9. Challenging Environments
How can we support children who experience violence and displacement?
The Forum on Investing in Young Children Globally (iYCG) focused on:
- children growing up in challenging environments,
- understanding the dynamics of extremism, and
- building peaceful societies by starting early.
- How are children impacted by experiences of severe hardship including chronic poverty, separation from family, displacement from their homes or on-going conflict – or in many cases a combination of all of these conditions?
Read about what science tells us about the effects of extreme chronic conditions on children, as summarized in the Lancet.
Resilience is the capacity of some individuals to ward off the negative effects of challenging or traumatic experiences and environments. The concept of resilience is important as we consider strategies to support children living in challenging environments.
Watch as Ann Masten, University of Minnesota, presents on the concept of resilience at the March 2016 Jordan workshop
Masten - Resilience of Children
I want to begin with world war II, and that’s been mentioned a number of times in this conference, and that’s because world war II had such a profound and devastating effect on children around the globe that it motivated not only the founding of UNICEF but many other efforts by clinicians and researchers and humanitarian agencies to respond. So that concern has continued to grow over the years. We all hoped that that would be the end of global conflict, but of course we’re living with the fact and reality that children still face this kind of experience. There’s still research going on to this day that started right after World War II, research on the long-term effects of the experience of war, even on children who weren’t born yet, that are now being followed. There are lifelong impacts on those children, and there are also intergenerational effects of war on children.
There’s been a lot of progress in research since world war II, and I’m sure many of you are aware of this, and I can’t begin to go into all of the research that’s happened. So I just want to focus on a few highlights from the resilience research. The whole field of research on resilience developed after world war II and has been going on now for half a century. And this science is dedicated to understanding how children survive, recover, and even thrive after they are recovering from adversity.
And what can we learn about naturally occurring resilience that might help us when we’re trying to promote better outcomes in children. We’re not doing a very good job preventing exposure to violent conflicts, we need to keep working on that, but in the meantime we have to have strategies for helping children who face these kinds of issues. So what does resilience mean? This can be controversial. This is my definition of resilience, and I like this kind of definition because it works in different kinds of systems at different levels, and I think we need definitions of resilience to help us organize our thinking and put together action across sectors and across levels.
So I would think of the resilience of a child as the capacity of that child to adapt successfully to very serious threats, threats that may affect that child throughout their life, but that disturb the child’s life in such a way that it may influence the rest of their development.
But I could also talk about the resilience of a family, or the resilience of a community, and it’s important to be able to think like that, because it turns out that the resilience of a child depends a great deal on the resilience of other systems around that child, the most important being the resilience of the family caring for that child. We’ve learned through diverse research from all over the world that there are important aspects of risk and protection that make a difference when children are exposed to great adversity. First of all it matters what you’re experience. So not only what you’re experiencing right now, what kind of threat, but all of the traumatic experiences you’ve had in your life, how have they accumulated over time.
It also matters what the recovery environment is like, how supportive is the physical environment, the social environment, the spiritual and cultural environment for that child to recover. We know the resilience of the family and community, how well they are continuing to function makes a great deal of difference to children. And we also have learned about many individual differences that affect how children respond to great adversity. Children differ. And one way of course they differ is that the same person will respond differently depending on their age. Early in development they respond differently than later in development. Boys and girls respond somewhat differently. We have learned that some individual children are more sensitive to adverse experiences than other children, and we’re even beginning to study that at the level of the way the brain and epigenetic processes work.
Because all of these influences matter for the resilience and recovery of children, we can draw pictures like this that represent different pathways. This picture shows all the possible patterns of response of different individuals to trauma. This is a sudden trauma, out of the blue.
Some people respond and just carry on, that’s pattern A. Some people break down and then recover, that’s pattern B that you see here. Pattern B is very common when you have overwhelming adversity. And there are many other patterns. Some children break down and never do recover, because they don’t have the opportunity to recover. Maybe their family has been destroyed and nobody has come in to help that child.
- What services or supports would you want to see in place to support all children to have the opportunity to bounce back from trauma?
- Why does Masten advocate for supports to family and community rather than direct supports to children who experience trauma?
- In her guiding principles she includes the importance of training for first responders in best practices for supporting children and calls for a broad definition of first responders. Who would you include in this group?
Masten - Capacity Resilience
Our capacity is connected deeply to our biology and to everything around us, and so resilience is spread out through our relationships it's spread out. We draw on our communities. We draw on our family, but our family is drawing on their social network. Their social network is drawing on the resources we have in the community, ranging from our crisis response teams to medical care to you know, the hope that a community can generate. And none of us is doing this on our own. So I think it's in the middle of a complete catastrophe, when everything is breaking down. Whether it's due to a hurricane, or it's due to a terrorism attack, that's when you see how interconnected we all are, and that, you know, we have to get a lot of systems back connected and going. But often, people will reach out to each other and support each other, to try to rebuild that collective capacity. But you know, one child, whether they're a very young child or a teenager, depends on lots of other people and lots of other resources to make it. And I think at some level we really understand that, but I think that we haven't fully appreciated it when we think about how do we prepare. How do we get ready? We know we're going to have more conflict, more terrible catastrophes from natural disasters, climate change, and the political situation we're in around the world, we're gonna have a lot of struggles coming up, and I think that's one of the reasons we have a great interest in resilience right now. We know we have to get ready, and we have to build capacity.
- How ready is your own community to deal with the effects of sudden or prolonged traumatic events on children?
- Are there efforts underway to promote protective factors for children to support resilience?
Read the following Brief prepared by the Harvard Centre for the Developing Child.
9.1 Children in Challenging Environments
Children who are on the move including refugees, migrants and immigrants must be considered. Many have experienced trauma, violence and hostile living conditions throughout their young lives. Support to family and other caregivers helps to provide a buffer to the adversity they experience. Children living in disease breakout zones need consideration beyond disease protection and treatment. The nature of the trauma matters. We will begin with a look at the circumstances for children separated from their families, communities and cultures.
Vesna Kutlesic, Eunice Kennedy Shriver National Institute of Child Health and Human Development, provides opening remarks to a panel on Children Living Outside of Family Care at the November 2015 Prague workshop:
Kutlesic - Children in Institutionalized Care
DR. KUTLESIC: I’m going to be hitting the highlights of our presentations today with some of my slides and really putting an emphasis on evidence based approaches to working with children outside of family care. And we’d like to encourage all of you to develop research and your own evidence in your own countries so you’re more aware of what the needs are of the children in your countries and also are not always borrowing from examples from other countries but know exactly what works best in your environment.
So as far as children and families in crisis, orphans and separated children while living in their families are often exposed to poverty, stigma, lack of educational resources, and exposure to physical and sexual violence. And then when these children are left without the care of their parents and families they’re vulnerable to further harm. So there’s an appeal to all of us that to intervene and see how we can help these children have the best health and developmental outcomes. Sometimes when we look at society’s reaction to these children there’s a lot of stigma, and there’s the question of whether these children were already, I have this in quotes, damaged while they were in their families, and they’re exposed to these different types of adversity. Or are they in quotes damaged later when they’re separated from their families in an institutional or foster care of adoptive placements. And so we definitely want to get past the stigma of these children and really see them as individuals who need our comprehensive care and support. We also want to think about whether these children show signs of resilience and the ability to improve at various stages of their health and development, and what health, education, psychosocial interventions have the best evidence of having a positive impact.
Low and middle income countries are home to an estimated 132 million single and double orphans. That means that either one or both parents are deceased. And over 95 percent of children who are orphans are over the age of five years. Additionally there are tens of millions of children who are street children in need of care, and sometimes the street children are actually more vulnerable to further trauma than the children in the institutions. There’s also more than two million children in institutions around the globe.
So caring for these children presents a complex problem that demands evidence based solutions, a continuum of care, and placements for children with a diverse set of health, education, and psychosocial needs. As far as trends in child development outcomes with institutional and family based care, each model of care has been shown to have strengths and weaknesses, and a primary goal is protecting children from further trauma and abuse, regardless of the placement setting. For example institutional care versus family based care. In fact our research shows different trends. Sometimes the trauma based adverse experiences are higher in institutions, sometimes in family based care, so there’s no clear trend that institutions are always worse for children.
Also, for children under age two research has focused largely on infants cared for in large hospital style institutions that employ shift workers, and this includes both the Bucharest early intervention project and the St. Petersburg Orphanage Research Team. And so not all institutions are organized the same way, they’re not all the same size. And institutions are just a building without the staff members that run the institution. So the training of the staff members, the proportion of the staff ratio per child are all important considerations among other variables in this regard. These studies have demonstrated for the children that we’ve mentioned under age two powerful negative effects on infant and brain and child development.
And when these infants that were in the Bucharest and St. Petersburg studies were placed later with trained, paid, and supervised foster parents, some brain and child development improvements showed some positive effects, and then others seemed irreversible. So as far as some of the effects, particularly for young children, and Ann will be speaking on that today, we do see some opportunity for intervention, but there is a timing factor that is important to keep in mind.
Other studies of children older than age five have found more nuanced outcomes. This also includes for low income countries versus middle income countries, sometimes more positive outcomes within institutional settings, the Positive Outcomes for Orphans Study, with Whitten et al, looked at the outcomes of children in Cambodia, Ethiopia, Kenya, India, and Tanzania, and they found that children age five or older living in institutional settings scored as well or better than those in family based settings in a number of measures of physical and emotional wellbeing.
And this does not suggest institutions are preferred necessarily over family settings, but that if they’re organized well and there’s a strong educational component that actually children can do fairly well in smaller institution-like settings or group homes for example.
And also it’s important to keep in mind that quality of care is essential regardless of the placement of the setting. So if the family, particularly foster families are not well trained, if de-institutionalization happens without developing community services in parallel then there is a concern that we can contribute to further problems with street children and other kinds of unintended consequences if we don’t approach this in a systematic way.
Kutlesic speaks of the stigma attributed to children who grow up in institutionalized care.
- What sorts of perceptions might people have about these children?
- How might those perceptions effect their short and long term development?
- How might their early years experience effect their life circumstances?
Ann Berens, Harvard University, provides a succinct review of a major longitudinal study which informs our understanding of how placement in large institutions impacts young children's development.
Berens - Bucharest Early Intervention Project
DR. BERENS: So I will be speaking today about some findings from the Bucharest Early Intervention Project, which is a major longitudinal study that’s taking place in Romania, beginning in 2000, and still ongoing with follow-up today. So first just to begin, the aims of the study developed in a particular historical context in Romania.
So some of you may know under Ceausescu’s regime in Romania there was social policy encouraged, rising fertility rates, this included banning contraception, taxing families without any children, there’s really an encouragement for families to have more children. This in combination with a setting of poverty contributed to relatively high rates of child abandonment, often for reasons of poverty and placement in state institutions.
So at the end of his regime in 1989 there were an estimated 170,000 children living in state institutions. By the time the project arrived in 2000 there had been a lot of efforts towards institutionalization. By 2002 there were an estimated 40,000 children in institutions in Romania. So still a major problem.
In that context the goals of the study were to try to understand better the effects of institutionalization in these large state institutions on the brain and behavioral development of young children. And so it’s important that the study was looking specifically at infants and toddlers, children who were institutionalized at that age, and then following them throughout middle childhood.
The second aim was to see if these effects, if some of the negative effects that were already being observed among these children, might be remediated by early intervention, in this case placing into a high quality foster care program. So as Vesna said these were trained, supervised, and paid foster care families. And then the third aim was to try to improve the welfare of children in Romania by advocating for policy change based on results of the study.
