חומר רקע

1 Shadow Report Presented to the UN Committee on the Rights of the Child By The Israel National Council for the Child August 2024 2 The Israel National Council for the Child The Israel National Council for the Child (NCC) is Israel’s leading NGO dedicated to advancing and safeguarding the rights and well-being of children and youth in Israel, both day-to-day and in cases of emergency. As a non-governmental, non-profit organization, the NCC does not accept government funding for its core activities, and in this way safeguards its independence. Relying on decades of experience and expertise in children's rights, the NCC operates in multiple arenas to drive change in policy, legislation, and practice. It serves as a crucial national direct assistance center, operating the Child Victim Assistance Center, which accompanies over 500 child victims and their families a year through criminal proceedings, as well as the Ombudsperson for Children and Youth, offering assistance and advice regarding children’s rights and other issues relating to children and their parents. Beyond direct assistance, the NCC, as a well-recognized agent possessing expertise and advocacy for children’s rights in the parliamentary and governmental arenas, actively promotes children’s rights through policy and legislation. The NCC is also engaged in raising awareness of children’s rights and promoting the engagement of youth in policymaking. Since its inception, the NCC has introduced more than 140 laws and legislative amendments. In addition, the NCC monitors the range of services and policy implementation regarding children and youth and gathers comprehensive data on children in Israel, with a particular focus on children at risk. The NCC has established itself as a trusted source of knowledge on children's rights for decision-makers, field professionals, researchers, government ministries, and civil society. 3 The Convention on the Rights of the Child The Convention on the Rights of the Child (CRC) enshrines the rights of children to life, liberty, dignity, protection, social security, health, education, equality, and proper development. The right to health is enshrined in Article 24 of the CRC, guaranteeing children the right to the highest attainable standard of health services and access to healthcare and treatment. This article obliges member countries to work towards the full realization of this right by taking various measures and promoting and encouraging international cooperation. Subsection 2 of Article 24 requires member countries to take steps to, among other things, ensure the provision of medical assistance to all children. Access to health care and mental health services is an integral part of realizing children's and adolescents' right to health as part of their right to development and overall well-being. The CRC interpreted this right as guaranteeing children's access to quality health services, including prevention, promotion, treatment, rehabilitation, and palliative care. Furthermore, the Committee linked the right to health with the right to life, survival, and development, suggesting that the right to health should be broadly interpreted to include children's right to grow and develop to their full potential and viewing children's health as a state of physical and mental well-being.1 Moreover, the Committee interpreted Article 24 in a way that obligates member countries to work towards making mental health services accessible to children. Section 2(b) requires member countries to ensure the provision of necessary medical assistance and healthcare to all children. In this context, the Committee emphasized its concerns about the rise in mental health problems among adolescents, including behavioral disorders, substance abuse, depression, eating disorders, and abuse-related trauma. The Committee expressed concern about the tendency to treat mental health issues through institutionalization and called for early detection and treatment. Specifically, the Committee cautioned against over-medicalization and institutionalization and urged member countries to adopt an approach based on public health and psychosocial support to address mental ill-health among children and adolescents and to invest in primary care approaches that facilitate the early detection and treatment of children's psychosocial, emotional, and mental problems.2 1 CRC/C/GC/15, 2013, par. 7 2 CRC/C/GC/15, 2013, par. 38 4 Furthermore, the Committee noted that Article 24 requires member countries to ensure universal coverage, health promotion, care, treatment, and vital medications.3 Finally, the Committee stated that Article 24 requires countries to pay special attention to underserved populations to ensure that every child has the right to access healthcare services.4 Israel ratified the Convention on the Rights of the Child in October 1991, thereby assuming the obligations and responsibilities stemming from the CRC. The Israel National Council for the Child serves as a key advocate ensuring the appropriate implementation of the tenets of the Convention in Israeli society since its ratification. 