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Annual Research Review: Breaking cycles of violence - a systematic review and common practice elements analysis of psychosocial interventions for children and youth affected by armed conflict

Journal of Child Psychology and Psychiatry

December 2016
58(4)

DOI:10.1111/jcpp.12671

Authors:

Felicity L Brown

War Child Holland

Anne M de Graaff

Vrije Universiteit Amsterdam

Jeannie Annan

University of Chicago

Theresa S Betancourt

Boston College

Background: Globally, one in 10 children live in regions affected by armed conflict. Children exposed to armed conflict are vulnerable to social and emotional difficulties, along with disrupted educational and occupational opportunities. Most armed conflicts occur in low- and middle-income countries (LMICs), where mental health systems are limited and can be further weakened by the context of war. Research is needed to determine feasible and cost-effective psychosocial interventions that can be delivered safely by available mental health workforces (including nonspecialists). A vital first step toward achieving this is to examine evidence-based psychosocial interventions and identify the common therapeutic techniques being used across these treatments. Methods: A systematic review of psychosocial interventions for conflict-affected children and youth living in LMICs was performed. Studies were identified through database searches (PsycINFO, PubMed, Cochrane Central Register of Controlled Trials, PILOTS and Web of Science Core Collection), hand-searching of reference lists, and contacting expert researchers. The PracticeWise coding system was used to distill the practice elements within clinical protocols. Results: Twenty-eight randomized controlled trials and controlled trials conducted in conflict-affected settings, and 25 efficacious treatments were identified. Several practice elements were found across more than 50% of the intervention protocols of these treatments. These were access promotion, psychoeducation for children and parents, insight building, rapport building techniques, cognitive strategies, use of narratives, exposure techniques, and relapse prevention. Conclusions: Identification of the common practice elements of effective interventions for conflict-affected children and youth can inform essential future treatment development, implementation, and evaluation for this vulnerable population. To further advance the field, research should focus on identifying which of these elements are the active ingredients for clinical change, along with attention to costs of delivery, training, supervision and how to sustain quality implementation over time.

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Annual Research Review: Breaking cycles of violence –

a systematic review and common practice elements

analysis of psychosocial interventions for children and

youth affected by armed conﬂict

Felicity L. Brown,

1,2

Anne M. de Graaff,

1,3

Jeannie Annan,

and Theresa S. Betancourt

Research Program for Children and Global Adversity, Department of Global Health and Population, Harvard T. H.

Chan School of Public Health, Boston, MA, USA;

War Child Holland, Amsterdam;

Faculty of Social and Behavioral

Sciences, Leiden University, Leiden, The Netherlands;

International Rescue Committee, New York, NY, USA

Background: Globally, one in 10 children live in regions affected by armed conﬂict. Children exposed to armed

conﬂict are vulnerable to social and emotional difﬁculties, along with disrupted educational and occupational

opportunities. Most armed conﬂicts occur in low- and middle-income countries (LMICs), where mental health

systems are limited and can be further weakened by the context of war. Research is needed to determine feasible and

cost-effective psychosocial interventions that can be delivered safely by available mental health workforces (including

nonspecialists). A vital ﬁrst step toward achieving this is to examine evidence-based psychosocial interventions and

identify the common therapeutic techniques being used across these treatments. Methods: A systematic review of

psychosocial interventions for conﬂict-affected children and youth living in LMICs was performed. Studies were

identiﬁed through database searches (PsycINFO, PubMed, Cochrane Central Register of Controlled Trials, PILOTS

and Web of Science Core Collection), hand-searching of reference lists, and contacting expert researchers. The

PracticeWise coding system was used to distill the practice elements within clinical protocols. Results: Twenty-eight

randomized controlled trials and controlled trials conducted in conﬂict-affected settings, and 25 efﬁcacious

treatments were identiﬁed. Several practice elements were found across more than 50% of the intervention protocols

of these treatments. These were access promotion, psychoeducation for children and parents, insight building,

rapport building techniques, cognitive strategies, use of narratives, exposure techniques, and relapse prevention.

Conclusions: Identiﬁcation of the common practice elements of effective interventions for conﬂict-affected children

and youth can inform essential future treatment development, implementation, and evaluation for this vulnerable

population. To further advance the ﬁeld, research should focus on identifying which of these elements are the active

ingredients for clinical change, along with attention to costs of delivery, training, supervision and how to sustain

quality implementation over time. Keywords: Armed conﬂict; war; violence; developing countries; children;

adolescents; youth; mental health; well-being; psychosocial treatment; systematic review.

Introduction

The context of war and the impact on child and

youth mental health

Globally, it is estimated that one in 10 children –

nearly 250 million –live in areas affected by armed

conﬂict (UNICEF, 2016). War-related fatalities have

increased sharply in recent years (IISS, 2015; Pet-

tersson & Wallensteen, 2015), alongside a trend of

increasing intensity of the killing, maiming, recruit-

ment into armed forces, and other grave violations of

children (United Nations Ofﬁce of the Special Repre-

sentative of the Secretary-General for Children and

Armed Conﬂict, 2016). Through 2015, global con-

ﬂicts contributed to an estimated 65.3 million

forcibly displaced people; thus, we are witnessing

the highest overall rates and sharpest increases in

displacement on record (UNHCR, 2015, 2016). Half

of those displaced (51%) are estimated to be under

the age of 18 years (UNHCR, 2016).

Beyond direct exposure to violence, death, loss,

and other atrocities, armed conﬂict disrupts the life

trajectories of children and their families, by limiting

their basic opportunities to pursue an education or

occupation long into the postconﬂict period (Betan-

court, 2015; Tol, Kohrt, et al., 2010). With the

changing nature of modern warfare, conﬂicts are

no longer conﬁned to distinct battleﬁelds, but often

speciﬁcally target civilian populations and essential

infrastructure such as schools and hospitals (Betan-

court & Khan, 2008). Damage to social and commu-

nity support networks, lack of access to services,

increased daily stressors in the postconﬂict setting,

shifting of behavioral norms including increases in

other forms of violence, disrupted family environ-

ments, and the intergenerational transmission of

trauma can exacerbate and perpetuate the social,

emotional, and economic consequences of war for

young people (Betancourt, 2015; Betancourt,

Conﬂict of interest statement: No conﬂicts declared.

Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA

Journal of Child Psychology and Psychiatry **:* (2016), pp **–** doi:10.1111/jcpp.12671

McBain, Newnham, & Brennan, 2015; Newnham,

Pearson, Stein, & Betancourt, 2015; Panter-Brick,

Grimon, & Eggerman, 2014; Slone & Mann, 2016).

The global development community is increasingly

recognizing the signiﬁcance of mental health prob-

lems as leading causes of illness and disability that

affect the lives of young people worldwide (Davidson,

Grigorenko, Boivin, Rapa, & Stein, 2015; Erskine

et al., 2015; Gore et al., 2011). Indeed, the newly

launched Sustainable Development Goals (SDGs;

Interagency Expert Group on SDG Indicators, 2016)

acknowledge mental health and well-being as inte-

gral components of overall health, and speciﬁcally

aim to enhance services and reduce exposure of

children to violence and other adversities. The

impacts of war on youth mental health and well-

being are immense; high rates of traumatic stress

reactions and posttraumatic stress disorder (PTSD),

symptoms of depression and anxiety, psychosomatic

symptoms, functional impairments, social difﬁcul-

ties, and risky behaviors all have consequences for

the immediate well-being as well as life course

opportunities of children and adolescents exposed

to armed conﬂict (Attanayake et al., 2009; Betan-

court, Newnham, McBain, & Brennan, 2013; Fazel,

Reed, Panter-Brick, & Stein, 2012; Okello, Nakimuli-

Mpungu, Musisi, Broekaert, & Derluyn, 2013; Slone

& Mann, 2016). Thus, in order to advance human

development globally, it is essential that effective

services are developed and implemented to prevent

and respond to distress, and promote well-being in

this vulnerable and rapidly growing group.

The challenge of improving access to quality

services in conﬂict-affected settings

Tremendous care gaps exist in access to mental health

services globally, particularly in situations of armed

conﬂict. In low- and middle-income countries

(LMICs), it is estimated that over 80% of individuals

requiring mental health services do not receive the

care they require (WHO, 2012). With armed conﬂicts

more common in LMICs (Kim & Conceicao, 2010),

increased mental health needs frequently emerge in

the context of health systems that are ill-equipped to

cope with the burden (WHO, 2013). The growing trend

of limited humanitarian access in conﬂict-affected

settings further prevents provision of essential mental

health services (Collinson & Elhawary, 2012). Calls to

action from the Lancet Global Mental Health series

have underscored that in order to truly make progress

toward the SDGs, explicit evidence-based indicators

of mental health outcomes and service provision must

be speciﬁed, and strategies for reducing this vast

treatment gap implemented (Gureje & Thornicroft,

2015; Izutsu et al., 2015; Kieling et al., 2011). Yet

access to quality mental health care and other social

services in conﬂict-affected settings, especially for

children and youth, currently remains an urgent and

poorly addressed issue.

A growing body of research has documented that

evidence-based interventions developed in high-

income countries can be effective across cultures in

LMICs (Barry, Clarke, Jenkins, & Patel, 2013; Patel,

Araya, et al., 2007) and in conﬂict-affected areas

(Betancourt, Meyers-Ohki, Charrow, & Tol, 2013;

Jordans, Pigott, & Tol, 2016; OʼSullivan, Bosqui, &

Shannon, 2016; Tol et al., 2011). Two recent sys-

tematic reviews of children and adolescents affected

by armed conﬂict have highlighted promising effects

of interventions, particularly trauma-focused cogni-

tive behavioral therapy (CBT) for clinical populations

(Jordans et al., 2016; OʼSullivan et al., 2016). Yet

there is less consistent evidence for other interven-

tion modalities and for nonclinical populations.

Furthermore, treatment beneﬁts are often limited to

speciﬁc subgroups of youth, and methodological

limitations remain (Jordans et al., 2016; OʼSullivan

et al., 2016).

Moreover, an overwhelming key barrier in real-

world implementation of such interventions and the

advancement of child and youth mental health

globally is the scarcity of mental health specialists

in LMICs and conﬂict-affected settings (Lancet

Global Mental Health Group, 2007; Patel, Flisher,

Hetrick, & McGorry, 2007), with an estimated short-

age of 1.2 million health workers required to meet

global needs (Kakuma et al., 2011). Recent innova-

tions have been implemented to address this chal-

lenge of scaling up care for mental health disorders

in LMICs. These have involved simpliﬁed treatments

and task-shifting and task-sharing approaches,

whereby nonspecialist lay interventionists are

trained to deliver psychological interventions (van

Ginneken et al., 2013; WHO, 2010). Intervention

models involving nonspecialist providers have also

shown promise in high-income countries (Fuhr

et al., 2014). Therefore, an ongoing core research

priority is to develop and evaluate effective and cost-

effective treatments for delivery by nonspecialists

with minimal training to respond to the high burden

of mental health needs, unique risk and protective

factors, and service delivery challenges in conﬂict-

affected settings (Collins et al., 2011; Lancet Global

Mental Health Group, 2007; Tol et al., 2011).

Distilling the common elements of effective

psychosocial treatments in conﬂict-affected settings

With the growing progress in the global mental health

ﬁeld, it is now possible to take stock of the cumulative

evidence and begin to shift from a focus on pure

efﬁcacy and effectiveness research, to thinking sys-

tematically about treatment mediators and modera-

tors, and utilizing dismantling approaches to identify

necessary and sufﬁcient active treatment compo-

nents for effective interventions for children and

youth affected by war. As in broader ﬁelds of

psychosocial interventions, treatments are com-

monly implemented and evaluated as comprehensive

2Felicity L. Brown et al.

manualized packages, and treatment content and

ﬁdelity are often poorly speciﬁed in outcome reports.

Yet without an understanding of the speciﬁc tech-

niques delivered within a psychosocial intervention

package, it is impossible to draw adequate conclu-

sions about the existing evidence-base, and use these

to inform clinical practice. In order to develop feasible

treatments for delivery by nonspecialist providers, it

is essential to ﬁrst identify the key treatment compo-

nents that must be included and implemented with

ﬁdelity in order to effect change.

In an attempt to improve understanding of the key

ingredients of effective mental health interventions

for different patient groups and presenting prob-

lems, Chorpita, Daleiden, and Weisz (2005) devel-

oped a distillation and matching approach to

empirically identify proﬁles of common elements of

interventions. During the distillation process, key

characteristics of intervention trials and patient

groups and the corresponding intervention protocols

are systematically coded to identify the common

‘practice elements’ across intervention protocols.

During the matching process, data mining proce-

dures are used to determine speciﬁc proﬁles of

common components included in evidence-based

treatments and to determine where these proﬁles of

included elements may vary between particular

patient groups and settings. Rather than considering

the effectiveness of comprehensive intervention

packages, this approach aims to drill down to

individual therapeutic techniques commonly found

in effective treatments, in order to obtain a more ﬁne-

grained understanding of the current evidence-base

(Chorpita et al., 2005).

Such an approach cannot identify whether speci-

ﬁc components are ‘active ingredients’ in producing

the observed treatment effects. However, a focus at

the level of speciﬁc common practice elements used

in efﬁcacious interventions, rather than at the level

of comprehensive multicomponent treatment pack-

ages, can improve coordination and reduce waste

in research efforts. It can also inform later dis-

mantling studies to determine active ingredients,

and may enable improved integration of speciﬁc

treatment elements into a treatment package to

target particular symptom domains or functional

impairments in a given population at risk for

mental health problems (Chorpita et al., 2005;

Michie et al., 2013).

