Introduction
It is almost 30 years since the publication and presentation of the report ‘Impact of Armed Conflict on Children’ to the General Assembly of the United Nations (UNGA, 1996). This seminal report, conducted by Graça Machel in 1996 and submitted to the UN Secretary-General, within its mandate to promote and protect children, was released against a backdrop of global upheaval. The world was still reeling from the genocide of the Tutsi people in Rwanda, which led to over one million deaths and the collapse of Rwanda’s health and social systems. It followed the brutal war in Bosnia and Herzegovina (1992–1995), the most intense conflict in Europe since World War II, resulting in over 100,000 deaths –many of them children. These tragedies exposed the urgent need for coordinated international action to prevent war and address its far-reaching humanitarian consequences, particularly for children.
The Machel Report was commissioned to “improve the protection and care of children in conflict situations, and to prevent these conflicts from occurring” and synthesised, for the first time in a single document, six grave violations against children in armed conflict that are prohibited in International Humanitarian Law. These violations had been explicated previously, specifically in the Geneva Convention IV (International Committee of the Red Cross (ICRC), 1949) and Additional Protocols, however the Machel Report brought children to the forefront of the global human rights and peace-building agenda. Between 1985 and 1995, an estimated two million children were killed in armed conflict, and six million were left with life-changing injuries or disabilities. Children were not only caught in the crossfire – they were actively targeted, recruited, and exploited. The report documented the widespread psychosocial toll of war, including trauma from witnessing violence, the breakdown of family and community structures, and the collapse of education and healthcare systems.
Internally displaced children, often unaccompanied, faced heightened risks of exploitation, trafficking, and recruitment into armed groups. Thousands were forced to become child soldiers – many under the age of 15 – experiencing extreme forms of abuse and coercion. The loss of access to schooling was another major theme highlighted by Machel, with attacks on schools, forced displacement, and prolonged insecurity leaving many children without education for years. The impact of war on children was described as a violation of every fundamental right: the right to life, development, protection, and participation in society.
Institutional developments, legal frameworks and mechanisms of accountability
The Machel Report highlighted the role of international law in protecting children, referencing both international humanitarian law – such as the Geneva Conventions (International Committee of the Red Cross (ICRC), 1949) – and human rights law, including the United Nations Convention on the Rights of the Child Convention on the rights of the child (1989). These frameworks offer legal protections for children in conflict, prohibiting torture, forced recruitment, and attacks on civilians and civilian infrastructure. However, enforcement has often been inconsistent or ignored, especially where state systems have collapsed.
The Machel Report on Children and Armed Conflict also laid the groundwork for identifying the six grave violations committed against children during armed conflict (Office of the Special Representative of the Secretary-General for Children and Armed Conflict, 2009): (i) Recruitment and use of children as soldiers, (ii) Killing or maiming of children, (iii) Sexual violence against children, (iv) Attacks on schools or hospitals, (v) Abduction of children and (vi) Denial of humanitarian access. These violations are now used by the UN as triggers for monitoring, accountability, and advocacy.
One of the report’s most enduring legacies was the creation of the role of the UN Special Representative for Children and Armed Conflict, following General Assembly Resolution 51/77 (A/RES/51/77, ). This role has been instrumental in tracking violations, raising awareness, and promoting adherence to international standards. Additional mechanisms, such as the Optional Protocol to the CRC on the involvement of children in armed conflict (UN General Assembly, 2000), banned the use of child soldiers and created new norms for child protection.
The UN Security Council resolutions – including 1539 (UN Security Council 2004), 1882 (UN Security Council, 2009), and 1998 (UN Security Council, 2011) – have strengthened international monitoring and accountability, especially in protecting schools and hospitals and documenting grave violations.
Children and armed conflict: Report of the Secretary-General 2024 (UN General Assembly, 2024).
In the most recent annual report of the Secretary-General on Child and armed conflict in June 2024, the state of the global impact of armed conflict on children was reviewed. It is difficult to see where progress has been made over the past three decades. The report commences with the acknowledgement that “violence against children in armed conflict reached extreme levels, with a shocking 21% increase in grave violations,” highlighting that incidences of killing and maiming had increased by 35% globally.
The report specifically references many current war zones, where children were “killed and maimed in unprecedented numbers in devastating crises in Israel and the Occupied Palestinian Territory, notably in the Gaza Strip, in Burkina Faso, the Democratic Republic of the Congo, Myanmar, Somalia, the Sudan, the Syrian Arab Republic and Ukraine, among many other situations.” When examining numbers of verified grave violations, the highest levels were recorded in Israel and the Occupied Palestinian Territory, the Democratic Republic of the Congo, Myanmar, Somalia, Nigeria, and the Sudan. It also highlights the limiting effects of conflict on the monitoring capacity of violations, and the threat that those who monitor experience in doing so.
