The fallout of war

For community practitioners (CPs) to best understand the needs of children and families displaced by war, it helps to think about the road they have taken.

‘Go back to where their journey starts – with the trauma of living in a country at war,’ says Janet Taylor, CPHVA Executive chair, and nurse manager, children’s services, at South Eastern Health and Social Care Trust in Northern Ireland.

‘Children and young people, some travelling with parents, some with relatives, have left behind everything they know. As they travel through their country, some of them walking for miles, they will be experiencing so much. They may have lost relatives, or witnessed explosions. They may be separated from their father who is fighting in the war.

They will be experiencing anxiety, uncertainty, danger.

‘Then they arrive in the UK, perhaps for the first time, and may be staying with relatives – or complete strangers. They have brought with them only what they can carry. And they are left with the uncertainty of what’s happening back home.’

When it comes to the war in Ukraine, government figures show that 104,000 Ukrainians have already made this journey to the UK (Department for Levelling Up, Housing and Communities (DLUHC), 2022a). Almost 47% of Ukrainian refugees said they were accompanied by at least one dependent child (Office for National Statistics, 2022).

While as of mid-2021 there were 135,912 refugees, 83,489 pending asylum cases, and 3968 stateless persons in the UK from around the world, due to conflict or causes such as persecution, violence or violation of human rights (UN refugee agency UNHCR, 2021).

Urgent needs

Children and young people displaced by war ‘are some of the most vulnerable individuals in society and may present many complex needs’, says Meta Randles, senior policy adviser for refugee and migrant children at children’s charity Barnardo’s.

‘These needs are often multi-layered, resulting from separation from their family and environment, bereavement, and the traumatic events they might have witnessed, both in their home country and on their journey to the UK,’ she says.

A priority is to ensure children’s health needs are met. Ane Lund Ringen is a looked after children nurse at Crowndale Children’s Services Clinic in Camden, London, supporting the health needs of children and young people who have come to the UK from across the globe seeking asylum. ‘Sometimes, so many other things are going on in these children’s lives that their health needs are forgotten. We need to make sure this doesn’t happen,’ she says.

Physical health issues she encounters include headaches, dental pains, scabies, acid reflux, limb pain, weight loss and, sadly, signs of torture.

Children’s mental health

War and forced displacement also impacts on children’s mental health. Research has highlighted war’s ‘multiple implications, including immediate stress-responses, increased risk for specific mental disorders, distress from forced separation from parents, and fear for personal and family’s safety’ (Bürgin and Anagnostopoulos, 2022).

Refugees fleeing Ukraine are likely to have experienced ‘significant trauma and have limited resources, which in combination make them highly vulnerable’, says Meta. She says that in one local authority area Barnardo’s is working in, 55% of Ukraine families who have fled war have witnessed a family member or someone they know being tortured or killed.

Dr Stevan Radoja, an educational and child psychologist working for Northamptonshire County Council, recently visited Ukraine to look at psycho-educational support for children on behalf of the charity Caritas. He says children displaced by war may be irritable, have poor concentration, and are in a state of hyperarousal, so are easily startled. They may be tearful, experiencing panic attacks, and appetite issues. ‘And they may be grieving for the loss of their life as they knew it,’ he says.

Stress and anxiety may have disrupted children’s sleep patterns. ‘They worry about their past, their future, their families, and whether they are safe now,’ says Ane.

Dr Siobhan Currie, chair of the British Psychological Society Crisis, Disaster and Trauma Section, says: ‘If you’re a practitioner or teacher, you may worry about doing the right thing to help the child, dealing with angry behaviour – a common and expected response in these children – and managing language issues.’

Barbara Evans, a play therapist and a community nursery nurse based in the Midlands, says people may not be prepared for the trauma children and young people experience and how it might be expressed. For example, autism or attention deficit hyperactivity disorder (ADHD) may be diagnosed in children as their behaviour appears to indicate this, when they may in reality have post-traumatic stress disorder (PTSD).