Identiﬁcation of common practice elements can

complement and enhance efforts to develop inter-

ventions that can be used across multiple different

disorders. These approaches are gaining interest in

high-resource settings (e.g. Ellard, Fairholme, Bois-

seau, Farchione, & Barlow, 2010; Hayes, Strosahl, &

Wilson, 2003; Weisz, Bearman, Santucci, & Jensen-

Doss, 2016; Weisz et al., 2012) and low-resource

settings (e.g. Betancourt, McBain, et al., 2014;

Epping-Jordan et al., 2016; Murray, 2014; Sijbrandij

et al., 2015). Treatment approaches incorporating

core components of psychosocial interventions that

are safe and effective for delivery by lay intervention-

ists and can be applied across a range of commonly

co-occurring mental health problems have the poten-

tial to reduce the burden of training in multiple,

discrete intervention packages and limit the number

of referral points required before receiving treatment

(Murray & Jordans, 2016). This has particularly

important implications in emergency or postconﬂict

settings where human resources, access to special-

ists, and training and supervision opportunities are

extremely limited.

Given the growth in implementation and evalua-

tion of psychosocial treatments in conﬂict-affected

settings, the unprecedented numbers of people dis-

placed by armed conﬂicts globally, and the height-

ened demand for targeted, ﬂexible, and affordable

intervention options, an analysis of common practice

elements in this setting is valuable and timely as a

ﬁrst step to inform ongoing research and treatment

efforts. To date, this approach has not been applied

speciﬁcally to conﬂict-affected youth, nor has it been

applied to the broad range of psychological problems

and treatment modalities present in such settings.

The present review

We conducted a systematic literature review of

randomized controlled trials (RCTs) and controlled

trials of psychosocial interventions addressing the

mental health and well-being of conﬂict-affected

children and youth in LMICs, and an analysis of

common practice elements across efﬁcacious inter-

vention protocols. Previous reviews have considered

the evidence-base for children and adolescents in

LMICs or conﬂict settings (Barry et al., 2013; Betan-

court, Meyers-Ohki, et al., 2013; Jordans, Tol, Kom-

proe, & De Jong, 2009; Jordans et al., 2016;

OʼSullivan et al., 2016; Tol et al., 2011); however,

we broadened our inclusion criteria to include youth

up to 24 years (UNESA, 2010). As a well-functioning

family environment may mitigate the detrimental

effects of violence on children (Betancourt & Khan,

2008; Slone & Mann, 2016), family interventions

where the well-being of children was addressed

indirectly via parents were also included.

This is the ﬁrst study to distill the practice

elements included in efﬁcacious interventions

speciﬁcally for youth in conﬂict-affected settings. It

is an important extension of existing work distilling

the practice elements for interventions with children

more broadly (Chorpita & Daleiden, 2009), given the

realities of low resources, cultural considerations,

typically nonspecialist workforces, and health sys-

tem strains in these settings. It can inform future

research into active therapeutic techniques, which

will in turn guide development of intervention mod-

els that are maximally targeted to improve function-

ing and reduce distress even in the challenging

context of humanitarian emergencies.

Breaking cycles of violence 3

Methods

The methodology and results for the review are presented

according to the PRISMA standards for reporting systematic

reviews (Moher, Liberati, Tetzlaff, & Altman, 2009).

Search strategy

A systematic literature search was conducted on the following

databases: PsycINFO (1840 –August 2015), PubMed (1951 –

August 2015), Cochrane Central Register of Controlled Trials

(1974 –August 2015), PILOTS (1871 –August 2015) and Web

of Science Core Collection (all Citation Indexes; 1900 –August

2015). Limits were not applied to searches in terms of language

or publication date. The searches used exploded Medical

Subject Headings (MeSH) terms where relevant and the com-

prehensive list of keywords is shown in Box 1.

Hand-searches of the reference lists of two relevant journals

in the ﬁeld (Intervention and Journal of Traumatic Stress

Studies) as well as relevant review papers were also conducted

to identify additional studies. In addition, we contacted

authors of included studies to identify additional articles not

yet retrieved.

Inclusion criteria

Inclusion and exclusion criteria are shown in Box 2. The

full search yield was initially reviewed for inclusion by two

independent reviewers (FB and AdG) on the basis of title

and abstract. Both reviewers then assessed the full text of

the remaining articles for adherence to the inclusion crite-

ria. At both points, discrepancies were resolved by discus-

sion, and remaining queries were discussed with a third

reviewer (TB).

Box 1 Search terms used for systematic database

searches

Population: Child*OR Adolescen*OR Preado-

lescen*OR Youth*OR “Young people” OR “Young

person*” OR Infant*OR Family OR Families OR

Pediatric*OR Paediatric*OR Parent*

AND

Population: War OR Genocide OR “prisoners of

war” OR “mass violence” OR “community vio-

lence” OR “mass conﬂict*” OR “post-conﬂict*”OR

“post conﬂict*” OR “political conﬂict*” OR “polit-

ical violence” OR “armed conﬂict*” OR “Armed

violence” OR “ethnic cleansing” OR “child sol-

dier*” OR “child combatant*” OR “children asso-

ciated with armed forces and armed groups” OR

“CAAFAG” OR terrorism

AND

Intervention: treatment*OR intervention*

OR therapy OR psychotherapy OR counseling

OR counselling OR training OR psychoeduca-

tion OR promotion OR prevention OR Program*

OR “Home visiting” OR Support

AND

Outcome: Behavior OR Behaviour OR Function*

OR Externalizing OR Externalising OR Conduct

OR “Mental Health” OR “Mental-Health” OR Psy-

chosocial OR Psycholog*OR resilienc*OR “post-

traumatic growth” OR “post-traumatic growth”

OR “post traumatic growth” OR “Posttraumatic

stress” OR “Post traumatic stress” OR “Post-

traumatic stress” OR Trauma OR Internalizing

OR Internalising OR PTSD OR PTSS OR Depres-

sion OR “Depressive Disorder*” OR MDD OR

Anxiety OR “Anxiety disorder*” OR Stress OR

Distress OR Emotion*OR Suffering OR “Depres-

sive symptom*” OR “anxiety symptom*” OR well-

being OR “well being” OR well-being OR coping OR

psychopathology OR “Quality of life” OR Suicid*

OR “Mental Disorder*

Box 2 Inclusion and exclusion criteria for studies in this

systematic review

Inclusion criteria:

1. Participants were children or youth

(24 years and younger) of both sexes who

lived or are living in an area affected by

recent or ongoing conﬂict (post-World War

II), including former child soldiers. We also

included interventions where the parents of

youth participated in an intervention related

to youth outcomes.

2. Treatment was a psychosocial intervention,

including group, individual, self-help, fam-

ily-based, or community-based interven-

tions. As described by the Inter-Agency

Standing Committee for Mental Health and

Psychosocial Support in Emergencies

(2007), we included specialized services,

focused nonspecialized services, and

strengthening community and family sup-

ports, but excluded interventions focused

solely on basic needs and services and

security.

3. The treatment was delivered in an LMIC

4. Design was randomized controlled trial

(RCT) or controlled trial (i.e. a comparison

of a psychosocial intervention condition with

either another active intervention, standard

care, waitlist, or no treatment).

5. Outcomes included internalizing symptoms

(e.g. depression, anxiety, distress, stress,

trauma, posttraumatic stress), externalizing

symptoms (e.g. conduct problems), mental

disorders, functioning.

Exclusion criteria:

1. Pre- and postintervention data were not

collected for each group, or no between-

group comparison was conducted.

2. Included youth affected by conﬂict who now

lived in high-income countries.

3. Included youth affected by single incidents

of terrorism.

4Felicity L. Brown et al.

Data extraction for study characteristics

Data were extracted independently from each study by two

reviewers (FB and AdG) using a coding scheme based on the

PracticeWise coding manual (2005). Data extracted included

study design (RCT or controlled clinical trial), participant

characteristics (sample size, age, gender, inclusion and

exclusion criteria), study methods (recruitment and sampling

strategies), intervention protocol characteristics (therapist,

session format, number and duration of sessions), relevant

outcomes measured (outcome, tool used), and treatment

effects (signiﬁcant between-group differences, signiﬁcant

within-group differences). We made adaptations to the Prac-

ticeWise coding structure to suit the purpose of this review,

and the postconﬂict and LMIC context. For example, we

coded: country of origin rather than ethnicity; war experi-

ences in terms of whether the conﬂict was ongoing or past;

whether the study included children associated with armed

forces or armed groups (CAAFAGs) or orphans; cadre of

therapist (peer, lay health worker, teacher, counselor, social

worker, psychologist, medical doctor, psychiatrist); and

whether therapist was local or nonlocal to the country of

implementation. We also added Internally Displaced Person

(IDP) Camp or Refugee Camp as potential intervention

settings, and where group sessions were held, we coded

the group size when available. When reported, we also

collected descriptive information on therapist training and

supervision, and cultural adaptations made to the interven-

tion. There was 97% initial agreement on characteristics of

studies and 95% initial agreement on treatment effects.

Discrepancies in coding of treatment studies were resolved

by discussion.

As described by Chorpita and Daleiden (2009), ‘study

groups’ were deﬁned as a group of participants who received

a speciﬁed protocol; a ‘protocol’ was deﬁned as the treatment

procedures in which members of that group participated.

A‘winning treatment’ was deﬁned as a psychosocial treat-

ment protocol received by a study group, which was superior

to another study group within the study (e.g. a comparison

psychosocial treatment, waitlist condition, no-treatment, or

other control group) on at least one outcome measured.

A winning treatment was indicated via a signiﬁcant between-

group treatment effect (p<.05), whereby either the winning

group improved while the comparison group did not, both

groups improved but the winning group improved signiﬁ-

cantly more, or the comparison group deteriorated while the

winning group did not. If a control condition consisted of a

psychosocial treatment and showed greater improvement on

outcomes than another condition in the study (e.g. a second

control condition, or the primary treatment condition), this

would also be considered a winning treatment. The protocol

for each winning treatment was subjected to further coding

to identify the practice elements included. Nonwinning

protocols (i.e. a psychosocial treatment delivered to a study

group that did not show greater improvement in outcome

when compared to a study group receiving a comparison

psychosocial treatment, waitlist condition, no-treatment, or

another control condition) were not coded for their practice

elements (in line with standard procedures; Chorpita &

Daleiden, 2009).

Where moderator effects were examined in a study and

signiﬁcant treatment effects were only found for a speciﬁc

subgroup on given outcomes, these effects are speciﬁed in

Table S1, available online. In order to classify a treatment as a

winning treatment for that outcome, it was required that either

there was an overall treatment effect, or a treatment effect for a

speciﬁc subgroup by age or gender (the two most common and

relevant moderators). Other moderation effects are reported,

but these effects were not sufﬁcient for a treatment to be

included as a winning treatment. Where a cluster RCT design

was employed, analyses adjusted for clustering were consid-

ered when available.

Coding of practice elements

As speciﬁed by Chorpita and Daleiden (2009), a ‘practice

element’ is a discrete clinical technique or strategy (e.g.

exposure, relaxation) included in a larger intervention protocol

(e.g. a manualized anxiety treatment). Written requests to

access the manuals for treatment protocols were sent to all

authors of papers reporting winning treatments, or developers

of winning treatments, and one follow-up request was sent.

Where actual manuals were available and it was clear that

these were the exact protocols followed in the study, these were

used for coding of practice elements along with any additional

information presented in the journal article (n=16; indicated

in table). However, in other cases where the treatment manual

was not available (n=9; four manuals unavailable, ﬁve

manuals not exact protocol delivered), coding of practice

elements was conducted on the description of the treatment

protocol provided in the text of the journal article.

Using the PracticeWise (2005) coding system, we coded the

protocols of all winning treatments for the presence or absence

of 73 practice elements codes. One critique of the practice of

identifying discrete practice elements is that the process tends

to favor CBT-based approaches, and other modalities are less

represented (Swartz, 2015). To compensate for this, we

undertook an additional two steps. First, we reviewed the 59

common elements for evidence-based trauma treatment iden-

tiﬁed recently (Strand, Hansen, & Courtney, 2013) and added

two additional relevant codes –‘homework’ and ‘interventions

for grief and loss’ –to our coding system. Second, as recom-

mended by the PracticeWise manual (2005), additional treat-

ment components not captured by existing codes were

recorded as free text and reviewed for frequently occurring

practice elements. Through this process, we added three

additional codes –‘safe place techniques,’ ‘parenting skills’

(this was included to capture provision of broader training in

parenting skills that were not speciﬁc codes in the PracticeWise

coding system; e.g. parenting psychoeducation, child rights

education, strategies for improving interactions with youth, or

parental supervision), and ‘expressive therapies’ (e.g. drama,

movement, or art). Coding was conducted independently by

two raters (FB and AdG) and this resulted initially in 92%

agreement between raters. Discrepancies were reviewed by a

third expert rater (JA) and were resolved by discussion until

the two original raters and the expert rater were in agreement.

As an additional control, coding was compared across studies

that used conceptually similar treatments to check for consis-

tency in ratings across the manuals. This resulted in the

identiﬁcation of 12 additional discrepancies, and these were

again reviewed and resolved by an expert rater (JA).

We had planned to undertake matching analysis where

proﬁles are created to match a given treatment to a patient

population (Chorpita et al., 2005); however, due to the small

yield of studies, and small yield of winning treatments on the

different outcomes measured in particular, this was not

considered an appropriate analysis.

Methodological quality assessment

Two authors (FB and AdG) assessed the methodological quality

of the included studies using a modiﬁed version of the Effective

Public Health Practice Project (EPHPP) Quality Assessment Tool

for Quantitative Studies (Jackson & Waters, 2005). This tool was

selected as the reviewed studies included both RCTs and

controlled trials. Discrepancies were solved through discussion.

Results

Descriptions of studies

The search strategy yielded 9,390 unique references

(see Figure 1). Of these papers, 9,319 were excluded

Breaking cycles of violence 5

on examination of the title and abstract. The remain-

ing 71 papers were accessed for detailed review, of

which 33 met inclusion criteria, describing 28 stud-

ies. Of these, 20 studies were randomized controlled

trials, while eight were controlled trials (i.e. pre-

postevaluation trials with a control group, but with-

out randomization). Pertinent details are described

below and presented in Table S1.

