Interventions for Children Affected by Armed Conflict: a Systematic Review of Mental Health and Psychosocial Support in Low- and Middle-Income Countries

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

BACKGROUND

Given the protective effect of nurturing caregivers and families for child and adolescent mental health, there is a need to review and synthesize research evidence regarding the effectiveness of parenting and family interventions in low and middle-income countries, including humanitarian settings. To advance practice, further understanding of the active ingredients of such interventions and implementation factors that lead to effectiveness are essential.

METHOD

This systematic review, an update from a previous review, included studies on any parenting or family intervention for children and adolescents aged 0-24, living in a low- or middle-income country, that quantitatively measured child or adolescent mental health outcomes. We searched Global Health, PubMed, PsychINFO, PILOTS and the Cochrane Library databases on the 9th July 2020, and updated on the 12th August 2022. Risk of bias was assessed using an adapted version of the NIH Quality Assessment Tool. We extracted data on: effectiveness outcomes, practice elements included in effective interventions, and implementation challenges and successes.

MAIN FINDINGS

We found a total of 80 studies (n = 18,193 participants) representing 64 different family or parenting interventions, 43 of which had evidence of effect for a child or adolescent mental health outcome. Only 3 studies found no effect on child, adolescent or caregiver outcomes. The most common practice elements delivered in effective interventions included caregiver psychoeducation, communication skills, and differential reinforcement. Key implementation strategies and lessons learned included non-specialist delivery, the engagement of fathers, and integrated or multi-sector care to holistically address family needs.

PRELIMINARY CONCLUSIONS

Despite a high level of heterogeneity, preliminary findings from the review are promising and support the use of parenting and family interventions to address the wider social ecology of children in low resource and humanitarian contexts. There are remaining gaps in understanding mechanisms of change and the empirical testing of different implementation models. Our findings have implications for better informing task sharing from specialist to non-specialist delivery, and from individual-focused to wider systemic interventions.

The call for an "educational footprint" in conceptualizing mental health and psychosocial support: the case of Norwegian kindergarten teachers

This article presents an in-depth qualitative case study asking, "How do Norwegian kindergarten teachers conceptualize and negotiate the field of psychosocial support?" This article thoroughly explores how Norwegian kindergarten teachers perceive of the field Mental health and psychosocial support (MHPSS). Recognizing the global imperative to advance mental health and psychosocial support for children, the study highlights the crucial need for interprofessional grounded concepts and logics in developing MHPSS interventions. The study employs a grounded theory approach to actively develop concepts in the MHPSS field in Norway. The six selected Norwegian expert teachers can make up a so-called "unique case", representing a high-income country with a robust welfare system and child-centered pedagogy. Yet, they reveal challenges in embracing the concept of psychosocial support: The analysis shows that the teachers seem to neglect and even reject the concept of psychosocial support, while also expressing inferiority and lack of agency towards other professions. However, the teachers also express the desire for more knowledge, and with proudness they energetically engage in fostering children's agency and functioning by their everyday descriptions of «meeting with the child». The study calls for the kindergarten teachers' increased efforts to actively participate in MHPSS interventions, advocating for the further development of an «educational footprint» that can empower interprofessional work.

Psychological and social interventions for the promotion of mental health in people living in low- and middle-income countries affected by humanitarian crises

BACKGROUND

Because of wars, conflicts, persecutions, human rights violations, and humanitarian crises, about 84 million people are forcibly displaced around the world; the great majority of them live in low- and middle-income countries (LMICs). People living in humanitarian settings are affected by a constellation of stressors that threaten their mental health. Psychosocial interventions for people affected by humanitarian crises may be helpful to promote positive aspects of mental health, such as mental well-being, psychosocial functioning, coping, and quality of life. Previous reviews have focused on treatment and mixed promotion and prevention interventions. In this review, we focused on promotion of positive aspects of mental health.

OBJECTIVES

To assess the effects of psychosocial interventions aimed at promoting mental health versus control conditions (no intervention, intervention as usual, or waiting list) in people living in LMICs affected by humanitarian crises.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and seven other databases to January 2023. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies, and checked the reference lists of relevant studies and reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing psychosocial interventions versus control conditions (no intervention, intervention as usual, or waiting list) to promote positive aspects of mental health in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were mental well-being, functioning, quality of life, resilience, coping, hope, and prosocial behaviour. The secondary outcome was acceptability, defined as the number of participants who dropped out of the trial for any reason. We used GRADE to assess the certainty of evidence for the outcomes of mental well-being, functioning, and prosocial behaviour.

