Violence harms children’s mental health

The Convention on the Rights of the Child guarantees every child’s right to freedom from violence and to the highest attainable standard of mental health. The 2030 Agenda for Sustainable Development equally commits Member States to ending all forms of violence and promoting mental health and well-being.

Despite these obligations and commitments, children are increasingly exposed to violence, with a severe influence on their mental well-being as a result. This exposure can be direct, such as experiencing physical, sexual or emotional violence in their community, at home or at school, or indirect, such as witnessing violence and hearing or watching violent content online. Moreover, there is now a recognition that interpersonal violence spills from one setting to another, resulting in what is commonly known as poly-victimization.

Evidence from high-, middle- and low-income countries indicates clearly that violent experiences increase the risk of negative mental health consequences. These include depression, post-traumatic stress disorder, borderline personality disorder, anxiety, sleep and eating disorders, suicide and suicide attempts. In addition, exposure to childhood violence can increase a wide range of adult psychopathologies, including mood, anxiety, behaviour and substance disorders.

Research has consistently shown that childhood adversity and violence are key risk factors for the onset and persistence of mental disorders. Exposure to adverse childhood experiences, such as violence, can be traumatic, evoking toxic stress responses that have immediate and long-term adverse physiological and psychological effects.

The impact of violence on the architectural development of children’s brains is of particular concern, as this is linked with consequent emotional and behavioural disorders, poor health and poor social outcomes. Those effects are especially concerning in the light of the stark reality that more than 1 billion children – half of all children in the world – are exposed to violence every year.

Research has found associations between physical punishment and negative effects on children’s mental health, including behaviour disorders, anxiety disorders, depression and hopelessness. The available evidence also indicates that there is an association between physical punishment and increased aggression, reduced empathy and poor moral internalization.

Bullying has been linked to a variety of negative child well-being outcomes, including poorer education results and mental health problems, such as anxiety and depression symptoms, suicidal thoughts and actions, self-harm and violent behaviour, which have been found to persist into adulthood. Moreover, bullying is not only a concern for the victim’s well-being; research has shown that being the child that bullies is also associated with poorer child and later-life outcomes. In particular, bullies have been shown to exhibit higher antisocial and risk-taking behaviour, as well as later criminal offending. Importantly, being both a perpetrator of bullying and a victim further compounds the risks for psychological and conduct problems.

Online exposure of children to violence and to inappropriate content (such as child abuse material, pornography, hate-speech material and material advocating unhealthy or dangerous behaviour, such as self-harm, suicide and anorexia) is consistently associated with problem behaviour, such as increases in aggression, anxiety and post-traumatic stress symptoms. Children could also end up with lower levels of empathy and compassion for others. Adolescents exposed to high levels of violence reported high levels of anger and depression. They also reported higher rates of wanting to hurt or kill themselves compared to adolescents in groups with a lower exposure to violence. Equally, being online brings risks related to contact and conduct, as in cases where children are induced or coerced into sharing sexual images of themselves that are then used for extortion or to humiliate them publicly.

More generally, experiencing sexual violence can have a range of adverse outcomes, including depression, post-traumatic stress disorder, suicide risk, substance use, teenage pregnancy, risky sexual behaviour, poorer educational outcomes and poorer self-rated health. The psychological and emotional impact of child sexual abuse can be particularly devastating because the surrounding secrecy, shame and stigma mean children who experience this often have to cope alone. In the context of a culture of disbelief or victim blaming, where victims are seen as responsible, shamed and shunned, it will be very difficult for a child or young person to tell anybody what has happened.

The impact of institutionalization and deprivation of liberty can include severe developmental delays, disability, irreversible psychological damage and increased rates of suicide and recidivism (A/61/299, para. 54).

Harmful practices can have both immediate and prolonged negative psychological consequences. With regard to female genital mutilation, for example, studies have found that girls and women who have experienced it may have higher rates of mental health disorders, particularly depression, anxiety disorders, post-traumatic stress disorder and somatic (physical) complaints with no organic cause (for example, aches and pains).

Emergencies create a wide range of problems experienced at the individual, family, community and society levels. Emergencies erode normally protective supports, increase the risks of diverse problems and tend to amplify pre-existing problems of social injustice and inequality. Parents and other attachment figures may be killed, disabled or traumatized; schools may be damaged or become targets for military attack; and opportunities for play and friendship are often diminished as families are displaced and safe communal spaces disappear. Such situations can induce problems of a psychological nature, such as grief, non-pathological distress, depression and anxiety disorders, including post-traumatic stress disorder. Cumulative trauma experienced pre- and post-migration also contributes to overall child distress.