Setting and participant characteristics

Included studies involved a range of participants

from varying settings and regions. Classifying the

location of the trials by WHO regions, 13 were

conducted in Africa, eight in the Eastern Mediter-

ranean, four in South East Asia, and three in

Europe. While 12 studies were conducted in a region

where the conﬂict had ceased, 16 were conducted in

a region with ongoing conﬂict. Six studies were

conducted within camps for refugees or IDP. Several

studies speciﬁcally targeted (n=2) or included

(n=5) CAFAAGs, and several targeted (n=2) or

included (n=5) orphans; however, generally the

samples were children more broadly affected by

conﬂict in their region. Six studies included young

adults (deﬁned as aged between 19 and 24 years) as

well as children and/or adolescents. None of the

reviewed studies included children <3 years of age.

The remainder included only children and adoles-

cents aged 3–18 years old. Two studies only included

male participants, one only included female partic-

ipants, and all others included both genders.

In terms of presenting problems, only one study

involved children who were speciﬁcally seeking

treatment; in all other cases, broad screening or

wide recruitment was conducted. Where inclusion

criteria involved a particular life experience, this was

most commonly exposure to a traumatic event

(n=6), bereavement (n=3), involvement in an

armed group (n=2), or being a minor in a brothel

(n=1). A clinical diagnosis was generally not

required for inclusion in the study; ﬁve studies

required a PTSD diagnosis, 11 studies had an

inclusion criteria of scoring above a cutoff on a

screening measure (e.g. for PTSD symptoms, general

distress), two studies had teachers or staff identify

children in their care displaying the most signiﬁcant

signs of distress, and the remaining 10 studies had

no inclusion criteria based on symptom severity. No

studies targeted children or youth immediately after

a traumatic event (i.e. for debrieﬁng, or early crisis

support).

Outcomes measured

A range of psychosocial outcomes were measured

across trials, and results varied substantially, but

the most commonly assessed speciﬁc outcome

domains were posttraumatic stress, internalizing

(depression and anxiety) symptoms, externalizing

Original articles found through

electronic searches and screened on

title and abstract by 2 reviewers

(duplicates deleted) (n = 9,374)

Articles excluded based on title

and abstract (n = 9,319)

Articles retrieved for

detailed examination by 2

reviewers (n = 71)

Articles excluded (n = 38)

Reasons for exclusion:

•Not original study: conference

abstract (n = 3); article review (n = 3)

•Wrong population: adults (n = 13);

study in HIC (n = 2); population not

war-affected (n = 1)

•Not psychological intervention: HIV

prevention intervention (n = 2);

music/sport program (n = 2)

•Study design: no comparison group

(n = 7); not intervention study (n = 1);

retrospective study (n = 1); no baseline

data collected (n = 1); no between-

group comparison (n = 2)

Articles included (n = 33)

Original articles found through hand

searching reference lists of relevant

articles and hand searching issues of 2

key journals (n = 16)

Total original articles

(n = 9,390)

Figure 1 Flow diagram of search strategy of systematic review of psychological interventions for war-affected children, adolescents, and

youth in LMIC

6Felicity L. Brown et al.

symptoms, prosocial behavior, and functioning.

Outcomes measured in each study and treatment

effects observed are presented in Table S1. Only 19

studies conducted follow-up assessments beyond

the postintervention period (ranging from 3 to

12 months). Two of these only measured outcomes

at a 12-month time point. Seven did not maintain a

control group through the follow-up period, and/or

only reported maintenance of effects in the treatment

group rather than comparing treatment and control

at follow-up. Thus, we considered between-group

treatment effects from preintervention to postinter-

vention, or preintervention to follow-up, whichever

was available. Where analyses were conducted only

from preintervention to follow-up, this is noted in

Table S1.

Descriptive summary of interventions, comparison

groups, and outcomes

Below, the outcomes of studies are described by

category of intervention.

Parent interventions. Two studies trialed parent-

only interventions. A two-session group parent psy-

choeducation intervention delivered by lay health

workers in rural Burundi led to reduced child

aggression in boys only, compared to a waitlist in a

controlled trial (Jordans, Tol, Ndayisaba, & Kom-

proe, 2013). No effects were found for girls. An RCT

of medical care plus a parent psychosocial interven-

tion with group and individual components in Bos-

nia found improvements on child weight for height

and weight for age, and interviewer observed prob-

lems (Dybdahl, 2001). Furthermore, results were

seen for parent social support in terms of advice,

mother’s usual well-being, and maternal PTSD (Dyb-

dahl, 2001).

Parent and child interventions. Two studies trialed

treatments jointly involving children and caregivers.

O’Callaghan et al. (2014) conducted an RCT of an

eight-session family-focused group psychosocial

intervention delivered by lay health workers in the

Democratic Republic of Congo (DRC). The treatment

group had greater improvements than a waitlist

group on child PTSD, but no other treatment effects

were found (O’Callaghan et al., 2014). In a controlled

trial of a structured activities program with parent

education classes delivered by lay health workers in

West Bank and Gaza, Loughry et al. (2006) found

certain subgroup differences between the treatment

group and a no treatment control for certain sub-

groups of children. There were treatment effects on

behavioral/emotional problems and externalizing

symptoms for girls but not boys, internalizing symp-

toms for girls in both locations and for boys in Gaza

only, and parental support for girls in the West Bank

only. The control group improved more than the

treatment group on hope among boys in Gaza, and

parental support for girls in Gaza.

Child interventions. The remaining studies involved

primarily group or individual sessions with children,

and a few (n=4) had adjunctive parent meetings.

Narrative Exposure Therapy. Five studies assessed

the effect of a version of individual Narrative Exposure

Therapy with children. In an RCT of an eight-session

Narrative Exposure Therapy protocol delivered by lay

health workers in IDP camps in northern Uganda

versus an academic catch-up and counseling pro-

gram, and a waitlist, Narrative Exposure Therapy had

greater effects than an academic catch-up condition

on PTSD symptoms, and functioning, and better

effects than the waitlist on PTSD symptoms, function-

ing, and guilt (Ertl, Pfeiffer, Schauer, Elbert, &

Neuner, 2011). No differences were observed between

the academic catch-up condition and the waitlist.

Hermenau, Hecker, Schaal, Maedl, and Elbert (2013)

conducted an RCT of an adaptation of Narrative

Exposure Therapy to suit forensic settings (FORNET;

ﬁve individual sessions, one group session), delivered

by psychologists, with CAAFAGs in the DRC. Com-

pared to a standard reintegration comparison group,

the treatment showed better effects on PTSD symp-

toms and a measure of closeness to other combatants.

In Rwanda, an eight-session psychologist-delivered

treatment involving Narrative Exposure Therapy and

Interpersonal Psychotherapy with orphaned or wid-

owed survivors of the genocide showed signiﬁcant

treatment effects on PTSD symptoms compared to a

waitlist in an RCT (Jacob, Neuner, Maedl, Schaal, &

Elbert, 2014). Only the results of the orphan group

(youth) were considered for this review. A controlled

trial of a four-session Narrative Exposure Therapy

treatment delivered by counselors to children having

lost at least one parent in the Rwandan genocide

found signiﬁcant treatment effects compared to an

Interpersonal Psychotherapy comparison condition

on guilt at postintervention, and PTSD symptoms,

PTSD diagnosis, and depression at follow-up (Schaal,

Elbert, & Neuner, 2009). In an RCT of a six-session

version of Narrative Exposure Therapy adapted

speciﬁcally for children (KIDNET) and delivered by

teachers in IDP camps in Sri Lanka, the treatment did

not perform better than a meditation–relaxation pro-

tocol on any outcome measured (Catani et al., 2009).

Trauma-focused CBT. Five studies tested group

trauma-focused CBT treatments. Two studies trialed

the group-based Teaching Recovery Techniques pro-

tocol. In an RCT conducted in West Bank Barron,

Abdallah, and Smith (2013) found signiﬁcant effects

for a ﬁve-session teacher-delivered treatment com-

pared to usual health education curriculum on PTSD

symptoms, depression symptoms, traumatic grief

symptoms, school performance and general mental

Breaking cycles of violence 7

health. An RCT of an eight-session psychologist-

delivered version was also trialed in Gaza and found

an overall treatment effect only for sibling conﬂict

(which was stronger in boys), while the waitlist

showed greater improvements on proportion of chil-

dren scoring in the clinical range on distress and

prosociality (Diab, Peltonen, Qouta, Palosaari, &

Punam€

aki, 2015; Qouta, Palosaari, Diab, &

Punam€

aki, 2012). Several moderator effects were

identiﬁed, whereby boys in the treatment group

showed greater reductions than the waitlist on

proportion of children scoring in the clinical range

for PTSD symptoms and loneliness (Diab, Punam€

aki,

Palosaari, & Qouta, 2014; Punam€

aki, Peltonen,

Diab, & Qouta, 2014; Qouta et al., 2012). Girls in

the treatment group showed greater improvements

compared to the waitlist on sibling rivalry, and girls

with low levels of dissociation showed improvements

in PTSD symptoms and proportion of children scor-

ing in the clinical range for PTSD (Diab et al., 2014;

Qouta et al., 2012).

Three RCTs were conducted to test a similar

trauma-focused CBT approach. Two RCTs were con-

ducted of a 15-session intervention consisting of both

individual and group child sessions as well as three

adjunctive group parent sessions for conﬂict-affected

youth in the DRC, one delivered by a psychologist to

boys including CAAFAGs and compared to an exist-

ing psychosocial program (McMullen, O’Callaghan,

Shannon, Black, & Eakin, 2013), and one delivered

by a social worker to girls who had experienced

sexual violence, compared to a waitlist condition

(O’Callaghan, McMullen, Shannon, Rafferty, &

Black, 2013). In both trials, signiﬁcant treatment

effects were seen on PTSD symptoms, depression and

anxiety symptoms, conduct problems, and proso-

ciality. In the treatment for boys, distress was also

measured and improved (McMullen et al., 2013). A

three-arm RCT was conducted with children in the

DRC, comparing a nine-session teacher-delivered

version of the trauma-focused CBT program (with

group and individual child sessions along with two

parent group sessions), compared to Child Friendly

Spaces, and a no-treatment control (O’Callaghan,

McMullen, Shannon, & Rafferty, 2015). Both the

trauma-focused CBT and Child Friendly Spaces

programs showed greater effects compared to the

control on PTSD symptoms, depression and anxiety,

and conduct problems. The Child Friendly Spaces

showed a deterioration on prosociality at follow-up

compared to trauma-focused CBT.

Classroom-based interventions. Four RCTs were

conducted of the 15-session classroom-based inter-

vention delivered by lay health workers versus a

waitlist condition. A trial in Indonesia found

improvements overall for hope, positive coping, and

peer and play aspects of social support, and effects

for girls only on PTSD symptoms and functioning

(Tol et al., 2008; Tol, Komproe, et al., 2010). In a

trial in Sri Lanka, overall effects were observed on

conduct problems and this was stronger in younger

children. Sub-group ffects were also observed for

boys on PTSD and anxiety, and for younger children

on prosociality (Tol et al., 2012). In two other trials in

rural Nepal and Burundi, no effects were seen in the

overall sample but several moderator effects were

identiﬁed. In Nepal, improvements were seen for boys

on overall mental health and physical aggression, for

girls on prosociality, and for older children on hope

(Jordans et al., 2010). In Burundi, effects were seen

on hope for younger children (Tol et al., 2014). In

both Sri Lanka and Burundi, speciﬁc changes on

other outcomes were seen for demographics based on

household composition, displacement status, or

war-related stressors (Tol et al., 2012, 2014).

A controlled trial of 15 sessions of teacher-

delivered structured classroom activities (combined

with periodic parent meetings) compared to a waitlist

in Uganda found improvements in parent- and

self- reported child well-being (Ager et al., 2011).

However, Karam et al. (2008) found no effect of a 12-

session teacher-delivered classroom-based interven-

tion compared to a no-treatment control in a con-

trolled trial in Lebanon.

Writing for recovery. The three-session school-

based Writing for Recovery protocol was tested in

two trials with differing results. An RCT in Iran found

signiﬁcant improvements compared to a no-treat-

ment control on traumatic grief (Kalantari, Yule,

Dyregrov, Neshatdoost, & Ahmadi, 2012). A con-

trolled trial conducted in West Bank and Gaza found

no beneﬁts of psychologist-implemented Writing for

Recovery compared to waitlist on any of the outcome

measures, and the treatment group deteriorated on

depression symptoms (Lange-Nielsen et al., 2012).

Other interventions. Betancourt, McBain et al.

(2014) conducted an RCT of the 10-session, group-

based, Youth Readiness Intervention (containing

elements of both CBT and Interpersonal Psychother-

apy) delivered by lay health workers, compared to a

waitlist control group in Sierra Leone. They found

that the treatment led to improved emotional regu-

lation skills, prosociality, functioning, social sup-

port, teacher-rated school attendance, classroom

behavior, and school retention. Layne et al. (2008)

conducted an RCT in Bosnia of a 17-session coun-

selor-delivered trauma- and grief-focused treatment

(with individual and classroom-based sessions),

compared to classroom-based psychoeducation and

skills training, and found signiﬁcant treatment

effects on PTSD and depression symptoms. In an

RCT in Kosovo, a 12-session group teacher-delivered

Mind-Body Skills intervention demonstrated signif-

icant improvements on PTSD symptoms compared to

waitlist (Gordon, Staples, Blyta, Bytyqi, & Wilson,

2008). In a three-arm RCT conducted in Uganda,

Bolton et al. (2007) compared group Interpersonal

8Felicity L. Brown et al.

