PICKING UP THE PIECES

Rebuilding the lives of Mosul’s children after years of conflict and violence PICKING UP THE PIECES

Rebuilding the lives of Mosul’s children after years of conflict and violence

“I wake up and I witness war every day. I don’t want to go through another war.” Rahaf, 10-year-old girl, west Mosul Cover: Fahad, 12, outside his school in west Mosul, which was extensively damaged during fighting between Iraqi forces and ISIS (Photo: Sam Tarling/Save the Children) Back cover: Aya, 7, at her uncle’s house in west Mosul, where she has been living since her mother was killed in an airstrike (Photo: Sam Tarling/Save the Children)

Acknowledgements This report was written by Eileen McCarthy and Yousra Semmache with support from Dr Marcia Brophy, Amanda Brydon, Misty Buswell and Simona Sikimic from Save the Children. The research and analysis was led by Dr Marcia Brophy, with support from Rana B. Khoury. We are grateful to colleagues from Save the Children’s Iraq Country Office and Ninewa Field Office for their inputs and for facilitating the field research. Save the Children would like to thank the Danish International Development Agency (DANIDA), the UK Department for International Development (DFID) and the Office of US Foreign Disaster Assistance (OFDA) for their support in the development of this key report and its dissemination. In particular, we want to express our sincere appreciation to the 252 children and adults from Mosul in Iraq who participated in this study and whose voices are reflected in this report.

To protect the identities of those who participated in the research, all names have been changed and specific locations withheld.

Published by Save the Children savethechildren.net

First published 2018

© Save the Children 2018

This publication may be used free of charge for the purposes of advocacy, campaigning, education and research, provided that the source is acknowledged in full.

Design: GrasshopperDesign.net Contents

Executive summary 4

Methodology 7

A year of never-ending sorrow 8 Ongoing sadness 8 Children at risk from cumulative stress 9 Lasting sense of insecurity 10 No one to turn to 12 Attempting to cope 16

Putting children’s recovery at the heart of Iraq’s reconstruction 18 Addressing children’s emotional distress 18 Ensuring children feel safe 19 Creating a protective family environment 20 Rebuilding Mosul’s sense of community 21 Instilling hope 22

Recommendations 24

Notes 26 Executive summary

AN IMPOSSIBLE WAR TO FORGET wellbeing. It found that children and families were living in constant fear for their lives and that 90 per Life for millions of children in Iraq was turned upside cent had lost a loved one. Children interviewed at down in 2014 as the Islamic State in Iraq and Syria the time displayed clear signs of ‘toxic stress’ – the (ISIS) began a rapid advance that saw waves of most dangerous form of stress response. They violence escalate across much of the country. In suffered vivid waking nightmares and were left the onslaught that ensued, over 5 million people – numb, unable to display emotions. half of them children – were displaced.1 During In the intervening year, since Mosul was recaptured the years of brutal ISIS rule, Iraqi children were by the Iraqi government, there have been a number subjected to some of the most heinous violations of developments. The government’s counteroffensive of their rights imaginable. ended in December 2017 and since then across the For many civilians the subsequent fight to retake country more than 3.7 million people have returned control brought more suffering. Homes and to their homes, including more than 785,000 people whole communities were destroyed or uprooted to Mosul.4 in the fighting and countless children and families Nevertheless, staggeringly difficult challenges were injured. remain. Millions of children are retracing their A year after ISIS was expelled from Mosul, the steps to their old homes – which are often trauma of war lives on. Children are constantly uninhabitable. Children have told us of returning reminded of the past horrors they experienced to find dead bodies littering the streets, schools and still face constant danger from mines and damaged and destroyed, and limited access to unexploded ordnances, which continue to kill, safe drinking water and electricity. In Mosul alone, maim and terrorise on a regular basis. Many some 8,500 homes are damaged, affecting up to are struggling to return to school after years 25,000 children and adolescents.5 The situation is without education. particularly dismal in west Mosul, where 38 out of 54 residential neighbourhoods were moderately Iraq’s population is comprised mostly of children or heavily damaged,6 and where 73 per cent of and young people, with nearly 60 per cent under households reported living in damaged shelters.7 As the age of 25.2 And it is this group who are often the offensive closed around the city, public services the worst affected psychologically by the fighting. were cut or destroyed and have been slow to Only by supporting their resilience and safeguarding restart. Half of all schools in conflict-affected areas their mental health and psychosocial wellbeing can have been destroyed and children are struggling to communities truly move forward, securing a more resume their education or to catch up after missing positive future for their country. years of school.8 To understand the unique sets of challenges Our new research, conducted in May 2018 Iraqi children face, in July 2017 Save the Children in communities that have returned to west published An Unbearable Reality, a report looking at Mosul, found that the impact of this multi-stress the impact of war and displacement on children’s environment on children has been profound. mental health.3 It was the first study of its kind Children have not only had to live through war, conducted in Iraq since conflict broke out in 2014 but have returned to new challenges that remind and highlighted how the traumatic experiences them daily of their past traumatic experiences. children have faced in the last four years have had a massive impact on their mental health and

4 EXECUTIVE SUMMARY 5 the main of stress. source More than 73 per cent of households reported challengesin gaining employment and 90 per cent reported debt. More than 80 per cent that said worry caused them to sleeplose per and 87 cent that they feel constantly under strain. Almost per cent 70 felt unable to enjoy normal day-to-day activities, 72 per cent reported feeling unhappy or depressed, and more than 90 per cent reported feelings of worthlessness. The support received from a caregiver is a key mentalindicator health a child’s for and wellbeing and can often the make difference between child a being able to cope or further deterioration of their mental health. A widespread breakdown of community ties caused by the means war that caregivers lost have a key of support,source which is hindering their ability – abilityand therefore in – to their recover children’s the longer term. While children did report turning to their own coping methods – such as trying to forget, not speaking about their problems and withdrawing from other people – these strategieswholly are insufficient cannot and compensate for the kind of support children need from friends, relatives and the wider community. WE MUST NOW ACT sense of safetyUnless is re-established, children’s and parents given better tools to helpthemselves and their stress families, management children’s system will remain activated, leaving them at serious risk of further and long-lasting mental health issues. It is therefore essential that urgently we address the issue of unexploded ordnances and speed up the process of mine clearance and reconstruction to ensure that children can once again feel safe walking around their must city. own also quickly make We schools safe spaces children for to begin to heal and learn again. Furthermore, the emotional distress that children experiencingare must be addressed through gentle approaches to help them through work their grief. Programming that places the needs of children at the centre of reconstruction efforts must be introduced and psychosocial support and counselling expanded to support children and adolescents in Caregiversclearly are burdened with their own problems. Almost 30 per cent they said felt stressed about their inability to basic meet their children’s needs while 82 per cent cited lack of money, work opportunities and poor economic conditions as This clear disconnect is to likely be caused by caregivers’ inability to support provide and children not feeling able to talk to their families about their distress. This is in sharp contrast to what their caregivers felt was going on, with only 3 per cent of parents saying that their children did not feel safe in school and cent saying18 per that their children to afraid were be from their away parents. Nearly one-third of adolescents reported never feeling safe at school, and only one-quarter consider school a safe space. The lack of safety that many girls and boys continue to feel is to likely be fuelling their inability to heal and driving is a key their for force worries. More than 80 per cent to of adolescents aged 13 that said they did not feel17 safe walking alone and almost 50 per cent did not feel from safe away their parents. Under such stressful situations, children might be expected to exhibit signs of behavioural distress like hyperactivity and aggression that clear are markers the children spoke we acutefor stress. However, with displaying were symptoms associated with accumulative stress – a type of stress response that is created time when over children exposed are to traumatic experiences and then not given the space and whento recover they continue to be exposed daily to sources of stress. Children signs showed of emotional distress, sadness, depressionrepresented feelings in and like anxiety. This suggests that they internalising are their issues and letting things build up on the inside. Girls on the whole tended to internalise their issues more than boys. Childrenthey said experiencing were intense sorrow and extreme sadness, with nearly 43 per cent reporting feeling grief always or lot a of the time. More than a quarter of adolescents reported never liking per who cent they they said and only are 12 themselveslike a little. Only 9 per cent could think of something happy relating to their present and future, such as a school achievement. 6 PICKING UP THE PIECES include making use of technology. technology. of use making include that innovativenew provide and support to ways explore to need may providers service and agencies people, young and children reach to order In the family. within violence and concentration, and sleep with problems –including families and individuals have on they effects the and anxiety, stress and with deal to able better be will caregivers and children counselling, as such approaches Through emotions. heightened their reducing and stabilising of new classrooms. construction the and training teacher classes, catch-up education, non-formal activities, Development Care and Childhood Early deliver we programming, education our of part As programmes. (WASH) promotion hygiene and water, of provision the and education, sanitation, activities, (PSS) support psychosocial including programmingthrough in child protection, andimmediate needs, ongoing delivery service meet to response arapid delivering on focuses al-Din) Salah and Ninewa Kirkuk, Dohuk, (Diyala, governorates five in displacement and 1991. conflict since to response current Our Iraq in working been has Children the Save IRAQ IN SAVE CHILDREN THE 87,525 children. 87,525 including Iraq, in refugees Syrian 165,009 reached 2013, Since we have also displacement. and conflict by affected children 576,348 including people, displaced internally 768,464 reached has response 2014, countrywide our February Since PSS. of provision the in staff field our support to specialist (MHPSS) Support Psychosocial and Health a Mental recruited has Children the Save addition, In schemes. youth and knowledge critical building communities, their in factors protective and risks identifying and learning workshops, of aseries through 10–20-year-olds work with that interventions PSS structured of up made is programme resilience youth and child Our horrors they have experienced. have experienced. they horrors overcome eventually to the them support better can government Iraqi the and donors agencies, how and humanitarian families, their and children affect to continue will experiences how traumatic assess to we working keep that important is It future. asustainable build to seek that for strategies are cornerstones wellbeing psychosocial and health overlooked, mental often While Iraq. rehabilitate and rebuild to plans any of centre and front the at placed be must –children clear remains thing One Methodology