As noted by the World Health Organization (WHO), mental health is more than the absence of mental disorders; mental health is fundamental to health and overall well-being.

According to WHO, up to 50 per cent of mental disorders during adulthood have their onset in adolescence and up to 20 per cent of children and adolescents experience mental disorders. An important problem is that about 70 per cent of children and adolescents with mental disorders do not receive an appropriate intervention at the right time.

Despite this grave situation, mental health issues among children and adolescents are often neglected owing to lack of awareness or existing stigma of mental disorders and they remain untreated. If left untreated, mental disorders may have far-reaching negative impacts on a young person’s development, educational attainment and transition to adulthood. Mental disorders at a young age can lead to discrimination, stigma and exclusion, and may even result in limited access to social, education and health services.

The lack of priority accorded to child and adolescent mental health is also reflected in the limited global coverage of prevalence data for mental disorders in this group. Average global coverage of prevalence data for mental disorders in children and adolescents aged 5 to 17 was 6.7 per cent. Of 187 countries, 124 had no data for any disorder. Without focused strategies to address the paucity of epidemiological data, poor coverage in both high-income countries and low- and middle-income countries will present a major challenge for child and adolescent mental health advocacy and the planning and allocation of the scarce resources available for child and adolescent mental health.

Mental health is also a major concern for children themselves. In its report entitled “Voices of children and young people: child helpline data for 2017 & 2018”, Child Helpline International indicated that the two most significant concerns for children contacting its member helplines related to abuse and violence on the one hand and to mental health on the other. Suicidal thoughts, fear and anxiety were the most significant issues children and young people talked about in relation to mental health. Physical and emotional abuse were the most significant issues in the abuse and violence category. The findings were based on data received from child helplines in 84 countries and territories around the world, underlining their global relevance.

Main negative effects of violence on children’s mental health

In considering the impact of violence on children’s mental health, it is important to recall the different types of negative effects it can have, as well as the differences between children’s experience of violence across the life course.

Research has demonstrated that the most commonly reported problems fall into three categories: behavioural and emotional, cognitive and attitudinal, and long-term problems.

In terms of behavioural and emotional disorders, research has found that those who are exposed to violence during their lifetime, including violence at home, violence in the community and war trauma exposure, are more likely to develop mental health problems including post-traumatic stress disorder, depression, psychological distress, aggression and significantly harmful effects on the development process.

Children tend to either externalize (exhibiting greater levels of aggression, rule-violation and acting out) or they internalize (suffering from increased anxiety, depression and moodiness). For example, in various studies it has been reported that neglected children are more likely to suffer from behavioural, cognitive and internalizing problems, as well as physical and mental health problems.

In terms of externalizing disorders, one consequence of experiencing trauma and violence during childhood can be the adoption of behaviour that poses health risks. Drug and alcohol use by children has risen globally and in the context of children should be viewed as a means of coping and managing negative emotions. Children who experience violence and maltreatment in one setting are at risk of also experiencing violence in other settings. The external expression of mental health symptoms, such as aggressive or antisocial behaviour, is more likely to result in increased peer victimization.

As regards internalizing disorders, in a study carried out in Norway, all combinations of childhood violence were significantly associated with anxiety or depression. Among participants exposed to one childhood violence category, those exposed to neglect and/or psychological violence reported more anxiety or depression than those exposed to sexual abuse alone or to family violence alone. Of those who were exposed to two childhood violence categories, those exposed to neglect or psychological violence in combination with sexual abuse and/or family violence reported more anxiety or depression than individuals reporting a combination of sexual abuse and family physical violence. Individuals experiencing three childhood violence categories had the highest anxiety or depression scores.

There is also now convincing evidence of a causative association between peer bullying and depression, anxiety and self-harm. Peer bully victims are at increased risk of internalizing disorders, whereas peer bullies are at increased risk of externalizing disorders, with peer bully victims suffering the greatest adult consequences, including both more internalizing and externalizing disorders.

Peer victimization has been specifically associated with an elevated risk of anxiety disorders, depression, self-harm, suicidal ideation and suicide attempts, even after accounting for other major childhood risk factors, trauma and genetic liability. Research on a sample of over 6,900 children from the Avon longitudinal sample of parents and children in the United Kingdom of Great Britain and Northern Ireland found that sibling bullying increased the risk of depression, anxiety and self-harm twofold, with results remaining similar in strength for depression and self-harm even after accounting for a range of childhood confounders.

