RPN 24 September 1997

7. Promoting psychosocial wellbeing among children affected by armed conflict and displacement

This article is extracted from a working paper written by a group of Save the Children Alliance professionals(1). It is concerned with approaches to the healing process for war-affected children and the characteristics of intervention programmes. The paper presents a number of proposals concerning the need for community-based solutions to problems, genuine participation of affected groups in decision-making and implementation, understanding of and drawing upon local culture, tradition and resources, and avoiding the inappropriate use of western treatment models in non-western countries.

1. Apply a long-term perspective that incorporates the psychosocial wellbeing of children

Emergency assistance conjures up images of material aid such as water and sanitation facilities, food, shelter and health care. Non-material aspects, however, are central to the psychosocial wellbeing of children.Will the way the help is provided tend to create passive receivers or help people to help themselves? One of UNHCR's first actions in response to an emergency is to send out a team of professionals to assess the situation and start up programmes; social workers are now usually part of that team. Their tasks include identifying vulnerable groups and assessing and mobilising resources among the refugees themselves as well as those of local authorities and NGOs.

What is done at this early stage has long-term implications. For example, it is essential to involve women in decisions: it is much more difficult to do it later on and without women's participation children become more at risk. Reconstructing a social web and a sense of community helps refugees act together to improve their lives, and the care and protection of children is usually an area where people can work together.

Psychosocial wellbeing and competence to satisfy material needs are inter-related. Vocational and skills training for young people helps to augment income-earning ability and economic independence and also increases their sense of identity and self-worth.

2. Adopt a community-based approach that encourages self-help and builds on local culture, realities and perceptions of child development

If interventions are to be effective and appropriate, those who make them need to have a more than superficial knowledge and experience of local history, culture, traditions, ways of life and local power structures. More than one western aid organisation in the Rwandan emergency employed local staff to assist and protect children without being aware they were Hutu extremists; to the Rwandan children in their care, this was obvious.

Expatriates need to know basic principles of child development and how it is understood locally, as well as about local culture and practices. What are attitudes toward orphaned children and who has the obligation to care for them? What are attitudes to widows, their rights to remarry and inherit, and how do these affect children? Programme staff involved with psychosocial aspects need knowledge that goes deeper, touching on ceremonies and rites around growing up and becoming adult, about death, burial and mourning, as well as ceremonies to give spiritual and psychological cleansing (for example, for a girl who has been raped or a child who has killed). Integrating modern knowledge of child development and child rights with traditional concepts and practices may take time but is likely to result in more effective and sustainable ways to meet children's needs.

3. Promote normal family and everyday life so as to reinforce a child's natural resilience

Some factors that promote the psychosocial wellbeing of children seem to be universal: safety and security, sympathetic care-givers (preferable one or both parents), familiar routines and tasks (such as schooling), and interaction with other children.

Monitored foster care is usually preferable to an orphanage as it does not separate the child from family and community life, though sometimes older children prefer to live with siblings or others of the same age and sex. Evacuating children from a war zone carries the risk that obvious short-term benefits may be outweighed by the trauma of separation and the negative effects of temporary or permanent loss of contact with their family. In an emergency, family reunification must take priority.(2)

Familiar routines and tasks create a sense of security and purpose. In addition to family routines, organised activities, especially educational ones, are important for children; even without a school building, lessons and play groups can be held and sports and games organised.

4. Focus on primary care and prevention of further harm in the healing of children's psychological wounds

Rebuilding the ability to trust is a task for everyone but especially for those closest to children in their daily life. The most effective way to do this is by establishing good relationships with children, through play, listening, supporting, keeping promises, involving children in real tasks and giving them proper feedback. One of the most important contributions is to help adults in a family re-establish their capacity for good parenting. Assistance to improve self-esteem does not require expensive clinical intervention; a caring environment is what matters.

Interventions that automatically provide individualised trauma therapy and recommend the establishment of residential treatment centres are most often inappropriate, unsustainable and a poor use of resources. They may even inflict further psychological harm on children. Exploring a child's experience of violence and displacement can be important to the process of healing and recovery but should take place in a stable, supportive environment with the participation of care-givers who have a solid and continuing relationship with the child. In-depth clinical interviews may be very harmful, especially if conducted with an unprepared child by a stranger. This kind of interview risks tearing down a vulnerable child's defences; furthermore, talking about intimate feelings and fears with anyone but one's closest family is taboo in many cultures.