One year after Mosul was retaken, Save the Children interviewed a group of children and caregivers in west Mosul who had been affected by conflict and displacement to further investigate the impact of the violence on their mental health and psychosocial wellbeing and better understand the needs and solutions for children in the current stabilisation, reconstruction and recovery context. In May 2018, Save the Children interviewed grounding12 techniques to keep a person in the 252 children and caregivers living in west Mosul. present moment. The team obtained the informed The research consisted of a quantitative and consent of all participants (in addition to obtaining qualitative analysis of standard mental health children’s consent, parents provided consent for and psychosocial support questionnaires given their children to participate) and were able to to 138 children aged 13 to 17 years (82 boys refer any cases with high levels of mental health and 56 girls)9 and 114 caregivers (49 women and distress or psychosocial support needs to specialised 65 men).10 mental health services. The participants interviewed for this report were While the findings of this report are indicative randomly selected among school-aged children of the experiences of the children and caregivers and among adults with children in their care who interviewed as part of the assessment, the were supported by Save the Children programmes conclusions drawn are representative of adolescents in west Mosul. Prior to the research, in order to currently living in west Mosul. However, further ensure the safety and protection of participants, research would be required to understand the the Save the Children field team received training needs and appropriate programmatic response for to administer the mental health questionnaires. younger children and those in other areas of Iraq. The training included Psychological First Aid (PFA),11 Additional research that continuously tracks and non-intrusive techniques to reduce stress, how to monitors children’s mental health over time would support individuals in distress and how to use simple also be useful.

7 A year of never-ending sorrow

“When I remember what happened, I get sad. I remember my mother and father and how I was happy. I was with them, but I have lost them.” Rahaf, 10-year-old girl, west Mosul

ONGOING SADNESS Keeping it all in

The research conducted with children and Compared with their emotional health, caregivers in west Mosul clearly shows that a adolescents – particularly girls – scored themselves year after ISIS was officially pushed out of the in the normal range for conduct, hyperactivity and city conflict and displacement continue to attention problems. They spoke of struggling with severely affect children’s mental health and their emotions, rather than with their behaviour. psychosocial wellbeing. “She suffered a lot as a result … Her whole family Children rated themselves with high levels of got buried in front of her eyes.” emotional problems, with scores indicating Abdullah, 35, taking care of his orphaned borderline mental health issues (17.5 out of 40). niece, Rahaf, west Mosul Children experience intense sorrow and extreme These differences in emotional, social and sadness with nearly 43 per cent of children behavioural issues show that children are reporting feeling grief always or a lot of the time. internalising their problems, which then manifest Caregivers reported their children as having very as depression, withdrawal, anxiety and loneliness.15 high emotional and behavioural difficulties, with This behaviour can have detrimental effects, such a score falling in the ‘abnormal’ range, which is as poor self-esteem, suicidal behaviour, decreased indicative of likely mental health disorders. They academic progress, and social withdrawal,16 and can also reflected that 66 per cent of their children cause problems to grow into larger burdens with displayed grief most of the time. the symptoms just mentioned or other unexplained Children interviewed for Save the Children’s 2017 physical responses.17 report who had been recently displaced from Mosul Further, 26 per cent of adolescents report 13 and were living in Hammam al Alil IDP camp never liking who they are and 12 per cent only reported similar feelings of sorry and grief. Around liking themselves a little. These children are at 90 per cent said they felt upset due to the loss of a the greatest risk of self-harm and will require relative and 45 per cent shared lengthy stories of specialised support.18 violence and the deaths of loved ones.14

8 A YEAR OF NEVER-ENDING SORROW 9

20 and 19

21 Rahaf, 10, with her uncle, Abdullah, who has been looking after her since herparents were killed (Photo: Sam Tarling/Save the Children) increase in bedwetting – both signs of an acute response to stress. This contrasts with Save the study in Syria per 2016 where cent of 71 Children’s children reported an increase in bedwetting, These findingsillustrate the differences between acute and cumulative stress – with children responding to the accumulation of extremely Similarly, caregivers and adolescents in Mosul both report that currently per cent around of 10 children many nightmareshave a lot or always. In 2017, recently displaced children in Hammam Alil al said that they experienced hauntingly vivid nightmares that lasted throughout the day. 48 per cent of adults had seen children who lost the speech impediments. developed to speakability or Dina, years 12 old, west Mosul “When I felt a bit better retaken], was [Mosul and my life changed but the fear is still there.” Results from the recent study indicate that, although still worrying, the distress children currently are experiencing in Mosul does not characterise an acute response to stress caused by a new situation such as bombing and rapid displacement. As compared high of with levels the children’s emotional distress, 25 per cent of caregivers reported that their children lost have the ability to speak and per 23 cent that there had been a recent CHILDREN AT RISK CHILDREN FROM AT CUMULATIVE STRESS 10 PICKING UP THE PIECES specialised interventions across various sectors – sectors various across interventions specialised provide then and stress of sources daily address first should approach This needed. is status health mental to stressors daily and war exposure both of relationship the have examined that studies recent of findings the on drawing approach integrated needs. health mental profound and develop serious likely to are more they support, physical and emotional adequate given are not and adversity, cumulative face boys and girls where like this, situations In (36%). services public of (36%) lack the and (56%), looted or displacement destroyed homes their finding (72%), schooling of lack the by affected are Mosul in children of lives daily the that report Caregivers events. stressful daily experiencing as well as have through, lived they what of reminders constant are now faced with they events, these from fully heal to time the had having Without extreme violence. experienced and group armed aterrifying of control the under were live forced for years to Many loved lost and ones. destruction devastating have Iraq in witnessed children years, four last the In event. traumatic sudden or unexpected an to than rather over years events the stressful and health consequences if left unaddressed. left if consequences health and life events produce negative functional psychological, impacted militarily and in terms of services.” of services.” terms in and militarily impacted were areas of the most and operations, military of the because destroyed were houses their school, left kids because regressed have levels “Children’s educational badly affected.” psychologically were Children explosives. and explosions the bombing, the shelling, the due to is This before. knew they It’s school noplace. longer the this alot in witnessed They crying. started school to came they when of them Some psychologically. affected badly very were they so bodies the saw They killings. the witnessed they and present [children] they were started, problems the “When died instantly. My baby girl saw it all.” it saw girl baby My instantly. died her, hit door the had When she fallen her on face. door iron The ground. the on wife my Isaw I returned when and things some buy to shop the to went “I 23 Moderate and major negative cumulative a mortar shell hit their home in west Mosul west in home their hit shell a mortar Faisal, father of two whose wife died when when died wife whose two of father Faisal, Omar, 50, father living in west Mosul west in living father Omar, 50, Awad, 47, teacher, west Mosul 47, west Awad, teacher, 22 24 An An