3 CRC/C/GC/15, 2013, par. 73(b) 4 CRC/C/GC/15, 2013, par. 29-28 5 Introduction On October 7, 2023, thousands of terrorists from Hamas and other Gazan terrorist organizations invaded southern Israel by land, sea and air. They entered cities and towns in order to murder, rape, abuse, and abduct Israeli civilians, conducting heinous acts of sheer evil and spreading recordings of the visual evidence of these acts. As violent terror entered civilian communities, children were placed at the forefront of this catastrophe. That day, tens children (birth-18) were murdered, and violently kidnapped into the Gaza Strip. As of today (August 2024), two children remain captive – brothers Kfir Bibas (one year old) and Ariel Bibas (five years old). Since then, the State of Israel has been engaged in an ongoing, multi-front war – including intensive fighting in the country’s north and south, as well as threats and attacks on the country’s center, including from non-neighboring countries. The ensuing war has put Israeli children in harm’s way. As of March 2024, as a result of the war, 19,528 Israeli children were officially recognized as victims of hostilities, either physically or mentally, or both, most of them from the war’s early days. That number is certainly not exhaustive of the war’s impacts. The continuous war has completely upended children’s realities, which are now beset with extreme threats and life- disrupting challenges. Children were abducted, killed, wounded, abused. Children sought shelter from terrorists entering their homes and from missile barrages. Tens of thousands of children were evacuated and displaced from their cities and towns, forced to leave their schools and homes for temporary ones. Children experienced parents and relatives harmed. Due to the pervasiveness and ubiquity of recordings of explicit and violent war acts in digital channels accessible-to-all, even children who did not experience gruesome violent scenes firsthand, have been adversely impacted by these scenes while viewing them. Thus, the reality of the war has forced upon Israeli children many dangers. It has generated considerable challenges for those who seek to address and mitigate these dangers. While acknowledging the horrid reality of children killed, wounded, and abducted, this report seeks to highlight challenges connected to the adverse impact of the war on the mental health of children in Israel. Often an “invisible injury”, it is only in recent decades that mental health and its treatment have begun to acquire its vital recognition in public discourse and governmental services. The war, indeed, has made the issue of mental health urgent. However, this urgency has met a complex, uneasy 6 reality of mental health services not operating at their required capacity, and unable to fully protect and ensure children’s rights to health and wellbeing. In this reality, the Israel National Council for the Child is a central and committed player in the struggle for the improvement of mental health services provided to children and youth in Israel. To this end, we hereby submit this report to the UNCRC, surveying the current state of affairs with regard to children’s mental health and mental health services in Israel, containing relevant data, focusing on the consequences of the War, and offering relevant constructive recommendations. Children’s Mental Health and the Israel-Hamas War – Key Data This report provides an overview of the relevant data regarding the consequences of the war in the context of children’s mental health, and then delves into issues, policies and services within the different systems that affect mental health treatment to children in Israel – health, education and welfare. One issue of concern is that no single entity – besides the NCC – gathers comprehensive child-related data in Israel. Similarly, there is no dedicated entity that collects children’s mental health data. However, by examining the data the NCC has collated, it has become clear that the reality of war has generated particularly worrisome outcomes for children’s mental health – a veritable mental health crisis: • Israeli Health Management Organizations (‘Kupot Holim’),5 which operate the community health services in Israel, have published information – at the request of the NCC - that confirms that in the months of October-December 2023, compared to the respective months in 2022, the rates of anxiety among Israeli youth aged 12-18 rose by 33%. • In November 2023, five weeks after the outbreak of the war, 84% of parents of children aged 2-12 reported symptoms of mental distress, 64% of parents reported their child being fearful, and 62% of parents reported their children being anxious.6 5 The data was provided by the Israeli HMOs Clalit, Maccabi, Meuhedet, and Leumit to the NCC following a Freedom of Information request. 