Mental health and psychosocial

well-being of children
The insecurity experienced by displaced and refugee children can have damaging physical, social and psychological
consequences affecting their well-being and development. In contexts of forced displacement, parents and caregivers
may have difficulties in caring adequately for their children when livelihoods options have diminished and essential
CHILD PROTECTION ISSUE BRIEF

services are no longer operational. Parental distress greatly affects and impacts the well-being of their children.
Changes in daily life and routine (such as school interruption), sudden and abrupt separation from family, friends and
familiar places, as well as other child protection risks can greatly impact a child’s psychosocial well-being.
All children have the right to protection and care that is necessary for their well-being (the Convention on the Rights
of the Child, art. 3). Children who have been exposed to traumatic events during conflict or displacement or who
are victims of abuse, exploitation, neglect have a right to physical, psychological recovery and social reintegration
in an environment that fosters the health, self-respect and dignity of the child (art. 39). Therefore, it is essential
for UNHCR operations to take actions to preserve and improve the well-being of displaced and refugee children,
by mainstreaming psychosocial support in all aspects of its work as well as implementing specific psychosocial
support programmes. The mitigation of immediate and long-term risks and consequences for the mental health and
psychosocial well-being of individuals, families and communities is a core part of UNHCR’s protection mandate. This
requires strong collaboration between specialists and sectors to ensure a holistic and child-centered response that
fosters the well-being of all children.

“Girls’ and boys’ coping mechanisms and resilience are strengthened and severely
affected children are receiving appropriate support.”
Inter-Agency Minimum Standards for Child Protection in Humanitarian Action, Standard 10.

Key messages
Ü Nearly all children will show some changes in emotion, behaviour, thoughts and social relations in the
short term in humanitarian settings. These reactions, sometimes referred to as ‘distress’, are usually normal.
When access to essential services, family and community support, and security are restored, the majority of
children will regain normal functioning.
Ü While many children may be emotionally affected by what happened, only a minority will develop
psychological disorders. It is not helpful to consider all children ‘traumatized’.
Ü The way services are delivered may positively and negatively influence psychosocial well-being.
Therefore, it is essential to ensure that programmes do not undermine the dignity and resilience of persons of
concern.
Ü Restoring and strengthening family and community support and promoting positive coping mechanisms
for affected children and their families are some of the most important psychosocial interventions.
Ü Providing social, creative, recreational and learning activities is vital in re-establishing children’s sense
of normalcy and routine. Getting children back into school and providing activities in Child Friendly Spaces
are thus important activities and are also useful in identifying children that might need more targeted support.
Ü Some children may need specific psychosocial interventions. However, the services provided should not
stigmatize these children.

This briefing note has been produced by the Child Protection Unit, Division of International Protection and the Public Health Section, Division of
Programme Support and Management, for field operations as a quick reference note on key thematic child protection issues.
Key concepts MHPSS Intervention Pyramid
PSYCHOSOCIAL refers to the two-way relation The intervention pyramid represents the cornerstone of mental
between psychological factors (the way a child feels, health and psychosocial support. It outlines the importance of
thinks and acts) and social factors (related to the differentiating specific layers of interventions and supports adapted
environment or context in which the child lives: the to different groups. Preventive interventions as well as initiatives
family, the community, the state, religion, culture). that restore safety and a sense of normalcy are complementary to
WELL-BEING refers to the condition of holistic clinical support. This multi-layered framework highlights the need
health and the process of achieving this condition. for services to be integrated and holistic. It is not possible for one
Well-being has physical, cognitive, emotional, social agency to implement all levels of the pyramid and all levels might not
and spiritual dimensions. The concept includes be required at all stages of the displacement cycle or emergency.
‘what is good for a child’ such as developing The layers are not mutually exclusive, so a child that receives
emotional bonds with trusted adults, participating in support on layer 4 will also need the supports of layer 3, 2 and 1.
meaningful social roles, feeling happy and hopeful,
having positive social and learning experiences in a The IASC pyramid for mental health and psychosocial support in
supportive environment, developing healthy coping emergencies as adapted in the UNHCR Operational Guidance:
mechanisms, having access to basic necessities and Mental Health & Psychosocial Support Programming for Refugee
feeling safe. Operations.