Case Study Gaza – ACAPS (Palestine, Reference Abu-Jamein.d.) and (GCMHP 2024) Reports on the Mental Health and Psychosocial Impact of Armed Conflict in Gaza (2024)
The war in Gaza has had catastrophic consequences for children, families, and mental health systems. Even before the latest escalation in October 2023, the Gaza Strip had one of the highest self-reported rates of psychological distress in the world. Almost 70% of the population reported symptoms of depression, and approximately 22–24% of adults were thought to have post-traumatic stress disorder (PTSD) (Palestine, Reference Abu-Jamein.d.; World Bank, 2022). Children were already growing up in a context of chronic instability, displacement, and recurrent trauma. Now, the situation is unfathomably worse. The report of the UN Special Rapporteur on Palestine, Francesca Albanese, has highlighted the “unchilding” effect of occupation, depriving children of their very identity and identifying them as “racialised others,” depriving them of childhood itself (Albanese and UN, 2024; Shalhoub-Kevorkian, 2019). The following case study, illustrates how occupation, conflict and war impacts not only bodies, but minds, attachments, and development – especially in children.
According to a 2024 report from ACAPS (the Agency for Crisis Assistance and Preparedness), since October 7th, 2.1 million Gazans have experienced or directly witnessed violent and life-threatening events (Palestine, Reference Abu-Jamein.d.). These include the deaths of family members and neighbours, injury from bombs and shrapnel, mass displacement, starvation, and the complete destruction of homes, schools, and hospitals. In this context, pre-existing mental health difficulties are severely exacerbated. The most affected are those already known to psychiatric services: children, people with mental illness or intellectual disabilities, women of childbearing age, and the elderly (Human Rights Watch 2025; Latif et al. 2025).
Despite relentless bombardment, aid blockades, and mass civilian casualties, efforts to assess and support mental health needs continue. However, traditional clinical or research methodologies are almost impossible to implement in such contexts. Surveys are conducted online or through mobile outreach by local workers. Narrative accounts and rapid psychosocial assessments are often the only viable means of capturing the scope of mental health needs. This presents obvious limitations but offers critical real-time insight into community-level suffering and resilience.
One of the leading organisations documenting and responding to the psychological impact of war in Gaza is the Gaza Community Mental Health Programme (GCMHP). Founded in 1990 by the late Dr Eyad El Sarraj, GCMHP has long served as a cornerstone of community-based psychiatry and human rights advocacy in the region. Its services include clinical care, family outreach, training, and research, with a strong emphasis on disability inclusion and equity.
In 2024, GCMHP published a qualitative report titled “There People Suffer and Die” (Gaza Community Mental Health Programme, 2024), based on data collected by its Psychological First Aid (PFA) teams. Eighteen mental health workers provided narrative responses via online surveys, reflecting their observations while working with displaced and traumatised families. The report gathered information on three central questions: the most pressing needs of children, adults, older people, and those with disabilities during the war; the key psychological and social symptoms emerging in the population; and the ways individuals were managing these symptoms, whether through positive or negative coping strategies. Findings revealed that basic survival needs – food, water, safety, shelter, medical, and psychological care – dominate every conversation. However, embedded within these were frequent reports of acute psychiatric symptoms: sleep disturbances, hallucinations, severe anxiety, mutism in children, regression in behaviour, persistent suicidal thoughts, and symptoms suggestive of PTSD and major depression. Among families, chronic grief, rage, helplessness, and survivor’s guilt were widely reported.
One health worker described the case of “Ahmad,” aged 7. Ahmad went out to play on the first day of Eid. He was jumping on a trampoline with his sisters and other children when the area was bombed. His sisters were killed instantly. Ahmad sustained a severe brain injury and survived, but with a life-changing disability. GCMHP staff visited the family soon after. Despite unimaginable loss and trauma, they provided initial psychological support to help the parents begin to process their grief and to help Ahmad begin adjusting to his new reality. The intervention also focused on preventing long-term psychiatric sequelae by promoting attachment, stability, and therapeutic communication within the family unit.
Ahmad’s story is tragically not unique – but it illustrates a vital point. Amid mass death, physical injury, hunger, and displacement, the need for mental health and psychiatric care does not disappear – it becomes even more urgent. PFA, trauma-informed care, and community-based psychiatry must be embedded in all humanitarian responses, even under the most extreme conditions and in all responses thereafter.