So a little bit of background on the policy context. In 2000 there was no national foster care system in Romania. There had been some small local initiatives, largely supported by NGOs, but for the most part foster care had not been scaled up and there was a little bit of skepticism among some political leaders and some people about whether institutions were harmful for young children. Here’s an example of the baseline findings on cognitive development in the Bucharest study. It was observed that children in institutions had really significantly lower cognitive development scores.
The Bailey Scale, you can think of that as an infant IQ test. It’s normed within each population to 100, so 66 represents a pretty marked cognitive impairment, but it was debated and not really known, was this a reflection of the underlying risk factors that had led to children’s placement in institutions, or did this reflect the impacts of the care environment itself. So in particular, kids who are placed in institutions might have higher rates of exposure to fetal drugs and alcohol, or poor access to maternal care, or other things that could impair their cognitive development.
So this study, the response was that within a unique kind of historical context they were able to do a randomized control trial which allowed them to control a little bit for what might have been those background differences between children and look at what might be the actual kind of treatment effects that were incurred by the environment itself.
The unique environment was there was no national foster care system. The approach was then to recruit as many foster families as they could with support from their study grant. The challenge is that they were only able to recruit 58 families with the funding that they have and the resources and the families that they’re able to reach, they decided that the most ethical way to allocate the spots was to randomize children, to randomly select the children who’d be able to be placed into families, they kept siblings together, and then they selected a group of children who was going to be staying behind in institutions to serve as a control group.
They used an intent to treat analysis approach, so that means they did their comparison analysis based on the groups that children were randomized into, but they would still be encouraging the children who had been kind of left behind in institutions to be placed into families if that was possible. There was also significant ethical oversight of the study. There have been many papers written on ethics by outside ethicists, and just a lot of oversight to make sure this very vulnerable population was appropriately cared for in a research context.
So the study design, there was an institutional sample of 136 children. They were drawn from all of the state institutions in Bucharest at that time. And those were divided into 68 who were placed into foster care. They were randomized into 58 families with siblings kept together, so it ended up working out to 68 children. And then they recruited a control sample of 72 children from the community who had never been institutionalized.
They did baseline assessment, the mean age at baseline was 21.6 months, and the mean age at placement into foster care was 22 months. That will end up being important for how we interpret the results of the study. And they did follow-up assessments at nine, 18, 30, and 42 months, and at eight and 12 years, and age 16 follow-up is currently ongoing.
And they examined really a vast array of outcomes. I won’t have time to go into all of them. I’ll only be touching on a few, and even those I’m going to kind of have to give the 10,000 foot view. But I would encourage you at the Bucharest Early Intervention Project website there’s a list of all publications and there’s also a book that has come out in 2014 called Romania’s Abandoned Children: Deprivation, Brain Development, and the Struggle for Recovery, and that will go into all of the results in detail. I’ll be focusing on cognition, neurodevelopment, and psychopathology findings.
So first, cognition. There’s a lot of information on this slide but you can sort of conceptualize the two slides. On the left you see evidence of what we would call intervention effects. So at all the different ages of assessment, here we show the findings for 30, 42, and 54 months. You see really significant improvement in IQ among children who had been placed into families. And again these are randomly placed, so this is evidence of the effect of the care environment itself. And then on the right side you see what we would call timing effects.
So this is looking at 54 month IQ and dividing it up by the age at which the child was placed into foster care. So it’s the age they happen to be at the start of the study. And we see some evidence of greater gains in IQ for younger children, and in particular in the statistical analysis there was kind of an inflection point at 24 months. So children who were placed before 24 months had significantly greater gains in IQ than children who were placed after 24 months.
Here we have findings from our EEG study, and this again is an example of timing effects. So if you look at the upper left quadrant we see EEG is a measure of brain electrical activity. So it’s a measure of brain function, and the different colors represent the wavelengths. In the upper left quadrant we see the EEG of children in the Institutional Care Group who are in institutions. In the lower right we see the community control says significant differences at age eight. And then in the upper right we see children placed into foster care after age 24 months. In the lower left we see children placed before 24 months.
So the finding was that children placed after 24 months at an older age into foster care had EEG patterns that were indistinguishable from the children who remain in institutions, whereas children placed before 24 months similarly had EEG patterns that were indistinguishable from the community children.
Briefly, this is findings on the brain structural studies, so the MRI looked at grey and white matter cortical volume and they found decreases in cortical volume for both grey and white matter but found recovery only for white matter, and grey matter is where the cell bodies lie, it’s responsible for a lot of the kind of higher cognitive process. White matter is kind of connectivity tracts. It’s a big topic, I suggest you look into it if you’re interested.
And finally we have findings on psychopathology. So on the left side we see that this is comparing children who are ever institutionalized to community controls. So we see really quite striking rates of psychopathology, suffering from psychiatric disorders among children in the institution about as high as 37-38 percent for having any psychiatric disorder, and then increased rates of what you might call behavioral difficulties, so ADHD and externalizing, so things like aggression. On the right side we see some evidence of treatment effects. On the top we see externalizing symptoms, which were driven by boys in our sample. And we see significant improvement in externalizing behavior, so aggression, acting out, in kids who are placed in foster care. In the bottom we see something interesting. There was some suggestion of improvement in internalizing symptoms, which were greater among girls. Those were things like depression among kids who were placed in foster care, but it was not statistically significant.
However, when we divided the sample, broke the intent to treat analysis and compared children who had stable foster care placement versus disrupted foster care placement, we had marked improvement in children with stable foster care placement and much higher rates of internalizing symptoms in kids whose care was disrupted over time.
And finally this is just a note that these timing effects were really seen across a number of domains. So evidence of greater recovery with earlier placement into foster care, and the timing at which that kind of inflection point occurred varied by developmental domain, so language, there’s a tipping point around 15 months. 20 months saw differences in social skills and inhibitory control, and then 24 months is when you saw the IQ, the brain functional measures, and attachment.
So that’s it. I would say that this study exists in a much larger body of scientific evidence, and we put out a recent review in the Lancet that tries to provide a broad overview of the scientific evidence to date, so I’d invite you to look at that if you’re interested. And there’s my contact information. Thank you very much.
- What does Berens mean by a "tipping point" in the development of the children in the study?
- One of the objectives of the Bucharest intervention was to use the learnings to advocate for policy change in Romania. What are two key points you would draw on to influence policy?
For a list of scholarly articles on the Bucharest Early Intervention Project follow this link.
As stated earlier, the nature of the trauma experienced by children matters. Consider the effects of systemic ethnic discrimination. There are tragically many examples of historical and systemic ethnic or cultural discrimination around the world. The case of the Roma children of Europe is illustrative of the impact of systemic discrimination and of possible approaches to redressing these. At the November 2015 Prague workshop, Sarah Klaus of the Open Society Foundations set the context for discussion.
Klaus - Roma Children
DR. KLAUS: We thought it would be good to give you a little information on the context of Roma in Europe, for those of you who are let’s say coming across the issue for the first time in more detail. 2015 marks the end point of something that’s called the Decade of Roma Inclusion, which was a political effort of the World Bank, the European Union, the Open Society Foundations, and a number of other governments in the region, about 10 governments in the region, to try between 2005 and 2015 to make an enormous change in the lives of Roma generally, families, communities, across all of Europe. And we’re now at the end of that period, 2015, and there has been some progress but really far too little progress. If we look at the situation now the decade focused on four areas of life of Roma families and children. It focused on education, health, housing, and employment.
I picked out for you just one statistic from each of those areas to give you the picture. Europe is, first of all just demographically it’s Europe’s largest ethnic minority. It’s hard to estimate the numbers, our colleagues will talk about that today, because of course people self-declare their nationality or ethnicity across many European countries, and many Roma are afraid to do that.
So it is estimated that there are 10 to 12 million Roma in Europe, it’s the largest ethnic minority. Fewer than a third of the Roma population that’s of employable age is employed. And that’s because probably, I forget the exact statistic, I think it’s about 15 percent in some countries are graduating from secondary school, which would mean they’d have a lot of the qualifications that are needed for some positions.
So we see different levels of participation. So 20 percent never enroll into school, and at the same time we have to acknowledge that Roma communities are very diverse. We have here two Roma PhDs on this panel, and there are also Iliana who is going to be here also is working on her PhD, so there’s a wide variety across education, but we can say 20 percent of Roma have never enrolled in school.
Life expectancy is eight to 12 years shorter for Roma. There’s high infant mortality, and Roma are more likely to be evicted as a community than any other Europeans. I’ll also add a statistic that 50 percent of Roma in the last year will indicate in surveys that they’ve been discriminated against. So the level of discrimination is really enormous, we don’t see that in many other contexts.
Those of you who went on a site visit yesterday, two of the site visits we relooking at preschools or community based preschools. Those preschools or communities that you visited had some Roma children in it. And I thought that I would give you a slide to contextualize that a little bit.
What this slide shows is the rate of participation of children between the age of three and formal schooling in preschools in a number of European countries that have high Roma populations. And you can see first of all that the rates of participation in preschool vary a lot. Of course you see, this is from three to six, so we see 20 to 40, let’s say 30 percent or so participating in Macedonia, Italy, and Bosnia of the whole population.
But what we see on average is that Roma children are participating at half the rate of other children in preschools. So what we find is that the most disadvantaged group in Europe has the least access to preschool education, and I bet if we further tackle that statistic we would probably find that it is the higher income bracket Roma that are making more use of the preschools, and that those that are the poorest are probably having the hardest time getting into preschools.
Secondly, I’ve done some work looking at how many Roma are employed in preschools and primary schools, and we find that if we wanted the population of teachers to look like the community, so there would be a proportionate number of Roma teaching in preschools and primary schools, we have only about five percent of the Roma we would need employed in the early childhood education teaching force, so that’s another thing that we need to look at. Because when we interview Roma families, some of them who don’t send their children to preschool would if there was a Roma person at the preschool, they’d be more comfortable. The biggest barriers to preschool attendance are that there aren’t preschool places, or the preschool is too far, or there’s no transportation, or there are direct or indirect costs associated with attending preschool. So most of the factors here are structural, but I do want to emphasize there are cultural issues too. So more Roma parents who could overcome those barriers would do it if there was a Roma person at the preschool.
For those of you who visited the baby homes, this is a statistic that looks at Roma children in institutional care. So this is zero to 18, it’s not zero to three like we saw the other day. But what you can see, just highlighting Czech Republic, if the Roma population is about three percent on average we might say of the Czech Republic population, it makes 40 percent of the children in institutionalized care. So you see huge discrepancies. Really the largest discrepancy you see in Slovakia where Roma make up nine percent of the population, but over 80 percent of the children in institutional care.
I think that you have this PowerPoint in your presentations or it’s available online. So if you’re interested in more statistics about Roma these are some of the sources that we use that we think are the better reports.
Klaus provides a brief statistical portrait of the current conditions for the Roma people. Despite a focused ten-year effort by governments and major organizations to make a substantive difference in the lives of the Roma people, "far too little has changed."
Now watch Margareta Matache, Harvard University, at the Prague November 2015 workshop as she presents on the risks and protective factors that impact these families, drawing on both personal experience and research.
Matache - Risk and Protective Factors
DR. MATACHE: Hello everyone and thank you so much for the invitation to participate in this forum. Thank you Sara, for a kind introduction, allow me just to say that along with my professional affiliations I’m also a member of the Roma community from Romania, and I grew up in a Roma family and experienced some of the challenges that I’m going to talk about today. In my presentation today as Sarah mentioned I will try to touch upon some of the risk and productive factors that Romani children encounter in their closest environments during early years, and allow me to start off by underlining that there is an alarming lack of data regarding the early development of Romani children in their former presentation today which is a case study in Romani, yet there is information from different sources, different applications in relation to Roma, and put them together or correlate them with general global data on early development.