PROTECTIVE FACTORS are the characteristics

of the child themselves and their environment that

LAYER 4
support that child to cope in difficult situations.
The presence of multiple protective factors will Clinical
MHPSS Interventions
also decrease the risk of a child developing mental Services
health or psychosocial problems and can limit
Focused
LAYER 3

their severity or duration. RISK FACTORS, on the

Psychosocial
other hand, increase the vulnerability of a child to
Supports
developing mental health or psychosocial problems.
RESILIENCE refers to a child’s ability to overcome
LAYER 2

difficulties such as exposure to significant adversity Strenghtening Community

and to positively adapt to change. The balance of and Family Supports
protective and risk factors is likely to significantly
influence a child’s resilience. While the well-being of
LAYER 1

each child needs to be evaluated on an individual Social Considerations MHPSS Approaches

basis, risk factors due to age, gender, and care status in Basic Services and Securiry
frequently impact children’s resilience.

MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT LAYER 4. CLINICAL SERVICES and professional mental health
(MHPSS) describes any type of local or outside support for children under significant distress that disrupts their
support that aims to promote psychosocial well- ability to function on a day-to-day basis. Interventions at this level
being and/or prevent or treat mental disorder. should be undertaken by specialised mental health professionals
PSYCHOSOCIAL SUPPORT includes all processes and the treatment (e.g. counselling or psychotherapy) is often more
and actions that promote the holistic well-being long-term and should not be disrupted. It is done via individual case
including support provided by family, friends and management it is preferable to keep the child on site as long as
the wider community. An MHPSS INTERVENTION proper treatment options are possible.
in child protection refers to a set of activities with
the primary goal of improving the mental health and LAYER 3. FOCUSED PSYCHOSOCIAL SUPPORT is specific
psychosocial well-being of refugee children and assistance provided to children at risk of developing mental
their families. Using an MHPSS APPROACH means disorders. Interventions are not specialised, but should be
providing a humanitarian response in ways that are undertaken by staff with significant training and supervision.
beneficial to the mental health and psychosocial Examples could be support groups, peer-to-peer support
well-being of refugees, especially those most at programmes, and structured sessions aimed at strengthening
risk. It involves participatory approaches, involving resilience.
refugees, including boys and girls, at all stages of the
programme, rather than a pure service-delivery model. LAYER 2. STRENGTHENING FAMILIES’ AND COMMUNITIES’
This is relevant for all actors involved in the protection ABILITY TO SUPPORT children’s learning and development. It is
of and assistance to refugees. important to promote everyday activities such as attending play
and social activities, going to school and options of participation in
traditional and community events. Interventions could include child
friendly spaces, support for family tracing and reunification, and
other family, peer and community support initiatives.
Psychological first aid (PFA) LAYER 1. SOCIAL CONSIDERATIONS IN BASIC SERVICES
AND SECURITY implies ensuring or advocating for basic services
PFA refers to a humane, supportive response to to be functional and accessible to children and their caregivers.
distressed people who have recently been exposed Important activities are re-establishing a sense of safety, ensuring
to a serious crisis and who may need support. With basic services such as water, food and shelter, and access to
appropriate training it can be provided by anyone, by health services for the whole community, including child-friendly
refugees themselves and professional aid workers. information on where to go for help. This should take into account
It has been developed as an evidence informed ‘hard to reach’ categories of children such as adolescent girls,
alternative to unhelpful methods such as Critical younger children and children with disabilities. This work represents
Incident Stress Debriefing. a general approach carried out by all humanitarian workers.
Key actions: What UNHCR Prevention & Response
and partners can do Ü Involve key resource persons in the community in delivering
recreational, social, creative and learning activities for boys
and girls of all ages and abilities. For example, youth groups
Legal & Policy Framework may provide peer support or recreational activities for other
young people as well as younger children, and older persons
ÜW
 ork to ensure that refugee children have access to na- may be able to support traditional activities for children such
tional child protection and mental health services. as story-telling.