Psychotherapy (16 group sessions and 1–2 individ-

ual sessions) to a creative play intervention and a

waitlist and found that Interpersonal Psychotherapy

was superior to the waitlist in improving depression

and anxiety; however, exploratory moderator analy-

ses found that the change in depression symptoms

occurred for females only (Bolton et al., 2007), and a

later analysis found that that treatment effects were

largely driven by improvements for males with a

CAAFAG history, and females with or without

CAAFAG history (Betancourt et al., 2012). In a

three-arm controlled trial of a seven-session crisis

group intervention delivered by a psychiatrist, com-

pared to psychoeducation and a control group in

Gaza, Thabet, Vostanis, and Karim (2005) found no

group differences on any of the measured outcomes.

Another controlled trial in Gaza found that a peer-led

school-based mediation intervention, designed to

assist students to learn to manage conﬂicts,

demonstrated detrimental effects on PTSD symp-

toms compared to a no-treatment group; however,

the treatment showed a preventive effect on deteri-

orating prosociality and friendship quality seen in

the control group (Peltonen, Qouta, El Sarraj, &

Punam€

aki, 2012). Moderator analyses indicated that

the effect on friendship quality was stronger for girls

with a history of exposure to more kinds of poten-

tially traumatic conﬂict-related events.

Implementation characteristics

The majority (75%) of interventions were conducted

in schools or other community settings. As described

above, some interventions were implemented by a

specialist mental health provider such as a psychol-

ogist (n=5), psychiatrist (n=1), social worker (n=1)

or counselor (n=3); however, many were delivered by

nonspecialists including community health workers

(n=8), teachers (n=6), or peers (n=1; cadre of

therapist was not reported in three studies). Thera-

pist education was rarely reported (n=7), and

whether therapist was local or nonlocal to the country

was often not speciﬁed (n=8). In seven cases, no

details were provided on duration of training, in 15

cases no details were provided on who delivered the

training, and in nine cases no details were provided

on the supervision process. When information was

provided, it was often limited in detail. In 12 studies,

cultural adaptations made to the intervention were

either not reported, or provided extremely limited

detail. Where reported, the adaptations included

using relevant local examples, or culturally relevant

stories and games. Beyond using local language,

terminology, and exemplars, no in-depth adaptations

to common treatment techniques were reported.

Quality assessment

Results of the quality assessment ratings conducted

according to EPHPP criteria are provided in Figure 2.

The studies reviewed had several methodological

weaknesses that may introduce bias; these com-

monly included failure to blind assessors and/or

participants to the research question and/or

treatment allocation and failure to select highly

representative samples. Only one study assessed

and reported whether concurrent interventions were

received by participants and may have introduced

possible contamination of measured treatment

effects. Additionally, only ﬁve studies assessed and

reported ﬁdelity to the intervention protocol (only

three studies did so via independent observers), and

only six studies reported the number of participants

completing the full intervention.

Common elements analysis and proﬁles

Of the 28 included trials, 25 winning treatments

were identiﬁed, where a treatment effect was

observed on at least one measured outcome. In one

study, two winning treatments were identiﬁed as

both the primary treatment (trauma-focused CBT)

and active control (Child Friendly Spaces) demon-

strated effects over a nonactive control (O’Callaghan

et al., 2015). The four classroom-based intervention

trials used the same manual, thus 22 unique proto-

cols were coded. In four studies (Catani et al., 2009;

Karam et al., 2008; Lange-Nielsen et al., 2012; Tha-

bet et al., 2005), no-treatment effects were observed

and these nonwinning treatments were not included

in the analysis of common practice elements.

The 25 winning treatments (22 protocols) were

coded for 78 individual codes. Only 37 practice

element codes were applied in at least two of the

coded manuals, and these are displayed in Figure 3.

As seen in Figure 3, the practice elements occur-

ring in more than 50% of the 25 winning treatment

groups were: accessibility promotion (i.e. holding the

intervention in a convenient location, and/or pro-

viding transport for participants; occurring in 23

treatments); psychoeducation for the child (e.g. on

common reactions to trauma; occurring in 21 treat-

ments); insight building (i.e. strategies designed to

help youth achieve greater self-understanding;

occurring in 20 treatments); relationship/rapport

building (i.e. strategies to increase the quality of the

therapeutic relationship; occurring in 19 treat-

ments); cognitive strategies (i.e. strategies designed

to alter interpretation of events through examination

of thoughts; occurring in 18 treatments); narratives

(i.e. development and review of a narrative of story

about one’s life events; occurring in 16 treatments);

exposure (including imaginal or in vivo; occurring in

16 treatments); strategies for maintenance/relapse

prevention (i.e. exercises designed to consolidate

skills and anticipate future challenges that might

arise after termination of treatment; occurring in 14

treatments); and psychoeducation of the caregiver(s)

(e.g. on common reactions to trauma and effective

parenting strategies; occurring in 13 treatments).

Breaking cycles of violence 9

Discussion

Overview

This review provides a ﬁrst step at distilling the

evidence-base and unpacking the common elements

of interventions that have demonstrated efﬁcacy

across a range of presenting problems and settings

for conﬂict-affected children and youth. We exam-

ined the literature on psychosocial interventions for

conﬂict-affected children and youth (aged 24 and

under) living in LMICs, and identiﬁed 28 RCTs or

controlled trials of interventions in a range of

settings with either past or current conﬂict. Many

(54%) were delivered by nonspecialist providers,

in keeping with task-sharing and task-shifting

approaches, whereby nonspecialist workforces are

trained to deliver services to increase availability of

care. In these 28 studies, 25 treatment groups

(from 24 trials; representing 22 unique treatment

protocols) showed a positive treatment effect on at

least one outcome. There was signiﬁcant hetero-

geneity in the range of outcomes assessed, and

treatment effects varied between studies. Many

studies examined moderator effects and this is

important in determining subgroups of individuals

for which certain treatments are most effective in

terms of symptom domains and patient characteris-

tics. However, in the current literature, there are no

consistent patterns in subgroup effects and more

research is needed to determine which interventions

work optimally for which speciﬁc populations.

We distilled the common practice elements from

treatment protocols with demonstrated efﬁcacy.

Overall, the most common practice elements in

winning treatments for children and youth affected

by armed conﬂict were accessibility promotion, psy-

choeducation for the child and caregiver, insight

building, relationship/rapport building, cognitive

0% 20% 40% 60% 80% 100%

Selection bias

Confounders³

Blinding²

Outcome tools

Withdrawal and dropout¹

Strong

Moderate

Weak

0% 20% 40% 60% 80% 100%

Fidelity reported¹?

Indicated % receiving

full intervention?

Reported potential

contamination/

co-intervention?

Conducted analyses by

intention to treat?

Yes

Can't tell

(A)

(B)

Figure 2 (A) Quality ratings for trials (n=28) of psychosocial interventions for war-affected children, adolescents, and youth in LMICs

according to modiﬁed EPHPP

criteria.

Withdrawal and dropout criterion modiﬁed: we rated withdrawal and dropout to

postintervention only, as several studies did not include follow-up assessments.

Blinding criteria modiﬁed: a rating of strong was

assigned when both assessors and participants were blinded, a rating of moderate was assigned when either assessors or participants

were blinded, and a rating of weak was assigned when neither were blinded or it could not be determined.

Confounders criteria

modiﬁed: age and gender were considered as the important potential confounders. Where there were either no important differences,

or where both were accounted for in analyses, a rating of strong was assigned. Where there was a difference in one variable that was

unaccounted for, or differences for one variable were not reported, a rating of moderate was assigned. Where there were baseline

differences in both variables that were unaccounted for, or differences were not reported, a rating of weak was assigned.

EPHPP =Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. (B) Additional characteristics of trials

(n=28) of psychosocial interventions for war-affected children, adolescents, and youth in LMICs according to modiﬁed EPHPP

criteria.

Fidelity-reported studies must report that ﬁdelity was measured, and the results.

EPHPP =Effective Public Health Practice Project

Quality Assessment Tool for Quantitative Studies

10 Felicity L. Brown et al.

strategies, narratives, exposure, and strategies for

maintenance/relapse prevention.

Accessibility promotion (deﬁned in the coding

system as ‘any strategy used to make services

convenient and accessible or to proactively enhance

treatment participation’; PracticeWise, 2005, p. 66)

was found in all but two winning treatments and

usually consisted of delivering services in convenient

locations. An example was described in the imple-

mentation of the Youth Readiness Intervention in

Sierra Leone (Betancourt, Newnham, et al., 2014). In

order to remove barriers for youth participation, the

implementation team negotiated to hold the groups

in convenient community spaces such as vacant

classrooms not in use during weekend breaks, or in

other private rooms made available by community

leaders. It seems that this aspect of treatment

delivery may be inherent and essential for interven-

tions in LMIC, and particularly in complex human-

itarian emergencies and settings of adversity. There

are a number of potential reasons for this including a

lack of available formal clinical facilities, difﬁculties

in transport and travel time for service users, and

stigma within communities in attending a mental

health service.

While the four treatments that showed no signif-

icant treatment effects were not coded systematically

for common practice elements, it is interesting to

note that in two cases, they trialed an intervention

that is similar to one that showed efﬁcacy in another

trial –that is KIDNET as a version of Narrative

Exposure Therapy (Catani et al., 2009), and the

Writing for Recovery manual (Lange-Nielsen et al.,

2012). Furthermore, group crisis intervention was

compared to education about trauma (Thabet et al.,

2005), and KIDNET was compared to a meditation–

relaxation protocol (Catani et al., 2009). It may be

that the comparison conditions in these trials were

therapeutically active themselves, thus leading to

reduced likelihood of demonstrating signiﬁcant

treatment effects compared with other studies using

waitlist or no-treatment controls.

0 5 10 15 20 25

Anger management

Medical care or recommendation

Motivational enhancement

Self-reward/self-praise

Talent or skill building

Assertiveness training

Caregiver coping

Communication skills

Eyemovement/tapping

Family engagement

Psychoeducation teacher or school staff

Self-monitoring

Social skills training

Support networking

Activity scheduling

Problem solving

Goal setting

Grief/loss

Play therapy

Parenting skills

Personal safety skills

Therapist praise/rewards

Expressive therapies

Emotional processing

Homework

Modeling

Relaxation

Safe place

Psychoeducation-caregiver

Maintenance/relapse prevention

Exposure

Narrative

Cognitive

Relationship/rapport building

Insight building

Psychoeducation-child

Access promotion (location, transport)

Figure 3 Practice element proﬁle

for trials of psychological interventions (n=25) showing signiﬁcant treatment effects for war-affected

children, adolescents, and youth in LMIC.

Coded according to PracticeWise (2005) coding system

Breaking cycles of violence 11

Limitations of this review

There are inherent limitations in the analysis of

common practice elements used in this study. In line

with the PracticeWise (2005) process, we identiﬁed

winning treatments as those that had demonstrated

efﬁcacy in a given study. This meant that several

treatment protocols were found to be efﬁcacious in

multiple trials, and thus the practice elements from

those protocols are represented multiple times in the

frequency results. Additionally, some treatments

were coded as winning for one study and are

represented in the common practice elements fre-

quencies, yet very similar treatments showed null

results in other trials (Catani et al., 2009; Lange-

Nielsen et al., 2012). Our summary of common

practice elements therefore only represents what

has frequently been done in studies that showed

positive treatment effects, and does not take into

account the quality or consistency of the evidence

supporting these treatments. It is not possible to

draw inferences from these frequencies about which

elements are necessary and/or sufﬁcient to achieve

clinically signiﬁcant effects, nor which processes are

driving the effects of treatment on symptom improve-

ment. Nonetheless, the results provide important

preliminary information for the ﬁeld in terms of the

speciﬁc components contained within interventions

trialed to date, and can inform future research

efforts to ultimately determine which elements are

most active and important.

There were several other limitations to our analy-

sis. We were unable to access the treatment manuals

for nine interventions included in the common

elements analysis, and consequently coded only on

information reported in the paper, which was less

detailed. Additionally, as many studies did not report

on treatment ﬁdelity, there may have been differ-

ences in what was coded from the manual and what

was actually operationalized in treatment delivery. In

order to increase the scope of our review, we

included controlled trials as well as more rigorous

RCT designs, and we did identify several weaknesses

in methodology, thus the strength of the conclusions

that can be drawn from the review is limited to the

quality of available literature.

Recommendations for the ﬁeld

There are several unique considerations when devel-

oping interventions for children in conﬂict-affected

settings, where the availability of specialists for

implementation, training, and supervision is extre-

mely limited. Innovations are needed to enhance the

access and quality of preventative and treatment

services in LMICs and emergency settings, including

ways to improve the capacity of health systems and

effectively strengthen and utilize nonspecialist work-

forces. Key recommendations for the ﬁeld are pre-

sented below.

Focus on elements rather than packages and

determine minimally effective doses. First, inter-

ventions should be comprised of the most potent

active ingredients to produce clinically meaningful

change, and this is particularly pertinent in low-

resource settings. As in other ﬁelds, treatments are

commonly evaluated as manualized packages, and

the actual techniques contained in these programs

are often poorly reported in published trials (Glasziou

et al., 2014; Lorencatto, West, Stavri, & Michie,

2013). In line with progress in psychosocial treatment

research more generally, the ﬁeld of global mental

health must now also turn attention to identifying

speciﬁc psychological processes that may act as

mechanisms of change on a variety of symptom

domains, and determine the active ingredients of

interventions that work on these mechanisms. Fur-

ther research utilizing RCTs with active comparison

groups, dismantling studies, and mediational analy-

ses will assist in determining the relative effectiveness

of interventions, and identifying mechanisms of

change and the active treatment components that

work on these, in the hope of enabling more targeted

treatments with maximal impact.

When developing interventions that are cost-effec-

tive and scalable, it is essential to determine the

relationship between dosage and impact. In the stud-

ies reviewed here, ﬁdelity to intervention components

was rarely reported, and many intervention studies

did not report the number of sessions completed by

participants. Only three studies reported using exter-

nal ﬁdelity checks. Measuring and reporting sessions

attended and components received by individuals will

allow analyses to determine how these aspects relate

to outcomes. Furthermore, rigorously designed stud-

ies should speciﬁcally compare different dosages of

treatment to determine the minimum effective dose.