The effects of sibling and peer bullying were found to be cumulative for depression, suicidal ideation and suicidal self-harm. Peer and sibling bullying are traumas that should be considered on a par with traumas such as physical or sexual abuse.

Those who witness or are victims of violence can show symptoms of post-traumatic stress disorder similar to those of soldiers coming back from war, with the distress symptoms increasing according to the number of violent acts witnessed or experienced. Symptoms included distractibility, intrusive and unwanted fears, and thoughts and feelings of not belonging.

As regards impairments to cognitive functioning, evidence shows that physical punishment negatively impacts intellectual learning. School violence can severely hamper a child’s ability to learn and adversely affect their development. Previous studies conducted in East Africa indicated that harsh punishment was related to negative consequences, including internalizing and externalizing problems, poor cognitive functioning and poor school performance. Researchers are also finding that physical punishment is linked to slower cognitive development and adversely affects academic achievement. In addition, physical punishment can cause alterations in the dopaminergic regions associated with vulnerability to the abuse of drugs and alcohol.

Children and adolescents exposed to chronic childhood trauma show a significant risk of increasing mental health disorders with subsequent poor academic achievement. Exposure to community violence inversely affects school engagement and performance when mental health disorders are included. Mental health symptoms and disorders that predict poor academic achievement are post-traumatic stress disorder, anxiety, aggressive behaviour and depression. Reviews show that there are elevated levels of violence experienced within institutions and negative cognitive effects associated with institutionalization, especially for younger children and those who spend long periods in institutions.

As regards long-term effects, exposure to trauma has been associated with depression, low self-esteem and substance abuse in late adolescence and early adulthood. Adverse childhood experiences can also compromise the development of healthy coping strategies, which can in turn affect health behaviour, physical and mental health and life opportunities and bring on premature death. Adverse childhood experiences have been linked to increased risk for alcohol and substance use disorders, suicide, mental health conditions, heart disease, other chronic illnesses and health risk behaviour throughout life.

Adverse childhood experiences have also been linked to reduced educational attainment, employment and income, which directly and indirectly affect health and well-being. At least 5 of the 10 leading causes of death have been associated with exposure to adverse childhood experiences, including several contributors to declines in life expectancy. Depression, heavy drinking, smoking, lower educational attainment, lack of health insurance and unemployment are significantly associated with them.

Cumulative exposure to violence in more than two contexts (for example, witnessing violence at home, sexual abuse, parenting stress) leads to greater behavioural and emotional problems in children, as well as post-traumatic stress disorder.

One study found that for both men and women, there was a strong and significant relationship between childhood violence and violence in adulthood that was not restricted to violence within a similar category. Childhood exposure was associated with a 2.2–5 times higher occurrence of adult violence.

Differences between children’s experience of violence across the life cycle

The nature of the impact of violence on children’s mental health depends on their experience of violence across the life course.

The experience of violence can set in as early as pregnancy, with a high risk of problems in the child’s nervous system and brain. Domestic violence against pregnant women by their partners, spouses and other members of the family is the most substantial risk before birth.

Normal and healthy development of infants through to preschool age depends upon secure relationships with caregivers. Disruption of this process, for instance by exposure to violence, can interfere with all aspects of children’s development. More specifically, children may not acquire a healthy level of trust and autonomy. In infancy, secure attachment may be derailed, sleep and eating disturbances introduced and even brain development may be altered.

Pre-schoolers have not achieved the ability to control their own emotions. The literature sets out some of the behavioural effects of being exposed to violence at this age, including ambivalence toward parents, acting out, whining and clinging or crying that may result from anxiety and post-traumatic stress.

Infants and toddlers who witness violence either in their homes or in their community show excessive irritability, immature behaviour, sleep disturbance, emotional distress, fear of being alone and regression in toileting and language. Exposure to trauma, especially violence in the family, interferes with a child’s normal development of trust and later exploratory behaviour, which lead to the development of autonomy.

In recent reports, the presence of symptoms in young children has been noted that is very similar to post-traumatic stress disorder in adults, including repeated re-experiencing of the traumatic event, avoidance, numbing of responsiveness and increased arousal.

