How is the Ukraine war affecting children’s mental health?

Nearly a quarter of the world’s children are estimated to live in countries affected by armed conflict or disaster.

Following Russia’s invasion of Ukraine, the children there are experiencing the devastating consequences of living in a war zone – the constant threat of shelling, shooting and losing loved ones, as well as the worry over accessing food, clean drinking water and healthcare, and the breakdown of their usual routines and structures.

“The legacy of this war will be a traumatised generation,” wrote Serhii Lukashov, the director of SOS Children’s Villages in Ukraine.

The mental health impact of this is likely to have consequences for years to come.

Post‐traumatic stress disorder (PTSD) and depression are the most common mental health disorders in the aftermath of war – for both adults and children. While the incidences of these disorders are difficult to estimate, most studies have found significantly raised levels of disturbance compared with control populations. For example, past studies of newly arrived refugee children show rates of anxiety from 49 percent to 69 percent, with prevalence dramatically increasing if at least one parent had been tortured or if families were separated.

PTSD can occur in children after even a single traumatic event, but repeated or prolonged trauma increases the risk. The symptoms of PTSD vary; sufferers may show intense fear, helplessness, anger, sadness, horror or denial. They can also develop physical symptoms including headaches and stomach aches; show more sudden and extreme emotional reactions; or have problems falling or staying asleep. Children who experience repeated trauma may develop a kind of emotional numbing to deaden or block the pain and trauma. This is called dissociation.

Depression can occur in children as young as three years old – they can feel sad or hopeless, or show disinterest in things they used to enjoy. Their sleep patterns and energy levels may change, and some may even self-harm.

How a child’s mental health is affected will depend to a large extent on the support they receive from their caregivers. But this, too, becomes difficult during times of war as normal attachments are frequently disrupted. Some children could lose their caregivers, be separated from them as some members of the family flee and others stay behind to fight, or find that their caregivers are themselves too depressed or anxious or too preoccupied with protecting and finding subsistence for the family to be fully emotionally available.

For children, the detrimental effects of war trauma are not restricted to specific mental health diagnoses but also include a broad and multifaceted set of developmental outcomes that compromise relationships, school performance and general life satisfaction. This is exacerbated by the fact that violent conflict often destroys or significantly damages schools and educational systems. Without the structure offered by schools, children will need the adults in their lives to provide this; we have seen videos online of Ukrainian children in underground bunkers where adults are facilitating lessons and designated playtimes.

It isn’t just loved ones and routines children may be separated from. Many will have to flee their homes at short notice, leaving behind their treasured possessions, such as a specific ‘attachment object’ – usually a favourite blanket or a soft toy. Children often reach for these things when they need to feel safe. But during war, when children are forced to flee and need these objects more than ever, many are left without them.

For many Ukrainian children, leaving their homes will also mean leaving their country. Displaced children, especially refugees, are more vulnerable to experiencing psychological issues. They also encounter additional risk factors and could be exposed to different forms of exploitation.

Studies have shown that children are particularly sensitive to an accumulation of stressors; in fact, there is considerable evidence for a dose‐response relation between the number of stressors experienced by children and their mental health outcomes. For child refugees, the accumulation of stress generally comes from three main contributors:

1. In their native countries, many may have witnessed or experienced violence, torture and the loss of family and friends.
2. The journey to a country of refuge can also be a time of further stress. Refugee children may experience separation from their parents, either by accident or as a strategy to ensure their safety.
3. The final stage of finding respite in another country can be a time of additional difficulty as many have to prove their asylum claims and also try to integrate into a new society. This period is being increasingly referred to as a period of “secondary trauma” to highlight the problems encountered. On arriving, a refugee child will need to settle into a new school and find a peer group. Children might have to prematurely assume adult roles, for example, as a vital language link with the outside world.

Refugee children suffer both from the effects of coming from a war zone and of adjusting to an unfamiliar culture. These stressors also affect their families which in turn has an adverse effect on them. And the longer wars go on, the worse it is for children.

Longitudinal studies, during which children are examined at different points of their lives, tend to show these mental health issues persist over time, while also creating increased susceptibility to other psychological issues. Adolescents with cumulative exposure to war and those with PTSD resulting from war events have been found to have significantly higher rates of substance abuse. Children who have witnessed war and conflict have higher rates of depression and anxiety long into adulthood. Specifically, the prolonged activation of stress hormones in early childhood can reduce neural connections in areas of the brain dedicated to learning and reasoning, affecting children’s abilities to perform later in their lives. In this way, conflict imposes a huge social cost on future generations.

It is crucial that children are quickly integrated into the schools and healthcare systems of the countries they have taken refuge in. They will need emotional and psychological support from cross-cultural teams who can work in an extended outreach manner with children at schools and families at home. There is a need for a variety of different treatments, including individual, family, group and school-based interventions. Schools are uniquely placed to play a vital part in their integration by becoming an anchor, not only for educational but also for social and emotional development, and as an essential link between children, their parents and the local community.