Combined with information on the essential and most

active ingredients, this will allow development of

interventions that are as brief as possible while still

producing clinically meaningful change, which is of

critical importance in limited-resource settings.

Explore common elements approaches. Develop-

ment of effective interventions that are applicable

across a range of psychological symptom domains and

disorders has signiﬁcant potential to optimize impact

and reach in LMIC and conﬂict-affected settings,

where opportunities are scarce for both specialist

and nonspecialist workforces to receive adequate

training and supervision in multiple diagnosis-speci-

ﬁc intervention packages. A recent innovation in this

ﬁeld is the Common Elements Treatment Approach

(CETA), which uses simpliﬁed materials to teach lay

counselors to ﬂexibly deliver common practice ele-

ments of psychological interventions and provides

training and supervision on selecting, sequencing,

and dosage of components based on presenting prob-

lems and clinical progress (Murray, 2014). Results

12 Felicity L. Brown et al.

from studies with adult trauma survivors on the Thai-

Burma border and southern Iraq demonstrate the

ability of lay counselors to maintain ﬁdelity and

achieve signiﬁcant outcomes in multiple domains

using this approach (Bolton et al., 2014; Weiss et al.,

2015). The CETA approach has recently been adapted

for children and piloting has demonstrated feasibility

and acceptability (Sim, 2014). A common elements

approach applied to children and explored in this

review, the Youth Readiness Intervention delivered in

Sierra Leone, has demonstrated impact across a range

of outcomes including emotion regulation, daily func-

tioning, and prosocial attitudes and behaviors (Betan-

court, McBain, et al., 2014).

Consider implementation science questions. In

order to make progress toward closing the global

treatment gap, it is crucial that the ﬁeld focuses

increasingly on issues of implementation, dissemi-

nation, and scale-up (Murray et al., 2014). Innova-

tive methods must be explored to address human

resource limitations for training and supervision,

which often become a bottleneck for scale-up of

treatments in low-resource settings. Furthermore,

information is needed on optimal selection and

retention strategies, and methods for ensuring qual-

ity and ﬁdelity for nonspecialist providers.

However, our review found that explicit details on

therapist recruitment, training, and supervision pro-

cesses are rarely provided, and therapist education and

origin (i.e. local vs. nonlocal) is commonly not reported

in publications. These details are essential in ade-

quately understanding the evidence-base from an

implementation perspective. As an example, in the

Youth Readiness Intervention (Betancourt, McBain,

et al., 2014), facilitators were local mental health work-

ers with a bachelors degree or diploma in social work or

a similar ﬁeld. An international expert team conducted

the initial intensive 2-week training, and individuals

from that training then trained additional facilitators.

Facilitators were required to demonstrate a high level of

competence in the intervention before conducting ses-

sions. A senior local mental health worker conducted

weekly supervision, and there was weekly group super-

vision by phone with a clinical psychologist and other

study team members. A comprehensive search and

review of available project documents from all existing

trials relating to recruitment, training, supervision, and

ﬁdelity of therapists could assist in shedding further

light on these important factors.

Recent efforts are underway to measure and

promote therapist competence as a mechanism for

improving implementation quality. A promising

study in India found that lay workers could be

trained to effectively evaluate the quality of therapy

delivery of peers, and also to provide general peer

supervision (Singla et al., 2014). Similarly, Khort

and colleagues (Kohrt et al., 2015) have developed

the ‘ENhancing Assessment of Common Therapeutic

factors’ (ENACT) rating scale, which can be used by

nonspecialists to monitor and enable quality

improvement of lay counselor competence in basic

practices of behavior change interventions. Without

such tools in place, it is not possible to tell whether

null results are due to ineffective treatments, nonﬁ-

delity, or lack of therapist competence.

Determine required cultural adaptations. Given

the varied cultural contexts in which interventions

for conﬂict-affected children and youth are delivered,

it is essential that cultural and contextual adaptations

made to interventions are adequately reported to

assist other research groups and clinicians working

with similar groups or settings (Bernal, Jim

enez-

Chafey, & Domenech Rodr

ıguez, 2009). In our review,

many studies did not report whether cultural adapta-

tions were made, or provided very limited detail, in line

with the ﬁndings of a similar recent systematic review

that looked speciﬁcally at cultural adaptations (Jor-

dans et al., 2016). An example of adaptations made to

the group-based trauma-focused CBT approach used

in several trials included using culturally applicable

analogies and exemplars throughout as well as the use

of culturally familiar games and songs (McMullen

et al., 2013; O’Callaghan et al., 2013, 2015).

There is evidence that culturally adapted treat-

ments are more effective than nonadapted (Benish,

Quintana, & Wampold, 2011; Griner & Smith, 2006;

Harper Shehadeh, Heim, Chowdhary, Maercker, &

Albanese, 2016). A recent systematic review found

that treatment effects increased with increased adap-

tations made (Harper Shehadeh et al., 2016), while

another review found that adaptation to the explana-

tion of the ‘illness’ was the sole moderator of interven-

tion effectiveness (Benish et al., 2011). Further

research on the adaptation process should comple-

ment future work on identifying the core components

of interventions. Understanding the type and extent of

adaptations required for optimal intervention effec-

tiveness will assist intervention developers in main-

taining the complex balance between improving

cultural and contextual ‘ﬁt’, while maintaining ﬁdelity

to evidence-based therapeutic techniques.

Measure long-term functioning as an outcome. In

conﬂict-affected settings where goals of reengagement

of youth in educational or occupational activities are

often paramount, interventions should aim to effect

change in both symptoms and daily functioning. Yet,

in the current review, few studies report on function-

ing, and of those only few found an effect (Barron et al.,

2013; Betancourt, McBain et al., 2014; Ertl et al.,

2011; Tol et al., 2008). Furthermore, many studies

reviewed here did not conduct follow-up assessments

to determine long-term effects of interventions, and of

those that did, many did not maintain a comparison

group throughout that time. Future studies in this

ﬁeld should prioritize assessments of functional

impairment and daily functioning, and long-term

follow-up as key indicators of intervention success.

Breaking cycles of violence 13

Conclusion

In the world today, knowledge about how to ensure

optimal impact, parsimony, cost, and scalability of

evidence-based interventions for conﬂict-affected

youth could not be more crucial. Recent armed

conﬂicts have led to staggering populations of

refugees and displaced individuals (UNHCR, 2016)

and upwards of 250 million children living in conﬂict-

affected settings (UNICEF, 2016). This leads to

tremendous burdens on host societies and nations

seeking to rebuild after conﬂict. In this light, ensur-

ing optimal access to effective interventions for

improving the mental health, well-being, and social

and economic participation of children exposed to

armed conﬂict and other forms of adversity deserves

urgent attention on the global policy agenda. Such

investments may go a long way in helping fragile

states break cycles of violence and increase their

capacity to marshal and maximize human capability.

The literature on mental health interventions for

conﬂict-affected children and youth has grown sufﬁ-

ciently to afford an analysis of common practice

elements of evidence-based interventions. Our review

highlighted several common elements that were found

across a majority of interventions used successfully

and effectively to improve outcomes in these popula-

tions. To continue to advance this critical ﬁeld,

enhanced collaboration, transparency, and coordina-

tion in treatment development and reporting is

required. It is essential to build the evidence-base not

just only on common treatment elements but also on

identiﬁcation of the most active ingredients of inter-

ventions, and important mediators and moderators of

treatment effects. This must be in conjunction with

essential implementation science work considering

optimal practices to train, supervise, incentivize, and

retain nonspecialist workforces to deliver such inter-

ventions. Such work can make vital contributions

toward improved access and quality of mental health

care, and progress toward the vision of the SDGs of

ensuringhealthy lives and promotingwell-being for all.

Supporting information

Additional Supporting Information may be found in the

online version of this article:

Table S1. Descriptions of included studies (n=28) of

psychological interventions for war-affected children,

adolescents, and youth in LMICs and outcomes.

Appendix S1. PRISMA 2009 checklist.

Acknowledgements

Funding support was received from an Endeavour Queen

Elizabeth II Diamond Jubilee Fellowship under grant

number 4764_2015 (FB); and the National Institute of

Health under grant number 5R01HD073349-04 (TB)

and the kNOw Violence in Childhood Initiative (FB, JA,

TB). This paper was prepared under the Know Violence in

Childhood: Global Learning Initiative (http://www.

knowviolenceinchildhood.org/). The authors acknowl

edge the support and internal review provided by the

Initiative and its funders. They thank the Harvard T.H.

Chan School of Public Health and the International

Rescue Committee, for supporting this work. The

authors have declared that they have no potential or

competing conﬂicts of interest.

This review was invited by the Editors of this journal,

who offered a small honorarium to cover expenses. This

work has undergone full, external peer review.

For his input in the early stages, we thank John

Weiss. We also thank Bruce Chorpita and Eric Daleiden

and PracticeWise for sharing the coding manual and for

their valuable input. The authors acknowledge the

many researchers globally who shared their interven-

tion protocols to make analysis possible. This work

would not be possible without the research staff in

Boston, including Robert Brennan, Lori Holleran, Set-

soakae Thipe, and Grace Lilienthal.

Correspondence

Theresa S. Betancourt, Research Program for Children

and Global Adversity, Department of Global Health and

Population, Harvard T. H. Chan School of Public

Health, 655 Huntington Ave, Room 1213 Boston, USA;

Email: theresa_betancourt@harvard.edu

Key points

•Exposure to armed conﬂict has detrimental effects on children’s mental health, development, and life

opportunities; thus, the issue is central to the global development agenda.

•There is a substantial global treatment gap for mental health services; 80% of individuals in low- and middle-

income countries do not receive the care they require.

•Feasible, effective interventions must be developed that can be safely delivered by nonspecialist providers to

improve access to care.

•Identiﬁcation of the common elements of evidence-based interventions is an important step in coordinating

research and implementation efforts.

•This systematic review distills common elements of existing psychosocial interventions for conﬂict-affected

children and youth, and presents recommendations for advancing the ﬁeld.

14 Felicity L. Brown et al.

References

Ager, A., Akesson, B., Stark, L., Flouri, E., Okot, B., McCol-

lister, F., & Boothby, N. (2011). The impact of the school-

based psychosocial structured activities (PSSA) program on

conﬂict-affected children in northern Uganda. Journal of

Child Psychology and Psychiatry,52, 1124–1133.

Attanayake, V., McKay, R., Joffres, M., Singh, S., Burkle, F., &

Mills, E. (2009). Prevalence of mental disorders among

children exposed to war: A systematic review of 7,920

children. Medicine, Conﬂict and Survival,25,4–19.

Barron, I.G., Abdallah, G., & Smith, P. (2013). Randomized

control trial of a CBT trauma recovery program in Pales-

tinian schools. Journal of Loss and Trauma,18, 306–321.

Barry, M.M., Clarke, A.M., Jenkins, R., & Patel, V. (2013). A

systematic review of the effectiveness of mental health

promotion interventions for young people in low and middle

income countries. BMC Public Health,13,1–19.

Benish, S.G., Quintana, S., & Wampold, B.E. (2011). Cultur-

ally adapted psychotherapy and the legitimacy of myth: A

direct-comparison meta-analysis. Journal of Counseling

Psychology,58, 279–289.

Bernal, G., Jim

enez-Chafey, M.I., & Domenech Rodr

ıguez,

M.M. (2009). Cultural adaptation of treatments: A resource

for considering culture in evidence-based practice. Profes-

sional Psychology: Research and Practice,40, 361–368.

Betancourt, T.S. (2015). The intergenerational effect of

war. Journal of the American Medical Association,72,

199–200.

Betancourt, T.S., & Khan, K.T. (2008). The mental health of

children affected by armed conﬂict: Protective processes and

pathways to resilience. International Review of Psychiatry,

20, 317–328.

Betancourt, T.S., McBain, R.K., Newnham, E.A., Akinsulure-

Smith, A.M., Brennan, R.T., Weisz, J.R., & Hansen, N.B.

(2014). A behavioral intervention for war-affected youth in

Sierra Leone: A randomized controlled trial. Journal of the

American Academy of Child and Adolescent Psychiatry,53,

1288–1297.

Betancourt, T.S., McBain, R.K., Newnham, E.A., & Brennan,

R.T. (2015). The intergenerational impact of war: Longitudi-

nal relationships between caregiver and child mental health

in postconﬂict Sierra Leone. Journal of Child Psychology and

Psychiatry,56, 1101–1107.

Betancourt, T.S., Meyers-Ohki, S.E., Charrow, A.P., & Tol,

W.A. (2013). Interventions for children affected by war: An

ecological perspective on psychosocial support and mental

health care. Harvard Review of Psychiatry,21,70–91.

Betancourt, T.S., Newnham, E.A., Brennan, R.T., Verdeli, H.,

Borisova, I., Neugebauer, R., ... & Bolton, P. (2012). Moder-

ators of treatment effectiveness for war-affected youth with

depression in northern Uganda. Journal of Adolescent

Health,51, 544–550.

Betancourt, T.S., Newnham, E.A., Hann, K., McBain, R.K.,

Akinsulure-Smith, A.M., Weisz, J., ... & Hansen, N. (2014).

Addressing the consequences of violence and adversity: The

development of a group mental health intervention for war-

affected youth in Sierra Leone. In J. Raynaud, S.S. Gau & M.

Hodes (Eds.), From research to practice in child and

adolescent mental health (157–178). Plymouth, UK: Rowman

& Littleﬁeld.

Betancourt, T.S., Newnham, E.A., McBain, R.K., & Brennan,

R.T. (2013). Post-traumatic stress symptoms among former

child soldiers in Sierra Leone: Follow-up study. The British

Journal of Psychiatry,203, 196.