damaged, the majority in west Mosul. west in majority the damaged, been had 69 showed schools that assessment Cluster Education an offensive, the of end the By their physical and psychological health. psychological and physical their protecting in factor important an on out are missing they that means also this safe, feel not do they that indicating well as As sometimes. to alittle sleeping difficulty having –report girls (66%) particular –in children of majority The parents. away fromtheir safe feel cent per 54 only and alone walking when are afraid cent 83 per home, at safe feel adolescents most While safe. feel not do still children ayear ago, ended Mosul on offensive the Although LASTING SENSE OF INSECURITY Airwars offensive. Mosul the during attacks of target the were and parties various by militarily used also were Schools content. violent with a curriculum introduced which over were taken ISIS, by they that Mosul’s is safe consider to schools difficult it find children so many why reason One space. a safe school consider one-quarter only and school, at safe never feeling report children of one-third Nearly has been rebuilt. been has community their even reduce when not does distress whose children support to broadly more community the through and education – and health including reminded of the violence that took the lives of so of lives the took that violence the of reminded are constantly bombing of marks showing still or bullets with riddled classrooms and unsafe physically are that buildings damaged in school to back going schools in Mosul in the first four months of 2017.of months four first the in Mosul in schools be rebuilt.” be rebuilt.” to We school for the ask afrontline. became street whole The afrontline. became area the and hit badly got school The family. whole the would shoot he them, rescue to came fathers and mothers the when that so children the targeted sniper the area, this In class. the Idon’t in damaged. good are feel walls the and no doors has now in it Iam class “The means the fear of war is still present within her.” within present still of war fear is the means you.’ from It separated be Iwill and again happen her father, to says ‘don’t will something me, leave She shock. from suffering now been has she “Until 25 and the UN reported 18 attacks on on 18 attacks reported UN the and Amani, case worker in west Mosul speaking about about speaking Mosul west in worker case Amani, 6-year-old Thani who saw her mother die when when die mother her saw who Thani 6-year-old a mortar shell hit her home in west Mosul west in home her hit shell a mortar Fahad, 12, west Mosul west 12, Fahad, 27 Children Children 26

A YEAR OF NEVER-ENDING SORROW 11 term ‑ 29 stress management system remains activated. All children experience fears during childhood, such as fear of the dark, monsters, and strangers. These fears normal are aspects of development and are temporary in nature. In contrast, threatening circumstances that persistently elicit fear and anxiety predict significant riskadverse of long outcomes from which children do not easily recover. Studies that show experiences exposure like to violence that cause fear and chronic anxiety in children triggerextreme, prolonged activation ofthe stress-system Thus, system. response stress body’s can significantlyoverload ability diminish a child’s to learn and engage in typical social interactions across their lifespan. These experiences cause changes in brain activity been and have shown to long-term,have adverse consequences learning, for behaviour and health.

28 Thani, 6, rides with her father on his cart, from which he sells livestock feed (Photo: Sam Tarling/ Save the Children) Safety has notyet been fullyrestored in many areas of Iraq,including those that children and their families returning are to. Ongoing violence, booby traps, unexploded ordnance and other explosive remnants pervasive are of war and continue to pose dangers to children. In a recent Save the Children study across the Middle East, children and caregivers in Iraq, alongside their counterparts across the region, prioritise safety and security. many of their friends and teachers. Schools may also be unsafe due to violence in and on the to way school. Stress teachers could make moreprone to use corporal per cent punishmentof young and 74 people reported having been on, picked harassed or intimidated their in neighbourhood. Feeling safe in their environment is an important contributing psychological factor to children’s health. When children do not feel safe, their body’s 12 PICKING UP THE PIECES away from parents/at alone school/walking home/ at safe felt children whether asked when ‘never’ responded who caregivers of percentage Caregivers: alone school/walking parents/at from away home/ at safe felt they whether asked when ‘never’ responded who adolescents of percentage Youth: of safety in their neighbourhood could be because because be could neighbourhood their in safety of lack the about parents among awareness of lack main hazard in their environment. their in hazard main the war of as remnants explosive and landmines reported key of informants cent 75 and per children of cent per 90 Mosul, west in Children the Save by conducted assessment needs arapid In city. the of were forced out they when ISIS by behind left traps incidents that had happened in the area. the in happened had that incidents were aware not security cent of per 88 and safe felt they that reported overwhelmingly adults place, took research this where neighbourhoods the In school. at and caregivers away their from safety of sense adolescents’ in apparent particularly is This home. their children’s outside safety of sense however,Parents, their greatly overestimate Mosul in strikes 1,250 than more out carried forces Coalition and Iraqi the that fact the to related be may which explosions, of sound like the noises loud of fearful remain children that They and report ongoing nervousness. fearfulness children’s report cent per 80 and children, their and themselves on displacement and conflict of impact amajor report 93caregivers of cent per Similarly, FIGURE 1: PERCEIVED LACK OF SAFETY FOR CHILDREN FOR SAFETY OF LACK 1: PERCEIVED FIGURE Youth 40 45 30 20 25 50 35 10 15 0 5 Caregivers At home 30 31 and to the booby booby the to and Away from parents from Away 32 This This children need. need. children their care and that support necessary provide the to able are less they children’s safety, of perception aware fully their are of not caregivers If fears. their discuss to parents their to turning are not children are sad upset. or they when to go aplace or to to talk to someone have they feel not do majority overwhelming the parents, and siblings friends, their to connectedness and belonging of have asense children While their friends. well with along getting cent per 65 and sisters and brothers their by 74 per helped feeling cent take care them, of to are able parents their that believing cent per 65 with family, their to connected well feeling report Mosul west in boys and Girls TO TO ONE NO TURN children’s mental health. for factor protective important are an to talk to someone having as such factors Social problems. emotional around scores high their considering At school 33 This is particularly worrying worrying particularly is This Walking alone 34 A YEAR OF NEVER-ENDING SORROW 13 As 38 Afaf, mother, west 41, Mosul Hadeel, 30, mother, west Mosul 37 severe and prolonged violence severe and 39, 40 “This has affected as me well, psychologically… a nervous I was retaken], was when [Mosul Even wreck. stand anybody I couldn’t any or noises. If I heard planes, get scared. I would scared I was of everything.” “Families lost all they owned during the bombing. childrenNow need a great deal support of but the parents are to unable provide it.” A key protectiveA key factor ensuring for children’s mental health is their parents’ presence and ability to support them. When parents stressed, are and less able to a safe and protective provide space, their children at greater are risk of developing mental health disorders, such as depression, anxiety, stress. post-traumatic and The ongoing stress and anxiety that children in Mosul facing are puts them at risk of toxic stress. This can occur when children experience continuing adversity without adequatesupport, and has long-term effects and severe on their mental and physical health, as as well affecting their cognitive, development. physical and socioemotional previously identifiedresearch in Save the Children’s mental healthinto children’s and wellbeing in Syria and Iraq, adversity experienced by children in their young lives that has not been adequately addressed may long-lasting effects and have development their on their mental and physical health the for rest of their lives. caregivers’ poor mental health andMoreover, difficulty in managing theirrole as parents may translate into domestic violence. When asked about exposure to violence,children’s caregivers reported physical violence abuse (73%), and at discord home emotionaland school (59%), abuse and neglect and societal violence (54%), (27%). Parents, especially mothers, themselves are not finding support to help themcope with the difficulties they facing. are While 60 percent of parents attendschool meetings, overwhelmingly these male caregivers are (78%). Only one-fifth of caregivers find informationsessions at health clinics useful and meetings with religious leaders not are