Syria, Yemen, Afghanistan: Children of war

Of course, children are caught up in conflicts in other parts of the world as well.

After more than a decade of conflict in Syria, UNICEF says every child there has been affected by the violence, displacement, severed family ties and lack of access to vital services caused by the massive physical devastation of the war.

Almost 13,000 children have been killed and injured since the beginning of the conflict. Meanwhile, a severe economic crisis, mass displacement, widely devastated public service infrastructure and the COVID-19 pandemic have left 6.5 million children requiring humanitarian assistance.

For many Syrian children, war is all they have ever known, and the perpetual threat of violence and hunger has had profound effects on their mental health. The war has also brought on one of the largest education crises in recent history. As places where children get together with peers, become competent members of society, and find consistent social support, schools can help them cope with trauma. However, Syria’s education facilities are overstretched, and many schools cannot be used because they have been destroyed or damaged or are being used to shelter displaced families or for military purposes. By March 2022, more than three million Syrian children were out of school.

In Yemen, children are also suffering in what can only be described as a humanitarian disaster. At least 10,200 children have been killed or maimed since the war began, thousands have been recruited to fight, and two million are internally displaced. The damage and closure of schools and hospitals have also disrupted access to education and health services, leaving them even more vulnerable. The most urgent crisis in Yemen is hunger. It will come as no surprise that children who are persistently hungry and malnourished have higher incidences of stress, anxiety, depression and even schizophrenia. More than two million Yemeni children are out of school, but even those who still have access to educational facilities will have reduced learning and productivity due to nutritional deficiencies that directly undermine their cognitive capacities and ability to learn.

The children of Afghanistan have witnessed or experienced poverty, malnutrition, violence and death consistently. A large proportion of children in Afghanistan suffer from depression and anxiety but lack access to vital support services to help them. A staggering two-thirds of parents surveyed in parts of Afghanistan said their children were scared of explosions, kidnappings or other forms of extreme violence on their journeys to and from school, according to a 2019 report by Save the Children. And now, secondary schools have been closed to girls.

How to speak to children about the war in Ukraine

For many of us in the rest of the world, the challenges and horrors children and their families face in places of conflict are unimaginable, and our natural reaction is to want to protect our own children from being exposed to the grim reality of what is going on.

But the news cycles have been heavy with updates about Ukraine and with young people talking in playgrounds and having access to social media, many of them will inevitably have seen some of the harrowing images and read some of the stories, and they will ask questions. So what is the best way to speak to children about the war in Ukraine?

Children are good at picking up on the anxieties of adults, so if we are anxious or stressed about what is going on in Ukraine, they will know something is wrong. They have also suffered the stress of two years of living through a pandemic and many of their routines – so crucial for children’s mental health – were disrupted.

The timing may be bad, but age-appropriate honesty is the best policy. Anxiety can manifest itself in a number of ways in children, depending on their age. Younger children may have non-specific tummy aches, difficulty sleeping, show behavioural changes, become clingier and can even wet the bed. Older children may have symptoms similar to adults, showing mood and behavioural changes and becoming more withdrawn and unable to enjoy the things they once did.

Ask children what they already know and whether they have any questions for you. Give them time to talk about how they are feeling and what is worrying them. Validate their feelings by acknowledging them and saying it is okay to feel this way given the circumstances. Do not tell them that you are feeling anxious or worried too; this must be their time and adults must not project their emotions onto them.

Explain what is being done to remedy the situation in Ukraine; that adults are working hard to resolve the conflict. Tell them about all the work that is being done to help refugees, including the charities that are helping to distribute donations and how generous people are being in supporting refugees by inviting them to stay in their homes. Ask them if they would like to do anything to help – they may want to donate some things such as their toys or make a poster about world peace – being proactive may help children deal with some of their anxieties.

It is tough, and you know your children best – some may want lots of information while others may simply want a hug or to play a game to take their mind off things. But do not think of it as a one-off conversation; if your child needs to revisit the topic and talk more, be prepared for this. You are there to listen and it’s important they know this. It is okay for them to feel worried about what is going on, but they are children and need to know it is still okay to play, have fun and enjoy life.

Children have been the innocent victims in so many conflicts. What they see, hear and feel will have long-term consequences for them as they develop into adults. Many organisations are doing what they can to help protect and support children during times of war, but it is hard and, inevitably, many children will suffer. Food, water and disease become issues, all of which hit the most vulnerable the hardest. And even after conflicts end, families are scattered and broken, economies destroyed and neighbourhoods obliterated. Some say there are no easy answers, rather naively I would say there is, to use diplomacy over violence.