Bolton, P., Bass, J., Betancourt, T., Speelman, L., Onyango,

G., Clougherty, K.F., ... & Verdeli, H. (2007). Interventions

for depression symptoms among adolescent survivors of war

and displacement in northern Uganda: A randomized con-

trolled trial. Journal of the American Medical Association,

298, 519–527.

Bolton, P., Lee, C., Haroz, E.E., Murray, L., Dorsey, S.,

Robinson, C., ... & Bass, J. (2014). A transdiagnostic

community-based mental health treatment for comorbid

disorders: Development and outcomes of a randomized

controlled trial among Burmese refugees in Thailand. PLOS

Medicine,11, e1001757.

Catani, C., Kohiladevy, M., Ruf, M., Schauer, E., Elbert, T., &

Neuner, F. (2009). Treating children traumatized by war and

tsunami: A comparison between exposure therapy and

meditation-relaxation in North-East Sri Lanka. BMC Psychi-

atry,9, 22.

Chorpita, B.F., & Daleiden, E.L. (2009). Mapping evidence-

based treatments for children and adolescents: Application

of the distillation and matching model to 615 treatments

from 322 randomized trials. Journal of Consulting and

Clinical Psychology,77, 566–579.

Chorpita, B.F., Daleiden, E.L., & Weisz, J.R. (2005). Identifying

and selecting the common elements of evidence based

interventions: A distillation and matching model. Mental

Health Services Research,7,5–20.

Collins, P.Y., Vikram, P., Joestl, S.S., March, D., Insel, T.R.,

Abdallah, S.D., ... & Mark, W. (2011). Grand challenges in

global mental health. Nature,475,27–30.

Collinson, S., & Elhawary, S. (2012). Humanitarian space: A

review of trends and issues. London: Overseas Development

Institute.

Davidson, L.L., Grigorenko, E.L., Boivin, M.J., Rapa, E., &

Stein, A. (2015). A focus on adolescence to reduce neuro-

logical, mental health and substance-use disability. Nature,

527, S161–S166.

Diab, M., Peltonen, K., Qouta, S.R., Palosaari, E., & Punam€

aki,

R.-L. (2015). Effectiveness of psychosocial intervention

enhancing resilience among war-affected children and the

moderating role of family factors. Child Abuse and Neglect,

40,24–35.

Diab, M., Punam€

aki, R.L., Palosaari, E., & Qouta, S.R. (2014).

Can psychosocial intervention improve peer and sibling

relations among war-affected children? Impact and mediat-

ing analyses in a randomized controlled trial. Social Devel-

opment,23, 215–231.

Dybdahl, R. (2001). Children and mothers in war: An outcome

study of a psychosocial intervention program. Child Devel-

opment,72, 1214–1230.

Ellard, K.K., Fairholme, C.P., Boisseau, C.L., Farchione, T.J.,

& Barlow, D.H. (2010). Uniﬁed protocol for the transdiag-

nostic treatment of emotional disorders: Protocol develop-

ment and initial outcome data. Cognitive and Behavioral

Practice,17,88–101.

Epping-Jordan, J.E., Harris, R., Brown, F.L., Carswell, K.,

Foley, C., Garcia-Moreno, C., ...& van Ommeren, M. (2016).

Self-Help Plus (SH+): A new WHO stress management

package. World Psychiatry,15, 295–296.

Erskine, H.E., Mofﬁtt, T.E., Copeland, W.E., Costello, E.J.,

Ferrari, A.J., Patton, G., ... & Scott, J.G. (2015). A heavy

burden on young minds: The global burden of mental and

substance use disorders in children and youth. Psychologi-

cal Medicine,45, 1551–1563.

Ertl, V., Pfeiffer, A., Schauer, E., Elbert, T., & Neuner, F. (2011).

Community-implemented trauma therapy for former child

soldiers in Northern Uganda: A randomized controlled trial.

Journal of the American Medical Association,306, 503–512.

Fazel, M., Reed, R.V., Panter-Brick, C., & Stein, A. (2012).

Mental health of displaced and refugee children resettled in

high-income countries: Risk and protective factors. The

Lancet,379, 266–268.

Fuhr, D.C., Salisbury, T.T., De Silva, M.J., Atif, N., van

Ginneken, N., Rahman, A., & Patel, V. (2014). Effectiveness

of peer-delivered interventions for severe mental illness and

depression on clinical and psychosocial outcomes: A sys-

tematic review and meta-analysis. Social Psychiatry and

Psychiatric Epidemiology,49, 1691–1702.

Breaking cycles of violence 15

Glasziou, P., Altman, D.G., Bossuyt, P., Boutron, I., Clarke, M.,

Julious, S., ... & Wager, E. (2014). Reducing waste from

incomplete or unusable reports of biomedical research. The

Lancet,383, 267–276.

Gordon, J.S., Staples, J.K., Blyta, A., Bytyqi, M., & Wilson, A.T.

(2008). Treatment of posttraumatic stress disorder in post-

war Kosovar adolescents using mind-body skills groups: A

randomized controlled trial. Journal of Clinical Psychiatry,

69, 1469–1476.

Gore, F.M., Bloem, P.J.N., Patton, G.C., Ferguson, J., Joseph,

V., Coffey, C., ... & Mathers, C.D. (2011). Global burden of

disease in young people aged 10–24 years: A systematic

analysis. The Lancet,377, 2093–2102.

Griner, D., & Smith, T.B. (2006). Culturally adapted mental

health intervention: A meta-analytic review. Psychotherapy:

Theory, Research, Practice, Training,43, 531.

Gureje, O., & Thornicroft, G. (2015). Health equity and mental

health in post-2015 sustainable development goals. The

Lancet Psychiatry,2,12–14.

Harper Shehadeh, M., Heim, E., Chowdhary, N., Maercker, A.,

& Albanese, E. (2016). Cultural adaptation of minimally

guided interventions for common mentaldisorders: A sys-

tematic review and meta-analysis. Journal of Medical Inter-

net Research Mental Health,3, e44.

Hayes, S.C., Strosahl, K., & Wilson, K.G. (2003). Acceptance

and commitment therapy: An experiential approach to behav-

ior change. New York: Guilford Press.

Hermenau, K., Hecker, T., Schaal, S., Maedl, A., & Elbert, T.

(2013). Addressing post-traumatic stress and aggression by

means of narrative exposure: A randomized controlled trial

with ex-combatants in the Eastern DRC. Journal of Aggres-

sion Maltreatment and Trauma,22, 916–934.

IISS (2015). Armed conﬂict survey 2015: The worldwide review of

political, military and humanitarian trends in current conﬂicts.

London: International Institute for Strategic Studies.

Interagency Expert Group on SDG Indicators (2016). Compila-

tion of metadata for the proposed global indicators for the

review of the 2030 Agenda for Sustainable Development: 4th

March 2016. New York: United Nations.

Inter-Agency Standing Committee (2007). IASC guidelines on

mental health and psychosocial support in emergency set-

tings, IASC ed. Geneva: Inter-Agency Standing Committee.

Izutsu, T., Tsutsumi, A., Minas, H., Thornicroft, G., Patel, V., &

Ito, A. (2015). Mental health and wellbeing in the sustain-

able development goals. The Lancet Psychiatry,2, 1052.

Jackson, N., & Waters, E. (2005). Criteria for the systematic

review of health promotion and public health interventions.

Health Promotion International,20, 367–374.

Jacob, N., Neuner, F., Maedl, A., Schaal, S., & Elbert, T.

(2014). Dissemination of psychotherapy for trauma spec-

trum disorders in postconﬂict settings: A randomized con-

trolled trial in Rwanda. Psychotherapy and Psychosomatics,

83, 354–363.

Jordans, M.J.D., Komproe, I.H., Tol, W.A., Kohrt, B.A., Luitel,

N.P., Macy, R.D., & de Jong, J.T.V.M. (2010). Evaluation of a

classroom-based psychosocial intervention in conﬂict-

affected Nepal: A cluster randomized controlled trial. Journal

of Child Psychology and Psychiatry,51, 818–826.

Jordans, M.J.D., Pigott, H., & Tol, W.A. (2016). Interventions

for children affected by armed conﬂict: A systematic review

of mental health and psychosocial support in low- and

middle-income countries. Current Psychiatry Reports,18,9.

Jordans, M.J.D., Tol, W.A., Komproe, I.H., & De Jong, J.V.T.M.

(2009). Systematic review of evidence and treatment

approaches: Psychosocial and mental health care for chil-

dren in war. Journal of Child and Adolescent Mental Health,

14,2–14.

Jordans, M.J.D., Tol, W.A., Ndayisaba, A., & Komproe, I.H.

(2013). A controlled evaluation of a brief parenting psychoe-

ducation intervention in Burundi. Social Psychiatry and

Psychiatric Epidemiology,48, 1851–1859.

Kakuma, R., Minas, H., van Ginneken, N., Dal Poz, M.R.,

Desiraju, K., Morris, J.E., ... & Schefﬂer, R.M. (2011).

Human resources for mental health care: Current situation

and strategies for action. The Lancet,378, 1654–1663.

Kalantari, M., Yule, W., Dyregrov, A., Neshatdoost, H., &

Ahmadi, S.J. (2012). Efﬁcacy of writing for recovery on

traumatic grief symptoms of Afghani refugee bereaved

adolescents: A randomized control trial. Omega,65, 139–

150.

Karam, E.G., Fayyad, J., Nasser Karam, A., Cordahi Tabet, C.,

Melhem, N., Mneimneh, Z., & Dimassi, H. (2008). Effective-

ness and speciﬁcity of a classroom-based group intervention

in children and adolescents exposed to war in Lebanon.

World Psychiatry,7, 103–109.

Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G.,

Ertem, I., Omigbodun, O., ... & Rahman, A. (2011). Child

and adolescent mental health worldwide: Evidence for

action. The Lancet,378, 1515–1525.

Kim, N., & Conceicao, P. (2010). The economic crisis, violent

conﬂict, and human development. International Journal of

Peace Studies,15,29–43.

Kohrt, B.A., Jordans, M.J.D., Rai, S., Shrestha, P., Luitel, N.P.,

Ramaiya, M.K., ... & Patel, V. (2015). Therapist competence

in global mental health: Development of the ENhancing

Assessment of Common Therapeutic factors (ENACT) rating

scale. Behaviour Research and Therapy,69,11–21.

Lancet Global Mental Health Group (2007). Scale up services

for mental disorders: A call for action. The Lancet,370,

1241–1252.

Lange-Nielsen, I.I., Kolltveit, S., Thabet, A.A.M., Dyregrov, A.,

Pallesen, S., Johnsen, T.B., & Laberg, J.C. (2012). Short-

term effects of a writing intervention among adolescents in

Gaza. Journal of Loss and Trauma,17, 403–422.

Layne, C.M., Saltzman, W.R., Poppleton, L., Burlingame, G.M.,

Pasali, A., Durakovi, E., ... & Pynoos, R.S. (2008). Effective-

ness of a school-based group psychotherapy program for

war-exposed adolescents: A randomized controlled trial.

Journal of the American Academy of Child and Adolescent

Psychiatry,47, 1048–1062.

Lorencatto, F., West, R., Stavri, Z., & Michie, S. (2013). How

well is intervention content described in published reports of

smoking cessation interventions? Nicotine and Tobacco

Research,15, 1273–1282.

Loughry, M., Ager, A., Flouri, E., Khamis, V., Afana, A.H., &

Qouta, S. (2006). The impact of structured activities among

Palestinian children in a time of conﬂict. Journal of Child

Psychology and Psychiatry,47, 1211–1218.

McMullen, J., O’Callaghan, P., Shannon, C., Black, A., & Eakin,

J. (2013). Group trauma-focused cognitive-behavioural ther-

apy with former child soldiers and other war-affected boys in

the DR Congo: A randomised controlled trial. Journal of Child

Psychology and Psychiatry,54, 1231–1241.

Michie, S., Richardson, M., Johnston, M., Abraham, C.,

Francis, J., Hardeman, W., ... & Wood, C.E. (2013). The

behavior change technique taxonomy (v1) of 93 hierarchi-

cally clustered techniques: Building an international con-

sensus for the reporting of behavior change interventions.

Annals of Behavioral Medicine,46,81–95.

Moher, D., Liberati, A., Tetzlaff, J., & Altman, D.G. (2009).

Preferred reporting items for systematic reviews and meta-

analyses: The PRISMA statement. British Medical Journal,

339, b2535.

Murray, L.K. (2014). A common elements treatment approach

for adult mental health problems in low- and middle-

income countries. Cognitive and Behavioral Practice,21,

111–123.

Murray, L.K., & Jordans, M.J.D. (2016). Rethinking the service

delivery system of psychological interventions in low and

middle income countries. BMC Psychiatry,16, 234.

Murray, L.K., Tol, W., Jordans, M., Sabir, G., Amin, A.M.,

Bolton, P., ... & Thornicroft, G. (2014). Dissemination and

16 Felicity L. Brown et al.

implementation of evidence based, mental health interven-

tions in post conﬂict, low resource settings. Intervention,12,

94–112.

Newnham, E.A., Pearson, R.M., Stein, A., & Betancourt, T.S.

(2015). Youth mental health after civil war: The importance of

daily stressors. British Journal of Psychiatry,206, 116–121.

O’Callaghan, P., Branham, L., Shannon, C., Betancourt, T.S.,

Dempster, M., & McMullen, J. (2014). A pilot study of a

family focused, psychosocial intervention with war-exposed

youth at risk of attack and abduction in north-eastern

Democratic Republic of Congo. Child Abuse and Neglect,38,

1197–1207.

O’Callaghan, P., McMullen, J., Shannon, C., & Rafferty, H.

(2015). Comparing a trauma focused and non trauma

focused intervention with war affected Congolese youth: A

preliminary randomised trial. Intervention,13,28–44.