ÜB
 e aware of local and national policies and interventions Ü Ensure that outreach is conducted to support the most vul-
on MHPSS, and, where necessary, advocate for these to nerable and marginalised children to attend activities.
reflect international good practice guidelines as reflected Ü Ensure that specific referral pathways and services are in
in the UNHCR operational guidance for Mental Health and place for children who may need specific support, such as
Psychosocial Support Programming in Refugee Operations. survivors of sexual violence and children associated with
armed forces and armed groups.
Ü P romote specific policies to encourage positive practices
for MHPSS for children post-emergency, e.g. that there is Ü Develop specific activities tailored to support the coping
guidance to prevent a focus on individual counselling at the capacities of particular groups of children and caregivers
expense of community-based interventions. as necessary and based on participatory assessment – for
example, adolescent girls, child mothers, parents of children
with disabilities, etc. Ensure that services are provided in a
non-stigmatising manner.
Knowledge & Data
Ü Undertake a mapping of psychosocial resources in the Advocacy & Awareness
community, including community based organizations,
parent-teacher associations, mental health facilities, clinical Ü Disseminate child-friendly information that facilitates
social workers, self-help and support groups, traditional access for children and their caregivers to basic services in
and religious healers, etc. Focus on understanding the order to reduce stress.
people and mechanisms that boys and girls of different
ages turn to when in distress.
Ü Provide information for parents and caregivers about psy-
chosocial distress and how they can support their children.
Ü Analyse existing data from different sectors, such Ü Work with the community, camp management, shelter and
as education, nutrition and health, from an MHPSS
other relevant partners to ensure that the design of facilities
perspective. Share relevant child protection data with
and governance is child-friendly and sensitive to the needs
other sectors in order to support linked-up and targeted
of boys and girls of different abilities.
programming.

Coordination
SEVEN KEY STEPS FOR COMMUNICATING
Ü Ensure UNHCR and partners coordinate with other WITH CHILDREN IN DISTRESS
agencies across sectors (health, education, protection) and
promote an MHPSS approach that is child-sensitive and 1 LET THE CHILD SET THE PACE. Children should
child-friendly. not be forced to discuss or reveal experiences and
the lead should always come from the child.
Ü Support and involve government actors in designing child-
focused psychosocial programmes. Use and strengthen 2 GIVE ADEQUATE TIME TO THE CHILD. Do not
pre-existing services whenever possible. expect the whole story to be revealed in one session.
3 PROVIDE EMOTIONAL SUPPORT AND
ENCOURAGEMENT. Give this to the child in
Human & Financial Capacity whatever ways are appropriate to the child’s
culture and stage of development.
Ü Designing and delivering psychosocial programmes for 4 ACCEPT THE CHILD’S EMOTIONS. Accept all
children requires specific skills. Ensure that staff in this
area have the required qualifications and experience. It emotions, for example guilt or anger - even if they
is a good idea for all UNHCR and partner staff to have seem to you to be illogical reactions to the event.
some training on MHPSS and working with distressed 5 NEVER GIVE FALSE REASSURANCES. Helping
populations, such as Psychological First Aid training. the child to face the reality of her/his situation is
almost always preferable to avoiding it, provided this
Ü Build local and community capacity by hiring and training is done in an atmosphere of trust and support.
community volunteers and staff wherever possible,
ensuring a gender balance. This may require planning 6 TALKING MAY PROVIDE SOLUTIONS. Talking about
for regular trainings, technical supervision and support difficult situations may enable children to work out their
mechanisms for those who are directly in contact with own solution, especially in the case of older children
children in order to maintain and improve skills. and adolescents. Simply listening in an attentive
and supportive way can be extremely helpful.
Ü Train child protection workers, health workers, teachers
and other personnel in contact with children on how to 7 SOME REGRESSION MAY BE NECESSARY. Regression
identify and refer children who may be in need of more is a return to behaviour typical of younger children. Children
specialised support. or adolescents may need personal care, affection and
physical contact more characteristic of younger children, in
Ü Ensure that psychosocial support systems are in place for order to overcome the emotional problems they are facing.
those providing MHPSS interventions.
Adapted from Action for the Rights of the Child
UNHCR in Action: Youth Collective in Kuala Lumpur