Clinical and programmatic implications
The Machel Report (UNGA, 1996) argued that war is a violation of every fundamental right of the child. Almost 30 years later, children like Ahmad are still paying the price. For clinicians and humanitarian responders supporting children like Ahmad, and others who have been evacuated from war zones, it is vital to balance compassion with evidence. The Inter-Agency Standing Committee Guidelines on Mental Health and Psychosocial Support in Emergencies (Inter-Agency Standing Committee (IASC), 2007; Marshall, 2022), provide a framework for coordinated multi-sectoral action that prioritises safety, predictability, and practical care. This includes establishing secure environments, maintaining routines, ensuring access to education and play, and fostering supportive relationships before initiating any formal psychological therapy. At the same time, clinicians should be mindful of evidence cautioning against early, unstructured psychological debriefing. As Neil Greenberg and colleagues have cautioned, the instinct to “do something” immediately after trauma can inadvertently cause harm (Greenberg and Wessely, 2017). The same principles of watchful waiting, attunement, and restoration of social bonds are likely to apply equally to children and family units displaced by war. In the early phase, the most therapeutic actions are often practical: warmth, food, shelter, comfort, and reliable human connection.
The NICE guidelines recommend trauma-focused cognitive behavioural therapy (TF-CBT) for children with significant, enduring symptoms, but the supporting evidence is drawn mainly from survivors of sexual abuse rather than war-affected or refugee populations (National Institute for Health and Care Excellence, 2005). Adaptations for these contexts are therefore essential and have been evaluated. A recent systematic review found that across the 23 studies of diverse interventions to enhance resilience in forcibly displaced children, significant improvement in outcomes of children’s coping mechanisms, behavioural problems, and general well-being, but not caregiver support or psychiatric symptoms. The need for further research and more rigorous evaluation of interventions to support resilience of children displaced by war was highlighted (Thabet et al. Reference Thabet, Ghandi, Barker, Rutherford and Malekinejad2023). Teaching Recovery Techniques (TRT) – a brief, group-based programme derived from TF-CBT and developed by the Children and War Foundation – offers a pragmatic alternative for low-resource and large-scale humanitarian settings (Warner et al. Reference Warner, Durbeej, Salari, Fängström, Lampa, Baghdasaryan, Osman, Löfving, Aronsson, Feldman and Sampaio2020). TRT combines psychoeducation, emotional regulation, cognitive coping, and strengthening of caregiver relationships, helping children normalise reactions to trauma and regain control without forced retelling of events. The emerging evidence base, while mixed, indicates that such approaches can reduce distress and enhance coping when delivered within safe, supportive environments (Barron et al. 2016).
Ultimately, our paper reminds us that mental health must be central to all recovery efforts – effective programmes should integrate psychosocial and clinical care, emphasise stability and social connection first, and provide stepped access to specialist trauma treatment only where truly indicated. Delivering such care is complex and painful, yet it remains an act of defiance and humanity, reminding us that while war destroys lives, mental health services can preserve dignity, rebuild identity, and restore hope – even amid the ruins.
Conclusion
This paper has explored the rights of children to life, protection, and care in times of war and armed conflict – rights that have been powerfully articulated in international humanitarian law and advanced through the landmark Machel report (UNGA, 1996). Her work catalysed a global understanding of the wide-ranging and enduring harm that war inflicts on children, underscoring the urgent need for international intervention to prevent, mitigate, and respond to these harms.
Children’s rights are among the most fundamental responsibilities of all nations. In times of war, they become even more urgent, yet across the world today – from Gaza to Sudan, Ukraine to Myanmar – children continue to experience violations of these rights at a staggering scale (WHO, 2024). Despite legal protections, widespread and flagrant breaches persist, with profound physical, psychological, and social consequences.
Among the most serious and least visible consequences is the psychological toll of war on children. Exposure to trauma, loss, displacement, and chronic fear not only causes acute suffering but also poses serious risks to long-term mental health and development, with the potential for lifelong and transgenerational effects (Veronese et al. Reference Veronese, Mahamid and Bdier2023). Mental health care must be recognised as a core humanitarian need – alongside food, water, and medical care – and be included from the earliest stages of response (Abu-Jamei, 2025).
In the face of such grave and lasting harm, the international and medical communities have a moral and professional obligation to act. This includes calling for an immediate cessation of violence, unimpeded access to humanitarian aid, and the prioritisation of psychological and psychiatric care for children and families affected by conflict.
We must ensure that grave violations against children are eradicated, and that their rights – to life, family, security, health, and education – are preserved and attained. Only through such collective action can we begin to honour our commitments to children’s rights and help them recover from the horrors of war.
Funding statement
This publication received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Competing interests
The authors declare no competing interests.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