Between the ages of 6 and 12, children begin to recognize normative standards and derive their sense of self from comparisons with others around them. Research indicates that the effects of domestic violence on latency-age children can include feelings of guilt and shame, as well as anxiety and symptoms of post-traumatic stress disorder. These children may begin to do poorly in school and peer relationships can suffer. They may lack motivation or have difficulty concentrating owing to intrusive thoughts. Gender socialization is occurring at this age and children are making judgments about fairness and appropriate means to having their needs met.

As with pre-schoolers, school-age children exposed to violence are more likely to show increases in sleep disturbances and are less likely to explore and play freely and show motivation to master their environment. They often have difficulty paying attention and concentrating because they are distracted by intrusive thoughts. In addition, school-age children are likely to understand more about the intentionality of the violence and worry about what they could have done to prevent or stop it.

Several studies support a link between exposure to community violence and symptoms of anxiety, depression, and aggressive behaviour in school-age children living in violent urban neighbourhoods. In extreme cases of exposure to chronic community violence, school-age children may also exhibit symptoms akin to post-traumatic stress disorder. Some studies have highlighted the link between the witnessing of violence and such symptoms as nightmares, fear of leaving their homes, anxiety and a numbing of affect.

Other studies have reported that school-age children who are exposed to family violence are affected in a similar way to those exposed to community violence. Such children often show a greater frequency of internalizing and externalizing behaviour problems in comparison to children from non-violent families. Overall functioning, attitudes, social competence and school performance are often negatively affected. In addition, studies show that as children get older, those who have been abused and neglected are more likely to perform poorly in school, to commit crimes and to experience emotional problems, sexual problems and alcohol or substance abuse.

Cognitive psychology and neuroscience studies have transformed our understanding of the potential reasons for the onset of mental disorders in adolescence. One of the unique transitions that occurs during adolescence is that the opinion of peers begins to take precedence over that of family members and parents. That sensitivity to peer influence leads to adolescents being sensitive to social stimuli and having an increased propensity for risky behaviour. Delayed maturation of the prefrontal cortex, involved in impulse control and the reward system, could be responsible for behaviour related to impulsivity and risk-taking.

As children begin to become more independent and interact with peer groups, they become more susceptible to interpersonal violence. Generally, children aged 10 to 18 become vulnerable to all forms of violence but the most prevalent form of violence is physical violence for both boys and girls by a member of their peer group. Along with physical attacks, that age group sees an increase in fighting between children and sometimes with violent means such as a firearm.

The effects on adolescents of exposure to violence can include depression and suicidal ideation, dating violence, substance abuse and use of violence as a control tactic.

Adolescence involves the active search for identity and a lack of guidance at this stage could lead to poor choices. The sexual coming of age and onset of sexual experiences may be adversely influenced by the results of exposure to violence and the perpetuation of violent norms of behaviour. It may be difficult for adolescents to get the appropriate style or level of help they need because the effects of exposure to violence may be masked by their own law-breaking or violent behaviour.

Considerable research has been done on adolescent youth violence. Such research indicates that adolescents exposed to violence, particularly those exposed to chronic community violence throughout their lives, tend to show high levels of aggression and acting out, accompanied by anxiety, behavioural problems, school problems, truancy and revenge-seeking.

The more severe effects on adolescents of exposure to violence may be related to the fact that they are exposed to much more violence than younger children. Such chronically traumatized youths often appear deadened to feelings and pain and show restricted emotional development over time. Alternatively, such youths may attach themselves to peer groups and gangs as a substitute for family and incorporate violence as a method of dealing with disputes or frustration.

In low- and middle-income countries, recent studies have demonstrated that maternal maltreatment and exposure to violence are predictive of an increase in violent attitudes and tendencies towards children. Maternal depression has also been linked to childhood disturbances in emotional, behavioural and cognitive development, including self‐reported mental health problems, increased risk of violence and substance use and deficits in educational achievement.

Children can also be harmed when their caregivers are subjected to intimate partner violence or when they witness it taking place. Research has shown that children who witness violence at home or live with mothers who are victims of intimate partner violence are at a heightened risk of experiencing abuse within the home. There is also evidence to suggest that children exposed to domestic violence are more likely to act aggressively towards peers or siblings and to carry violence into adulthood as either victims or perpetrators. Witnessing violence between parents or caregivers can also influence children’s attitudes about its acceptability within the family and close relationships; in turn, this could be passed down to the children, thus perpetuating the cycle of violence.