36 Afaf, mother, west 41, Mosul Yasser, 38,Yasser, father,west Mosul and therefore suggesting a risk of mental 35 “We stayed No electricity, six days in a cellar. no Then, atfood the and water. no end, an aeroplane hit the building where were we and destroyed it; of half it got buried fell on us. in the We cellar.” “Every time Rima remembers mum, her she makes upset.me She cries, wanting her.“ health issues. Around 44 per cent of caregivers report psychological stress and anxiety within the family as the biggest sources of distress, 82 per cent report losing sleep worry per and 87 cent over feel constantly under strain. More than two-thirds feel less(69%) able to enjoy normal day-to-day activities and 72 per cent report feeling unhappy or confidence report lost also They depressed. having in themselves and almost a feeling have all (65%) of worthlessness (91%). Caregivers themselves lived through have the their alongside displacement and conflict of horrors children stressed and now are about their family’s opportunities, livelihood and situation economic and their ability to meet the needs of their family. They told us they feel stressed by their inability to basic needsmeet with (27%), children’s 82 per cent reporting lack of money, opportunities work and poor economic conditions as the main of source stress. In an assessment of the Al Jadida municipality by REACH in May 2018, 73 per cent of households reported challenges with gaining employment and 90 per cent reported debt, with debt an average of nearly 4 million IQD (US$3,376). Children indicated have that they do not feel comfortable talking to their families when they feel sad. This may be because their parents and siblings already are distressed themselves. Overall, caregivers reported poorly on their mental health and also display high of mental levels health distress that require urgent support. Both male and female caregivers struggling, are with male and female caregivers scoring of 12) 5.23(out their for general health, of 12) caregivers (out 6.71 significantly the above normal threshold(3 out of 12) Caregivers under stress under Caregivers 14 PICKING UP THE PIECES remain under house arrest during ISIS occupation. occupation. ISIS during arrest house remain under were and forced to homes their leaving feared also fathers and mothers Many displaced. repeatedly being families and control, ISIS under living while homes their in kept and school of out taken being children with networks, community and peer on had has displacement and conflict that impact the of result the be may This friends. their to go can they that feel cent per 66 only and community their in supported feel not do children of particular, cent In per 73 emotions. and experiences their workthrough and identify to them to turn to able seem not do Mosul west in interviewed children the but children, to support providing in are important community and Friends communities Broken ISIS. under war life and years of have after broken down community the within networks support traditional because be could This opportunity. an as them reporting cent 1 per than less with information, and a source support of my neighbourhood.” in space Children’s the child-friendly Save to going to addition in home, at parents my with be and friends my “To with play to better, Itry feel Percentage of caregivers who reported on forms of violence that children are exposed to in their community their in to exposed are children that violence of forms on reported who caregivers of Percentage FIGURE 2: REPORTED FORMS OF VIOLENCE OF FORMS REPORTED 2: FIGURE Emotional abuse and neglect and abuse Emotional Abuse at home and school and home at Abuse Physical violence Societal violence Societal

0 Saleh, 15, west Mosul 15, west Saleh, 10 20 27% Percentage of caregivers 30 homogenous having suffered inter-sectarian violence violence inter-sectarian suffered having homogenous more are generally which selected, neighbourhoods the to related be may This sometimes. or a little only tensions reported cent per 46 additional an and family, another with fight family their never seen over (51%) half Just communities. their had within tensions social high report not do research for this however, noting, interviewed worth is children It that members. community and age their children with relationships build to opportunities have limited labour, child in engaged or school of children out still children many and in play to spaces safe Without outside. played said they one-third and friends with time spending reported children of one-quarter only activities, after-school and weekend their about asked When disintegrate. to have continued which networks, these to rebuild difficult it made has The continuing challenging living situation in Mosul through displacement. through displacement. were broken networks kinship wider and Friendship a sin. They didn’t They allow out.” go me to a sin. me of committing accused ISIS out. go allowed to Iwasn’t Ididn’t school. to go didn’t friends. any have house and Ididn’t of the home. out go at staying bored Igot years. for three of school was out “I 40 60 50 54% 59% 73% 70 80 Dina, 12, west Mosul west 12, Dina, A YEAR OF NEVER-ENDING SORROW 15 44 sectarian violence before ISIS even took ‑ children but communities in Mosul had experienced inter control in 2014. control in 2014. The fact that these social and cultural ties within the community down broken can also have be an indication that children,their families and the wider community experiencing are a collective trauma. Collectiveevents and consequences may more have significance in collectivistic communities Iraq like than in individualistic societies the like US and UK. The cumulative effect these of all devastating events on the community can be described as collective trauma. In addition to the sum-total of individual traumatic experiences, which can in themselves be substantial, there effects are at the family, community and social that levels produce systemic changes in social dynamics, processes, structures and functioning. In fact, the psychosocial reactions in the individual may come have to be accepted as a normal part of life. In the future, emerging 41 Historically in the 43 42 Dina, 12, at home with her aunt, Afaf, in west Mosul (Photo: Sam Tarling/Save the Children) tensions around limited livelihood opportunities limitedtensions livelihood around as a result of having no connections, local and the perception that a primary barrier to receiving humanitarian is aid other households who are not in need still receiving assistance, may affect social cohesion. In a 2017 Save the Children study inIn Egypt, a 2017 Iraq, adolescentsJordan across and the Yemen, region reported that conflict and violence hasalso permeated into their communities and family units, including through incidents of community and domestic violence. prior to 2014 that displacedprior to many 2014 minority groups. Additionally, the ongoing presence of security with restrictions movement along on – personnel as a result ofroadblocks and checkpoints, damage, and the needto government-issued provide identification – may be limiting violence conflict and caused by tensions. social region, wider networks of community trust and oversight enabled a protective environment for 16 PICKING UP THE PIECES their problems. accept to decided or down, themselves calm to tried angry, became and screamed problems, their about speak not and silent remain to chose forget, to tried they experience adifficult with confronted were they when that reported adolescents of majority overwhelming the asked, When distress. emotional their with cope to strategies of arange are trying they that shows research our them, support to community their or friends family, to turn cannot like they feeling children With TOATTEMPTING COPE differences, with girls more often withdrawing withdrawing often more girls with differences, (Photo: Sam Tarling/Save the Children) the Tarling/Save Sam (Photo: 2018 in ISIS and forces Iraqi between fighting during damaged extensively was which Mosul, west in aschool at teaches Awad 45 There were some notable gender gender notable were some There among adolescents in their community. community. their in adolescents among attempts (29%) suicide (39%) and self-harm drug use, alcoholcoping and mechanisms, reported and negative extreme, more to resort adolescents that us –told fathers particular –in Caregivers in thebetter long term. feel them making in useful provenhas particularly strategies these of none children, the According to problems. for their others blamed and played or phones their on things watched often more boys and anxious less feel to praying tried often more also Girls problem. solve to their answers of think to trying and side, positive the on look to trying people, away and other from alone staying and A YEAR OF NEVER-ENDING SORROW 17 8070 50 60 40 at school and among their communities and cared byfor their families and friends. this research shows that children’s However, resilience is not helping to reduce their current high of emotionallevels distress and that these children need additional support that will be essential to safeguard them from further mental health distress and psychosocial harm. With almost 60 per cent of its population under the age of 25, Iraq is a country of children and young people. But, without urgent, targeted action to ensure that they can access the mental health and psychosocial support they need, it risks not being a country children. for Deliberate, targeted and specialised action by authorities at the local, national and international the can provide platformlevel children for and communities to heal themselves and rebuild their futures – providing hope and working to break a cycle of conflictfor generations come.to 30 Percentage of respondents of Percentage 20 10 0

Praying or playing or Girls Staying alone Staying Children’s resilience in the of face Children’s Blaming othersBlaming 46 Boys Boys Trying to solve problems Watching things on mobile mobile on things Watching FIGURE 3: COPING STRATEGIES COPING 3: FIGURE Percentages of boys and girls responding ‘yes’ when asked if they used ‘praying’; ‘trying to solve problems’; ‘blaming others’; ‘lookingat the positive ‘staying side’; alone’; and ‘watching thingson mobile or playing’ to cope with recent a experience difficult very Looking at the positive side The fact that the vast majority of children trying are to find positiveways copingof shows that they not givenhave up. The research also shows that, despite the high of emotional levels distress that adolescents exhibiting, are they report high scores on resilience. extreme, difficult or traumatic situations is drawn from various parts of their lives – personal skills, aspects. Adolescents cultural and spiritual education, report on a high what score personal skills they can draw on – their inner resilience (7 and out of 10) their social skills with out of8), (6 girls reporting higher than boys. Adolescents, particularly girls, on their out of 14) also reported high scores (11 relationships with their caregivers and how supported, safe and secure they feel physically and psychologically. Caregivers also report positively resilience; theyon their note children’s that their children models role have and invested are in doing at school,well problems and can solve without mechanisms. They coping resorting negative to report that their childrenfeel a sense of belonging Putting children’s recovery at the heart of Iraq’s reconstruction