6 The Israel National Council for the Child, ‘Children in Israel 2023’ Statistical Yearbook, page ח. (Hebrew). The data is based on a poll published in December 2023 among Israeli children by the Israeli NGO ‘Goshen’, dedicated to community child health and wellbeing. 7 • The ubiquitous viewing and oversharing of war scenes had negative consequences for children: In the first quarter of 2024, 63% of Israeli youth aged 12-17 reported they were exposed to disturbing and difficult content as a result of the war in social networks and video games, and 61% of them reported being concerned or having difficult emotions as a result of their exposure to war- related content. 7 • Compared to the respective months in 2022, the last three months of 2023 saw a 28% increase in calls to the 118 Hotline of the Ministry of Welfare, concerning violence, sexual abuse, and child neglect.8 • As of March 2024, 19,528 Israeli children were recognized as ‘victims of hostilities’, which includes mental health-related distress. Of the total, 7,283 are children under the age of six.9 The sharp increase in mental health distress during wartime has compounded the children’s mental health crisis that began with the COVID-19 pandemic and the related quarantines. Among children in Israel, the period of 2020-2022 has seen, even before the war, significant increases in mental health-related hospitalizations, interventions, symptoms, and diagnoses. Many of these have a significant gender component: • Between the years of 2019-2022, the number of child visits to psychiatric emergency departments increased by 19%. For girls, this increased by 34%.10 7 Based on a poll conducted among 1,155 Israeli youth, sponsored by the Child Online Protection Bureau, of the Israeli Ministry of National Security. https://www.gov.il/BlobFolder/reports/survey_anti_social_behaviors_youth_feb_2024/he/publications_%D7%93%D7%95%D7% 97%20%D7%9C%D7%A1%D7%A7%D7%A8%20%D7%94%D7%AA%D7%A0%D7%94%D7%92%D7%95%D7%99%D7%95%D7 %AA%20%D7%90%D7%A0%D7%98%D7%99%20%D7%97%D7%91%D7%A8%D7%AA%D7%99%D7%95%D7%AA%20%D7%9 1%D7%A7%D7%A8%D7%91%20%D7%91%D7%A0%D7%99%20%D7%94%D7%A0%D7%95%D7%A2%D7%A8%20%D7%9C% D7%A4%D7%A8%D7%A1%D7%95%D7%9D%20%D7%A4%D7%91%D7%A8%D7%95%D7%90%D7%A8%202024.pdf 8 The Israel National Council for the Child, ‘Children in Israel 2023’ Statistical Yearbook, page ז. (Hebrew) 9 The recognition and data are provided by the Israeli National Insurance (‘Bituah Leumi’) institute. The original data point appears in The Israel National Council for the Child, ‘Children in Israel’ Statistical Yearbook, page ג (Hebrew), and slightly increased since (https://www.ynet.co.il/news/article/bjrozlq6t). 10 The Israel National Council for the Child, ‘Children in Israel 2023’ Statistical Yearbook, page 260. (Hebrew), The Israel National Council for the Child, ‘Children in Israel 2021’ Statistical Yearbook, page 259 (Hebrew). 8 • During the same period, the number of child suicide attempts that reached hospital emergency departments increased by 16%. For girls, this increased by 25%.11 • Quantitative research has revealed that during the period of COVID-19, among Israeli youth aged 12-17, there was an increase of 36% in the rate of diagnosis of depression, an increase of 31% in the diagnosis of anxiety, an increase of 20% in the diagnosis of stress, an increase of 50% in the diagnosis of eating disorders, an increase of 25% in the use of antidepressants, and an increase of 28% in the use of antipsychotic medicine. These effects have been most prominent in female youth.12 • Between 2020-2021, the number of psychological treatments by school psychologists for students with suicide risk has increased by 43%, and the number of interventions performed by educational psychologists in the context of students with suicidal distress has increased by 122%.13 While the children’s mental health crisis caused by the war has served to augment the effects of the children’s mental health crisis associated with the COVID-19 pandemic, the Israeli systems in charge of addressing these crises continue to operate under a severe lack of resources. The State of Israel is obligated to protect and ensure children’s right to health. However, the reality of the war has met the stark reality of the shortcomings of a system unable to meet children’s needs even before the war. Children not receiving adequate mental health care violates their guaranteed rights and the state’s obligation to them. Yet, as data shows, even in pre-war Israel, these violations were exceedingly common: • There is a significant shortage of mental health professionals in public health services. In 2019, the Israeli State Comptroller noted a shortage of hundreds of psychiatrists and psychotherapists in the public health system, especially those serving the Arab, Ultra-Orthodox, and Ethiopian-descended Jewish 11 The Israel National Council for the Child, ‘Children in Israel 2023’ Statistical Yearbook, page 554. (Hebrew) 12 Bilu, et al. 2023. Data-Driven Assessment of Adolescents’ Mental Health During the COVID-19 Pandemic. Journal of the American Academy of Child & Adolescent Psychiatry, 62 (8). 