As we all know child development is influenced by a continuous interaction between sources of vulnerability and sources of resilience. And among the sources of vulnerability that we need, especially in relation to marginalized children, I think that the social and economic context but also the school environment and also the family play an important role. And allow me to start with the social and economic context by saying that this is a strong determinant in inequalities in education, but also it affects long-term employment, and it’s an interesting aspect of what poverty means.
And in relation to poverty I think we in the Roma field we are used to speaking very generally but some of the recent literature speaks of poverty in different elements, and I think that the geographic location, the physical proximity, and the neighborhood resources are some of the elements that we really want to look at when we discuss the risk factors associated with the social context and the economic context in which the Romani children live. And allow me to touch upon two of these aspects. One of them is the geography of the Roma communities. Many of you may know that a lot of the Roma communities in Romania but also overall in Europe they live in residentially segregated communities.
Some Roma activists may argue that there are some positive aspects of these residential segregation, especially in relation to promotion of cultural rights and so on, but on the other hand there are a lot of negative aspects in relation to early childhood I just want to mention, for instance segregation. You briefly touched a point, and I think that along with many other forms of segregation, segregation in kindergartens and segregation in schools is led by the fact that many of these communities are isolated.
And it’s not just that the children are separated and they learn in their own environment, but segregation education comes with a lot of other consequences. One of them is that the quality of education in Roma schools, in ghetto schools as they are called in some countries, is much lower than in the mainstream schools.
On the other hand the infrastructure of these school environments is lower and is not as good as the one where the non-Romani children learn. And even more in some countries like in Romania it was shown by the studies that the teacher absenteeism in the Roma schools is much higher than in the non-Roma schools, and I think these are elements that we all have to look at when we discuss education of young Romani children.
And even more residential segregation leads to other problems. One is the fact that there is a lack of kindergartens in the Roma communities, and even more some communities, although it may sound unrealistic, some communities are separated by walls in different regions, and this is an example in Romania where in Baia Mare the mayor built up a wall to separate the communities, this is not the only example in my country.
Another aspect of poverty that we want to look at is the resources that we have in the neighborhoods. And there are serious accessibility problems in many Roma communities, but also in Romania 15 percent of the Roma families do not have access to electricity, and even more, 36 percent of the Roma families, they have difficulties to access drinking water. Just to continue speaking about the influence of the socioeconomic status, we all know that studies proved already that children who grow up in communities that have a lower socioeconomic status, they tend to learn less words than the children who grow up in higher socioeconomic families.
And although there is no data about the language development for the Romani children per se, I think that we can correlate this general information with the fact that 66 percent of Romani children in Romania live in poverty, and 20 percent of them live in extreme poverty.
If we correlate this with the language development I think it’s an important factor that we have to look at. And in addition to that, speaking more about vocabulary and language development, we do lack in Romania as we also lack in Croatia, in Czech Republic, and in other countries, bilingual education, and that also has an impact on the language development of our children. We all know that malnutrition also triggers negative consequences on early childhood development, and in my country 40 percent of the Romani children suffer from severe malnutrition. There are studies that show that 40 percent of our families in the Roma communities, there is a person in that family that always goes to sleep hungry.
Another factor that I really wanted to touch upon is the stress syndrome that normally occurs as a consequence of traumatic events. I think this is a highly undocumented, highly un-discussed factor in relation to Roma community. And a very specific source of chronic stress in Roma community I think is discrimination and stigmatization, and there is no literature on that, but what I can say is that the NGOs that work in Romania, but also in other countries, they prove that there are so many cases of discrimination that exist in countries, and many of these cases affect the development of Romani children. For instance we have abuse police in many communities, we have force evictions, but we also met cases where the Romani families have vanished or been chased away from their communities, and let me just give you an example on that.
Back in 2009, while I was still working with a Roma NGO there called Romani Kreez, we went and documented a case in Harghita where due to the fact that some young people in the community had a conflict, the whole community ended up in a lot of tensions and Romani families including their children were chased away from the communities. Their houses were destroyed, one house was put on fire, dogs were killed, the windows were broken, and all these people had to live in the woods for almost a month.
It’s not like it was enough, almost every day people from the communities would go in the woods and chase these people and threaten them once again. I think that about 25 children were there and they were below the age of seven years old. When the tension finished in the community and the municipality took some measure there was no support for these children who have been going through a lot of chronic stress and trauma during this episode.
And I think that there are a lot of consequences that we can talk about and we can hypothesize and we can imagine, but I just think that we really have to focus much more on discrimination, rejection, and stigma, because what I argue is that this phenomenon, all this decreases dramatically the chances of Romani children for healthy development. And I’m talking about emotional, cognitive, social development, but also I think that this phenomena also pushes for social isolation in some cases. Let me move to another type of risk factors, and this is the school environment. And what we know from the literature is that every child crosses kindergarten with certain fears, with expectations, with experiences that the child and the way the child is perceived or is treated by the school, it influences his or her attitudes towards the educational establishment.
We also know that teacher expectations are assimilated by the children in building up their motivation for education. And we know that the effect of unfriendly behavior of teachers are more pronounced for children belonging to ethnic groups or to vulnerable and marginalized groups. Negative peer relations can lead to negative outcomes such as school dropouts or psychological difficulties. But what is happening in the schools where Romani children go to kindergarten is that we document a lot of cases of discrimination and bullying, but there is no solutions, no skills at the level of the schools to manage those.
What was interesting in Romania is that the Minister of Education, and I think a former colleague of mine, Michael Ionesque was part of that project, was that they trained kindergarten teachers in order to be able to work with Romani communities, and they received some trainings on cultural diversity, on human rights and Romani culture and Romani history. This was a limited amount of teachers. So we went and interviewed teachers where working with Romani children, both those who went to training and those who were not.
And as you can see in these codes you could easily find out that basically those that didn’t go to the trainings, they had this idea that Romani children tend to drop out from school, and that there is a value in Romani culture of not going to schools. But if we look at those who went to training, what they are saying is that the number of Romani children in their kindergarten is increasing, and that’s because they accept the children. And they also mention that these children who went through kindergarten in those environments, they also succeeded to go to high school.
I think these are powerful codes that teach us a lesson about what the school system means for the communities. There are also sources of vulnerabilities in the families, and I think that the literature mentioned as indicators the number of parents or adults in the house, the level of support to perform in education, but also the physical time that parents or caregivers spend with children to read, to explore, or to play.
And just to give you an example -- I’ll try to summarize everything. So 20 percent of Romani people over 14 years old in Romania cannot read and write, and therefore these adults are not able to support their children to reading and to support them to conduct their homework. There are also protective factors, and I think that the literature mentioned among others social maturity, also the extended family, the friends, and also the physical presence of the parents and other caregivers. In the Romani communities we don’t have data, so I just allow myself to mention some of the issues that I think in my opinion represent protective factors in these communities, but probably there are many others. I think that breastfeeding is an interesting phenomenon. Then we have mother and child relationship, which is strong, and also the involvement of the extended family in raising children.
And allow me to summarize and to finalize this presentation with a graphic, a skim that I prepared and which I call the Ecology of non-Roma Privilege in Early Childhood, which essentially summarizes my talk, but I think that what I’m trying to do is to move the focus from the victimhood approach in Romani children, move it a little bit on the other problem, which is I think the society and the discrimination and also all the privileges that the other children get. When I talk about privilege I think that every child is entitled normally to equal education, to health, to non-discrimination, but I think that only fewer, and typically those individuals who belong to dominant majority population, they in fact exercise those rights.
So at the end of the day these rights, although are intended both in theory and law to be the rights for all, at the end of the day in practice they become privileges for the majority groups. Let me just go briefly through this. I think that at the level of the family for instance a non-Roma child gets a lower level of poverty, no experience of stigma and discrimination, lower rates of child mortality, lower transmission of lack of education.
In kindergartens and in schools there are more qualified teachers in non-Roma schools, better equipped classes, welcoming environments where the teacher speaks the same language and they share similar cultural values, and the teaching materials inform about the non-Roma history, about the non-Roma culture, and then in the non-Roma neighborhoods we don’t have indiscriminatory access to kindergarten and daycare and there is more access to water, there is more access to electricity. I think at the level of the society I think that what we can say is that there is better access to power and resources. People who dominate power positions and design policies belong to the majority group, to the non-Roma groups, and I think this speaks for itself, and nevertheless, and I will end here, I think that non-Roma children and non-Roma communities, they had not experienced historic injustice, which is translated into slavery for 500 years for instance in Romania, a holocaust, and forced assimilation. I’ll just stop here. Thank you, and I’m sorry for taking much of your time.
- What stands out for you from Matache’s presentation?
- What type of investments could be made to enhance protective factors for Roma children?
- Why do you think Matache closed her presentation with the schematic The Ecology of non-Roma Privilege?
- What other populations are you aware of who live in similar circumstances to the Roma?
Watch now as the forum hears a policy response from Arthur Ivatts, Open Society Foundations:
Ivatts - Policy Implications
DR. IVATTS: So the cards are stacked against Roma children across Europe. In terms of their situation and the general attitudes which exist both in governments and general public, which really hinders their opportunities to have a good quality education with dignity and respect. And here I have to say it’s a hidden disgrace in Europe. There’s not a lot of publicity about it.
The international organizations have been superb over the last 20 years, and if all their reports have been put into this room we’d have found it difficult to get in ourselves, because UNDP, the World Bank, UNICEF, OSF, the Roma Education Fund, the number of heavy documents describing the research evidence is absolutely massive. But governments tend to be pretty silent on this issue. It’s not high profile, and that betrays all the politics of the situation.
This is the policy response. These are the things that look as though they’ve helped in different parts where we’ve had good pockets of really excellent practice developing. And these are the issues, I’ll go over these very quickly, ratified and transposed antidiscrimination legislation, human rights, rights of the child, and for governments to be responsible for seeing that they are implemented and for that to seep into the culture of the professional groups who are delivering public services. I’m rushing, but all of this will be in the final report of the conference.
Legal prescriptions on inclusive education, certainly training of teachers and all adults working in schools, that includes everybody, on what inclusive education is about, is absolutely vital. And that’s of course followed by the obvious thing. The people who are out monitoring and inspecting and evaluating inclusive education need to be superbly well trained to be able to make correct judgments and feedback to government.
Policy responses, kindergartens and schools, outreach. This conference is about investing and reaching out to marginalized children. So the fact that schools are there, and I remember in the UK we had a great argument with the Ministry saying well, if the Roma don’t go to school, tough cheese, because the schools are there, so if they want to take education they can go. If that’s your philosophy you’ve lost the plot. So there has to be a structural professional outreach function for marginalized children living in communities at the margins.
And ministries of education have to implement realistic inclusion policies. It needs a ministerial analysis of all the hindering factors that stops inclusion, that stops children participating freely and fully in quality education. And then for each of those hindrances to be identified and dealt with.