Examples from the Field The Youth Collective in Kuala Lumpur was the result of a
brainstorming session with a group of young people from
mixed ethnic backgrounds. They liked the idea of having
Parents support group in Yemen a common platform to voice their views. Together, they
decided on their membership (age 14-25 years), goal and
In the urban setting of Sana’a in Yemen, UNHCR and Educate leadership structure. Consultations among the youths led to
A Child have partnered seeking to enrol out of school children implementation of various activities supported by the office
and retain children in school. As part of this initiative, a support using Social Protection Funds. The activities include social
group for parents and caregivers was established, led by two and creative activities, such as Youth Cultural Night, creative
staff members. The group holds informal sessions during which writing and film-making workshops, and activities to help
caregivers can raise concerns with their peers and discuss young people to better adapt to Kuala Lumpur and to give
while the staff can provide appropriate guidance. The overall them opportunities for the future, such as Cultural Orientation
objective of the support group is to eliminate corporal punish- and Mobile Phone Repair Training. Other activities look
ment at home, to reduce domestic violence and to provide specifically to promote young people’s capacity to reach out
a safe environment that promotes the child’s psychological to and support other youths, such as Peer Support Training
well-being. The project therefore not only improves family sup- and Youth Outreach.
port for children, but as a consequence improves children’s
academic performance and prevents children from dropping
out of school.

Psychological trauma
Child education and welfare centres in Dadaab, Kenya
Historically, humanitarian organisations working on
During an acute emergency related to severe drought in MHPSS often focused on trauma and post-traumatic
Somalia, an international NGO established several “The Desert stress disorder (PTSD) when working with refugee
Flower” Child Education and Welfare Centres. These centres children. However, more recently, specialists and
provided children and adolescents with opportunities to learn, practitioners have determined that it is essential not to
develop and acquire contextually relevant skills and strengthen assume that all refugees and all children in an emergency
their resilience through providing a safe environment in which are traumatized. In the short term most children show
parents can be sure their children will be cared for. The parents some changes in emotions, thoughts, behaviour and
are also provided opportunities to be involved in an active way social relations. The majority of children will regain normal
to increase their participation and self-confidence to protect functioning with access to basic services, security and
and care for children. Facilitating provision of psychosocial family and community-based support. Only a smaller
support and promoting children’s active participation, the number of children showing persistent and more severe
range of activities includes areas of education, art and culture, signs of distress are likely to be suffering from more
life skills, sport and leisure and well-being. severe mental disorders, including post-traumatic stress,
and require focused clinical attention. In general, it is
recommended not to use trauma terminology outside of
a clinical context in order to avoid a focus on traumatic
Baby friendly space in Ethiopia stress disorders at the expense of other mental health and
Psychosocial caring practices and early childhood stimulation psychosocial problems.
are essential for the well-being and physical and mental
development of young children. In Dollo Ado refugee camps in
Ethiopia, Baby Friendly Spaces have been established as part
of the therapeutic and supplementary feeding centres. The
space provides a safe and comfortable place where caretakers For More Information:
and their children can get together and share experiences.
Mother and child play sessions are held, facilitating bonding. è Mental Health and Psychosocial Support Network,
Caretakers with breast-feeding or general feeding difficulties www.mhpss.net
and emotional distress are also provided psychosocial support
è Inter-Agency Standing Committee (IASC) (2007): IASC
by staff. Female staff were trained by UNHCR and partners
Guidelines on Mental Health and Psychosocial Support
to run activities and to train community Infant and Young
in Emergency Settings, available at: http://goo.gl/vYJtl4
Child Feeding counsellors, and community outreach workers.
Pregnant women and caretakers with infants and young è Action for the Rights of Children (ARC) (2009): Foun-
children are referred and welcomed to these spaces. dation module 7, Psychosocial Support, available at:
http://goo.gl/OgHpkA
è UNHCR (2013): Operational Guidance Mental Health &
Clinical referral in Southern Africa Psychosocial Support Programming for Refugee Op-
erations, available at UK: http://goo.gl/FUOD5j
In a Southern African country, a local partner established a FR: http://goo.gl/qDs5oX
collaborative link with a local clinical psychologist who was
è Save the Children (November 2013): Psychological First
experienced in working with children. The partner referred
Aid Training Manual for Child Practitioners, available at
some children with particularly complex problems to the
http://goo.gl/4IbtFS
psychologist who saw the children and their families as
outpatients. Clinical treatment was followed up by mental è WHO, War Trauma Foundation & World Vision Inter-
health and psychosocial support interventions by less national (2011): Psychological first aid: Guide for field
specialized staff in the partner NGO. workers, available at http://goo.gl/oNfyOP

UNHCR Geneva, January 2014