O’Callaghan, P., McMullen, J., Shannon, C., Rafferty, H., &

Black, A. (2013). A randomized controlled trial of trauma-

focused cognitive behavioral therapy for sexually exploited,

war-affected Congolese girls. Journal of the American

Academy of Child and Adolescent Psychiatry,52, 359–369.

Okello, J., Nakimuli-Mpungu, E., Musisi, S., Broekaert, E., &

Derluyn, I. (2013). War-related trauma exposure and mul-

tiple risk behaviors among school-going adolescents in

Northern Uganda: The mediating role of depression symp-

toms. Journal of Affective Disorders,151, 715–721.

OʼSullivan, C., Bosqui, T., & Shannon, C. (2016). Psychological

interventions for children and young people affected by

armed conﬂict or political violence: A systematic literature

review. Intervention,1, 142–164.

Panter-Brick, C., Grimon, M., & Eggerman, M. (2014). Care-

giver-child mental health: A prospective study in conﬂict and

refugee settings. Journal of Child Psychology and Psychiatry,

55, 313–327.

Patel, V., Araya, R., Chatterjee, S., Chisholm, D., Cohen, A., De

Silva, M., ... & van Ommeren, M. (2007). Treatment and

prevention of mental disorders in low-income and middle-

income countries. The Lancet,370, 991–1005.

Patel, V., Flisher, A.J., Hetrick, S., & McGorry, P. (2007).

Mental health of young people: A global public-health

challenge. The Lancet,369, 1302–1313.

Peltonen, K., Qouta, S., El Sarraj, E., & Punam€

aki, R.-L.

(2012). Effectiveness of school-based intervention in

enhancing mental health and social functioning among

war-affected children. Traumatology,18,37–46.

Pettersson, T., & Wallensteen, P. (2015). Armed conﬂicts,

1946–2014. Journal of Peace Research,52, 536–550.

PracticeWise. (2005). Psychosocial and combined treatments

coding manual. Satellite Beach, FL: PracticeWise.

Punam€

aki, R., Peltonen, K., Diab, M., & Qouta, S.R. (2014).

Psychosocial interventions and emotion regulation among

war-affected children: Randomized control trial effects.

Traumatology,20, 241–252.

Qouta, S.R., Palosaari, E., Diab, M., & Punam€

aki, R.L. (2012).

Intervention effectiveness among war-affected children: A

cluster randomized controlled trial on improving mental

health. Journal of Traumatic Stress,25, 288–298.

Schaal, S., Elbert, T., & Neuner, F. (2009). Narrative exposure

therapy versus interpersonal psychotherapy: A pilot ran-

domized controlled trial with Rwandan genocide orphans.

Psychotherapy and Psychosomatics,78, 298–306.

Sijbrandij, M., Farooq, S., Bryant, R.A., Dawson, K., Hamdani,

S.U., Chiumento, A., ...& van Ommeren, M. (2015). Problem

Management Plus (PM+) for common mental disorders in a

humanitarian setting in Pakistan; Study protocol for a

randomised controlled trial (RCT). BMC Psychiatry,15, 232.

Sim, A. (2014). Research brief: Promoting child mental health

and resilience in humanitarian settings. New York: Interna-

tional Rescue Committee. Available at: htt p://g bvres pon

ders.org/wp-content/uploads/2014/07/CCS-Ethiopia-

Research-Brief-April-2014.pdf.

Singla, D.R., Weobong, B., Nadkarni, A., Chowdhary, N.,

Shinde, S., Anand, A., ... & Patel, V. (2014). Improving the

scalability of psychological treatments in developing coun-

tries: An evaluation of peer-led therapy quality assessment

in Goa, India. Behaviour Research and Therapy,60,53–59.

Slone, M., & Mann, S. (2016). Effects of war, terrorism and

armed conﬂict on young children: A systematic review. Child

Psychiatry & Human Development,47, 950–965.

Strand, V.C., Hansen, S., & Courtney, D. (2013). Common

elements across evidence-based trauma treatment: Discov-

ery and implications. Advances in Social Work,14, 334–354.

Swartz, H.A. (2015). IOM report on psychosocial interventions

for mental and substance use disorders: The interpersonal

psychotherapy perspective. Depression and Anxiety,32,

793–795.

Thabet, A.A.M., Vostanis, P., & Karim, K. (2005). Group crisis

intervention for children during ongoing war conﬂict. Euro-

pean Child and Adolescent Psychiatry,14, 262–269.

Tol, W.A., Barbui, C., Galappatti, A., Silove, D., Betancourt,

T.S., Souza, R., ... & van Ommeren, M. (2011). Mental

health and psychosocial support in humanitarian settings:

Linking practice and research. The Lancet,378, 1581–1591.

Tol, W.A., Kohrt, B.A., Jordans, M.J.D., Thapa, S.B., Pettigrew,

J., Upadhaya, N., & de Jong, J.T.V.M. (2010). Political violence

and mental health: A multi-disciplinary review of the literature

on Nepal. Social Science and Medicine,70,35–44.

Tol, W.A., Komproe, I.H., Jordans, M.J., Gross, A.L., Susanty,

D., Macy, R.D., & de Jong, J.T. (2010). Mediators and

moderators of a psychosocial intervention for children

affected by political violence. Journal of Consulting and

Clinical Psychology,78, 818–828.

Tol, W.A., Komproe, I.H., Jordans, M.J.D., Ndayisaba, A.,

Ntamutumba, P., Sipsma, H., ... & de Jong, J. (2014).

School-based mental health intervention for children in

war-affected Burundi: A cluster randomized trial. BMC

Medicine,12, 56.

Tol, W.A., Komproe, I.H., Jordans, M.J.D., Vallipuram, A.,

Sipsma, H., Sivayokan, S., ... & de Jong, J.T. (2012).

Outcomes and moderators of a preventive school-based

mental health intervention for children affected by war in Sri

Lanka: A cluster randomized trial. World Psychiatry,11,

114–122.

Tol, W.A., Komproe, I.H., Susanty, D., Jordans, M.J.D., Macy,

R.D., & De Jong, J. (2008). School-based mental health

intervention for children affected by political violence in

Indonesia: A cluster randomized trial. Journal of the Amer-

ican Medical Association,300, 655–662.

UNESA (2010). World programme of action for youth. New York:

United Nations.

UNHCR (2015). World at war: UNHCR global trends forced

displacement in 2014. Geneva: UNHCR.

UNHCR (2016). Global trends forced displacement in 2015.

Geneva: UNHCR.

UNICEF (2016). Humanitarian action for children 2016: Over-

view. New York: UNICEF.

United Nations Ofﬁce of the Special Representative of the

Secretary-General for Children and Armed Conﬂict. (2016).

Report of the Secretary-General to the Security Council

(A/70/836–S/2016/360). Available at: https://childrenan-

darmedconﬂict.un.org [last accessed 01 September 2016].

van Ginneken, N., Tharyan, P., Lewin, S., Rao, G.N., Meera,

S.M., Pian, J., ... & Patel, V. (2013). Non-specialist health

worker interventions for the care of mental, neurological and

substance-abuse disorders in low- and middle-income coun-

tries. Cochrane Database of Systematic Reviews, (11),

CD009149.

Weiss, W., Murray, L., Kaysen, D., Dorsey, S., Lindgren, K.,

Gross, A., ... & Bolton, P. (2015). Community-based mental

health treatments for survivors of torture and militant

attacks in Southern Iraq: A randomized control trial. BMC

Psychiatry,15, 249.

Breaking cycles of violence 17

Weisz, J., Bearman, S.K., Santucci, L.C., & Jensen-Doss, A.

(2016). Initial test of a principle-guided approach to

transdiagnostic psychotherapywith children and adolescents.

Journal of Clinical Child & Adolescent Psychology,21,1–15.

Weisz, J.R., Chorpita, B.F., Palinkas, L.A., Schoenwald, S.K.,

Miranda, J., ... & Bearman, S.K., Research Network on

Youth Mental Health. (2012). Testing standard and modular

designs for psychotherapy treating depression, anxiety, and

conduct problems in youth: A randomized effectiveness trial.

Archives of General Psychiatry,69, 274–282.

WHO (2010). MhGAP intervention guide for mental, neurological

and substance use disorders in non-specialized health

settings. Geneva: WHO.

WHO (2012). Report by the Secretariat for the Sixty-ﬁfth World

Health Assembly (document A65/10): Global burden of

mental disorders and the need for a comprehensive coordi-

nated response from health and social sectors at the country

level. Geneva: WHO.

WHO (2013). Building back better: Sustainable mental health

care after emergencies. Geneva: WHO.

Accepted for publication: 14 October 2016

18 Felicity L. Brown et al.

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The 2023 War on Gaza has inflicted significant hardships on children, posing severe risks to their physical, cognitive, emotional, and social development. This paper explores multifaceted approaches to mitigate these developmental risks, emphasizing the need for comprehensive support systems for children in conflict zones. The study highlights the detrimental impact of the war, including trauma, malnutrition, disrupted education, and healthcare challenges. It advocates for trauma-informed, multilevel interventions focusing on psychological counselling, healthcare, educational support, and creating safe environments. The research identifies key areas of concern, such as the high prevalence of mental health issues like PTSD and depression, and the decline in social services and economic stability. It calls for collaboration among local governments, international organizations, NGOs, and communities to establish supportive frameworks for children's development. The paper proposes immediate and long-term approaches, including establishing safe spaces, providing psychosocial support, ensuring continuity of education through informal means, and addressing health and nutrition challenges. These approaches are aimed at fostering resilience, providing stability, and enhancing the capacity of children to cope with the adversities of war. The paper underscores the critical role of the community ever during the highest time of the war on Gaza, or similar situations in creating a protective development environment where children can receive education, healthcare, and emotional support. The research also highlights the need for sustainable and trauma-informed support systems, stressing the significance of collective engagement to reduce harm and support caregivers. Overall, this study offers a comprehensive framework for mitigating the risks of slow children's development due to the war on Gaza, providing valuable insights and practical recommendations for supporting children in conflict zones. The proposed approaches aim not only to address immediate needs but also to lay the groundwork for long-term recovery and resilience building among the affected Palestinian children so that they cope with Israeli atrocities.

Mental health provision for children affected by war and armed conflicts

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EUR CHILD ADOLES PSY

Panos Vostanis

The impact of mental health and psychosocial support programmes on children and young people’s mental health in the context of humanitarian emergencies in low- and middle-income countries: A systematic review and meta-analysis

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Feb 2024
GMH

Humanitarian emergencies pose a significant global health challenge for children and young people’s mental and psychological health. This systematic review investigates the effectiveness of mental health and psychosocial support (MHPSS) programmes delivered to children and young people affected by humanitarian emergencies in low- and middle-income countries (LMICs). Twelve electronic databases, key websites and citation checking were undertaken. Forty-three randomised controlled trials (RCTs) published in English between January 1980 and May 2023 were included in the review. Overall, the findings suggest that cognitive behavioural therapy may improve depression symptoms in children and young people affected by humanitarian emergencies. Narrative exposure therapy may reduce feelings of guilt. However, the impact of the other MHPSS modalities across outcomes is inconsistent. In some contexts, providing psychosocial programmes involving creative activities may increase the symptoms of depression in children and young people. These findings emphasise the need for the development of MHPSS programmes that can safely and effectively address the diverse needs of children and young people living in adversarial environments.

Critically Examining Social Emotional Learning with Refugees in East Africa: Tensions, Challenges, and Complex Dynamics

Article

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Sep 2023

Kelsey A. Dalrymple

Social emotional learning (SEL) has become a popular trend in the field of Education in Emergencies (EiE). Many SEL programs targeting refugee learners aim to help individuals develop skills that are necessary for learning and development, as well as mitigate the adverse impacts of crisis and displacement. While nearly half a billion USD has been invested in SEL initiatives for refugee and crisis contexts worldwide , little evidence exists about the impacts of SEL interventions with refugee communities. As 20% of all refugees globally reside in East Africa, and it is estimated that over 152 million African children live in active conflict zones, this study set out to qualitatively examine understandings, implementation, and implications of SEL interventions across actors engaging refugee communities in the region. The results expose tensions, challenges, and complex dynamics related to culture, power, and the complicated reality of implementing refugee education initiatives in East Africa. While further research into this area of inquiry is needed and proposed, these study findings provide a stronger understanding of the refugee education landscape in East Africa and its current insufficiencies through the example of SEL, and serve to inform other topical EiE interventions and the broader uptake of SEL by education systems globally.

What drives change in children receiving telephone-delivered Common Elements Treatment Approach (t-CETA)? A multiple n = 1 study with Syrian refugee children and adolescents in Lebanon

Article

Aug 2023
CHILD ABUSE NEGLECT

Background: Although the evidence-base for mental health and psychosocial support (MHPSS) interventions in humanitarian settings is growing rapidly, their mechanisms of change remain poorly understood despite the potential to improve the effectiveness and reach of interventions. Objective: This study aimed to explore the mechanisms or factors that drive change in a modular transdiagnostic telephone-delivered mental health intervention, Common Elements Treatment Approach (t-CETA). Participants and setting: Participants were Syrian refugee children and adolescents living in tented settlements in Lebanon. Methods: We used a multiple n = 1 design, drawing on secondary data from 9 children who completed t-CETA during a pilot randomized controlled trial. Results: Children with historical war-related trauma were more likely to show significant improvement across symptom clusters by the end of treatment compared to children presenting with depression related to daily living conditions. Children also showed fluctuating symptoms during the early stages of treatment (engagement and cognitive restructuring) but significant decline in symptoms after the trauma module (prolonged imaginal exposure) and depression module (behavioral activation). Salient external life events identified were starting or dropping out of school, working, change in living conditions, family conflict and the October Revolution; and interpersonal factors of parental engagement (with or without full attendance) and counsellor skills in building rapport were also identified as having an impact on treatment success. Conclusions: Implications of our findings are discussed in terms of integrating active ingredients into MHPSS programming, and building on parental and multi-sector involvement in child and adolescent mental health care in humanitarian settings.