So we are rushing now, I will rush very quickly. These will be in the presentations. And of course the importance of kindergartens in particular being really welcoming places which affirm children’s identity irrespective of their background. And these are teaching you to suck eggs as we would say in English because these are such obvious points, aren’t they? And the risk factors, again from your presentation, are enormous. And I think they outweigh massively, the threatening risk factors outweigh massively the protective factors within Roma communities. And for that reason I think poverty reduction, you asked us, the organizers asked us to end up with some conclusions and recommendations to our presentations, so these are they. Poverty reduction, free provision, and David has mentioned all the things that need to be put in place within an inclusive policy. Outreach institutional provision, and support, I’ve mentioned that. Provision of safe environments, health , nutrition, infrastructure, safe water, all these things have to be there, as we heard from a previous talk about horizontal and vertical connection of rights. And robust legal sanctions against hate speech and anti-Gypsy talk and language, particularly in the media and professional gatherings.
So why are such comprehensive actions needed to be part of ensuring equal education opportunities? there is a need, seriously, for governments to constructively take action to undo the damage that have been done by governments themselves over a number of centuries towards this particular community.
And because Roma continue to suffer ubiquitous race hatred in Europe, and this underpins everything that is happening and that we see, and I have to say that unless some governments start taking action, including some international organizations, we come uncomfortably close to the criteria for crimes against humanity. Tough talking, but okay, I’ve thrown it in, and it I think is worth keeping in the back of our minds if you start looking at the criteria. So, Sarah, I’m sorry.
- What do you think about Ivatt’s provocative statement that the treatment of the Roma comes "uncomfortably close to the criteria for crimes against humanity"?
At the close of this discussion at the Prague workshop, presenter Radosvetta Dimitrova, Stockholm University, shared this story, written by a young Roma girl which reminds us of the potential resilience of children despite their immediate circumstances.
- What might be the protective factors at work in this young girl’s life?
Given the current situation in the world, it is critical to consider the situation of refugee children. At the March 2016 workshop in Jordan, Mohannad Al-Nsour, Eastern Mediterranean Public Health Network, provided an overview of the current refugee population with particular attention to the Syrian situation.
Al-Nasour - Global Refugee Demographics
Within my allocated time, I will focus on presenting or highlighting the migration pattern and demographics of the global refugee population, taking care to highlight the Syrian Refugee case, migration and demography. I also will explore the impact of fleeing war on children wellbeing, display some regional highlights affecting Syrian refugee children wellbeing and finally, I would like to state some special considerations to be taken care of later on.
As of 2010, at least 15 conflicts have erupted in the world according to the UNHCR’s Annual Global Trends Report. Among these 15 conflicts, three of them in our Middle East region – Syria, Iraq and Yemen. The one in Syria is the worst single largest driver of displacement causing the massive increase in the number of displaced people. The Syrian crisis contributed to a massive increase of refugees globally.
The number has risen from 60 million at the end of 2014 compared to 51 million a year earlier and 37 million in 2005. The number of refugees and displaced people worldwide is higher than it ever has been since the Second World War. Globally, one in every 122 humans is now either a refugee, internally displaced or seeking asylum.
The proportion of refugee children stands at 49 percent upon excluding the Syrian refugee population in the Middle East and Turkey from the global demographic analysis, which stands at the global figure of 51 percent. This indicates that the number of Syrian refugee children is slightly higher than the average.
According to UNHCR statistics, 4,263,020 Syrian refugees registered in the Regional Refugee Resilience Plan countries, which include Egypt, Jordan, Iraq, Lebanon and Turkey. Additionally, we have 303,000 Syrian refugees and asylum seekers in 120 countries over the world – 27 countries in Africa, 24 countries in North and South America, 28 countries in Asia and Pacific, and 41 countries in Europe.
More than 50 percent of Syrian refugees displaced to Jordan, Lebanon, Iraq, Egypt and Turkey are children. Ninety percent of Syrian refugees live in urban, peri-urban and rural areas in Jordan, Lebanon and Iraq.
If we go to the impact of forced migration, fleeing from war of children, usually – and this is a global statistic – there is the impact on children of death, war injuries, disabilities, increased risk of illness and compromised health; additionally, separation from families and caregivers or ending up unaccompanied or stranded, psychosocial and mental health problems due to the war trauma, loss of family members and drastic disruption of their lives; impaired ability to cope, learn, socialize and have moral structure which would impact children’s transition to adulthood; and increased vulnerability to all forms of violence and abuse including child labour, sexual and gender-based violence, trafficking, early marriage, et cetera.
Regional highlights affecting children’s wellbeing include, according to the latest statistics, that only 14 percent of refugee households in Jordan are food secure compared to 53 percent last year. It is almost the same percentage in Lebanon – 11 percent of refugee households in Lebanon are food secure. More than 1.3 million school-age Syrian children are present in the Regional Refugee Resilience Plan countries. Of those, only 48 percent are accessing educational opportunities.
Primary healthcare is provided for free or at a nominal rate for Syrian refugees in Jordan, Lebanon, Iraq, Egypt and Turkey. The public health system is overwhelmed by the increased demand for health services which has resulted in overwhelming patient caseloads, over-worked health staff and shortages of medication and equipment.
Boosting routine immunization coverage for measles, polio and other vaccine-preventable diseases and strengthening disease early warning and surveillance systems is a key priority for the countries. Among the health sector priorities are provision of access to adequate and appropriate reproductive healthcare including clinical management of rape and referral mechanism for psychological services. There are gaps in specific health services for both refugees and host communities, including mental health, at primary, secondary and tertiary levels.
Now the third part of my presentation is special considerations: A resilience-based approach that targets both the refugee community as well as the host community to promote cohesion and reduce tension. Both the development and humanitarian resilience support need to be working in a complementary approach. Humanitarian support not to create a parallel system that cannot be sustained later on. Focus on a community-based approach to promote independency, dignity, self-esteem, satisfaction, ownership and sustainability. Alignment with host country standards and practices to prevent discrimination, competition and conflict later on.
Finally, the evidence-based approach should be promoted to make sure the resilience plan is based on evidence-based medicine. We need sometimes adaptation of international standards to fit with the country’s context, and well-coordinated integration of health services by different agencies to ensure standardized and cohesive care, and multi-sector and multi-level involvement.
Thank you very much.
- Why do you think Al-Nasour emphasizes the need for a "resilience-based approach" that targets both the refugee community, as well as the host community?
- What might that look like?
At the workshop in Prague, Jan Peeters provided an overview of policy recommendations to support refugee and migrant children through investments in ECD. Take note of two or three of his recommendations that strike you as significant or surprising.
Peeters - Supporting Refugee and Migrant Children
DR. PEETERS: After these touching stories I will talk more about how we can invest in early childhood education for refugee children and for migrant children. I will focus on the kind of opportunities that children need, and therefore we have organized until now six forums for policy makers and for researchers to discuss relevant issues on early childhood education.
I will only talk about because I have a limited time on those issues on which policy makers in total there were more than 100 policy makers from the United States and from Europe and also 120 leading researchers, and I will focus on those issues on which policy makers and researchers agreed.
What is very important is the whole question of access. And what we are seeing is in a lot of studies there was a lot of focus on accessibility, and of course accessibility for refugee children is very important, but what is also very important is that they must be useful, desirable, and also meaningful to migrant families and to refugee families.
Because especially refugee families, sometimes the only thing that they have when they are in that country are their young children, and a lot of the refugee parents do not want to give their young children to early childhood education, so we must invest a lot in convincing them that early childhood education can be very useful for them and for their children. And in general there are a lot of policy documents speaking about hard to reach parents, but when we discussed it in those six forums we think that the real problem is not hard to reach parents but it’s hard to reach services. This means that a lot of services do not have the right attitude to reach migrant parents and also refugee parents.
And then work first preparation was another topic of the second forum we did. Of course there are a lot of things that we have to focus on what we have to teach children, but another thing that is very important for the workforce is that they have the competencies to work in the context of hyper-diversity, and especially in the United States and Western Europe we are seeing now with all the new refugees that are coming to Europe we’re seeing that it’s really in a lot of classrooms in early childhood education there is a confrontation sometimes with children of 35-40 different nationalities that speak different languages, and that requires special competencies. And therefore it’s very important that we focus on reflective competencies. Another thing that the forum agreed on is we should avoid ethnic matching. In the beginning it’s always interesting to have the kind of bridge figures, for instance we expect a lot of people from Syria so you could try to hire a person from Syria, but in the long-term it’s not very effective. What we are doing is we have to train people that are able, that have the competency to work with people from very different origins.
And also very important is continuous professional development is as important for the workforce as the initial training. And which kind of competencies do we need? I think it’s very important that we have a workforce that can open us to dialogue with parents, that there is an engagement and an ability to work towards social change. I think it’s very important. In all the visits I’ve done for instance for people working with Roma children, it was also what Margaret said this morning, you have to believe that children are able to develop. I experienced that a lot of early childhood workers are so used to work with children from their ethnic background that they don’t believe that children from ethnic minority backgrounds, that they have huge potential to grow.
And another important thing is the continuous professional development. And I did together with all the other researchers, we did a systematic review on which kind of interventions are really effective, which has an effect on the quality of the service but also on the outcomes of the children. We started with more than 20,000 European studies, and at the end we ended with 70 studies, which are all of high quality.
And what we learned from that is that intensive CBD programs that are effective, they require an active involvement of the practitioners, that’s very important. They must be very focused on practitioners’ learning in practice, that’s also another important thing. And also important is that there is a coach, and that that coach is available during non-contact hours. And it must be embedded in a coherent pedagogical framework or curriculum that builds upon research, but that also addresses needs of migrant and refugee families, so that is adapted to the local context. So that is very important that we focus on CBDs, not only on sending the workforce to courses, but that it’s really that there are people who are coming in the centers and who are asking critical questions to the teams and so that those are the kind of interventions we are successful. And then the whole aspect of parent and family engagement is very important. We must go to more demand-led services and not that the parents have to adapt themselves to the services. And we must engage in reciprocal relation with migrant parents in response to their intent to start co-constructs and services and professions that have meaning to them, that’s very important that they really believe that it has a very good influence on their children. We must avoid the kind of labyrinth of services for very different groups.
And what we have also seen in the forum is that parent participation, everybody is in favor of parent participation, but in different countries it has a completely different meaning. Sometimes it is the fact that parents have to do some things with their children, if they go home and read books with their children then in some countries that is parent participation, but I think real parent participation is a form of citizenship in which parents are invited to take important decisions in the early childhood centers, and we have seen that in very few countries this is the case.
And then about evaluation. A very important is that monitoring and evaluation has to be based on a definition of quality, and then there is the question who defines quality. And in the forum researchers and policy makers, it’s very interesting, they agree on the fact that it’s not only the task because I myself am a researcher, and researchers sometimes think that the researchers have to define what quality is. In reality it doesn’t work like that. I think we thought in the forum that quality has to be defined by researchers, but also by practitioners, by parents, by policy makers.
And then we have also very important is and we see it now also again with the huge number of refugees that are coming to Europe, I think we need integrated systems. It’s very important that it’s not only the school who is taking care of the children, but that we are seeing that healthcare systems, educational systems, that they work together.
Very important is also smooth transitions between home and early childhood education. We see in a lot of countries that children have to adapt to school, and then we talk about school readiness, but school readiness means that the family is ready, that the school is ready, and that the community is ready for the transition. If those three are met then we have children who are ready for school.
Another important thing is that especially for refugee children and immigrant children who speak another language, every transition represents a challenge. We are seeing that the transitions in the educational systems are tailored for middle class parents. When our children are going to school then we are preparing them and saying next year you are a big boy, you are a big girl, you’re going to primary school and it’s great.
With parents who don’t know the educational system, for them it’s very difficult to prepare children for transitions, and I think they need additional help for that. And also we need to make that different parts of the education systems, that there is a kind of alignment to them, that there is a continuing curriculum and didactical methods and also in workforce and in governments.