‘There is a range of symptoms with PTSD that also match autism and ADHD, such as hypervigilance and difficulty concentrating,’ explains Barbara.

‘I would advise CPs that if they are dealing with a family where there is trauma then consider this as an option, alongside possible autism or ADHD,’ says Barbara.

The impact of conflict

Meta says other immediate worries for children displaced by war include a lack of consistency – due to their constant moving between accommodation and dealing with a range of services – and a risk of homelessness, with many local authorities finding it difficult to house homeless families, and little housing is available in the private rented sector.

For children in particular, a key issue is feeling secure, says Siobhan. ‘Children have lost the things that make them feel safe: their home, school, family and friends, consistency and routine. They need comfort, to stay close to their carer, and routine – including a sleep routine – to make the world feel a safer place.’

Conflict is also ‘a huge driver’ in risk of trafficking and exploitation, particularly among women and unaccompanied children, adds Meta.

Jan Moore, senior psychosocial practitioner for the British Red Cross, says the parental role for those displaced by war will be ‘very demanding’. ‘Parents will  be trying to support their children while trying to manage their own feelings,’ she says.

‘refugees are often desperate to work, but a lack of available childcare or nursery school places for them is a barrier to employment’

Families may also be experiencing bereavement and grieving for loved ones, or not even know the whereabouts of relatives and friends, says Janet.

Ukrainian Anya Abdulaka is a trustee of London based charity Families4Peace, which helps support families arriving from Ukraine and the hosts who sponsor them. She says families will be faced with ‘a new culture and a new language, along with the anxiety of building new groups of friends and missing their friends back home.’

Daily issues for families

An ‘extra layer of concern and anxiety’, says Anya, is that unless there are exceptional circumstances, men over the age of 18 are not permitted to leave Ukraine. This means that, in many cases, women are coming to the UK with their children, and need to look after and provide for them without their husbands to support them.

However, in the UK and elsewhere in Europe,  while Ukrainian refugee family members are often desperate to work, a lack of available childcare or nursery school places is a barrier to employment, says Stevan.

Immediate support required for children and families arriving in the UK includes housing, clothing, money to buy food and healthcare, says Ane.

Life with a host family can bring its own challenges, suggests Colin Levine, who is based near Stroud, Gloucestershire. Colin works in the voluntary sector in refugee support, and is host to a Ukrainian who left the country after war broke out. Colin says after an initial period of about three months, and the relief of having escaped a war-torn country, for some, ‘the reality of sharing a house with strangers starts to sink in, and irritations, even arguments, can emerge’.

He says ‘over-protective hosts’ – although well intentioned – may interfere with families’ parenting, such as specifying children’s bedtimes. ‘Feeling “under the microscope”, as a parent in someone else’s home, with someone else’s rules, is a complex issue for everyone,’ says Colin.

Not all placements work well. ‘On occasion, families have had to be relocated, as a placement hasn’t worked out as planned,’ says Janet, who manages a multidisciplinary public health nursing team who have been supporting displaced families from Ukraine.

Understanding culture and experiences

Barnardo’s children’s services managers have reported a number of themes they have found when working with children and young people who have arrived in the UK, which may be considered surprising, says Meta. This includes the importance of food, which is ‘integral to culture, identity and sense of community’.

Children’s services managers have also commented on the ‘amazing skills and talents that many refugee and asylum seekers have when they arrive in the UK, from musicians to poets and doctors’, says Meta.

That many Ukrainians speak Russian as their first language may surprise practitioners, says Colin. ‘Be sensitive to this, and don’t assume people speak Ukrainian – ask what their first language is,’ he advises.

Generally, Ukrainian people are ‘more direct than people in the UK – and while grateful, are not as diplomatic in asking for things – so be aware of these sorts of cultural differences’, says Anya.