Discussions on the strategy, planning and implementation of Iraq’s reconstruction have been taking place in multilateral forums, both at international and regional levels, as well as within the country itself. In February 2018, the Kuwaiti government hosted a conference on the stabilisation and recovery of Mosul but received pledges for only US$30 billion of the $88 billion Baghdad says it needs to recover from three years of war.47 The mental health and psychosocial needs of children gender-appropriate programming that places the in Mosul and across Iraq will require targeted and needs of children at the centre of reconstruction contextualised, short- and long-term approaches efforts will be essential to meet the needs of girls and to support children and young people, parents, boys and ensure long-term stability and peace. This peer networks and communities. In a 2007 article may mean supporting children to acknowledge and by Stevan Hobfoll and a team of international come to terms with the emotional distress they are experts,48 the authors synthesised available scientific experiencing and giving them a safe place to work evidence and distinguished five essential principles of though their high emotions. Through counselling psychosocial care to people confronted with disaster, and case management approaches, children and tragedy, and loss. These are, the promotion of: (1) a caregivers are and can be supported to deal with sense of safety, (2) calming, (3) self- and community stress and anxiety, and the effects they have on efficacy, (4) social connectedness, and (5) hope. These individuals and families, including nightmares and essential principles have influenced the thoughts sleep problems, concentration difficulties, anxiety of policy makers, care providers and scholars all and violence within the family. over the world, are embedded in several guidelines In order to reach children and young people, and now form the basis of our recommendations. agencies and service providers may need to explore The principles are designed for immediate to new and innovative ways to provide support. Our mid‑term interventions – and could be utilised in research showed, for example, that currently plans and discussions for stabilisation, recovery and adolescents –and boys in particular – frequently use reconstruction, ensuring early intervention to avoid their mobile phones to distract themselves. Sending much greater, longer-term problems. wellbeing and self-care messages via platforms such as WhatsApp groups could be an important way ADDRESSING CHILDREN’S to support them. Part of programming in this area involves teaching girls and boys more about how EMOTIONAL DISTRESS to look after themselves through the distribution of wellbeing kits (see box below). The emotional distress that children are experiencing must be addressed through gentle approaches to Children who are suffering from emotional distress help them work through their grief, loss and feelings and caregivers who are distressed themselves need of not being safe. self-care and family group support tools to alleviate their high levels of stress and trauma-related Psychosocial support and counselling can help to emotions. Approaches such as the Mind-Body support children and adolescents in reducing and Program (see box below) can support children and stabilising their high emotions. Within stabilisation, caregivers to use self-care and group support tools recovery and reconstruction frameworks, age- and to relieve distress and high emotions.

18 PUTTING CHILDREN’S RECOVERY AT THE HEART OF IRAQ’S RECONSTRUCTION 19 Awad, 47, teacher,Awad, west 47, Mosul “I hope school our gets rebuilt and returns to what it withwas the efforts those of who to want promote educationand help others. religion Our encourages us to help people.” Additionally, it is essential to address the lack of safety thatchildren feel in school bymaking these safe spaces where children can begin to heal and learn again. This starts with ensuring there is physical safety by clearing unexploded ordnances as part of stabilisation interventions, rebuilding or refurbishing school buildings, and also ensuring that schools not are used purposes for other than learning andclearing them of any military presence. Clearly marking schools as safe spaces and erasing signs of violence and destruction can also help children to dissociate them from the painful events thatof war may taken have in place schools. Addressing violence in schools and supporting teachers and educational staff is also essential. can be an essentialTeachers support children for but they need the tools their to relieve own emotional distress and training in the skills that will enable them to best support children. Building the capacity of school counsellors and integrating mental approaches health into psychosocial and school curriculums will be critical in ensuring that schools safe and are protective and that children can learn again. Central to stabilisation and reconstruction efforts, donors and national and authorities local must ensure that children protected are from landmines, remnants of explosive and ordnance unexploded more broadly bywar investing in demining and mine risk education, especially in areas where children reside and play. They must also facilitate the return of displaced families to their place of origin only if safeguards regarding children’s physical, material, legal and psychosocial safety metare in those areas. to support children 49 Body Program ‑ reflection self-care and that will and caregivers to use self-care and group support tools promoting self-awareness, self‑ support their psychosocial support needs. The programme teaches techniques such as meditation to quieten feelings of anxiety and energy; enhance and tension release anger, biofeedback to gain awareness about and thecontrol body; over and self-expression and movement to release and share emotions and memories of past distress held in the body. As part of a wider Middle East regional pilot, Savethe Children in Iraq will deliver a Mind MIND-BODY SKILLS MIND-BODY Save the Children has developed and piloted contextually and culturally appropriate wellbeing kits girls for and boys (aged living years) between in remote 5 and 17 locations, or those who do regular not have access to support services. Based on children’s input, the kits comprise reusable activity cards showing the to child: how reduce mental and physical stress and tension through simple stretching and breathing to exercises; how recognise strong emotions to and how talk about them to others; and prayer beads and comfort toys to hug when feeling sad, etc. WELLBEING KITS As caregivers do not seem to of be aware lack of safety,their the children’s humanitarian sensitise that approaches prioritise must community parents to the safety concerns their children are experiencing best and how to support. provide The persisting insecurity, damage and destruction and militarisation will continue to a significant have sense of security.impact on Unless children’s safety is re-established,children’s their stress management system will remain activated, leaving them at serious risk toxic for stress. ENSURING CHILDREN FEEL SAFE 20 PICKING UP THE PIECES during their stay in temporary shelters. temporary in stay their during as early as starting children, with people displaced of skills parenting improve to the programmes of provision have for called the UNICEF and UNHCR as such institutions International needs. health own mental their addressing in also but children, provide and for their support treat, how in they only not support, need also Parents FAMILY ENVIRONMENT CREATING APROTECTIVE child, no one is more important than a parent; and and aparent; than important more is one no child, any of life the in point acertain to Up presenting. be may children their that challenges considerable the despite and own traumatisation their despite way, apositive in annoyances everyday handle to them enable and children their with interactions facilitate will that strategies parents teach to is bring them up.” them bring to me strength give to and them, with through going Iam suffering the relieve to “All for God Iwant is Yasser, 38, father, west Mosul west father, Yasser, 38, 50 The goal goal The and their caregivers, and the wider community. wider the and caregivers, their and for children interventions individual with conjunction in used be should stress parenting-related health and mental parents’ targeting approaches move to towards family-based more need The recover self-worth. of asense help them to and income of lack their to related stress the relieve to livelihoods to access need also Caregivers with. deal haveto children their and they difficulties distressing for the support seek and discuss to space additional need homes, their to confined more be may who mothers, And ways. appropriate and safe in manage to support need are facing they anxiety and stress crippling the with struggling Parents rules of positive parenting is vitally important. vitally is parenting positive of rules and principles basic the on providecan education that programmes of provision the Thus, members. by all shared and are defined rules clear and limits place where reliable and asafe is environment home the achieved when best is stress with deal to ways finding adolescents, and children for both (Photo: Sam Tarling/Save the Children) the Tarling/Save Sam (Photo: killed was wife his since for caring been has he 2, 9, 7and aged daughters, three the with Yasser 51 PUTTING CHILDREN’S RECOVERY AT THE HEART OF IRAQ’S RECONSTRUCTION 21 Fahad, 12-year-old boy, west Mosul AMPLIFYING PEOPLE’S YOUNG VOICES Recognising children and young people as agents of change, and empowering rights holders to significant make contributions to future plans and discussions is crucial to rebuilding a strong, stable and sustainable that and embodies meaningful peace diverse views. In addition, with a youthful majority in the country, the young people to key of Iraq are rebuilding economy. a broken But they will struggle to do if so they not are able to access the mental health and psychosocial support they need. “In the future, like to I would become a doctor to help people and the sick. This is my dream. Mosul I love and Iraq a lot. Since ISIS came to Iraq and Mosul, they destroyed, killed and slaughtered everybody.” of resources based on needs will be vital in any support interventions.community Meaningfully engaging children and adolescents and prioritising theinclusion of traditionally excluded groupscan empower young people to be agents of change in their communities. own One entry point children, psychosocial be sensitive to children’s needs, and feel confident to be able to support children in meeting their emotional needs. This specialised, individual support girls, for boys and caregivers is essential to ensure that appropriate approaches utilised are to address the needs of children based on their individual experiences. Save the Children refers the most serious mental health cases in children or caregivers to specialised mental health service providers and advocates the for provision of child-focused services. health mental Conflictsensitivity and theallocation 52 Save the Children individual will provide and group counselling services to children, caregivers and teachers toenhance their communication and develop safe, non-violent child-parent relationships. Sessions support children and caregivers to deal with stress, addressing both general and specific stressors, including nightmares, sleep problems, concentration difficulties and anxiety. schoolsAs a criticalare entry point supporting for mental children’s health and psychosocial wellbeing, Save the Children will support teachers to process their problems,own build positive relationships with COUNSELLING SERVICES COUNSELLING It is also crucial to ensure that humanitarian or stabilisation interventions do not create social tensions since community support processes coupled with trauma may trigger in-group/out-group divisions, especially when competition resources for is fierce. Work should be done toWork prioritise the setting up of community groups where problems and collective solutions can be discussed, supporting the community to feel empowered, connected and in control of their futures. own Successful community-based psychosocial approaches rely on the participation of community members; paying attention to the amount of ownership they feel for a particular issue or problem; and giving priority to activities that the have potential to foster family and community support and increase bonds between people. The psychosocial element of this work is communityto move members from passive victims to active participants. It mitigates the emotional impact by action and gives hope, and encourages sustainability the for future. Alongside the widespread destruction the homes widespread of Alongside and neighbourhoods in west Mosul, natural support networks disintegrated. have It is therefore critical to rebuild strong social and cultural ties and ensure that children and caregivers the have tools, information and support they need to safeguard mental healthchildren’s and psychosocial wellbeing. REBUILDING MOSUL’S COMMUNITY OF SENSE for supporting children and adolescents to develop Children in this research expressed fear that conflict and build supportive peer networks may be through or ISIS may come back and that there may not be the youth volunteer groups that have emerged since a positive future for them. Similarly, when asked the retaking of Mosul to clear rubble and organise about something happy in their lives, most of their educational or cultural projects.53 By strengthening responses related to the past, with the retaking civil society actors to support young people, build of Mosul from ISIS coming up first, followed by existing youth networks and raise the voices of personal memories such as birthdays, holidays young people in their communities, nation and the and memories of the time before the war or when