Psychosocial support interventions in the context of forced displacement: A systematic review and meta-analysis

Article

Full-text available

Jan 2023

Background: Forced displacement is associated with elevated risk for poor psychosocial wellbeing, yet there remains a lack of clarity around the effectiveness of commonly implemented psychosocial support interventions focused on preventing disorder and promoting wellbeing. This study aimed to synthesize the literature on evaluations of psychosocial support interventions for populations affected by forced displacement. Methods: We searched for peer reviewed and gray literature in seven databases (PubMed, Embase, Global Health, CINAHL, SocIndex, PsychInfo, PILOTS), fifteen organizational websites, and via solicitation through multiple networks. Various study designs were included, with the criteria that they report an evaluation of a psychosocial intervention delivered to populations affected by forced displacement, and included quantitative or qualitative data on psychosocial outcomes. Records were screened independently by two reviewers at both title/abstract and full-text review; data was double-extracted and study quality assessed, with discrepancies resolved by consensus. Meta-analyses for seven outcomes were conducted on a subset of 33 studies. Results: We identified 162 reports. Over half (55%) used a single-group study design, with fewer using non-random (19%) or randomized (21%) comparisons. Study designs incorporating comparison conditions were less likely to report positive findings than single-group studies. In the meta-analyses, a moderately strong overall effect was found for psychosocial wellbeing (ES: -0.534, 95% CI: [-0.870, -0.197], p=.005); small effects on both internalizing (ES: -0.152, 95% CI: [-0.310, 0.005], p= .057) and externalizing (ES: -0.249, 95% CI: [-0.515, 0.016], p=.064) problems were promising but not conclusive. Subgroup analysis suggested differential impacts on internalizing problems for adults (improvement; ES: -0.289, 95% CI: [-0.435, -0.143], p=.001) and children (worsening; ES: 0.129, 95% CI: [.054, 0.204], p=.002). Other subgroup analyses showed little meaningful variation by context, population, or intervention characteristics. Conclusion: Pragmatic, field-driven program evaluations are dominated by single-group designs with significant risk of bias. Findings from controlled studies are promising but highlight a need for more rigorous research to support causal inference, align outcomes with theories of change, improve measurement of more positive or wellbeing-focused outcomes, examine subgroup differences, and report potentially negative impacts.

Parenting and family interventions in lower and middle-income countries for child and adolescent mental health: A systematic review

Article

Apr 2024
COMPR PSYCHIAT

Interventions targeting social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews

Article

Full-text available

Mar 2024

Globally, mental disorders account for almost 20% of disease burden and there is growing evidence that mental disorders are socially determined. Tackling the United Nations Sustainable Development Goals (UN SDGs), which address social determinants of mental disorders, may be an effective way to reduce the global burden of mental disorders. We conducted a systematic review of reviews to examine the evidence base for interventions that map onto the UN SDGs and seek to improve mental health through targeting known social determinants of mental disorders. We included 101 reviews in the final review, covering demographic, economic, environmental events, neighborhood, and sociocultural domains. This review presents interventions with the strongest evidence base for the prevention of mental disorders and highlights synergies where addressing the UN SDGs can be beneficial for mental health.

The Invisible Wounds: Mental Health Support for the War Injured Children

Chapter

May 2023

War exposure has extensive detrimental effects on the mental health and psychological well-being of children and adolescents. Many factors moderate and mediate the complex relationship between the war trauma itself and subsequent psychiatric morbidity, including resilience. Post-traumatic stress disorder, depression, and anxiety are the most common disorders after traumatic events. The clinical presentation of distress in children depends on their development level and must be understood from the standpoint of the child’s social, emotional, and cognitive development. Cognitive behavioral therapy and trauma-focused cognitive behavioral therapy are validated therapeutic approaches for children and adolescents who suffer from trauma-related symptoms.KeywordsMental healthTraumaPsychological interventionsArmed conflictPost-traumatic stress disorderChildren’s mental healthResiliencePsychosocial interventions

Feasibility randomised controlled trial of the Early Adolescent Skills for Emotions psychological intervention with young adolescents in Lebanon

Article

Full-text available

Mar 2023
BMC PSYCHIATRY

Background: Globally, there is a vast mental health treatment gap, whereby the majority of adolescents living in low- and middle-income countries requiring mental health services, do not have access to adequate care. To improve access, the World Health Organization (WHO) developed a range of interventions, designed to be low-cost and delivered by non-specialists. We conducted a two-arm, individually randomised group treatment feasibility trial of a new WHO group intervention for young adolescents with emotional distress ('Early Adolescent Skills for Emotions'; EASE) in Lebanon. Method: The aim of this study was to determine the feasibility of the intervention and study procedures. Adolescents aged 10 to 14 years were eligible to take part if they scored above a validated cut-off on the Child Psychosocial Distress Screener. Participants were randomized to EASE or enhanced treatment as usual (ETAU) control using a 1:1 ratio. EASE consisted of seven group sessions with adolescents and three sessions with caregivers. ETAU consisted of a single brief psychoeducation home visit. Child and caregiver outcomes were measured by blind assessors at baseline, endline (8 weeks post-randomisation), and three month follow-up (20 weeks post-randomisation), with the primary outcome measure being child psychological symptoms on the Pediatric Symptom Checklist. Qualitative interviews were conducted with adolescents (n = 13), caregivers (n = 17), facilitators (n = 6), trainers (n = 3), and outreach staff (n = 1) at endline to assess barriers and facilitators related to the feasibility and delivery of EASE and study procedures. Results: Of 154 adolescents screened, 67 (43%) were eligible, completed baseline, and were randomized. Sixty adolescents (90%) completed endline assessments (31 EASE, 29 ETAU), and fifty-nine (88%) completed three-month assessments (29 EASE, 30 ETAU). Qualitatively, participants provided overall positive feedback about the intervention. Several challenges and suggestions for improvement were raised around logistics, intervention content, and acceptability of assessment measures. Implementation data highlighted challenges with intervention uptake and attendance. Outcome measures generally had strong psychometric properties (range: α = 0.77 to α = 87), however did not demonstrate change over time in either group. Conclusions: The EASE intervention and study procedures are acceptable and feasible for implementation with vulnerable adolescents in Lebanon, however several improvements are necessary prior to full-scale evaluation. Trial registration: #ISRCTN60799626, retrospectively registered on 04/10/2022.

Cultural Adaptation of Minimally Guided Interventions for Common Mental Disorders: A Systematic Review and Meta-Analysis

Article

Full-text available

Sep 2016

Background: Cultural adaptation of mental health care interventions is key, particularly when there is little or no therapist interaction. There is little published information on the methods of adaptation of bibliotherapy and e-mental health interventions. Objective: To systematically search for evidence of the effectiveness of minimally guided interventions for the treatment of common mental disorders among culturally diverse people with common mental disorders; to analyze the extent and effects of cultural adaptation of minimally guided interventions for the treatment of common mental disorders. Methods: We searched Embase, PubMed, the Cochrane Library, and PsycINFO for randomized controlled trials that tested the efficacy of minimally guided or self-help interventions for depression or anxiety among culturally diverse populations. We calculated pooled standardized mean differences using a random-effects model. In addition, we administered a questionnaire to the authors of primary studies to assess the cultural adaptation methods used in the included primary studies. We entered this information into a meta-regression to investigate effects of the extent of adaptation on intervention efficacy. Results: We included eight randomized controlled trials (RCTs) out of the 4911 potentially eligible records identified by the search: four on e-mental health and four on bibliotherapy. The extent of cultural adaptation varied across the studies, with language translation and use of metaphors being the most frequently applied elements of adaptation. The pooled standardized mean difference for primary outcome measures of depression and anxiety was -0.81 (95% CI -0.10 to -0.62). Higher cultural adaptation scores were significantly associated with greater effect sizes (P=.04). Conclusions: Our results support the results of previous systematic reviews on the cultural adaptation of face-to-face interventions: the extent of cultural adaptation has an effect on intervention efficacy. More research is warranted to explore how cultural adaptation may contribute to improve the acceptability and effectiveness of minimally guided psychological interventions for common mental disorders.

Rethinking the service delivery system of psychological interventions in low and middle income countries

Article

Full-text available

Jul 2016
BMC PSYCHIATRY

Background Global mental health is a growing field intricately connected to broader health, violence and economic issues. Despite the high prevalence and cost of mental health disorders, an estimated 75 % of those with need in lower resource settings do not receive intervention. Most studies to date have examined the effectiveness of single-disorder mental health treatments – an approach that may be a significant challenge to scale-up and sustainability in lower resource settings. Main body This paper presents a brief overview of the scientific progress in global mental health, and suggests consideration of an internal stepped care delivery approach. An internal stepped care model is one idea of a delivery system, utilizing a common elements approach, where the same provider could navigate between different elements based on severity and type of problems of the client. It is distinct from traditional stepped care models in that clients remain with the same provider, rather than relying on referral systems. Conclusion An internal stepped care delivery system based on a simplified common elements approach could be more efficient, scalable, sustainable, and reduce the loss of clients to referrals in lower resource settings. Electronic supplementary material The online version of this article (doi:10.1186/s12888-016-0938-y) contains supplementary material, which is available to authorized users.

A randomized trial of a trauma-focused and non trauma-focused intervention with war-affected Congolese youth

Article

Full-text available

Jan 2015

Effects of War, Terrorism and Armed Conflict on Young Children: A Systematic Review

Article

Full-text available

Dec 2016
CHILD PSYCHIAT HUM D

Millions of children have been maimed, displaced, orphaned and killed in modern warfare that targets civilian populations. Several reviews have documented the impact of political trauma on children's mental health but none has focused specifically on young children (ages 0-6). Since developmental factors influence the young child's perception and experience of traumatic events, this developmental period is characterized by a unique spectrum of responses to political trauma. This systematic review, comprising 35 studies that included a total of 4365 young children, examined the effects of exposure to war, conflict and terrorism on young children and the influence of parental factors on these effects. Results showed that effects include PTSD and post-traumatic stress symptoms, behavioral and emotional symptoms, sleep problems, disturbed play, and psychosomatic symptoms. Correlations emerged between parental and children's psychopathology and, additionally, family environment and parental functioning emerged as moderators of the exposure-outcome association for children.

Methods of systematic reviews and meta-analysis preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Article

Jan 2009
J CLIN EPIDEMIOL

Self-Help Plus (SH1): a new WHO stress management package

Article

Oct 2016

Consistent with its recommendations for stress management interventions1, the World Health Organization (WHO) has developed a new psychological intervention for managing stress and coping with adversity. This new intervention is intended to be relevant for coping with any type of adversity, including chronic poverty, endemic community and gender‐based violence, long‐term armed conflict, and displacement. It is especially targeted towards places with enormous needs but limited humanitarian access, such as Syria and South Sudan.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement

Article

Jul 2009
PLOS MED

mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings

Article

Jan 2010

World Health Organization

Initial Test of a Principle-Guided Approach to Transdiagnostic Psychotherapy With Children and Adolescents

Article

Jul 2016
J CLIN CHILD ADOLESC

To address implementation challenges faced by some evidence-based youth psychotherapies, we developed an efficient transdiagnostic approach-a potential "first course" in evidence-based treatment (EBP)-guided by five empirically supported principles of therapeutic change. An open trial of the resulting FIRST protocol was conducted in community clinics. Following a 2-day training, staff practitioners treated 24 clinically referred youths ages 7-15, 50% male, 87% White and 13% Latino, all with the Schedule for Affective Disorders and Schizophrenia for School-Age Children Diagnostic and Statistical Manual of Mental Disorders (4th ed.) anxiety, depressive, or conduct-related disorders, and averaging 2.21 disorders. We evaluated the protocol's (a) feasibility for use in everyday clinical practice (examining therapy process, client engagement, and therapist adherence and competence in using the protocol), (b) acceptability (examining therapeutic alliance and treatment satisfaction by youths, caregivers, and therapists), and (c) potential for clinical benefit (examining treatment outcomes across multiple measures and time points). FIRST scored well on measures of feasibility, acceptability to clients and clinicians, and clinical outcomes, matching or exceeding the corresponding scores in most benchmarking comparisons. Observational coding of sessions showed high levels of protocol adherence (86.6%) and good therapist competence in the evidence-based skills. Weekly assessments throughout treatment showed effect sizes for clinical improvement ranging from .41 to 2.66 on weekly total problems and problems deemed "most important" by caregivers and youths. The FIRST protocol showed evidence of feasibility, acceptability, and clinical benefit when used by practitioners with referred youths treated in community clinics. The findings suggest sufficient potential to justify a full randomized controlled trial of FIRST.

Psychological interventions for children and young people affected by armed conflict or political violence

Article

Feb 2016

Youths exposed to armed conflict have a higher prevalence of mental health and psychosocial difficulties. Diverse interventions exist that aim to ameliorate the effect of armed conflict on the psychological and psychosocial wellbeing of conflict affected youths. However, the evidence base for the effectiveness of these interventions is limited. Using standard review methodology, this review aims to address the effectiveness of psychological interventions employed among this population. The search was performed across four databases and grey literature. Article quality was assessed using the Downs and Black Quality Checklist (1998). Where possible, studies were subjected to meta-analyses. The remaining studies were included in a narrative synthesis. Eight studies concerned non clinical populations, while nine concerned clinical populations. Review findings conclude that Group Trauma Focused-Cognitive Behavioural Therapy is effective for reducing symptoms of posttraumatic stress disorder, anxiety, depression and improving prosocial behaviour among clinical cohorts. The evidence does not suggest that interventions aimed at non clinical groups within this population are effective. Despite high quality studies, further robust trials are required to strengthen the evidence base, as a lack of replication has resulted in a limited evidence base to inform practice.

Annual Research Review: Breaking cycles of violence - a systematic review and common practice elements analysis of psychosocial interventions for children and youth affected by armed conflict

Abstract

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