Main risk and protective factors

Identifying risk and protective factors for violence against children provides the foundation for effective prevention, as an integrated approach to increasing protection and decreasing risk underlies successful prevention in the years ahead.

Some risk factors correspond to a particular form of violence but more generally the various types of violence have several risk factors in common. The prevalence of poly-victimization involving different forms of violence reflects this reality. Risk factors can be grouped into four categories: individual, relational, community and society.

Individual factors include biological and demographic characteristics that increase the risk that a person will be a victim of violence, such as gender, age, low level of education, low income levels, disability or mental health issues, being lesbian, gay, bisexual or transgender, harmful use of alcohol and drugs, and having a history of exposure to violence

Relational factors arise from relationships with peers, intimate partners and family members. They include lack of emotional attachment between children and parents or caregivers; poor parenting practice; family dysfunction and separation; association with peers in illegal activities; witnessing violence between parents or caregivers; and early or forced marriage.

Community-level risk factors include how the characteristics of settings such as schools, workplaces and neighbourhoods increase the risk of violence. They include poverty, high population density, transient populations, low social cohesion, unsafe physical environments, high crime rates and the existence of a local drug trade.

Society-level risk factors include legal and social norms that create a climate in which violence is encouraged or normalized. They also include cultural norms according to which it is acceptable to use violence to resolve conflicts; norms that affirm men’s domination over women and children; standards by which parental rights outweigh the well-being of children; health, economic, educational and social policies that maintain economic, gender or social inequalities; absent or inadequate social protection; social fragility owing to conflict and post-conflict situations or natural disasters; weak governance; and poor law enforcement.

The interaction between factors at the different levels is just as important as the influence of factors within a single level. Several other common risk factors, such as family dysfunction, poor parenting skills and low social cohesion within the community, place some children at much greater risk than others. In addition, as humanitarian crises, including war, mass refugee movements, economic migration, climate disasters and disease outbreaks proliferate, more children than ever are becoming vulnerable to violence of all forms.

Protective factors can be grouped into two main categories relating to the child and the family.

Child factors include adaptability, optimism and coping style. Other elements may be the child’s attribution and appraisal of events, personality and locus of control. The child’s most important personal quality in this context is average or above-average intellectual development with good attention and interpersonal skills. Additional protective factors cited in studies include feelings of self-esteem and self-efficacy, attractiveness to others in both personality and appearance, individual talents, religious affiliation, socioeconomic advantage, opportunities for good schooling and employment, and contact with people and environments that are positive for development.

Research on an ecological stress process model has explored relations between children’s exposure to family and community violence and child mental health, and emotionally regulated coping as a protective factor among Latino, European-American and African-American school-age children living in single-parent families who were either homeless and residing in emergency shelters or housed but living in poverty. The results highlight the critical role of child-adaptive coping strategies, specifically emotionally regulated coping, as a protective resource in relation to mental health symptoms in the presence of multiple forms of violence. Children who perceive their emotional coping as more effective report fewer mental health symptoms. Children’s coping strategies, whether as prevention or a treatment strategy, could buffer the detrimental effects of some exposure to violence.

Protective family factors include the strength and nature of the relationship with the non-offending parent or the presence and relationship with siblings and/or extended family members. The most important protective resource to enable a child to cope with exposure to violence is a strong relationship with a competent, caring, positive adult, most often a parent. With the support of good parenting by either a parent or other significant adult, a child’s cognitive and social development can proceed positively even in adversity.

An important area concerns the issue of resilience, which is the ability to determine which children will experience fewer negative effects in response to exposure to violence. Results from several studies of resilient infants, young children and youths exposed to community violence consistently identify a small number of crucial protective factors for development, including a caring adult, a community safe haven and a child’s own internal resources.

Effectiveness of interventions to prevent and provide care to children who experience or are exposed to violence

There is more data, research and other evidence on interventions to prevent and respond to violence against children than ever before. However, there are still significant data gaps that must be addressed, particularly the dearth of evaluations on interventions in low- and middle-income countries.

The report by WHO and others entitled INSPIRE: Seven Strategies for Ending Violence against Children is a resource that highlights a select group of strategies based on the best available evidence to help countries and communities intensify their focus on the prevention programmes and services with the greatest potential to reduce violence against children. With respect to response and support services that support the mental health of child victims, the report highlights important evidence on the effectiveness of trauma-focused cognitive behavioural therapy for individuals and groups in reducing trauma symptoms and long-term negative psychological and emotional outcomes in children and adolescents who have experienced violence – reducing them by up to 37 per cent for individuals and 56 per cent for group participants.