13 The Israel National Council for the Child, ‘Children in Israel 2023’ Statistical Yearbook, page 570. (Hebrew) 9 communities.14 At the beginning of the war, it was estimated that there was a shortage of at least five thousand psychologists in mental health systems serving children and youth15. • The average waiting time for psychotherapy treatments in the Israeli public health system, last measured in 2018, was 150 days – representing severely delayed treatments. Children who lived in ‘Gaza Envelope’ towns (populated areas in southern Israel within a short distance of the Gaza Strip), who are constantly exposed to shelling and missile fire, had to wait 7-13 months from the initial call to the HMO until the beginning of psychotherapy.16 • In 2022, the Israeli State Comptroller noted that children and youth requiring admission for psychiatric hospitalization, needed to wait for 3-7 months, including those after a suicide attempt.17 As crisis follows crisis, the fulfillment of children’s right to health requires strategic policy changes prioritizing the systems that can guarantee the fulfillment of this right. Thus, in the spirit of the CRC, this report includes a series of recommendations, designed to improve the mental health services given to children in Israel. Each part below includes, as a background to the recommendations, a short introduction to the challenges they are meant to solve – subdivided according to the respective governmental systems they pertain to. These challenges are divided according to an organizational criterion, but all in all, they stem from the same root – the basic obligation of the State of Israel to the health and well-being of the children residing in it. 14 State Comptroller of Israel, 2020, Annual Report 70b, p. 837, 842. (Hebrew) 15 Letter to the Committee of Directors General (Directors General of Government Ministries) on children's and Youth Rights, dated 19/11/23, from the Israel National Council for the Child, Bizchut – The Israel Human Rights Center for People with Disabilities, Israel Pediatric Association, Goshen - Community Child Health & Well Being, The Israel Child & Adolescent Psychiatric Association, Israel Psychological Association, The Union of Social Workers and the Movement for Public Psychology. 16 State Comptroller of Israel, Annual Report 70b, 2020, p. 773, 784. (Hebrew) In this context, it is important to acknowledge the Supreme Court of Israel’s verdict dated 8.5.2024, regarding a judicial appeal concerning the legally obligated need to shorten waiting times for mental treatment, an appeal led by several Israeli NGOs (“Justice for Children”, “Bizchut”, the Association of Rape Crisis Centers in Israel, the Society for Patients’ Rights in Israel, the Israel National Council for the Child and other professionals). The Supreme Court has accepted the appeal, yet it is too soon to understand its concrete ramifications (HCJ 6733/24). 17 State Comptroller of Israel, 2023, the State Comptroller Annual Report, May 2023. (Hebrew) 10 Service Provision Background and Recommendations Public Mental Health System: Lack of Manpower, Lack of Training The Israeli public health system suffers from a long-lasting shortage of psychiatrists, in particular, a severe shortage of psychiatrists who specialize in children and adolescents, as well as relevant specific therapeutic specializations professionals in the areas of eating disorders and post-trauma. This shortage is particularly felt in the social and geographic periphery, and in the Israeli Arab sector.18 The number of Arabic-speaking psychiatrists who specialize in children and adolescents amounts to a few percent of their overall number despite the fact that a quarter of Israeli children are Arab.19 There have been several attempts to solve this manpower crisis, such as incentive grants and dedicated scholarships for those who specialize in child and adolescent psychiatry, particularly from the Arab sector, but these have not had much success. 20 A similar shortage is felt among psychotherapists (clinical psychologists and social workers) employed in the public sector. 21 As a result, children and youth need to wait long periods of time before commencing psychotherapy or psychiatric treatment, which in some situations can even be life- endangering. Furthermore, it is clear that the lack of proper treatment in the community, at an early point in time, can eventually lead to hospitalization. Furthermore, the lack of community-based intensive psychological care, also requires many children to be unnecessarily hospitalized, for the lack of better intensive solutions. These shortcomings result in children receiving delayed treatment, or treatment which is less than optimal, impacting their well-being and violating their rights. To address these issues a drastic expansion of community-based mental health services is needed, which must go in tandem with the increased training and deployment of mental health professionals who will specialize in treating children and youth. The issue