PICKING UP THE PIECES region as a whole, we can support adolescents’ family members they have lost were still alive. mental health and meet their psychosocial needs, Only 9 per cent could think of something happy address protection issues, build resilience and that relates to their present and future, such as a enhance social cohesion. school achievement. Preparing for the worst can be a coping mechanism INSTILLING HOPE for children whose lives have been affected by cycles of conflict and whose future is uncertain. Supporting Research in nursing, medicine and psychology them by providing more information and realistic indicates that hope is crucial in coping with adverse expectations for themselves and their families may events,54 and hope is used intentionally in counselling help them feel less nervous and fearful, and more and psychotherapy to assist people in healing, hopeful. Our previous research showed that children recovery and life transitions.55 Building a sense of displaced from Mosul had unrealistic expectations hope in young people is critical to support children’s about their areas of origin – such as finding their mental health and psychosocial wellbeing. homes, schools and neighbourhoods as they left them – and may have lost hope when realising the “My children like school, but they fear for the return scale of destruction on their return.56 It is therefore of ISIS days. They’re always anxious about this.” essential for children returning to retaken areas Aisha, 30, mother, west Mosul

FIGURE 4: SOURCES OF HAPPINESS Percentages of children’s responses to the question ‘Can you tell me about something happy in your life?’

Nothing/don’t remember 12%

Mosul retaken from ISIS 38%

A happy memory 27%

Pre-war/when family member was alive 14% Education achievement 9%

22 PUTTING CHILDREN’S RECOVERY AT THE HEART OF IRAQ’S RECONSTRUCTION 23

niece, Rahaf, west Mosul Abdullah, 35,taking care of his orphaned A community-based approach community-based approach A 58 These can include theuse of 59 protection and the protection of peers. “We enrolled [my niece] at a school niece] and she started“We enrolled [my mixing with the other girls… She learned about their tragedies, those who have losttheir parents and siblings…She started getting better at getting on with other people. feel her let Slowly, didn’t we and thank isolated. gave opportunities her We […] God, she is getting better mentally.” People in Mosul eager are to repair and rebuild their homes and their city, get back to work, and move on from the conflict. can support the development of such hope-building interventions. The programme seeks cooperation to improve and peaceful interaction between children; increase the motivation to play; strengthen problem-solving and positive attitudes towards others; enhance impulse control; and build hope thefor future. It also works with children to enhance their capacity and awareness about self‑ photographs of their neighbourhood it and how now might look in the future; the development of hopeful narratives that children can then share with others; and child-focused and hope-based discussions between children, parents and other adults within families and communities. Individually, young people may feel hopeless about solving their problems, but by empowering them and supporting them to act collectively they can regain hope that they and their community can recover theand overcome challenges of a post-conflict Iraq. The areas in west Mosul where the 57 As part of a comprehensive psychosocial support package, Save the Children in Iraq’s Child/Youth Resilience Programme supports the psychosocial needs of children and adolescents. The programme a step-by-step follows approach threeover months to strengthen participants’ resilience and increase their wellbeing. It helps children to explore their cognitive, emotional and social health, that so they can better engage with their families, peers and communities. CHILD AND YOUTH RESILIENCECHILD AND YOUTH Previously, adolescents also inIraq have expressed feelings of hopelessness as a result of their education being disrupted, violence and abuse, and limited job opportunities. such as Mosul to access to have age-appropriate and realistic information about the areas they are returning to, and to be better engaged in decision making about their futures. In Mosul,adolescents’ self-assuredness and resilience appears strong. But as they exhaust their strategies to cope with emotional distress, they may hope lose about feeling further better, affecting their mental health. It is therefore important to act to now ensure that they better are supported and do not theirlose resilience and belief in a positive future. strengthsBuilding on children’s can be a sound high And children’s model to help them recover. of resiliencelevels also mean that programming that focuses on those strengths may serve as an entry point complementary for approaches to support their emotional health. assessments took this for place research some were of the least serviced neighbourhoods prior to the conflict and lack of materialsafety was identified as of stress a source both for parents and children. Ultimately, instilling hope means providing resources to meet the needs of children and their families and help them get their lives and their futures back on track. Recommendations

This report seeks to explore the experiences of children and young people affected by conflict in Iraq and assess the support networks and techniques available to help them process these experiences. One year on from the recapture of Mosul, as plans for the rebuilding of the country continue to be discussed and rolled out, Save the Children seeks to contribute to a roadmap for addressing the mental health and psychosocial needs of children and young people affected by the conflict. Prioritising the mental health and wellbeing of inclusive, children- and community-led initiatives children and young people as part of rebuilding an that empower them to be agents of change educated, productive and engaged young population and build their skills, expertise and leadership is a key step for local, national and international abilities. This includes: actors to achieve a society that can enjoy long-term – Promoting and ensuring integrated peace and stability. approaches to mental health and psychosocial support programming It is only through immediate and sustained action by across all sectors, not only through the these actors – each best placed to deliver different traditional route of child protection, but types of support for recovery to strengthen mental also incorporated into education, health, health and psychosocial wellbeing – that we will be shelter and nutrition programmes, ensuring able to truly make a difference for children in Iraq, their accessibility to marginalised groups. empowering and supporting their efforts to rebuild Teachers in particular must be trained and strengthen themselves and contribute to the as implementation agents to broaden rebuilding of their communities and their country. children’s access to supportive adults and In order to make this future of hope a reality, enhance the role of schools as supportive Save the Children calls on: community resources – Advocating for and supporting the Donors to: implementation of cluster coordination • Prioritise funding to long-term, flexible, and the reform of the humanitarian multisectoral, inclusive, age- and architecture to support a meaningfully gender-appropriate mental health integrated approach, avoiding duplication and psychosocial programming in and gaps humanitarian and development contexts, – Working to develop materials and recognising it as a core component of the programmes that are not literacy emergency response, as well as in the dependent, to ensure that those who are stabilisation, recovery and reconstruction unable to read are still able to access the phases of development. support they need. • Strengthen field-level technical expertise The humanitarian community to: and coordination on the delivery of mental • Advocate for and support age-appropriate health and psychosocial support (MHPSS) mental health and psychosocial support programmes through: programming that broadly focuses on – Ensuring funding and support for post‑conflict stressors and explores the specific MHPSS technical experts in programme needs of caregivers and children, incorporating creation and delivery (such as support