For example, in Lusaka, 257 boys and girls aged 5 to 18, who had experienced at least one traumatic incident (including abuse and exploitation) and reported significant trauma-related symptoms (such as post-traumatic stress disorder) were recruited from five communities. The children were randomly assigned either to an intervention group where they received between 10 and 16 sessions of trauma-focused cognitive behavioural therapy, or to a comparison group where they received the “treatment as usual” offered to orphaned and vulnerable children. Treatment as usual included psychosocial counselling, peer education, support groups and testing for and treatment of HIV/AIDS. Importantly, the trauma-focused cognitive behavioural therapy was delivered by trained and supervised lay counsellors rather than specialist mental health providers. The study found that trauma symptoms were reduced by 82 per cent in the intervention group compared to a 21 per cent reduction in the group receiving treatment as usual. Functional impairment was reduced by 89 per cent by the therapy intervention compared to a 68 per cent reduction from treatment as usual. Trauma-focused cognitive behavioural therapy was significantly more effective than treatment as usual. Those findings are especially important given that there are unlikely to be sufficient resources in most low-income settings to recruit specialist mental health-care providers or train lay workers in more than one approach to dealing with the effects of trauma.

The report entitled Promising Programmes to Prevent and Respond to Child Sexual Abuse and Exploitation, commissioned by UNICEF, has also drawn attention to the increasing focus by mental health professionals on evidenced-based practices for the treatment of child abuse and trauma. In high-income countries trauma-focused cognitive behavioural therapy, creative therapies, eye-movement desensitization and reprocessing and counselling are recognized as potential models of intervention for sexually abused children and young people. Creative therapies such as play, dance or music offer children an alternative for healing and restoration, and there are examples of this approach being used in low- and middle-income countries. A meta-analysis of play therapy for children in high-income countries found positive impact across modalities, settings, age and gender, with the most significant impact seen with humanistic, non-directive play therapy approaches.

The Know Violence in Childhood global learning initiative has also highlighted important evidence to inform action on violence prevention, including:

• The potential of parenting programmes to both prevent and reduce the risk of child maltreatment and to act as an entry point to address vulnerabilities and risks within home environments;
• Opportunities for greater synergies between intimate partner violence and child maltreatment programmes;
• The importance of coordinated and multisectoral responses to reduce the likelihood of children being separated from their families;
• The value of investing in changing social norms and linking initiatives to end violence against children with those aimed at ending violence against women;
• The good schools toolkit, implemented in Uganda, which has demonstrated significant positive results in addressing the dynamics of violence at multiple levels, across multiple stakeholder groups and with the potential to succeed at scale;
• Effective changes in institutions that can alleviate violence either by structural and code of conduct interventions or policy changes that avert such placements or expedite onward movement to family-type environments;
• Strategies to build resilient communities that are successfully reducing violence in cities and urban communities with high levels of homicide and gang violence, particularly in Latin America, Central America and the Caribbean;
• Community-based initiatives to engage at-risk youth in skill-building, vocational training, music, and art.

WHO has noted that there is increasing evidence of the effectiveness and cost-effectiveness of interventions to promote mental health and prevent mental disorders, particularly in children and adolescents. WHO itself has a number of initiatives aimed at increasing the information and evidence based on mental health, with a view to strengthening mental health-care systems.

The Lancet Commission on global mental health and sustainable development identified a range of interventions it considered necessary to prevent mental and substance use disorders and provide treatment and care to enhance recovery. It stressed innovative interventions with the potential for scaling up, which could be delivered either through routine health care or other platforms.

Preventive interventions focusing on maternal mental health, mother–infant interaction and play and stimulation, have positive long-term benefits for both infants and mothers. Interventions that promote early initiation of breastfeeding, close physical contact with the mother and enhance maternal responsiveness contribute to secure attachment. Such programmes focusing on the early interaction between newborn babies and their caregivers, and in particular on improving sensitive responsiveness, can also reduce the risk of child maltreatment. Additionally, parent education and multi-component interventions (which typically combine family support, preschool education, parenting skills and child care) also show promising effectiveness in preventing child maltreatment and reducing mental health problems in children exposed to adversity and children affected by armed conflict.