MAIN RESULTS

We included 13 RCTs with 7917 participants. Nine RCTs were conducted on children/adolescents, and four on adults. All included interventions were delivered to groups of participants, mainly by paraprofessionals. Paraprofessional is defined as an individual who is not a mental or behavioural health service professional, but works at the first stage of contact with people who are seeking mental health care. Four RCTs were carried out in Lebanon; two in India; and single RCTs in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The mean study duration was 18 weeks (minimum 10, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non-governmental organisations. For children and adolescents, there was no clear difference between psychosocial interventions and control conditions in improving mental well-being and prosocial behaviour at study endpoint (mental well-being: standardised mean difference (SMD) 0.06, 95% confidence interval (CI) -0.17 to 0.29; 3 RCTs, 3378 participants; very low-certainty evidence; prosocial behaviour: SMD -0.25, 95% CI -0.60 to 0.10; 5 RCTs, 1633 participants; low-certainty evidence), or at medium-term follow-up (mental well-being: mean difference (MD) -0.70, 95% CI -2.39 to 0.99; 1 RCT, 258 participants; prosocial behaviour: SMD -0.48, 95% CI -1.80 to 0.83; 2 RCT, 483 participants; both very low-certainty evidence). Interventions may improve functioning (MD -2.18, 95% CI -3.86 to -0.50; 1 RCT, 183 participants), with sustained effects at follow-up (MD -3.33, 95% CI -5.03 to -1.63; 1 RCT, 183 participants), but evidence is very uncertain as the data came from one RCT (both very low-certainty evidence). Psychosocial interventions may improve mental well-being slightly in adults at study endpoint (SMD -0.29, 95% CI -0.44 to -0.14; 3 RCTs, 674 participants; low-certainty evidence), but they may have little to no effect at follow-up, as the evidence is uncertain and future RCTs might either confirm or disprove this finding. No RCTs measured the outcomes of functioning and prosocial behaviour in adults.

AUTHORS' CONCLUSIONS

To date, there is scant and inconclusive randomised evidence on the potential benefits of psychological and social interventions to promote mental health in people living in LMICs affected by humanitarian crises. Confidence in the findings is hampered by the scarcity of studies included in the review, the small number of participants analysed, the risk of bias in the studies, and the substantial level of heterogeneity. Evidence on the efficacy of interventions on positive mental health outcomes is too scant to determine firm practice and policy implications. This review has identified a large gap between what is known and what still needs to be addressed in the research area of mental health promotion in humanitarian settings.

Scoping Review: Digital Mental Health Interventions for Children and Adolescents Affected by War

OBJECTIVE

More than 200 million children and adolescents live in countries affected by violent conflict, are likely to have complex mental health needs, and struggle to access traditional mental health services. Digital mental health interventions have the potential to overcome some of the barriers in accessing mental health support. We performed a scoping review to map existing digital mental health interventions relevant for children and adolescents affected by war, to examine the strength of the evidence base, and to inform the development of future interventions.

METHOD

Based on a pre-registered strategy, we systematically searched MEDLINE, Embase, Global Health, APA PsychInfo, and Google Scholar from the creation of each database to September 30, 2022, identifying k = 6,843 studies. Our systematic search was complemented by extensive consultation with experts from the GROW Network.

RESULTS

The systematic search identified 6 relevant studies: 1 study evaluating digital mental health interventions for children and adolescents affected by war, and 5 studies for those affected by disasters. Experts identified 35 interventions of possible relevance. The interventions spanned from universal prevention to specialist-guided treatment. Most interventions directly targeted young people and parents or carers/caregivers and were self-guided. A quarter of the interventions were tested through randomized controlled trials. Because most interventions were not culturally or linguistically adapted to relevant contexts, their implementation potential was unclear.

CONCLUSION

There is very limited evidence for the use of digital mental health interventions for children and adolescents affected by war at present. The review provides a framework to inform the development of new interventions.

DIVERSITY & INCLUSION STATEMENT

We actively worked to promote sex and gender balance in our author group.

STUDY PREREGISTRATION INFORMATION

Digital mental health interventions for children and young people affected by war: a scoping review; https://osf.io/; hrny9.

Evaluating a Movement-Based Mental Health Promotion Intervention for Refugee Children in Uganda: A Quasi-Experimental Study

OBJECTIVE

Mental health promotion interventions are widely implemented in humanitarian settings and low- and middle-income contexts (LMICs), yet evidence on effectiveness is scarce and mixed. This study evaluated the movement-based mental health promotion intervention "TeamUp" in Bidibidi refugee settlement, in Northern Uganda.