5. Provide support as well as training for personnel who care for children

Field staff do not always seem to be aware that their own behaviour and attitudes affect the psychosocial wellbeing of children in their care. Relief and development programmes in war-affected communities often require staff to work under highly stressful and sometimes dangerous conditions. A heavy workload, risk of injury or death, and frequent ethical dilemmas all contribute to high staff turnover. To counteract work pressures, maintain motivation and prevent 'burnout', it is important to involve front-line staff in developing a work plan that provides them with adequate moral and emotional support and guards them against mental and physical exhaustion. Ways to provide this include the following:

- training sessions that make direct use of experiences of the staff and of issues and problems raised by them

- regular changes of scene for locally-hired staff, including visits to family members

- codes of conduct which apply to personnel at all levels and which remind them of the difference in power between themselves and those whom they try to help

- participation in meetings and exchanges with counterparts in programmes elsewhere in order to upgrade skills and analyse lessons learned

6. Ensure clarity on ethical issues in order to protect children

Training in recognising and dealing with ethical issues is crucial; for example, how to protect children from intrusion into their private lives (covered by Article 16 of the Convention on the Rights of the Child). Many ethical dilemmas for field staff concern the protection of individual or small groups of children when, for example, perceiving neglect, abuse or exploitation within the family or community.

Another type of dilemma frequently arises in connection with interviewing children, in particular those in distress. Children who are pressurised into telling, and re-telling, their 'horror stories' to journalists, researchers and sometimes even to aid agency officials and psychologists may suffer secondary distress. Field staff cannot avoid the need to collaborate with researchers and journalists; it is the terms of such collaboration that require clarification. All staff should be aware of procedures to follow (in particular in relation to who is entitled to give permission for an interview to take place) and should ensure that any government guidelines and regulations are followed. As the interests of journalists and aid workers are bound to clash from time to time, clear guidelines such as the following may help:

- Obtain an understanding in advance concerning what information is confidential and must not be used

- Allow an interview only with a child's informed consent (and, where possible, that of a parent or guardian), ensure privacy for it, prepare the child, and have a familiar adult available during and after it. (Some would argue against allowing any interviewing at all of distressed children.)

Once interviewers have obtained material, they tend to consider that it belongs to them; the legitimate interests of the individuals and communities supplying it are not always taken into account. Usually, the resulting article or study is not even shared with them and sometimes they suffer from the way it is interpreted and used. For these reasons, there is need for clear understanding between those who provide information or pictures (children, parents, communities, aid organisations) and those who obtain it (psychologists, researchers, reporters and photographers). In the case of research, who pays for it and for whom is it being undertaken? How will it directly or indirectly benefit those interviewed? How will results and analysis of interviews be fed back to communities and field staff who participated in them?

7. Advocate children's rights

The work of certain NGOs and UN agencies in promoting an optional protocol to the Convention on the Rights of the Child, aimed at raising the age of recruitment to the military from 15 to 18 years, indirectly protects the psychosocial wellbeing of young people. Another advocacy task is to inform children and adults about the Convention and to try to ensure that its provisions are met; this includes protecting children from being lured or coerced into the military.

Article extracted from: Promoting psychosocial well-being among children affected by armed conflict and displacement: principles and approaches, International Save the Children Alliance, Working group on children affected by armed conflict and displacement. 1996. 14pp. Available from: Save the Children, 54 Wilton Road, Westport CT 06880, USA. Tel: +1 203 221 4000. Fax: +1 203 227 5667. or from: International Save the Children Alliance, 59 chemin Moise Duboule, CH 1209 Geneva, Switzerland. Tel: +41 22 788153. Fax: +41 22 788154. E-mail: alliance@iprolink.ch

1. Contributors: Kirk Felsman, Birgitta Gälldin-Äberg, Elizabeth Jareg, Naomi Richman, Hirut Tefferi and David Tolfree.

2. See article by Ulla Blomqvist - article number 6.

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October 1997