of the lack of manpower is basic, strategic, and acute, and has a long-term influence on 18 The National Council for Mental Health, 2019, Conclusion Report: Sub-Committee on Gaps in Community-Based Services in the Mental Health Reform. (Hebrew) https://www.health.gov.il/Services/Committee/NationalCouncils/mental/Documents/22072019.pdf 19 Elroy, I. Samuel, H., & Medina-Artom, T. (2018). The Shortage of Arab Professionals in Mental- Health Services — Causes and Solutions. RR-767-18. Myers-JDC-Brookdale Institute. (Hebrew) Eng_Summary_767_18.pdf (Brookdale-web.s3.amazonaws.com) 20 State Comptroller of Israel, Annual Report 70b, 2020, p. 833-836. (Hebrew) 21 State Comptroller of Israel, Annual Report 70b, 2020, p. 837-842. (Hebrew) 11 the ability to supply therapeutic services to children and youth. Stretching beyond the direct services given to children, it must be addressed already at the training stage. Importantly, in August 2024, as a result of a public campaign in which the NCC played a significant role, the government and the trade unions representing the psychologists who work in the public sector reached new agreements, intended to improve the state of the public psychological services and the employment terms of the psychologists. According to the new agreements, which are supposed to come into full effect in January 2025, the wages of public psychologists are supposed to increase by 40% (on average), with additional benefits afforded to them according to experience, education level, et cetera. As of now (August 2024), similar wage agreements are in negotiation with the public psychiatrists. However, unfortunately, it is not at all certain that these will include needed solutions for child and adolescent psychiatry, which is found in dire need and requires special attention both as a profession and as a public service. This, despite the fact that the war has resulted in enormous distress for children and youth and aggravated the state’s inability to provide suitable care for them. Furthermore, the war has spotlighted the issue of the preparedness of health professionals treating children to address traumatic events. Surveys among pediatricians revealed that a significant number of them identified severe lacunae in their own knowledge regarding such kind of events: 36% of pediatricians surveyed thought they have too little knowledge regarding the effects of traumatic events and war on children, and over half thought they have too little knowledge regarding post-traumatic stress disorder among children, or regarding trauma-informed care. Furthermore, only 12% of pediatricians reported taking part in any training related to the effect of war on the emotional state of children or trauma-informed care, and 80% of them think there is a need for additional training in these subjects. 22 Educational Psychological Service: Lack of Coverage An additional, alternative mental service is provided to children as part of the education system, through the Educational Psychological Service, a municipally based service 22 The Israel National Council for the Child, ‘Children in Israel 2023’ Statistical Yearbook, pages י-ט. (Hebrew). The data is based on a poll conducted in December 2023 among Israeli pediatricians by the Israeli NGO ‘Goshen’, dedicated to community child health and wellbeing. 12 operating educational psychologists, and the Psychological and Counseling Services, directly subordinate to the Ministry of Education and operating inside the schools. Since children spend a large part of their day at school and almost all children in Israel attend school, the psychological service within the education system has the potential to play a key positive role in the identification and treatment of mental health issues. Unfortunately, the psychological services extended by the Israeli educational system suffer from both the restricted range of coverage and the problem of understaffing. Recognizing these manpower issues, the Education Ministry has only obligated that psychological services under its supervision will be given to students of the ages 5-15. This leaves the age groups of 3 to 5, as well as 15 to 18, without mandatory coverage, despite the fact that children in both of these age groups attend the Israeli public education system. In addition to the lack of mandatory coverage in certain age groups, even the age groups ostensibly under the mandate of the educational psychological services are under- serviced. The Ministry of Education guidelines require one psychologist for every thousand students in most grades (from the second to the twelfth grade), 23 and one psychologist for every five hundred students in kindergarten and the first grade.24 These guidelines, in themselves, are insufficient and serve to establish a very thin system of support. Yet, manpower shortages prevent even these rudimentary standards from being realized. Prior to the onset of the war, in August 2023, the national ‘coverage rate’ of educational psychologists was only 71% - meaning 29% of