METHOD

A quasi-experimental study including four schools (two per arm) assessed the outcomes of 10- to 15-year-old South Sudanese and Ugandan children (n = 549). Randomly allocated, they either participated in up to 11 TeamUp sessions (n = 265) provided by trained facilitators; or belonged to a control group, which continued care as usual (n = 284). Primary outcomes measured psychosocial wellbeing, friendships and attitude to school; secondary outcomes included traumatic distress, depressive symptoms, quality of life, physical health, bullying, interoceptive awareness, and irritability. Data were collected at baseline and endline.

RESULTS

Children joining TeamUp, showed significantly more improvements on primary outcomes: emotional and psychosocial wellbeing (Mdiff = -1.49, SE = 0.6, p = .01), satisfaction with and attitude toward school (-0.57, SE = 0.2, p = .004); and secondary outcomes: traumatic stress (2.64, SE = 0.8, p < .001), health-related quality of life (-1.56, SE = 0.4, p = .001), physical health (-0.78, SE = 0.3, p = .014) and the TeamUp mechanisms of action scale (-3.34, SE = 0.9, p < .001), specifically the subscales social connectedness (-0.74, SE = 0.3, p = .007) and sense of agency (-0.91, SE = 0.3, p = .005), compared to the control group. No significant differences were found on bullying, interoceptive awareness, irritability and depressive symptoms.

CONCLUSION

The results are promising for TeamUp as a mental health promotion intervention for children affected by armed-conflict, displacement and on-going adversity. Further research will need to assess the intervention's effectiveness.

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

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.

Evaluation of the Early Adolescent Skills for Emotions (EASE) intervention in Lebanon: A randomized controlled trial

BACKGROUND

There is a need for scalable evidence-based psychological interventions for young adolescents experiencing high levels of psychological distress in humanitarian settings and low- and middle-income countries. Poor mental health during adolescence presents a serious public health concern as it is a known predictor of persistent mental disorders in adulthood. This study evaluates the effectiveness of a new group-based intervention developed by the World Health Organization (Early Adolescent Skills for Emotions; EASE), implemented by non-specialists, to reduce young adolescents' psychological distress among mostly Syrian refugees in Lebanon.

METHODS

We conducted a two-arm, single-blind, individually randomized group treatment trial. Adolescents aged 10 to 14 years who screened positive for psychological distress using the Pediatric Symptom Checklist (PSC) were randomly allocated to EASE or enhanced treatment as usual (ETAU) (1:1.6). ETAU consisted of a single scripted psycho-education home-visit session with the adolescent and their caregivers. EASE consists of seven group sessions with adolescents and three sessions with caregivers. The primary outcome was adolescent-reported psychological distress as measured with the PSC (internalizing, externalizing, and attentional symptoms). Secondary outcomes included depression, posttraumatic stress, well-being, functioning, and caregivers' parenting and distress. All outcomes were assessed at baseline, endline, and 3 months (primary time point) and 12 months follow-up.

RESULTS

Due to the COVID-19 pandemic and other adversities in Lebanon at the time of this research, the study was prematurely terminated, resulting in an under-powered trial sample (n = 198 enrolled compared to n = 445 targeted). We screened 604 children for eligibility. The 198 enrolled adolescents were assigned to EASE (n = 80) and ETAU (n = 118), with retention rates between 76.1 and 88.4% across all timepoints. Intent-to-treat analyses demonstrated no between-group differences on any of the outcome measures between the EASE and ETAU. We did observe a significant improvement on the primary outcome equally in the EASE and ETAU groups (-0.90, 95% CI: -3.6, 1.8; p = .52), - a trend that was sustained at three months follow-up. Sub-group analyses, for those with higher depression symptoms at baseline, showed ETAU outperformed EASE on reducing depression symptoms (difference in mean change = 2.7, 95% CI: 0.1, 5.3; p = .04; d = 0.59) and internalizing problems (difference in mean change 1.0, 95% CI: 0.08, 1.9; p = .03; d = 0.56) .

CONCLUSION

No conclusions can be drawn about the comparative effectiveness of the intervention given that the sample was underpowered as a result of early termination. Both EASE and single session psycho-education home visits resulted in meaningful improvements in reducing psychological distress. We did not identify any indications in the data suggesting that EASE was more effective than a single session family intervention in the context of the COVID-19 pandemic and other crises in Lebanon. Fully powered research is needed to evaluate the effectiveness of EASE.