A meta-analysis of 193 studies reported that maternal depression was significantly associated with increased internalizing and externalizing of mental disorders among children. Strong evidence exists for the effectiveness of interventions for maternal mental disorders in reducing internalizing and externalizing problems, and preventing the onset of childhood mental disorders. Home-visiting programmes for new mothers and their babies integrate the detection and treatment of maternal depression, including the delivery of psychosocial interventions, within routine pre- and postnatal care services.

Parenting and child welfare interventions are key investments for breaking toxic cycles of transgenerational transmission of violence, poverty and mental illness. For example, a psychosocial stimulation and parenting support intervention among growth-stunted toddlers led to substantial gains in adult functioning and labour market outcomes later in life. Within schools, life skills training focusing on the development of social, emotional, problem-solving and coping skills is considered best practice for building emotional and social competencies in children of all ages.

In terms of treatment, care and rehabilitation within low-resource settings, a basic package of interventions for children could include training programmes on parenting skills, which are effective for children with developmental, behavioural and emotional problems. The community-based rehabilitation model is a rights-based approach, building on the inherent strengths of the community and involving people with disabilities, family members and volunteers. The approach should be supported by local health professionals to facilitate inclusion in mainstream services, when possible, and tailored to local specific needs and resources. The evidence from community-based rehabilitation programmes is mostly supportive of their acceptability and beneficial effects.

Late childhood and adolescence present further opportunities for ameliorating the effects of early disadvantage, building resilience and reducing the harmful consequences of conditions that have an onset in this period. Family, parents, peers, school and community can provide the crucial protective inner circle. Universal socio-emotional learning interventions in communities and schools promote children’s social and emotional functioning, improve academic performance and reduce risk behaviour, including smoking and teenage pregnancy. Such interventions can be delivered by peers, teachers and counsellors through integrating them into youth programmes or school curricula (for example, the HealthWise programme in South Africa). The most effective interventions use a whole-school approach in which socio-emotional learning is supported by a school ethos and a physical and social environment that is health-enabling, involving staff, students, parents and the local community. Such interventions act directly by promoting self-efficacy and trust, and through reducing risk factors such as bullying. Economic analyses indicate that socio-emotional learning interventions in schools are cost-effective, resulting in savings from improved health outcomes and reduced expenditure on the criminal justice system.

Suicidality among adolescents is a major public health concern. Multimodal programmes, including community and school-based skills training for students, screening for at-risk young people, education of primary care physicians, media education and lethal-means restriction, offer the most promising prevention strategies (for example, the “Going Off, Growing Strong” programme in Canada). Targeted or indicated preventive interventions focus on young people who have had experiences that increase their vulnerability to mental disorders or who show sub-threshold symptoms. Interventions that promote coping and resilience, including cognitive skills training, help to prevent the onset of anxiety, depression and suicide.

A substantial body of evidence exists on effective clinical interventions for people with mental disorders in humanitarian emergencies. The Inter-Agency Standing Committee guidelines on mental health and psychosocial support in emergency settings include reinforcement of existing community resilience, avoiding medicalization of distress, proactive case identification with referrals to appropriate interventions, integration into emergency medical and social care responses, and actively promoting service use. Through a range of psychosocial interventions, mental health and psychosocial support is now more strongly aligned in the humanitarian context and other global mental health initiatives than previously. An active role for members of local communities and local authorities at every stage of organizing mental health care in these contexts is essential for successful, coordinated action and the enhancement of local capacities and sustainability. A coordinated response should ensure that the response builds the foundation of a sustainable mental health-care system.

Towards enabling and effective strategies to protect children’s mental health and well-being

Efforts to address mental health and violence against children should be guided by international human rights standards and the sustainable development framework, but they should also reflect a modern public health approach. One of the key principles of this approach is that good mental health means much more than the absence of a mental impairment: it is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.

Realizing the right of child victims and witnesses of violence to the highest attainable standard of mental health requires comprehensive and coordinated action. It requires an intersectoral and multi-stakeholder approach that encompasses both policies and actions to create an environment that decreases risks and vulnerabilities, as well as developing and strengthening services to provide timely and comprehensive mental health care to people who need it. There are already important frameworks in place to guide the actions of Member States in this field, such as the WHO mental health action plan 2013–2020 and the Lancet Commission on global mental health and sustainable development.