the positions of educational psychologists were not manned. This was even more severe in southern Israel, which was most impacted by the war where 36% of the positions of educational psychologists in the Ministry of Education’s Southern District were unfilled.25 This shortage constitutes a crucial violation of children’s right to treatment. Educational counselors and psychologists working with students have a key role in identifying mental distress and hardships and are often the ‘first-line’ element in the mental health system. The lack of resources in this central identification and treatment service significantly undermines the ability to provide children with the mental health treatment they deserve. This is particularly evident in municipalities with lower socio-economic 23 In the special education system, one psychologist is required for every three hundred students, regardless of the grade, extending even to non-minors (ages 3-21). 24 Rimon-Greenspan, H., & Barlev, L. (2023). Services for Children and Youth with Emotional and Mental Health Difficulties: Mapping of Services and Policy Issues. RR-942-23. Myers-JDC-Brookdale Institute. (Hebrew) 25 The Israel National Council for the Child, ‘Children in Israel 2023’ Statistical Yearbook, page יג. 13 ratings, peripheral municipalities, and populations such as Jews of Ethiopian descent, new immigrants, and students from the Ultra-Orthodox and Arab societies. 26 Importantly, the new wage agreements reached between the trade union representing public sector psychologists and the government, mentioned previously, are predicted to also impact the educational psychologists of the public education system, and thus may be able to mitigate some of these manpower issues, at least with regards to staffing the current guidelines. It is imperative to remember, however, that these current guidelines are, in themselves, not sufficient, and undermine the role of educational psychology services in fulfilling children’s right to health. Welfare Services: Lack of Resources, Lack of Consistency in dealing with Displaced Children Israeli welfare and social services are responsible for safeguarding and ensuring the rights of children in a variety of risk situations, and to that end rely, mostly, on community-based services and on various, dedicated out-of-home placements. The safety network of welfare services is meant to assist children who are often on the outer edge of the risk spectrum, whether as a result of abuse or other risk factors. As such, its role is crucial in safeguarding children’s rights in general. However, to the detriment of the children requiring its services, the State of Israel’s welfare and social services system is chronically understaffed, underbudgeted – and its resources are often spread unequally among different municipalities. 27 Not unlike the health and education systems, as Israeli social services are unable to meet the needs of children at regular times, they have found themselves often sorely lacking in their ability to deal with emergencies and wartime. As the ongoing war necessitated the unprecedented displacement of tens of thousands of children from their homes and communities, chaotic access to information and availability of services ensued, affecting the ability to address mental health issues that arose among children and youth nationally, and more acutely among displaced children and youth. Immediate care was given by civil society organizations and volunteer social workers in more than two hundred different facilities for the displaced, and state officials only gradually began taking on responsibilities. The resulting lack of clarity regarding the sharing of responsibilities has created inefficient work methods and inter- 26 Ashkenazi, Y., Angel, M., & Topilsky, T. (2014). Psychological Services in Elementary Schools in Normal Times and in Emergencies. RR-667-14, ES-44-14. Myers-JDC-Brookdale Institute. (Hebrew) 27 Johnny Gal and Shavit Ben-Porat. 2024. In the Social Front: On Social Workers in Israel in 2024. Taub Center for Social Policy Studies in Israel. (Hebrew) 14 organizational competition, that has often resulted in treatment which is lacking or less- than-optimal. 28 Displaced children and youth have faced hardships related to unsuitable living environments in the various places to which they were evacuated. In addition, there was a lack of a daily routine, as dedicated schools often operated for just a few hours every day. This has led to a rise in school dropouts, substance abuse, exposure to violence, and other risk behaviors.29 Among the displaced youth there are those who were considered at-risk even before the war, the challenges they are facing have been exacerbated. In many cases, there is a diminished ability of social services to assist them, as children have been displaced to other areas, where treatment options are not necessarily suitable.30 There is a nationwide shortage of social workers working in the various municipal departments of social services, and particularly