The effect of conflict on child and adolescent health in Amhara region, Ethiopia: Cross-Sectional Study

BACKGROUND

Currently, conflict become common phenomenon in the world affecting the lives of millions of children. Due the continued conflict in Ethiopia millions of children are suffering from extreme levels of violence, lack of basic humanitarian needs, and lack of health services.

OBJECTIVE

This study was designed to assess the effect of conflict on child and adolescent health in Amhara region, September 2022.

METHODS

A community-based cross-sectional study was employed among children agedd < 18 years in conflict affected areas of Amhara region. The sample size was determined using a single population proportion formula. Data was collected through face-to-face interviews of children or child legal guardians. Data was cleaned, verified, and entered into EpiData version 3.1 and analysis was done using SPSS version 24 statistical software.

RESULT

Seven hundred and ninety-eight children agedd less than 18 years were involved with a response rate of 94.33 percent. More than one thirds (276, 34.59%) of children were displaced due to the conflict. Three hundred and thirty one (41.48%) children get diseased with the majority didn't receive treatment. More than two thirds (557, 69.80%) of children had experienced violence of different types. One hundred and thirty four (41.23%) children had acute malnutrition with two third (66.42%) of them had severe acute malnutrition.

CONCLUSION

Conflict had deadly impacts on the lives of children and adolescents. It causes massive displacement, lack of basic humanitarian needs, extreme level of violence, hunger and malnutrition, and lack of health services. The government and other national and international humanitarian aids should give special attention to children living in war zone of Amhara region. In addition, rehabilitation services and resilience training should be designed and provided to children affected by the conflict.

Child and adolescent mental health and psychosocial support interventions: An evidence and gap map of low- and middle-income countries

Background

Mental disorders affect about one in seven children and adolescents worldwide. Investment in effective child and adolescent mental health prevention, promotion and care is essential. To date, however, the evidence from this field is yet to be comprehensively collected and mapped.

Objectives

The objective of this evidence and gap map (EGM) is to provide an overview of the existing evidence on the effectiveness of interventions aimed at promoting mental health and reducing or preventing mental health conditions among children and adolescents in lower-middle-income countries (LMICs).

Search Methods

We searched for studies from a wide range of bibliographic databases, libraries and websites. All searches were conducted in December 2021 and covered the period between 2010 and 2021.

Selection Criteria

We included evidence on the effectiveness of any Mental Health and Psychosocial Support (MHPSS) interventions targeting children and adolescents from 0 to 19 years of age in LMICs. The map includes systematic reviews and effectiveness studies in the form of randomised control trials and quasi-experimental studies, and mixed-methods studies with a focus on intervention effectiveness.

Data Collection and Analysis

A total of 63,947 records were identified after the search. A total of 19,578 records were removed using machine learning. A total of 7545 records were screened independently and simultaneously by four reviewers based on title and abstract and 2721 full texts were assessed for eligibility. The EGM includes 697 studies and reviews that covered 78 LMICs.

Main Results

School-based interventions make up 61% of intervention research on child and adolescent mental health and psychosocial support. Most interventions (59%) focusing on treating mental health conditions rather than preventing them or promoting mental health. Depression (40%, N = 282) was the most frequently researched outcome sub-domain analysed by studies and reviews, followed by anxiety disorders (32%, N = 225), well-being (21%, N = 143), and post-traumatic stress disorder (18%, N = 125). Most included studies and reviews investigated the effectiveness of mental health and psychosocial support interventions in early (75%, N = 525) and late adolescence (64%, N = 448).

Conclusions

The body of evidence in this area is complex and it is expanding progressively. However, research on child and adolescent MHPSS interventions is more reactive than proactive, with most evidence focusing on addressing mental health conditions that have already arisen rather than preventing them or promoting mental health. Future research should investigate the effectiveness of digital mental health interventions for children and adolescents as well as interventions to address the mental health and psychosocial needs of children in humanitarian settings. Research on early childhood MHPSS interventions is urgently needed. MHPSS research for children and adolescents lacks diversity. Research is also needed to address geographical inequalities at the regional and national level. Important questions also remain on the quality of the available research-is child and adolescent MHPSS intervention research locally relevant, reliable, well-designed and conducted, accessible and innovative? Planning research collaborations with decision-makers and involving experts by experience in research is essential.