And then the last part is also very important, the whole issue on multi-linguism and multiple identities. I think it’s very important in a lot of countries a child which is bilingual when it’s English and the national language then it’s seen as an asset, but when it’s a language like for instance in my country when it’s Arabic or Turkish then it’s seen as a problem. So I think children who are bilingual or trilingual, because a lot of immigrant children are even trilingual, that it must always be seen as an asset for the child and not as a problem.
And I think we think in the forum that a lot of work has to be done to learn for early childhood workers to work with dual language learners, and it has to have more attention in initial training and in continuous professional development. So thank you very much.
- Which of Peeter’s recommendations stood out for you?
- Why might refugee families be resistant to their young children attending centre-based programs?
Children living in disease breakout zones need consideration beyond disease protection and treatment. At the July 2015 workshop in Ethiopia, Janice Cooper of the Liberian Mental Health Initiative of the Carter Centre, sets the broad context of the Liberian experience in fighting the Ebola virus, with special consideration to the impact on children.
Cooper – The Ebola Outbreak
DR. COOPER: I want to start by saying a little bit about the programs we run in Liberia. The Carter Center has three programs and all three were actively involved in the Ebola response. We have an Access to Justice Program that works with chiefs and the intersection between traditional law and civil law. And during the Ebola crisis, they were involved in social mobilization to make sure that communities and villages would really respond to the messages that the government was providing. We also have an Access to Information Program that was focused on and is still focused on the freedom of information and they worked tirelessly with the Ministry of Information to allow journalists to do their job during the Ebola crisis.
The mental health program, which I run, trains nurses and physician assistants to be mental health clinicians in Liberia. We also have a fairly vibrant anti-stigma program that works with persons with mental illness and persons with disabilities. I had a lot of help. I first will start by saying that I was asked by the government of Liberia to join incident management system, which is the major response system as chair of the psychosocial pillar. I just want to acknowledge the very many people that contribute to the work that we did in Liberia.
These data are going to be slightly different from CDC. These are our own CDC. This is the Liberian data produced by the Ministry of Health and our epi surveillance unit along with a very famous epidemiologist, Hans Rosling, who was toe-to-toe with us in the need to keep on top of the data.
All together almost 11,000 cases of Ebola. That would be those who were suspected, probable and confirmed, 3170 confirmed cases. Close to 5000 deaths. To explain it very early on, every suspected death had to be considered an Ebola death because we had no way of tracking or doing any post-mortem swap. Only much later on were we able to start collecting accurate data on whether this person died from EVD or not.
We proudly say we have 1548 survivors. Even after the EVD-free declaration on May 9, we had gone 42 days without any EVD case, we got an outbreak, which reminded us that now Ebola is endemic to Liberia. We had out of this latest outbreak, six confirmed cases and two deaths.
Just to say that or to remind you that this last wave was our third wave of Ebola. Our first wave of Ebola happened as Dr. Taha said and basically we were on our way to 42 days and then there was an explosion. And then we went all these months with the epidemic raging.
I wanted to say a little bit about our data on children. We are still trying to disaggregate the data on the children that were affected by region, but most especially by age. We have close to 4000 orphans who had lost one or both of their parents, 52 percent of girls. We have close to 2000 of those 4000 that lost both parents. And we have close to 5000 children that are receiving case management services because they are affected by EVD. This is the data on child survivors that are under five. Five percent of all survivors were under five. Almost 30 percent of all survivors were children under 18. I should say before we go on that there are some positives to EVD. We had a history of Lassa fever that is endemic in our country. We knew that we could overcome the epidemic. Despite what you will see in terms of our health outcomes, we have come such a long way from 15 years of civil war when hardly any of the health infrastructure was standing. We have built on that. In fact, the health ministry was considered one of the most vibrant of the ministries.
EVD comes to our shores and we have, as we know, predictors of some not so great outcomes for early childhood development. We have high rates of poverty, high rates of malnutrition and poor health outcomes. On the other hand, there are in many of these communities, a lot of social trust and there are a lot of structures, which is why we were leaning so heavily on the chiefs that could promote a good response.
Looking at the data for children under five, 40 percent of under five die from childhood diseases. Thirty percent of the under fives die by month one. And another 35 before their first birthday. Our latest situation analysis in 2014 showed that 40 percent of the children experienced stunting. Immunization rates are still low. Birth registration rates are fairly low. Better than they were. At one point, they were four percent.
As we talk about what maternal health is like, which is another predictor of early childhood development, our numbers are much higher than the ones that were shown earlier. These numbers are from the ministry. We have high maternal death rates. Just over 50 percent of mothers have a skilled birth attendant at delivery. We have low literacy and education rates among moms. However, 72 percent of moms do get prenatal care. Sixty-two percent of moms do have access to vitamin A and 12 percent iron and half of moms have access to de-worming prior to birth. We have a significant water and sanitation problem in our country. Open defecation is still a problem. And access to safe drinking water while improving is still a major problem.
On the other hand, in 2011, our president was able to pass, nobody quite knows how, a children's rights law that was based on the convention rights of the child. However, when Save the Children did a survey, only a third of caregivers were aware that any laws existed to protect children and only 15 percent knew that we had a law. Seven percent were not aware of mandated child welfare committees within the communities. A quarter of those found them to be ineffective. We also have a history of a higher proportion of children who though they may have both parents alive are sent to live with someone else. Probably the biggest tragedy and we are trying to figure out why is the high rate of child sexual violence. In Liberia, we have high rates of gender-based violence and rapes. The bottom one is for the year to date, 2015 to date, and the top is for 2014.
The tragedy is that 86 percent of the rapes last year were for children three to 16. Ninety-one percent of the rapes this year so far are for children three to 16. Last year we had five child deaths as a result of rape. In early childhood development and I am sorry that the Minister could not be here, the Assistant Minister for Early Childhood was here for the last two days and she had to leave early. But we have been working along with OSF on developing an intersectoral policy on early childhood development. We have a champion in the current minister in supporting this movement and she has been intricately involved. They have started an early childhood training framework -- worked on the early childhood framework, training framework and our training communities as well as doing skills-based training for caregivers, parents, and teachers.
The training framework also includes and these parts have not been operational yet, certification for primary school teachers in our training institute, degree certification programs. A major disruptive even before EVD is insufficient funding to promote and we talked about this in an early breakout session, many of the plans and policies that are laid out by the government. In addition, Johns Hopkins has been very instrumental in training around early and newborn care in the health care setting.
We also have pretty poor educational outcomes. Liberia has the lowest number of qualified teachers in sub-Saharan Africa. The lowest proportion of female teachers. Only 35 percent of eligible children are attending primary school. And we have a heavy reliance especially K12 on donor support for education. Infrastructure is pretty bad especially when you get outside of the capital cities of the counties. There is a huge draw on parents' discretionary resources to pay even though schools are free. You have to pay for uniforms. You have to pay for books. You have to pay for food even though there are some schools that have supplemental feeding programs. On the other hand, parents are willing to do this and always say that they are willing to have their child get a good education as a result of that.
There is a misalignment too in terms of age-appropriate grade level. You can find someone that is 15, someone that is 20 that is in kindergarten and that makes for a difficult situation for younger children. That is just a precursor to what we were dealing with before Ebola struck. Who are the actors? What was the structure like and what were some of the results? UNICEF save plan. SOS is a local as well as think local NGOs. Child Fund and WHO were probably the fastest actors on the ground followed by IRC, ACF, IMC, and IOM. These are the actors in the child space. Obviously MSF and others more broadly.
I wanted to show you this because part of our structure involve that on a weekly basis, we reported on every aspect of the response and this went to the president. This is what the structure looks like. The pace is the president's advisory committee. There you see us sitting right on the case management. The case management was responsible for all of the medical delivery. Right next to us is dead body management. And has been alluded to before, the disposal of bodies with EVD is critical to stopping -- safe disposal is critical to stopping the infection.
I should say right now that one of the most controversial things that happened in the response was that after one day when there were over 100 bodies lying in different parts of the city dumped there by people who did not know whether their loved one died from EVD or cholera or another infectious disease. The President made the very unpopular decision that we would start to cremate. Very unpopular because that is totally antithetical to our culture. It did not go over very well. It led to a lot of distrust in communities, which of course distrust feeds an epidemic such as EVD.
What did the National Psychosocial Subcommittee -- what were they responsible for? Supporting affected families and children, helping families and communities understand the disease. This was particularly important when whole communities had to be quarantined. And also, to look at the quality of care that was being delivered in ETUs. I heard the illusion that Janna made to ETUs not being prepared to deal with children, especially young children. That was something that was addressed fairly early on in terms of working with UNICEF and our other partners to deliver protocols for how to work with persons. We borrowed very heavily from the HIV world in terms of people understanding that they did need to do both pre and post-test counseling and not just tell somebody that I am going to give you an Ebola test and you will die or you will likely to die.
Some of the things we did and they did not all come together right away. A lot were very much lessons learned. But it became very clear that with so many actors on the ground, everybody was on the ground trying to support the response that we did not know as a government what was happening when and to whom. You would have whole communities that had been visited many times and maybe they had one EVD case. Whereas communities that were highly affected had not been visited at all. One survivor said if I get another bucket and another mattress, I don't know what I will do with myself. And another survivor said why don't they stop scratching where I don't itch. I need money and a job. It was clear that we needed, A, make sure that we were all coordinated in the response especially the actors that were coming in from outside and that coordination came with commitment. We had a commitment conference and we only allowed those actors that were able to commit to what they were doing, when and where.
We had daily planning and reporting. We had documents to facilitate actions that were taken within ETUs, Ebola Treatment Units. Transfers that happened with individuals to and from communities. Ways to track individuals and unaccompanied children. Our committee met three times a week and that fed into daily meetings at the incident management system. We had a parallel system going on at each county.
The child protection. We had different subcommittees. One was child protection. The other was the Ebola Survivors Network that included a range of other activities including a clinical network. You heard that significant post-Ebola sequelae including eye problems, uveitis, non-specific chronic fatigue problems, a lot of arthritis, just a range of post-Ebola sequelae. It was very important very early on that the survivors got involved in terms of stigma because a lot of survivors were kicked out of their homes even though they had paid their rent. A lot of them were not allowed to go back to their jobs. There were significant issues even with when they were fit to work to be reintegrated into society. There were monthly meetings of survivors and a lot of coverage of that. Survivors were intricately involved in the coordination of the response.
We had a training subcommittee that became very clear early on. Everybody willing to do their own training and that is problematic. There were some people -- it was clear that we need to make sure we had gaps and what was not being covered whether it was a different population or whether it was a different community.
What happened to young children in the response? First of all, we had to set up what we called ICCs, which were childcare facilities. These were for children who were contacts, but did not have Ebola. As you can imagine, children in a family may have been exposed to EVD, but they did not have EVD. Their parents were admitted to treatment units. Actually, in total there were six facilities for children that were affected and unaccompanied, four in Monrovia and two in Central and Northern Liberia. Three of the ICCs were for children across the board and then we decided that we needed one specifically for zero to five. We had an ICC for zero to five. We also had a transit center because, as you can imagine, at some points, we had curfew and there were certain times that you could not travel long distances. Just outside of Monrovia, we had a transit center for children who may have been leaving an ETU or about to enter an ICC and needed a place to stay.
This is one of our ICCs. It is called a Kelekula. It means blessed heart in Pela, one of our dialects. The lady that you see there is a survivor. She was one of the first staff to the ICC in Monrovia.