social workers specializing in youth, and this shortage is tied to a lack of manpower influenced by low wages and a lack of benefits. Managing this shortage nationwide at a time of war and displacement of populations has been made difficult by the lack of a central, strong executive element that can allocate and channel resources. Additional challenges incurred by the war include the displacement of welfare facilities serving youth, further complicating the ability to maintain proper treatment of children during the war, and the fact that staff in various welfare facilities were called to reserve duty. Policy Recommendations: 1. Expanding the manpower infrastructure across all mental health therapeutic professions servicing children and youth, including child and adolescent psychiatrists, public sector psychologists, and social workers who specialize and work with children and youth. This expansion should have a focus on the Arab, Ultra-Orthodox, and Ethiopian-descended Jewish communities. It should include an increase in the number of staffed positions; combat manpower shortages through increased wages, incentives, and active efforts for employee preservations; incentivizing private sector employees to join public mental health services of children and youth (at least on a part-time basis); incentivizing 28 Taub Center Research Staff. December 2023. The 7.10 War and Its Impact on Israeli Society and Economy. Taub Center for Social Policy Studies in Israel (Hebrew.) https://www.taubcenter.org.il/wp-content/uploads/2023/12/War-HEB-2023-5.pdf 29 See for example: Elem – Youth in distress, Status Report on at-risk Youth, April 2024. https://www.elem.org.il/wp-content/uploads/2024/05/Elem-ENG-Print.pdf 30 Knesset Research and Information Center, 19.3.24, The State of Evacuated and Displaced Children and Youth. (Hebrew) https://fs.knesset.gov.il/globaldocs/MMM/07f839a5-ba92-ee11-8162- 005056aa4246/2_07f839a5-ba92-ee11-8162-005056aa4246_11_20461.pdf 15 training of professionals in areas severely lacking; and financial incentives for doctors, psychologists and mental health care professionals who service children to move to peripheral zones where there are acute shortages of them. 2. Expanding the range and variety of community-based mental health treatments given to children and youth, and the establishment of additional public mental health clinics in order to significantly aid the availability and accessibility of mental health services. 3. Expanding the educational psychological array in the education system, including an increase in the allotment of educational counselling hours to schools, and the expansion of mandatory coverage of the educational psychological services to all ages, from ages 3 to 18. 4. Mandating training regarding trauma and anxiety among children and youth for doctors, psychologists, care professionals, and educational staff. This should include the allotment of resources for parental guidance regarding these issues, an integral part of strengthening the resilience of communities and families in emergencies and wartimes. 5. Creating a dedicated position of ‘care coordinator’ for children and youth, responsible for assisting children requiring mental health care in realizing their rights and treatments across different governmental ministries. 6. Establishment of a permanent inter-ministerial and inter-sectorial forum dedicated to the issues of the mental health of children and youth. The forum would keep abreast of developments and raise awareness of problems and gaps and propose initiatives in the field. Conclusion: Terrorist acts, mass displacements, upending of lives, even the digital consumption of gruesome and explicit acts of violence – all of these took a significant toll on children in Israel, and have resulted in a crisis of mental health and wellbeing. This crisis, unfortunately, has compounded the effects of the COVID-19 mental health crisis among children and youth. The effects of both of these events have met a public mental health system that was unable to meet children’s needs even before these dramatic emergencies. 16 The State of Israel’s obligation to protect and ensure children’s right to health is unfulfilled, and the fulfillment of that obligation will require strategic initiatives, aimed at revitalizing children’s mental health services across different governmental systems: health, education, and welfare. To this end, the most urgent needs are the expansion of the manpower infrastructure of the mental health care professions, the expansion of the range and accessibility of community-based mental health treatments, and the expansion of education psychological services, and training. To meet this goal, the State of Israel will need to implement a comprehensive, strategic program. In this regard, it is crucial that the decision makers consider immediately both short- and long-term solutions, changes in the way services are provided, and any other measure that will alleviate the significant gaps described in this report.