acceptable ways to facilitate grief. Learn about traditional mourning rituals in the country and find ways to create safe and respectful versions of that. Support the development of services that encourage refugees to celebrate their lost culture, language, and security, as this may help them navigate ways to embrace new cultures and build new connections. Only when we know where we have been, can we know where we are going.

Discussion and conclusion

This letter to the editor aimed to provide multiple clinical and MHPSS systems perspectives of the ongoing aid efforts and discuss them with a trauma-informed care perspective to bridge and disseminate current observations from ongoing MHPSS to clinical practice within (European) psychiatric and mental health services and their responses to the ongoing war in Ukraine.

The different perspectives highlight the diverse burdens and needs of children facing situations of an existential nature. Children fleeing war experience vicarious and continuing traumatic experiences, stressors and anguish, ongoing threat, existential uncertainty, and continuing anxiety. They live through transformed social situations, deteriorated life conditions, and general uncertainty. As such, war is the ultimate non-normative experience facing affected individuals with very existential questions. Confronted with losses, conflict often leaves no time to grieve and mourn as decisions about survival and the future are seen as more urgent.

Thus, what can be done? The perspectives within this letter underline the need to bear witness—that is, see and hear people confronted with existential uncertainty and threat—and to accept loss and suffering, thereby potentiating ways to create socially and culturally acceptable grief facilitation practices, as well as to foster coping and recovery mechanisms. Personal, as well as interpersonal, safety can be developed in interaction with others who help oneself build new dynamic systmes of meaning. Within such intersubjective encounters, children might be able and enabled to build such dynamic systems of meaning and engage in dialogues that are mutually beneficial for themselves and others. Consequently, an integral aspect of caring for children includes providing care for their caregivers in being able to engage in such experiences of intersubjectivity, communication, and responsiveness.

Understanding help efforts as intersubjective human encounters also underscores the need to reflect on both parties involved in a helping encounter—those who receive care and those who provide care. As such, various studies demonstrate that mental health professionals in emergency settings and volunteers at humanitarian organizations face a high risk of burn-out, secondary traumatic stress, mental health challenges, and difficulties in close and romantic relationships during and after their aid missions (e.g. Cardozo et al., 2013; Connorton, Perry, Hemenway, & Miller, 2012; Lopes Cardozo et al., 2012; Rizkalla & Segal, 2020). Due to these results, and from a perspective of trauma-informed care (Forkey et al., 2021; Zhang, Conner, Lim, & Lefmann, 2021), it is important to build administrative, professional, and emotional supply-chains for professional humanitarian workers who are confronting children and adolescents with war experiences in Ukraine, which includes supervision and appropriate organizational structures (Aldamman et al., 2019; Perera et al., 2021; Thormar et al., 2013; Travers et al., 2022). Also, studies show the protective nature of parental support in times of crises (Eltanamly, Leijten, Jak, & Overbeek, 2021; Tol, Song, & Jordans, 2013), underscoring the need to support and enable parents to care for their children. Sustainably caring for those in need should always incorporate support for those who provide care.

Acknowledging the ongoing MHPSS aid and intervention efforts highlights the need for inter-agency and interdisciplinary collaboration and coordination of services following an agreed upon set of rules and standards addressing different levels of intervention from providing basic to highly specialised services (Inter-Agency Standing Committee [IASC], 2007). Most interventions following such a stepped-approach are lower-threshold interventions provided by non-specialists (without mental health training) and include the provision of basic services and resources (food, water, shelter, and healthcare) as well as strengthening of family and community support to (re-)activate resources and protective factors (Tol et al., 2011). Interestingly, the most frequently implemented non-specialised interventions have the weakest evidence base (Tol et al., 2011) – urging for more research that bridges this evidence gap.

Of note, most children are astonishingly resilient after experiencing major life events and potential trauma (Galatzer-Levy, Huang, & Bonanno, 2018). Thus, not all children following war are in need of specialised services, whereas still, others might be at risk for persistent symptoms over time (Bürgin et al., 2022). Therefore, it is important to not over-pathologize immediate psychological distress, to reactivate coping resources and support systems while remaining sensitive to those in need of specialised mental healthcare (Bürgin et al., 2022). Understanding resilience as developed and sustained within complex interacting biopsychosocial–ecological systems (Ungar & Theron, 2020) and as ‘the process of harnessing biological, psychosocial, structural, and cultural resources to sustain wellbeing’ (Panter-Brick & Leckman, 2013), urges to provide interagency, interdisciplinary, and multileveled aid and interventions aligned with a stepped care approach in general and particularly in emergency settings.

Better understanding the needs and burdens of refugee children underscores the need to invest in their futures by offering resources for humanitarian aid and early psychosocial interventions in emergencies worldwide. It also highlights the need for a comprehensive psychosocial agenda considering the double jeopardy of the war in Ukraine coinciding with consequences of the COVID-pandemic on children’s mental health (Bürgin et al., 2022; Fegert et al., 2021). In all our efforts of responding to the war in Ukraine, however, it is important to not lose sight of all the other crises, conflicts, and refugees flows worldwide. Upon reflection, the perspectives presented within this letter emphasise that (professional) psychosocial care is deeply rooted in intersubjective help-encounters and, therefore, a professionalisation of interventions implementing manualised-evidence should always co-occur with their humanisation and consequently be adapted to subjective needs, different sociocultural backgrounds, and the individuals themselves with the goals of reducing suffering and fostering well-being.

Short Bio-sketches of Contributors of the MHPSS perspectives:

Lyla Schwartz is a clinical psychologist with a decade of experience in providing mental health and psychological support services to vulnerable displaced populations. She received two master’s degrees in clinical psychology and advanced clinical social work in the United States and is now working towards her PhD in Clinical Psychology in Switzerland. Lyla has experience in several countries providing emergency psychological aid to traumatised youth and families, including Afghanistan, India, Peru, Haiti, South Africa, Greece, and the United States. Lyla resided in Poland between March and May to help implement MHPSS guidelines in response to the war in Ukraine.

Mariia Nakonechna received her PhD degree in psychology for the research entitled ‘Helping the Other as a Psychological Means of Personal Development’ and is now working on post doctorate study focusing on intersubjective relations in adolescence. Along with teaching psychology at Nizhyn Gogol State University (Ukraine) since 2004, she penned the monograph ‘Helping the Other: Psychological Aspects’ (2012) as well as many articles in scientific journals. Bringing her personal experience as a refugee together with practical professional skills and academic interests, Mariia currently works as a psychologist in a small, local charity organization ‘Poland Welcomes’ near the Ukrainian-Polish border, providing support for women and children fleeing war.

Georgina Grundy-Campbell is a mental health nurse who has been working in global mental health and humanitarian response programming for the past 15 years. Georgina has worked as a consultant with the World Health Organization as well as a Mental Health and Psychosocial Support Technical Advisor with international NGOs including International Medical Corps. She has developed and implemented MHPSS programmes in response to the Ebola outbreaks in West Africa, conflict and refugee settings in the Middle East, Central and West Africa as well as Latin America. Her interest is in designing culturally appropriate and holistic services that find the most efficient ways to support the people who need it the most.