When it comes to being able to integrate fully into life in the UK, such as attending school, and receiving appropriate healthcare, people on the Homes for Ukraine scheme (DLUHC, 2022b) enjoy most of the same rights  as other UK residents. They are entitled to stay for three years, as long as they obtain a biometric residence permit during the first six months, advises Colin.  

When dealing with families who cannot speak English, Meta says it is vital they have interpreters they feel comfortable with.

‘CPs will be at hand to help and support children and families, carrying out health assessments, checking mental and physical health, and establishing vaccination histories, and if there are any medical concerns’, says Janet.

Families’ issues will vary, depending  on what they have been through, so ‘don’t make assumptions – allow families to tell their stories”, says Siobhan.

It’s vital not to ‘pathologise people’s experiences’, says Jan. ‘Anyone who has experienced war and been displaced will inevitably have strong reactions to those abnormal events. But it is important to try and normalise those responses where appropriate, and not assume that someone will require specialist support.’

 It is important to see the child as an individual, adds Meta. ‘Trauma presents itself very differently: some will be loudly acting out, some might be numbing, and everything else in between.

Terms and rights

Common terms used to describe people who leave their countries for different reasons.

• An asylum seeker
• Flees their home
• Arrives in another country, whichever way they can
• Makes themselves known to the authorities
• Submits an asylum application
• Has a legal right to stay in the country while waiting for a decision.

A refugee

• Has proven that they’d be at risk if returned to their home country
• Has had their claim for asylum accepted by the government
• Has permission to stay in the UK either long term or indefinitely.

Refugees have a right under UK and international law to bring their immediate family members to join them.

A refused asylum seeker

• Hasn’t been able to prove that they would face persecution back home
• Has been denied protection by the authorities
• Must now leave the country – unless they want to appeal the decision or it isn’t safe or practical for them to return home (for example, they have a serious health condition or can’t get the documents they need to travel).

A migrant

• Has moved to another country, for example to work, study or join family members
• May be living there temporarily or permanently depending on their situation.

British Red Cross, 2022

Using professional curiosity

How else can you help children and advise families displaced by war? Stevan has conducted research into factors that build resilience in children. ‘Caring for friends, and friends caring back, sharing feelings and worries, and being part of a group can be helpful,’ he says. ‘Being able to share and display positive outcomes, such as a picture created at school, and doing the normal things children do, like singing and dancing, also helps them to “park” their worries elsewhere, and gives them a sense of hope,’ he says.

Ane suggests considering different ways of interacting with children and families: rather than a sit-down assessment, CPs can use pictures, or ‘walk and talk’.

‘You can also do so much by listening, observing and using your intuition – for example, if it seems like someone is having a flashback, try to bring them back into the room by, say, asking if they want water. Or consider using breaks in their assessments, as sometimes so there’s only so much children can take in,’ she says. ‘To list signs of trauma can be tricky, so use professional curiosity and judgement to consider what is going on,’ says Meta.

‘A sense of community and feeling part of something is really important to start building connections’

No matter whether a child is from Ukraine or the UK, ‘the same principles apply in terms of trauma support, and CPs can use all their knowledge and experience, making brief interventions, as well as making referrals to other sources of support, including specialist mental health services,’ says Janet.

There are many resources and organisations available that offer support, including charities such as Barnado’s, the Refugee Council and the British Red Cross (see Resources).

You should consider what help and support is available for children and families in their local area, linking in with core services, including those for long term conditions like diabetes, or with a local community Sure Start programme, advises Janet. She also recommends CPs signpost to community support, such as local churches or play groups. 

‘A sense of community and feeling part of something is really important for children and their carers to start building connections, such as through children’s centres or council led youth activities,’ says Siohban. 

In Camden, for example, Families4Peace runs a community centre at the local school, holding presentations, activities for children, and English language lessons, and helps hosts and their Ukrainian guests find support. ‘We give families as much information as possible, as soon as possible, and signpost them to what’s available, including charities offering toys, books, clothing, digital support and English classes,’ says Anya.