I should say that UNICEF was very helpful in training all of the survivors that worked as staff in the ICCs across the country. There are some issues in terms of how we worked. It was really important to continue to have strategic planning meetings with major partners to foster collaboration. Among the early actors, I said was UNICEF, Save, WHO as well. And some of the challenges were that people could promise something on the ground and there were log jams in delivery. And then other actors, as you can imagine, were very unfamiliar with the terrain and unfamiliar with the culture. That often added to problems on the ground.
In terms of coordination, some of the things we were keen to do very early on were, as a case management, we had to develop clinical guidelines for mental health and psychosocial in general that fed into the clinical guidelines for the management of the ETU. And then obviously we had to have specific guidelines for how children were taken. In the early days, children would be just roaming around. Their parents may have been on bed. And some NGO or ING would come and just collect them and nobody knew who those children were and where they got to. It became very clear very early on that we needed to get on top of, A, what were the specific guidelines of how children were to be released and not anybody who looked like a foreigner who was here to help just got to take a child away. And also, to make sure that we had ways of making sure that when journalists came and others to take pictures of children they knew what the protocols were. We also had to develop tracking forms for children that were separated and unaccompanied and forms for the NGOs that were working with families. We did not have the same families being visited all the time because they lived close to the main road and that those that lived further away were not seen. We had to have forms for reporting on mental health and psychosocial and guidelines for reporting on ETUs. We had a concept called CCCs. At one point, the ETUs were heavily oversubscribed to the point when you probably saw this on TV where people were dying outside the gates of the ETU. There was this idea that we would have communication where anybody with any kind of infectious disease could come. We only had a few of those that materialized.
What are some of the other consequences that impact children? Schools were closed. Schools were closed because, as I talked about before, there was poor infrastructure and poor wash within schools. The risk of infection was really high. The Ministry of Education did have a school radio program. In some parts of Monrovia, this was by no means widespread. There were some homeschooling programs that had been undertaken by various NGOs.
Children, especially young children, were often left unsupervised and unsupported. We had at the very beginning when the President declared an emergency, probably about a month where most people did not go to work if they were considered nonessential. But after that, people started going back to work and started being engaged in the response actually. Sometimes working the response paid more than your regular job. Often young children were left unsupervised and unsupported or supervised by other children.
We consequently as did Sierra Leone saw a surge in teenage pregnancy. Because the health care workforce for the most part was affected by the response, we also had poor or no prenatal care. This was especially difficult. We had 378 EVD infections and we lost 192 health care workers to EVD as they were carrying out their jobs.
But we also the halting of interpersonal contacts of rights and burials. You know what that generally means in a society that is used to holding, shaking hands and essentially showing their affection. We saw the closure of many health facilities, which led to a surge. We did have a measles epidemic just at the end of our 42 days.
School reopened recently and at that reopening, we found that all the wash facilities that had been put into place were clearly not enough. We had to redouble our efforts.
- Why does Cooper spend several minutes of her limited time describing the situation in Liberia, before the Ebola outbreak?
- As you listened to her, what struck you most about the situation for children?
Cooper – Lessons Learned
DR. COOPER: Let me quickly talk about some lessons learned. If you don't have the foundation, it is hard to build the foundation in the middle of an epidemic. There was a lot of foundation that we needed that we just did not have. Coordination, as I have said, was really important. In a humanitarian response, we always talk about depending on where you are, the three W's, the four W's or the five W's. All the W's were out of date by the time they arrived at a meeting. You just could not keep up with what was happening. That was a huge lesson for us.
There were short-term rotations, which were difficult to support in an emergency. People come in for two or three weeks and they are gone and there is not the history left behind. That was challenging. We had very few technical experts in our area. There were very few child developmental specialists. There were very few people that worked in early childhood. And there were very few people even that were psychologists or very few psychiatrists. There were no disability specialists at all. The other thing we learned is that integration was so critical, integration of education, of health, of child protection and of wash. We know what needs to be done. We know that promotive, protective factors, mental health, social skills, coping skills, parental mental health, community engagement, all of those contribute to supportive communities for early childhood.
We also know we need to address collective trauma. As have already been pointed out, we are aware that we came out of 15 years of civil war and we have been only been 10 years rebuilding. We have a lot of unresolved trauma. We know we need to strengthen families. What are we doing about that? Restoration of Heath Services through what is called Building Back Better is something that we have been involved with. Recently, the World Bank funded Mercy Corps to begin work that is called Comfort for Kids for children up to eight where they are going to be through schools during play therapy and working with kids to work through the trauma. And then we have a child and now a mental health clinician training program that the Carter Center is about to enroll. UNICEF and the Ministry of Education are now putting psychological first aid into all schools, a little late, but we are still doing it. And there is now the charge, I think, to look at how we fund the early childhood policy that we have, how we invest in the building blocks and apply the science that we know works especially in the areas of nutrition, health, wash, and social protection.
I want to just leave with a couple of cautionary words for us. Donors and NGOs must live up to commitment for prioritizing young children. I don't think that was necessarily done all the time in this epidemic. It is hard for us to see other countries that have really had with donor support investments in young children and seeing that is not the case in Liberia. I don't understand why the UNICEF policy is different in one country in terms of early childhood development and not in another. I don't need to pick on UNICEF about doing early childhood at least, but it seems to me that there should be similar things everywhere. All actors must be investing in communities and girls. Thank you very much for your time.
- Do the lessons learned from the outbreak offer some hope that conditions for children may improve as a positive outcome of a terribly negative event?
9.2 Understanding the Dynamics of Extremism
Children who grow up without hope and families who fear that today’s hardships will endure into the future are vulnerable to political and religious extremism. Despair nurtures violence and distrust. Recognizing and engaging trusted individuals and institutions is essential to counter violence and extremism.
Watch as Rami Khouri, American University of Beirut, provides an analysis of the underlying conditions which led to the current conflict in the Arab world.
Khouri - The Conditions for Violence
MR. KHOURI: I can’t tell you anything about investing in children. You are the experts on that. What I can tell you about it is the environment in which these children are born and are growing up and are maturing. Some of these people that we call children are actually adults at the age of 10 or 12 years old. There was a report released two or three days ago by UNICEF on regional condition and national condition of Syrian children because of the five years of fighting in Syria. If you haven’t seen it, just go to the UNICEF regional website and take a look at the executive summary. It is quite startling that you have kids at five, six years old who are working to bring in some money. Not just begging on the streets. Some of them are working as delivery boys or whatever. You have young girls at the age of 11 and 12 not just getting married, but also giving birth.
This is obviously an extreme situation. Not very many people are doing this, but it is more than 10 or 20 people who are in this situation. It is an indicator. It is a red light of the very difficult situation that exists and the trends that may continue to evolve.
In my 20 minutes, I will basically talk about three points, which we agreed upon when we discussed this as the problems and the vulnerabilities that face children and youth, the situation about youth realities and perceptions and responses the world is seen by young people, and finally some comments on the research and policy linkages and the policy recommendations or policy issues that should be taken into consideration by everybody, by governments, private sector, UN agencies, NGOs, educators, religious leaders, civil society, everybody has to be involved in addressing this issue.
Let me very quickly in the limited time I have make some general comments. We will have a brief Q&A, and I will be here until the end of your morning. I am happy to chat with anybody or this afternoon.
The reality of this generation, this cohort of young people, and we are talking of young people say up to the age of 14 or something like that, very young people. The reality is that this is the first generation of young people that was born into a situation of simultaneous hopelessness and rebellion by their parents and by their older siblings. The last five years have been an extraordinarily important turning point in the modern history of the Arab world and the Middle East. It is not an accident that this is the 100th year now of the last tumultuous century that started in 1915, which has been rather traumatic and tumultuous all over the Arab world. It is not an accident that five years ago, we started to have these major uprisings. Now we have four or five countries embroiled in civil wars and serious domestic tensions. The conditions that prevailed over the last century never, and I say never, truly gave citizens in any Arab country full citizenship rights. We never had an Arab country where the consent of the governed was an institutional imperative and a structural component of statehood.
We never had a situation where public power and authority invested in different kinds of national leaderships was ever fully defined and validated in a meaningful way by the citizenry. We had citizens whose lives improved, significantly improved from 1915 to around 1980. There was an incredible developmental spree. But in the ‘80s, it kind of stabilized, and it has been going downhill ever since. You measure it in any measure that you want. You can see the decline.
But the biggest measure, I would say, is four things. Starting in the 1980s, we had a mass immigration of the youngest and brightest people in the Arab world. They just left. They went to London, to New York, to Australia. Some of them went to Dubai, which is in the Arab world, but sort of different than the Arab world, as you know. But it gave them opportunities that they didn’t have at home. The second indicator was mass support for the Muslim brotherhood, non-violent, peaceful Islamist movements. The third indicators was the uprisings of five years ago that are still going on now in different forms. Mass citizen discontent, unprecedented across the whole region. The four indicator and the most ugly was the rise of the so-called Islamic state and everything that it represents, and the continued expansion of Al-Qaeda in pockets all over the region.
There were four very clear indicators. You had to be blind to miss them. In fact, the prevailing power structures in the Arab world, the foreign donors, the international powers that supported the Arab systems, were blind. They didn’t see what was going on. They didn’t look beneath the surface of GNP annual growth indicators. Therefore, they missed these signs. These signs have been with us for almost 40 years now, since the mid-1970s.
This is the first generation now of young kids that is growing up in this context in which this order of the last 100 years has started to fragment seriously and to collapse in some places. Young people see their parents or their older siblings today either demonstrating on the streets or fighting in civil wars or giving up the attempt to create more democratic participatory and accountable societies. Or desperately fleeing to Europe and risking death at sea because the risk at death at sea is less than the risk of death at home in your own country where you are being bombed either by your own government, regional powers, rebel groups or foreign great powers.
- What were some of the indicators or factors that Khouri contends should have signaled signs of growing discontent?
Conditions for Conflict, cont’d
MR. KHOURI: Keep in mind that 15 percent of the Arab world is fine. They are doing great. I am sure you talk to them, and they tell you about entrepreneurship and they tell you about private investment. All of that is correct. But 85 percent of the Arab world is not fine. It is in deep trouble. They are the people who are fleeing, joining Islamic groups, joining rebel groups, fighting their governments, breaking away from norms of authority, whether it is the family or the community or the religion or the state. Trying to come up with something responds to their needs.
Let me give you just a couple of quick statistics that show the magnitude of this. In April of last year, UNICEF did another study that showed that there were 21 million young people, children and adolescents, out of school. That figure now is probably around 24 million given the wars and Yemen and Syrian, probably 24 or 25 million. These are kids who should be in primary or secondary school, and they are not. They are out working, whatever they are doing. That figure is probably increasing.
The main reason that explains this according to research is the low education quality, the low standards of educational teaching, of instruction, and the low quality of the school environments. There is nothing wrong with the kids. But there is something wrong with the system that tries to teach them, especially in the public schools.
This cohort of children now that is between the ages of 5 and maybe 15 or 18 is, to a large extent, condemned to a lifetime of poor educational quality, low professional capabilities, lack of creative and entrepreneurial thinking. Therefore, they are probably going to perpetuate what some of their parents have experienced in the last 15 years, which is a steady by slow decline into poverty or the edges of poverty, marginalization, vulnerability and ultimately political despair.
What drew the uprisings, what pushed people over the edge was the sense of helplessness. It wasn’t just being poor. It wasn’t just living in an autocratic society. It was the feeling in the late 2000s, 2005, 2010, was that critical moment when millions of people, like Mohamed Bouazizi who set himself on fire to spark this process. Millions of people around the Arab world suddenly realized that there was no chance that they were ever going to improve their life conditions however much they went to school or went to work. The highest unemployment rate for the last 20 years has been with educated high school and college graduates in the Arab world.