24 RECOMMENDATIONS 25 , in , in , without and the and Guidelines Protecting for Ensuring that returns of displaced people are safe, voluntary and informed through developing and implementing a durable solutions those framework for affected by conflict that guaranteesaccess to essential services Developing and implementing policies and practices that allow displaced legally work to people negatively affecting the economies of the host communities. Training MHPSSTraining practitioners particular and child adolescent clinical psychologists and counsellors Building on and strengthening the national capacity on MHPSS to support the delivery of high-quality MHPSS for care those in need across the full spectrum of the Inter-Agency Standing Committee (IASC) MHPSS emergencies pyramid of intervention. Working with civil society organisations Working to provide safe communal spaces for people to reconnect and talk about their experiences with others, that so they can find appropriate communal cultural, spiritual and religious healing practices to deal with events children young people and Providing with meaningful to participate ways in post-conflict responseand planning line with the United Nations Convention on the Rights of the Child and the Commitments on Accountability to Affected Populations. – – Endorse and implement the Safe Schools Declaration Schools and Universities from Military Use during Armed Conflict. Draft national policy on MHPSS for children and communities affected by conflict to increased a framework for provide political prioritisation and leadership. Such a increased must an investment in: policy include – – Increase the skills and confidence of, and opportunities communities to for, be able to facilitate self-help and social support mechanisms by: – – • • •

, including that for allow , which build

, as as well the that young people can turn for MHPSSfor Advisory and Technical asCoordination as well support Groups), thefor development of a roster of child- and adolescent-specific MHPSS technical professionals to available be deployed to support not only in emergency settings but also in post-emergency work Investing in and developing a cadre of young psychosocial support experts and models role to support for and information on accessing additional support services Investing in adolescent- and family-led solutions community-based gentle and collective responses to traumatic experiences, placing emphasis on the strengths of peers, families and communities rather than on their problems or pathology. Increasing support demining for and activities education mine Supporting the creation of programmes and capacity-building provide that vocational-training activities, especially for adolescents and youth skills creating for and work livelihoods more broadly. Prioritising the clearing explosive of hazards and the reconstruction of critical civilian infrastructure homes and schools Sharing accurate information about issues,safety including landmines and ordnances unexploded availability of basic necessities and services to populations in areas recently retaken from ISIS to ensure that individuals’ decisions to return informed are – – Ensurethat children are safe and secure at home and in the community and address their families’ wider vulnerabilities by: – – Ensure a child-centred approach to stabilisation, and reconstruction recovery – that places children front and centre in any plans to rebuild and rehabilitate Iraq. Approaches must specificallyfocus on: – • The government of Iraq, including provincial including provincial Iraq, of government The and local authorities, with the support of donors, to: • Notes

1 UNOCHA (October 2017) https://reliefweb.int/report/iraq/ (2017) Political Violence, Armed Conflict and Youth Adjustment: A un-remains-deeply-concerned-safety-civilian-populations-enarku developmental psychopathology perspective on research and intervention https://www.springer.com/gb/book/9783319515823 2 Index Mundi, Iraq Demographic Profile 2018 https://www.indexmundi.com/iraq/demographics_profile.html 17 DiMaria, L. Internalizing Behaviors and Depression, http://depression. about.com/od/depressionsymptoms/a/internalizing-behaviors. 3 Save the Children (2017) An Unbearable Reality: The Impact of War and htm Retrieved 17 March 2014; Fayez El-Gabalawi, F., Karim Displacement on Children’s Mental Health in Iraq https://resourcecentre. Sedky, K. and Racha Nazir, R. (2017) Suicide Among Youth of Middle savethechildren.net/library/unbearable-reality-impact-war-and- Eastern Origin: A case-based guidebook, Springer Cham; Fegert, J.M., displacement-childrens-mental-health-iraq Diehl, C., Leyendecker, B., Hahlweg, K. and Prayon-Blum, V. (2018) 4 IOM Displacement Tracking Matrix: Ninewa Returns Dashboard, ‘Psychosocial Problems in Traumatized Refugee Families: Overview of March 2018 http://iraqdtm.iom.int/LastDTMRound/Round92_Map_ risks and some recommendations for support services’, Child Adolescent Ninewa%20returns%20dashboard_2018_March_31_IOM_DTM.PDF Psychiatry Mental Health 12( 5); DiMaria, L. Internalizing Behaviors and Depression, http://depression.about.com/od/depressionsymptoms/a/ 5 Ibid. internalizing-behaviors.htm Retrieved 17 March 2014 6 Ibid. 18 Laye-Gindhu A. and Schonert-Reichl, K.A. (2005) ‘Nonsuicidal 7 REACH, Mosul Al Jadida Area Based Assessment, May 2018 Self-Harm Among Community Adolescents: Understanding the http://www.reachresourcecentre.info/system/files/resource-documents/ “Whats” and “Whys” of Self-Harm’, Journal of Youth and Adolescence reach_irq_profile_mosul_al_jadida_area_based_assessment_ 34( 5), pp. 447–457; Cawood, C.D. and Huprich, S.K. (2011) ‘Late may_2018.pdf Adolescent Nonsuicidal Self-Injury: The roles of coping style, self- esteem, and personality pathology’, Journal of Personality Disorders 8 UNICEF, Iraq: Key Facts, February 2018 https://reliefweb.int/sites/ 25 (6), pp. 765–781; Mental Health Foundation (2006) Truth Hurts – reliefweb.int/files/resources/Key percent20fact.pdf Report of the National Inquiry into Self-harm among Young People 9 Adolescent MHPSS questionnaire based on the Inter-Agency 19 Save the Children (2017) Invisible Wounds: The impact of six years Standing Committee (IASC) guidelines and standard format for of war on the mental health of Syria’s children https://reliefweb.int/sites/ Mental Health and Psychosocial Support (MHPSS) assessments; Child reliefweb.int/files/resources/Invisible%20Wounds%20March%202017.pdf and Youth Resilience Measure (CYRM); Adolescents Strength and Difficulties Questionnaire (SDQ); Children’s Hope Scale and Coping 20 Ibid. Methods Scale for Children 21 Save the Children (2017) An Unbearable Reality: The Impact of War 10 Caregiver MHPSS questionnaires based on the Inter-Agency and Displacement on Children’s Mental Health in Iraq Standing Committee (IASC) guidelines and standard format for 22 Knott, D. (2016) Acute Stress Reaction https://patient.info/health/ Mental Health and Psychosocial support (MHPSS) assessments; stress-management/acute-stress-reaction General Health Questionnaire (GHQ-12); Caregiver Child and Youth Resilience Measure (CYRM); and Caregiver Strengths and Difficulties 23 Thabet, A. and Vostanis, P. (1999) ‘Post-traumatic Stress Reactions Questionnaire (SDQ) in Children of War’, The Journal of Child Psychology and Psychiatry and Allied Disciplines 40(3), pp. 385–391 11 Save the Children Psychological First Aid Training Manual for Child Practitioners https://resourcecentre.savethechildren.net/library/save- 24 Miller K.E. and Rasmussen A. (2010) ‘Mental health and armed children-psychological-first-aid-training-manual-child-practitioners conflict: The importance of distinguishing between war exposure and other sources of adversity: A response to Neuner’, Social Science & 12 Traumatic experiences can leave children in a state of terror, Medicine 71, pp. 1385–1389; Freedy, J.R., Hobfoll S.E. and Ribbe, D.P. tension, and nervousness for long after an incident. Grounding (2007) ‘Life events, war and adjustment: Lessons for the Middle East’, exercises keep them in the present and help their bodies to recover Anxiety, Stress & Coping 7(3), pp. 191–203. and restore themselves to a calmer state more quickly, managing any overwhelming feelings or intense anxiety. They help someone to 25 Airwars is a collaborative, not-for-profit transparency project regain their mental focus from an often intensely emotional state. aimed at tracking and archiving international military actions in conflict zones such as Iraq, Syria and Libya. See: https://airwars.org/ 13 Hamam al Alil is a camp south of Mosul for displaced people who lived under and fled ISIS during the offensive led by the Iraqi forces 26 GCPEA, Education under Attack 2018, Global Coalition to Protect in 2017. Education from Attack http://www.protectingeducation.org/sites/ default/files/documents/eua_2018_full.pdf 14 Save the Children (2017) An Unbearable Reality: The Impact of War and Displacement on Children’s Mental Health in Iraq 27 Iraq Education Cluster, National Education Cluster Meeting Minutes, 24 July 2017, p. 2 15 Smith, D.D. Emotional or Behavioral Disorders Defined, http://www.education.com/reference/article/emotional-behavioral- 28 Save the Children study on adolescents and conflict in the Middle disorders-defined/ Retrieved 17 March 2014 East and North Africa conducted in 2017, forthcoming 16 Internalizing Symptoms and Effect on Children with Emotional and 29 National Scientific Council on the Developing Child (2010) Persistent Behavioral Disorders, http://www.studymode.com/essays/Internalizing- Fear and Anxiety Can Affect Young Children’s Learning and Development: Symptoms-And-Affect-Of-Children-866577.html Retrieved 17 March Working Paper No. 9. Retrieved from www.developingchild.harvard.edu 2014; Cummings, E.M., Merrilees, C.E., Taylor, L.K. and Mondi, C.F.