The starting point is the need to protect and promote everyone’s mental health and well-being. It is essential to create the conditions that will allow children to develop, thrive and reach their potential. To achieve this, it is necessary to address the social and environmental determinants that have a crucial influence on mental health at developmentally sensitive periods, particularly in childhood and adolescence. Many of the Sustainable Development Goals explicitly address these determinants and progress towards their attainment has the potential to promote mental health and reduce the global burden of mental disorders.

Prevention requires a combination of universal and targeted interventions that address the barriers and threats to mental health, especially those that present in early childhood. They include action to reduce stigmatization, discrimination and human rights violations that undermine children’s mental health. Prevention also requires specific action to address the needs of vulnerable groups across the lifespan in a manner that is integrated with wider health promotion strategies. In addition, prevention efforts must respond to the increasing threats to mental health arising from global challenges, such as climate change and growing inequality.

Mental health services must be scaled up as an essential component of universal health coverage and should be fully integrated with other strategies in the fields of health and violence prevention. Comprehensive community-based health and social care services must be developed that ensure continuity of care between providers, effective collaboration between formal and informal care providers and the promotion of self-care. Children and adolescents with mental disorders should be provided with evidence-based psychosocial and other non-pharmacological interventions and be based in the community, avoiding institutionalization and medicalization. Early intervention is essential.

The empowerment of children to take an active part in decisions regarding their own care is a fundamental component of a rights-based approach to mental health. The views and experiences of children with lived experience of mental disorders and psychosocial disabilities must shape the design, delivery and evaluation of services.

It is essential to have the right number and equitable distribution of competent, sensitive and appropriately skilled health professionals, and to build the knowledge and skills of general and specialized health workers to deliver evidence-based, culturally appropriate and human rights-oriented services. New opportunities should be embraced in this domain, including those offered by the innovative use of trained non-specialist individuals and digital technologies to deliver a range of mental health interventions.

Substantial additional investments are required for promoting and protecting mental health. Although additional resources are essential, an immediate opportunity exists for efficient and effective use of existing resources. That could include, for example, the redistribution of mental health budgets from large hospitals to district hospitals and community-based local services; the introduction of early interventions for emerging mental disorders; and the reallocation of budgets for other health priorities to promote the integration of mental health care into established platforms of delivery.

Investments in research and innovation should also continue to grow. The imbalance whereby most research is conducted in and by high-income countries needs to be corrected in order to ensure that low- and middle-income countries have culturally appropriate and cost-effective strategies to respond to mental health needs and priorities. The crucial information needed to take effective action includes the prevalence and nature of mental health problems; coverage of policies and legislation, interventions and services; health outcome data; and social and economic outcome data. Those data need to be disaggregated by sex and age and reflect the diverse needs of subpopulations, including individuals from geographically diverse communities and vulnerable populations.

Finally, as the international community looks ahead to the decade of action for the Sustainable Development Goals, delivery for sustainable development, monitoring and accountability frameworks must be put in place to ensure that effective action is being taken to promote the mental health of all, prevent mental disorders among children who experience violence and others at high risk, and provide treatment and care to those who need it.

Looking forward

Since assuming her role in July 2019, the Special Representative has developed her strategy for this mandate period through a consultative and participatory process. The new strategy includes three priority areas: (a) advocacy and mobilization of all key stakeholders at the global, regional and national levels for the accelerated implementation of target 16.2 of the Sustainable Development Goals and of other related Goals; (b) ensuring that all forms of violence are included in the implementation of the 2030 Agenda for Sustainable Development, thereby ensuring that no child is left behind; and (c) amplifying the voices of children, with particular attention paid to the most vulnerable.

Effective cooperation between the many actors in this field is critical. Children’s lives are not divided thematically to correspond to the mandates of the organizations working on their behalf: they are often exposed to more than one form of violence and in more than one setting. Mobilizing partnerships at all levels and involving all stakeholders is essential to generate the necessary resources and spur action. The Special Representative will use a participatory and consultative approach to support cooperation and constructive dialogue with all relevant stakeholders at the national, regional and international levels to respond effectively to the continuum of violence that child victims face.

The most important partners in ending violence are children themselves. The active and meaningful involvement of children in identifying the challenges to sustainable development and how to overcome them both realizes their right to participation and provides an effective way to accelerate progress. The Special Representative will pursue close collaboration with child-led and child-focused organizations to ensure that the mandate amplifies children’s voices and takes their views fully into account. Particular attention will be paid to including the most invisible and vulnerable children in order to ensure that no child is left behind.