People realized about 10 years ago that there was no chance that they were ever going to get out of the poverty that they inherited from their parents and their chronic vulnerability and marginalization. They wouldn’t accept it. What they did is what they did, the uprisings.
- Do you see a relationship between the state of the education system and the degree of unrest in a society?
Khouri - Recommended Policy Responses
MR. KHOURI: First thing is to listen to young people seriously because what we found was that the grievances of youth very accurately reflect the grievances of adults. The only thing different is young people speak out more openly. They are willing to immigrate, whereas older people are not so much.
The second thing is to address the issues that youth complain about in a political and economic context. It is not enough just to create a job-training program or to try to train some teachers, which people have done for the last 40 years. The conditions are worse now than they were 40 years ago.
There needs to be political and economic and social progress done at the same time. The study we did with UNICEF ourselves just about six years ago, it is called The Generation on the Move. It is available on the UNICEF regional website. It is a study of youth all around the Arab world. Basically, it essentially said that this was done in 2009 or 2010, just before the uprising.
It essentially showed that young people have grievances. They have complaints, but they are not becoming revolutionaries. They are not becoming violent. They are fleeing or becoming criminals. They are creating their own parallel worlds in the internet, in the marketplace, in the mall, as the mosque, in the neighborhood. Young people are adapting to these conditions by creating their own wills as well as they can.
The last point I would say is the issue of recommendations and policy linkages. We need to understand, I think, three things. First of all, the drivers of discontent, what are the range of issues that young people actually suffer from? Not what we think they suffer from, but what they suffer from. We can get that very easily by listening to them. They are also putting it out there on the web.
The second thing is what are the priorities in the minds of young people as well as adults? Is it jobs? Is it money? Is it fresh water? Is it an independent judiciary, free media? What is it, less corruption? The third thing is the perceptions in the minds of youth and adults of what causes somebody to go over the edge when their grievances accumulate and become so great that they take that final step. They decide to flee to Europe, to go join Islamic state, to go join the Muslim brotherhood, to go and join their tribal leader and create a tribal unit instead of a political unit. What are the drivers of citizenship or lack of citizenship? How do people respond to their grievances and their stresses? In other words, subjective well-being of young people, how they perceive their condition, is probably the number one issue that we need to study together. My last sentence is that in studies again done by many reputable scholars show that in the period of 2009-2010, the Arab countries that showed the greatest amount and quality of discontent among their citizens were Egypt, Iraq, Tunisia, Syria and Yemen. Those were the countries where you have the most violent kinds of events going on today. Citizens in those countries were not satisfied. They were not satisfied by a combination of political and economic issues, which impact the young people today much more than they did 10 or 20 years ago. Ten or 20 years ago, people felt they had a chance to improve. Today, that sense is largely missing from 85 percent of the people in this region. I need to stop there. Thank you very much. I hope this has been useful. I would be happy to answer questions or hear your comments.
- Why does Khouri emphasize the need to involve youth in developing policy responses to conflict?
- Do you know of successful cases of youth involvement in developing policies?
Aber - The Complexity of Violence
The work I’m actually going to describe in a little bit of detail to be concrete is actually work that we did a while ago through a thing called the project on children in war at Columbia, at which time in the late 80s both the convention on the rights of the child was being developed, and the shift from survival to thriving was happening. But I think it has some lessons for us today. I’ve become increasingly convinced, unlike somebody in the audience, that science is important for action, research is important to inform action.
But two messages overarching today. The first is that violence is complicated. There’s many levels of violence, many types of violence, many correlates of violence, many consequences to violence. Violence is not monolithic. And we need to understand the varieties of experiences of violence at the individual level besides at the population level if we’re going to begin to understand this.
Just to be clear about it, violence can exist at at least five levels. Between countries, the geopolitical conflict between Iran and Saudi Arabia defines a lot of this region. Within regions, Syria the most glaring example right now. Within communities, between families and then in intimate relations.
And there are increasingly good interdisciplinary research that certain forms of violence potentiate other forms of violence across levels, that there is what Ann and other researchers called cascading effects of violence from one system to the next. And so the challenge of developing a peaceful society is going to have to recognize the complexity of violence in children’s lives and at these multiple levels.
We rarely actually ask children about the extraordinarily variable types and specific types of violence they’ve been exposed to through war. So back in the ‘80s Mona Macksoud and I developed a thing called the War Related Trauma Questionnaire, I think is what we called it. But it had 45 rotten things that could happen to kids in 10 categories of rotten things, and you can see some of them.
And we heard about some of them every day in the newspapers. But there are these kinds of varieties of things that can happen to kids in the context, and they were happening to children in Lebanon in the mid-‘80s during the civil war. You work on things like this, and we applied statistical procedures called factor analysis, but it’s just to look at patterns, to try to identify patterns of exposure to war.
And we found four big patterns to be representative of children’s experiences in Lebanon. Some children were actively involved in the conflict. They were direct victims of violent acts, they were involved in hostilities themselves, they were separated from their families often by being engaged in violence. There is another pattern that had to do with loss, displacement from their homes and interpersonal loss, bereavements, those clustered together.
There was a form of passive involvement that involved more exposure to shelling and bombings, witnessing violent acts, and physical injuries. And then there were things that were relatively limited. Some families emigrated, and those families that emigrated actually showed the lowest in socioeconomic deprivation. The families who could afford to leave did. What we find is actually meaningful patterns of associations between their patterns of exposure to war related trauma and children’s outcomes.
So for instance active involvement, as you might predict, the more children were separated from their parents the more depressed they were. This is a classic finding in mental health literature. The more they were a direct victim of violence the higher number of PTSD symptoms they had.
But unless you ask you might not discover that the more children were separated from their parents the more pro-social they became. This is a terrible paradox. I don’t recommend active involvement in war and separation from your parents as a normative developmental way to become prosocial, but children were developing adaptive responses as well as challenging responses to the experience of war.
Similar situation with loss. The more displaced, the more experiences of displacement children were, the less planful they became in their daily lives. The higher the bereavement however, we find again the more bereaved children increased their prosocial behaviors and their prosocial attitudes towards help, maybe through empathy. Bereavement though, the higher the PTSD. So we find these expected findings for mental health, but these paradoxical findings about prosocial things as well.
Finally, passive involvement. The more children witness violence the more planful they become. That makes a lot of sense. I’m going to figure out how to move through this environment in a safe and meaningful way. But it’s also the case that witnessing violence, exposure to shelling and bombing, increase PTSD. This shows the diversity of children’s experiences and the diversity of their reactions and the need and the desire to target interventions to those I think is one of the big messages.
I want to reinforce Ann’s major message. Ann’s major message is the way to help children and families is to provide a broader context of support. And we know that safe places for parents and parenting in the family, gender safety and in the community, are critical, and they’re vulnerable under conditions of armed conflict. Safe spaces for children like the McConny Center that we visited yesterday, ECD centers, play spaces and schools, as Ann said those are the first things to be restored on a path toward normality in post-conflict situations.
We haven’t talked much about economic and food security. Economic and food security keeps parents in refugee and conflict affected situations up every day and every night, virtually panicked. How to create work in refugee situations, and how in the absence of work we can provide cash assistance to families is critically important. And restoring those kinds of family and community routines. All of these will help with development. But they’re going to live, the children and the parents, with these residues of depression and PTSD and these challenges to parenting.
So besides supporting the broader context, I think there are two primary strategies that we could be pursuing now systematically. The first is short term targeted mental health interventions delivered by lay community health workers. We do not have, we will never have enough mental health professionals to address the mental health challenges associated with children exposed to armed conflict through mental health professionals. But we can train lay workers to do that. The same with parenting interventions.
The science is beginning to identify things like what are called common elements treatment approaches, where we’ve systematically reviewed the literature, this is Laura Murray’s work, there’s many others to it, to find common elements for successful treatment of things like depression and PTSD, to shift the task of that being provided from high educated professional mental health workers to being provided by lay or community health workers, with adequate training and supervision.
It requires cross-cultural adaptation, but in the specifics, not in the principles, and there’s a growing evidence base that it works. Six, five sessions, you can actually combine these such that you’re addressing issues related to PTSD and depression in the same program, five or six sessions. And they are showing efficacy.
Similarly there’s parenting programs that are also taking common elements approaches. What are the common elements of parenting interventions that we are beginning to identify that make a transformative effect? Parenting for lifelong health, a World Health Organization initiative, and parents making a difference, the IRSC doing it in Lebanon are just several examples of this.
So in closing I think that research can uncover patterns that can help us respond to kids in crisis due to armed conflict and war. I think the research community has a number of challenges about developing better measures. I think that the future for this will require a different relationship between NGOs, government service providers on the one hand, and the research community on the other. We do too many little fly by night uncoordinated research efforts, we don’t join research powerfully to service provision.
And that’s got to be the future, there is no ethical research without some thinking about the direct practical implications of providing services. And we’ve got to make the whole greater than the sum of the parts. This is the largest refugee crisis since World War Two, and we can socially organize to learn much more powerfully not only in Jordan but in Lebanon, in Turkey, in Egypt, in Iraq, and in Germany, and develop an understanding that we don’t have right now. Thanks very much.
Larry Aber, New York University, makes the point that violence takes different forms and occurs at different levels, from individual to inter-state. By collecting data from children who have experienced violence, Aber and others have discovered some predictable outcomes and some paradoxical outcomes. Challenge your recall with the True and False exercise below. Try to hypothesize an explanation for each situation.
In the following interview with Aber, he expands on the importance of linking humanitarian relief and development aid and in using the science of child development to guide investments.
Aber - Humanitarian Education
Absolutely education and child development should be part of humanitarian funding. There has grown up over since World War II a bit of divide between humanitarian relief and development aid. And for a very long time development aid was thought of as what it takes to survive at the moment; a tent, clean water, enough food, a place to move eventually that’s safe enough. And all of those are fundamental. But, children can’t wait to learn. If we’re asking them to wait for the length of time it takes for refugees to return to their home which is on average, seventeen years, a child is grown up. So we have to make education a part of humanitarian relief for multiple reasons. The biggest stress on parents in refugee situations and emergency situations is taking care of their kids while putting a little food in their mouth. If we can help take care of the kids, we actually free the parents; both from their own stress but their ability to do things that they can’t do if they’re with their child every single second. That’s number one. Number two, children languish if they are not engaged. From an infant and toddler through a pre-schooler through early elementary school age, if children are not engaged in learning, they’re engaged in other things, about two-thirds of which are not good. So, children are brought into this world with equipment, where the most urgent things in the first two decades of their life is to make relationships and to learn, and education is the fundamental path to learning.
- Do you agree with Aber’s position that the establishment of education be a priority in any humanitarian response?
- Where would you place this priority against health services or employment for adults?
As the interview continues, Aber outlines the approach to education that is needed in response to trauma and draws on the example of Learning and Healing Classrooms.