26 NOTES 27

. In the context of 37(1), pp. 44–51. 37(1), 29(1), pp. 32–41; 29(1), Edey, and W. 4(8), p. 583 19(1), pp. 7–20 19(1), , April 2018. , April 2018

38(2), pp. 218–235; Ungar, M. ‘The (2011) social ecology of 48 Hobfoll S.E., Bell Watson P., C.C., Bryant R.A., BrymerM.J., Friedman M.J., et al. (2007) ‘Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence’. Psychiatry 70(4), pp. 283–315 In49 partnership with The Centre for Mind-Body Medicine, https://cmbm.org/ 50 Williams N. (2012) ‘Child welfare and the UNHCR: a case for Developmentpre-settlement education’, parenting refugee in Practice pp.22(1), 110–122 Knaak51 S. and Ungar (2017) ‘Towards a mental T. health inequity audit’, Psychiatry Lancet The Giel,52 R. (1990) ‘Psychosocial Processes in Disasters’, International Health Mental of Journal Mercy53 Corps, Stabilizing Mosul: Research findings to inform the recovery reconstructionand effort 54 Farran, C.J., Herth, K.A. and Popovich, J.M. Hope (1995) and hopelessness: Critical, clinical, constructs . Thousand Oaks, CA: Sage 55 Dufrane, K. (1984) and ‘Using Leclair, S.W. hope in the counselling process’, Values and Counselling Jevne, R.F. (2003) ‘Hope, illness, and counselling practice: Making Counselling of Journal Canadian visible’, hope 56 Save the Children, (2017) An Unbearable Reality: The Impact of War and Displacement on Children’s Mental Health in Iraq Save57 the Children (2016) Uncertain Futures: Investigating the impact of displacement on internally displaced youth in Iraq and Syria https://iraq. savethechildren.net/news/uncertain-futures-impact-displacement- syrian-refugee-and-iraqiinternally-displaced-youth-iraq 58 Mercy Corps, Stabilizing Mosul: Research findings to inform the recovery reconstructionand effort Hobfoll59 S.E., Bell Watson P., C.C., Bryant R.A., Brymer M.J., Friedman M.J., et al. (2007) ‘Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence’. Psychiatry 70(4), pp. 283–315 45 68 per cent of children reported trying to forget; per57 cent choosing to remain silent and notspeak about their problems; 70 per cent screaming and becoming angry;82 per cent trying to calm themselves down when feeling anxious, scared, or sad;and per 67 cent decidingto accept their problems. 46 Ungar, M. (2008) ‘Resilience across cultures’, British Journal of Social Work resilience: Addressing contextual and cultural ambiguity ofnascent a Americanconstruct’, Journal of Orthopsychiatry Resilience pp. 1–17. 81(1), was measured using Dr Michael Ungar’s questionnaires, which can be found on the Resilience Research Centre’s website http://resilienceresearch.org/resources/tools exposure to significant adversity, resilience is both the capacity of individuals to navigate their way to the psychological, social, cultural and physical resources that sustain their wellbeing, and their capacity individually and collectively to negotiate for these resources to be ways. meaningful culturally in provided Chmaytelli,47 M. and Hagagy, A. (2018) Allies promise Iraq $30 billion, falling short of Baghdad’s appeal https://uk.reuters.com/article/uk- mideast-crisis-iraq-reconstruction-ku/allies-promise-iraq-30-billion- falling-short-of-baghdads-appeal-idUKKCN1FY12K ;

25(4), 29(2), pp. 460–472 379(9812), ; Tarullo, A.R., , Blackwell Publishing, Blackwell Publishing, , , American Academy of Pediatrics 1(5) ; Shonkoff, Richter, J. L., P., van der Gaag, J. and pp. 266–282; W.A., Tol, Song, S. and Jordans, M.J.D. ‘Resilience (2013) and mental health in children and adolescents living in areas of armed conflict – a systematic review of findings in low- and middle-income Journal ofcountries’, Child Psychology and Psychiatry 54(4), pp. 445–460 35 General Health Questionnaire. https://www.gl-assessment.co.uk/ products/general-health-questionnaire-ghq/ 36 REACH, Mosul Al Jadida Area Based Assessment, May 2018 http://www.reachresourcecentre.info/system/files/resource-documents/ reach_irq_profile_mosul_al_jadida_area_based_assessment_ may_2018.pdf Drury,37 J. and Williams, R. (2012) ‘Children and young people who are refugees, internally displaced persons or survivors or perpetrators massof war, violence Psychiatry in and terrorism’, Opinion Current 30 Oakford, S. (2018) Counting the Dead in Mosul: The civilian death toll in the fight against ISIS is far higher than official estimates https://www.theatlantic.com/international/archive/2018/04/counting- the-dead-in-mosul/556466/ Save31 the Children West Mosul Rapid Needs Assessment, May 2018 REACH,32 Mosul Al Jadida Area Based Assessment, May 2018 http://www.reachresourcecentre.info/system/files/resource-documents/ reach_irq_profile_mosul_al_jadida_area_based_assessment_ may_2018.pdf 6433 per cent of children said they have a place to go to or someone to talk to when they are sad or upset only a little to sometimes; per 17 cent said they have no place to go and no one to talk to. 34 Fazel, M., Reed, R., Panter-Brick, C.and Stein, A. ‘Mental (2011) health of displaced and refugee children resettled in high-income countries: risk and protective factors’, Lancet The pp. 277–284;W.A., Tol, Song, S. and Jordans, M.J.D. ‘Resilience (2013) and mental health in children and adolescents living in areas of armed conflict – a systematic review of findings in low- and middle-income Journal ofcountries’, Child Psychology and Psychiatry 54(4), pp. 445-460 38 Center on the Developing Child, Harvard University https://developingchild.harvard.edu/science/key-concepts/toxic-stress/ Shonkoff, and Gardner, J. A. P. S. (2012) The Lifelong Effects of Early Childhood Adversity and Stress Toxic http://pediatrics.aappublications.org/content/early/2011/12/21/ peds.2011-2663 Bhutta, Z. A. integrated (2012) ‘An scientific framework for child survival and early childhood development’, Pediatrics https://www.ncbi.nlm.nih.gov/pubmed/22218840 Bruce, J. and Gunnar, M.R.(2007) False Belief and Emotion Post-Institutionalized in Understanding Children https://www.bu.edu/cdl/files/2013/08/TarulloBruce-Gunnar-2007.pdf 39 Save the Children (2017) Invisible Wounds: The impact of six years of war on the mental health of Syria’s children 40 Save the Children (2017) An Unbearable Reality: The Impact of War and Displacement on Children’s Mental Health in Iraq REACH,41 Mosul Al Jadida Area Based Assessment, May 2018 42 Ibid. 43 Save the Children study on adolescents and conflict in the Middle East and North Africa conducted forthcoming in 2017, 44 Somasundaram, (2007) D. ‘Collective trauma in northern Sri Lanka: qualitative a of psychosocial-ecological Journal International study’, Systems Health Mental savethechildren.net