A joined-up approach

There may be many agencies involved in the care of children and families displaced by war, which can be ‘overwhelming and confusing for the child – so a joined-up approach is vital’, says Meta. 

She adds that mobilising strong partnerships between the voluntary and community sectors with national and local government will be key to meeting the needs of families and children effectively.

Good communication and joined-up thinking between agencies is crucial, ‘particularly in order to avoid duplicating resources, which is confusing for families, and means there is a danger of their being unhelpfully passed from one agency to another, creating more confusion and distress’, says Jan.

A single point of contact within communities coordinating the support of those displaced by war is also needed, says Anya. ‘We hear of families being seen by so many different people  – but they need consistency.’

Those supporting Ukrainian families in the UK warn that the risk of homelessness for children and families from Ukraine is set to become a growing problem.  ‘Most calls coming through the Barnardo’s helpline relate to housing issues,’ says Meta. ‘This is mostly due to refugees wanting to move out or rent, or being afraid of being made homeless due to a breakdown in the relationship with hosts. This risk is likely to be exacerbated once the six-month minimum condition has passed under the Homes for Ukraine Scheme.’

What now?

With the war in Ukraine – and others around the world – continuing to rage, life remains uncertain for many children and families, so CPs will need to draw heavily on their knowledge and skills to best support these casualties of war. ‘Practitioners shouldn’t underestimate their skills, or be concerned that this is such a specialist area that it’s outside their remit,’ says Barbara. ‘It’s about knowing their limitations, and working on their existing skills to give the best possible advice to these children and families.’

‘We need to recognise these families’ very difficult journeys, that began from a country at war,’ says Janet. ‘We need to have a lot of empathy and understanding. We cannot underestimate the impact of having to leave loved ones behind.’ 

Resources

• Advice for host families welcoming Ukrainian arrivals into their homes from Barnardo’s, the NSPCC, Save the Children and the Royal College of Paediatrics and Child Health bit.ly/Barnados_host-families
• British Red Cross: Help for young refugees and asylum seekers bit.ly/BRC_young_refugees
• British Red Cross: General information about refugees bit.ly/BRC_about_refugees
• Refugee Council: refugeecouncil.org.uk
• Barnardo’s: Help for families and children seeking asylum bit.ly/Barnados_families_help
• Barnado’s helpline for anyone fleeing to the UK as a result of the war in Ukraine with Ukrainian- and Russian-speaking advisers available 0800 148 8586
• Families4Peace: families4peace.co.uk
• Department for Education resources to help support children and young people arriving from Ukraine bit.ly/DfE_Ukraine_resources

References:

British Red Cross. (2022) Refugee facts and figures. See:  redcross.org.uk/about-us/what-we-do/how-we-support-refugees/find-out-about-refugees (accessed 15 August 2022).   

Bürgin D, Anagnostopoulos D, Board and Policy Division of ESCAP et al. (2022) Impact of war and forced displacement on children’s mental health—multilevel, needs-oriented, and trauma-informed approaches. European Child & Adolescent Psychiatry 31(6): 845–53.

Department for Levelling Up, Housing and Communities. (2022a) 100,000 Ukrainians welcomed to safety in the UK. See: gov.uk/government/news/100000-ukrainians-welcomed-to-safety-in-the-uk (accessed 15 August 2022).

Department for Levelling Up, Housing and Communities. (2022b) Homes for UK: record your interest. See: gov.uk/register-interest-homes-ukraine (accessed 15 August 2022).

ONS. (2022) Visa holders entering the UK under the Ukraine humanitarian schemes: 16 to 24 June 2022. See: ons.gov.uk/peoplepopulationandcommunity/populationandmigration/internationalmigration/bulletins/visaholdersenteringtheukundertheukrainehumanitarianschemes/16to24june2022 (accessed 15 August 2022).   

UNHCR. (2021) Asylum in the UK. See: www.unhcr.org/uk/asylum-in-the-uk.html (accessed 15 August 2022). 

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