Aber - International Rescue Committee
In many conflict affected, and some low income countries, forms of education, including early education, are top-down, teacher control, highly punitive in some instances, inducing compliance through fear. Some of that comes from colonial tradition that has been misplaced, some of it comes from teachers being under enormous stress themselves, and teachers and parents, when they’re enormously stressed, have shorter tempers, become more harsh and punitive in their approach to children, that’s almost a universal law of child development and parent development. So what can we do to break that cycle? The International Rescue Committee has developed programs called Learning and Healing Families, and Learning and Healing Classrooms, and they’re both meant to establish the caregiver’s or teacher’s ability to establish an environment of safety and support for the children. And they’re very practical and concrete things. The IRC has run a randomized control trial of Learning and Healing Families in Burundi with refugee families, and found it had very positive effects on parents and on early child development. I’ve collaborated with them in evaluating Learning and Healing Classrooms for children in early elementary ages in the Democratic Republic of Congo. So let me just spend a minute describing that work. The Democratic Republic of Congo has been the epicenter of what some historians call ‘Africa’s World War’. From the nineties through ‘til the two thousands, mid two thousands, there were seven or eight nations involved in cross-border and within border conflicts that have led to five and a half million deaths in the Great Lakes region of Africa. The one that’s most famous in the United States and Canada, for instance, is the Rwandan genocide that one tribe and ethnic group was persecuting another, the other rose up in rebellion, drove the first group into the eastern Congo. And that set of conflicts that were related to many, many things led, sometimes, to direct death through assault, but ninety percent of the time, people died because they fled into the jungle to escape violence, and they died of disease or starvation. So they fled, at first, for their safety, but they were hurt in that process. Imagine that being all around for twenty years, it was so bad that, they’re really, that the Congolese education system declined. Back around 2010, things got stable enough that international donors like the World Bank, like U.S. Aid, like DFID said ‘let’s try to start education again and support the Congolese people to create education, Learning and Healing Classrooms, how can you help a community and a culture like that, would turn to education where safety is a fundamental concern. So, Learning and Healing Classrooms was developed. We found that after, in two different big sets of regions in the Congo in a rigorous experimental trial, Learning and Healing Classrooms improves kids’ perceptions of their schools and their teachers as safe and supportive; that’s job number one. And happily, it also improved children’s literacy and numeracy. A year of Learning and Healing Classrooms improved children’s rate of growth in reading by four months to the year, and in math by ten months to the year. Now, these are gigantic relative gains, but they’re relative gains against very, very low learning rates. So, we were wildly successful and completely inadequate in helping children get to where they need on the learning cycle. That’s the good news. There’s two pieces of bad news. One is that we did not affect their mental health or their experiences of victimizing or being victimized by other children. So, being safe, in a safe and supportive environment is enough to do a first stage of learning, but it is not enough to really heal the mental health wounds. It’s necessary but not sufficient and it’s also not enough to promote the rapid learning it would take for children to really leave grade school literate and numerate. So this is a great success and wholly inadequate, and we are carrying that kind of work into the work now we’re doing in Niger and Lebanon and a second stage in the Democratic Republic of Congo to try to figure out how to do learning in emergency situations in a different way. The final thing I’ll say is the Congo, like many African countries, has over two hundred indigenous languages. Two hundred. Imagine, in a country of seventy-five million people, having two hundred different languages that people speak all the time. There is one language of instruction, French, because it was formerly the Belgian Congo, but there are also dominant mother tongues. Kiswahili is, in the eastern Congo, a dominant mother tongue. The really cool thing about Learning and Healing in Classrooms is that it helped minority mother tongue kids grow faster than majority mother tongue kids. Majority mother tongue kids, the Kiswahili speaking kids improved, but the language minority kids improved even faster and what we’re looking for are interventions that not only improve things for everybody, but they improve things faster for the most marginalized and the most deprived. You can imagine, imagine two lines. If the more deprived are going up faster than the less deprived, but everybody’s going up, that’s a positive thing. Imagine another set of lines, the more disadvantaged are growing slower, and the more advantaged are growing faster, so we’re trying to foster both positive development and equality, equity; we’re trying to close the gap between the most advantaged and the least advantaged, and Learning and Healing Classrooms looks like one tool to do that. And nutrition programs too, the nutrition programs mean the most for the kids who are the most malnourished, although everybody likes a good meal.
- In what ways did the Learning and Healing Classrooms project turn out to be "wildly successful and completely inadequate?"
- If you were a policy maker, what would you do with this information?
Recalling the story of Ashma and her family at the start of this unit and drawing on the information we have explored consider the following: You have been hired to coordinate family services and supports at Ashma’s refugee camp. The camp is home to thousands, most of them families with young children. Like Ashma and her children, they have experienced violence in their homeland, traveled great distances under harsh, traumatic conditions in the hopes of a better life and are now situated in a crowded refugee camp with no immediate options in sight. You have the opportunity to design a web of services to improve the situation for the children. The work is underway, but will be a work in progress for some time, as resources are limited. Who have you consulted with in your work? What supports or services have been prioritized and why? What would you hope to be able to say to Ashma on her first morning?
9.3 Building peaceful societies starts early
Humanitarian work in challenging environments can promote individual and community resilience. Learning to get along with others early in life carries forward to pluralistic, cohesive societies. Peace-building must be grounded in social justice, equity in opportunity and resources and respect for differences and diversity. Many of the experts who gathered at the iYCG workshops have come to believe that wise investments in early childhood development can not only change outcomes for individual children and subsequently their children and their immediate communities, but that investment in early childhood development may hold the key to building a peaceful world.
In the following interview, Masten articulates this position from a resiliency perspective.
Masten - Learning to Get Along
There's a real interest in the possibilities of early childhood for a peace building effort, and I think it's the realization that a lot of the roots of empathy, of understanding others, of, you know, getting along and learning about other people. A lot of those roots come about during early childhood, and we also want children to develop some foundational skills for learning and getting along with other people. You're not going to be done with this in early childhood, but you want to lay a foundation, so that children have the capability of, you know, playing with other children who are different than themselves, for understanding their different ways of doing things, that people have different cultures and traditions. And we know that interacting and you know, exposure to other children and playing together make a difference that of understanding, of having sympathy for the other. There has to be contact, but we also know that, you know, learning how to navigate difficult situations. You know, children learn that very gradually from experience. They learn it from those early serve and return experiences, but later on, they learn it from having little conflicts when they play with people around them, or getting the experience of getting along with other children in a classroom, and having that opportunity, and having that opportunity to work things out, when maybe you dress differently, you have different ceremonies, you have a different worldview. You know, we know from many studies of acculturation, that a lot of good can happen when there's a positive opportunity to do something together, whether it's in a classroom, a camp, or other kinds of activities. But, you know, peace requires reflection and thoughtfulness as people get older, and we want to build a good foundation of emotion, emotional control and regulation of negotiation skills of being able to understand other people. And exposure goes a long way, and then, opportunities that are structured by caring adults to, you know, help kids learn how to navigate conflicts and work things out.
- Are you convinced that there is a strong relationship between investing in early childhood development and achieving greater peace in the world?
- How would you support your position?
As the last commentary in this section, we will now hear from Pia Britto, UNICEF, as she speaks on the subject of building peaceful societies through early childhood development at the March 2016 workshop held in Jordan.
Your Majesty, Excellencies, esteemed guests and colleagues, the United Nations Secretary General, Ban Ki-moon, has shared the estimated cost of conflict and violence. In 2014, it was $14.3 trillion U.S. dollars -- almost 13.5 percent of the global economy. What a staggering cost! But we know the cost of violence to children and families is far worse. It cannot be estimated, and it is growing year after year, month after month, day after day, expanding across diverse geographies.
We need a transformative shift to break this tide. We need early and preventive action. We need to develop solutions that put people first, where young children, girls, women and youth are not seen as vulnerable populations but as agents of change who will create strong, just and harmonious societies. And it is with great excitement that we come here today to share a potentially transformative solution that can be the accelerator for peace. I am talking about early childhood development.
Science is changing the way we are thinking about the earliest years of life. We are in the midst of a revolutionary shift about what we know about brain development and its foundation not only for lifelong health, learning and productivity, but also for bringing change in societies. We know during the first years of life a child’s brain develops at an unprecedented rate. Brain cells, neurons, form almost 700 to 1,000 connections a second, and I guarantee you there is no Twitter feed that can achieve that rate. It is just phenomenal. We know that genes only provide the blueprint for the brain. It’s the experience that sculpts it. When children receive nurturing care, protection, stimulation, love, the potential for the complexity and the exuberance of the brain to develop is unfathomable, but there are also negative experiences. There is also chronic stress, violence and living in conditions of adversity that create toxicity that can derail the brain. Children need positive experiences to grow. Nutrition feeds the brain. Stimulation sparks the connections, and protection buffers it from toxic stress. And it is this early childhood period that lasts a lifetime and the foundation of who we ultimately become.
So, what is the relationship between early childhood and peace, and why is there this global buzz? Hundreds of people have come to Amman to discuss this. Why? I will give you five reasons today why. The first is we know that care and nurturance in these first years of life build the foundation for a child’s ability to trust, to form relationships with others. The neurobiology of peace tells us that in early attachment, the release of hormones like oxytocin starts to form the ability to form good, positive relationships. Second, early learning programs, community-based programs, parenting programs from India to Chile have been so successful in promoting young children’s pro-social behaviors, emotional regulation, executive functioning skills, the skills we need to succeed in a 21st Century economy with complex communications and relationships. Third, we know early childhood interventions are linked with the reduction of violence at home between parents and children and in spousal relationships. Jordan has led the Better Parenting Program and has so eloquently demonstrated this change.
We know that when youth are engaged in providing services for young children, we start to see a change in their behavior. There is beautiful evidence from Uganda, from child soldiers who have become caregivers in child centers, and the poignancy with which you watch them sing and play with children and transform is incredible. Fourth, early childhood programs serve as a platform for community cohesion. We were so struck this morning at the Makhani Center when we saw communities coming together, learning social harmony, and learning cohesiveness. We see this in the Ivory Coast, we see this in Turkey, we see this around the world, this platform that early childhood provides where everybody cares for their children to come together to start to build harmonious societies.
Finally, the fifth reason is early childhood interventions contribute to social justice by reducing inequality. From Jamaica to the United States, we have seen a phenomenal return on investment, almost 1 to 7, for every intervention in the early childhood period because income starts to equalize. We start to close the inequality gap.
And it is because of reasons like this that, for the first time in global development, early childhood has been recognized in the goals for 2030. The Sustainable Development agenda recognizes the important role of early childhood development.
UNICEF and partners have come together to create the Early Childhood Peace Consortium with this vision of preventing violence and promoting peace through the transformative power of early childhood development. This practice was recognized in a UN resolution as an innovative practice, a new solution to bring to the world to accelerate the vision we want.
And we have brought all this experience and knowledge to Jordan. Why to Jordan? Because Jordan has been the leader for early childhood development. Because Jordan has recognized the importance of youth in bringing change, in transforming conflict, in preventing and countering violence and sustaining peace. Jordan has championed the two windows of life -- early childhood and adolescence -- when we can make the difference we want to see. There is so much at stake. How are we going to promote this transformative solution? The evidence is credible, the moral argument irrefutable. The sustainable development momentum behind us and the power to act is in our hands. Are we going to take up this call and make it our own to bring lasting and sustainable peace in the world? Thank you.
- If you had an opportunity to meet with senior policy makers in your region, would you make the case for ECD as means of advancing peaceful societies?
- If yes, what are a couple of key points you might raise?
- If no, why would you not make the argument?
The Forum on Investing in Young Children Globally considered challenging environments in several of the workshop discussions and presentations. Key themes emerged:
- Challenging environments limit the capacity of families and communities to provide the responsive care, nurturing and security critical to children’s early development and long-term well-being.
- Understanding the risk and protective factors connected to resilience is key to reducing the negative impact of challenging environments.
- Responsive care, health care, protection, nutrition AND education are essential elements to effective humanitarian aid, building peaceful societies and reducing extremism and violence.