Effectiveness of the caregiver support intervention on child psychosocial wellbeing among Syrian refugees in Lebanon: Mediation and secondary analysis of a Randomized Controlled Trial

BACKGROUND

War and violence have a serious negative impact on the wellbeing and mental health of many children. Caregivers play an important role in mitigating or exacerbating this impact.

OBJECTIVE

This study evaluates the impact of the nine session Caregiver Support Intervention on improving children's wellbeing and examines putative mediators of changes in children's psychosocial wellbeing.

PARTICIPANTS AND SETTING

240 female caregivers were randomly allocated (1:1) to the CSI or a waitlist control comparison condition. The study was implemented in Lebanon, in an area characterized by high levels of poverty and a high number of the Syrian refugees.

METHODS

A parallel group Randomized Controlled Trial reporting on caregiver-reported child-level wellbeing. We used a combination of the Kid- and Kiddy-KINDL (parent version) for index children ages three to 12. Putative mediators of the CSI on children's psychosocial wellbeing included harsh parenting, caregiver psychological distress, caregiver wellbeing. Measurements were conducted at baseline, post-intervention and 3-months follow-up.

RESULTS

We demonstrated a statistically significant change in caregiver reported children's psychosocial wellbeing at post-intervention (Mdiff =4.39, 95 % CI = 1.12, 7.65, p < 0.01, d = 0.28) but not at follow-up (Mdiff = -0.97, 95 % CI = -4.27, 2.32, p > 0.05). The proportion of the total effect of the CSI intervention on child psychosocial wellbeing mediated by caregiver distress, caregiver wellbeing and harsh parenting was 77 %.

CONCLUSION

The CSI holds potential for down-stream short-term effect on improving children's psychosocial wellbeing, beyond the previously reported positive caregiver outcomes. This effect was not sustained three months post intervention. The study confirms caregiver wellbeing and parenting support as dual pathways mediating child psychosocial wellbeing. Prospective trial registration: ISRCTN22321773.

Bosnian Paternal War Orphans: Mental Health in Postwar Time

ABSTRACT

More research on the medium- and long-term effects of childhood exposure to war, including orphanhood, is needed. We compared 50 orphans 1 who lost their father during the war in Bosnia and Herzegovina (1992-1995) and 50 age- and sex-matched adolescents from two-parent families during 2011-2012 in terms of sociodemographic characteristics, behavioral/emotional problems, depression, resilience, maternal mental health, and perceived social support. The two groups differed on sociodemographic factors, that is, number of children, family composition, income, school grades, and refugeehood. Paternal war orphans did not differ in terms of adolescent mental health and resilience from their nonorphaned peers, controlling for sociodemographic variables. The mothers of orphans had comparably more posttraumatic psychopathology. As for perceived resources for social support, orphans identified those comparably more often among distant relatives and in the community, that is, religious officials and mental health professionals, and less often among siblings, paternal grandparents, paternal and maternal uncles/aunts, school friends and teachers. Our findings suggest that contextual factors may play an important role in orphans' postwar mental health.

Improving the Scope of Child Mental Health Interventions in Our Modern World

Twenty years ago, an important systematic review showed that the empirical research evidence for interventions available for children and young people with mental health problems were rarely developed with their specific developmental needs in mind [...].

Mental Health and Psychosocial Support Interventions for Children Affected by Armed Conflict in low-and middle-income Countries: A Systematic Review

Background

. Armed conflicts continue to threaten a vast number of children across the world, especially in low-and middle-income countries (LMICs). Evidence-based interventions are vital to adequately address the mental health needs in these groups.

Objective

. This systematic review aims to provide a comprehensive update of the most current developments in mental health and psychosocial support (MHPSS) interventions for children affected by armed conflict in LMICs, since 2016. Such an update may be useful in determining where the current focus of interventions lies and whether there are changes in types of interventions that are commonly implemented.

Methods

. The main medical, psychological and social sciences databases (PubMed, PsycINFO, Medline) were searched to identify interventions aimed at improving or treating mental health problems in conflict-affected children in LMICs. For the period 2016-2022, a total of 1243 records were identified. Twenty-three articles met the inclusion criteria. A bio-ecological lens was used to organize the interventions and the presentation of findings.

Results

. Seventeen forms of MHPSS interventions with a wide range of treatment modalities were identified in this review. The reviewed articles focused mainly on family-based interventions. Very few studies empirically evaluated community-level interventions.

Conclusion

. Current focus of interventions is family-based; the addition of caregiver wellbeing and parenting skills components had the potential to enhance the effects of interventions designed to improve children's mental health. Future trials for MHPSS interventions need to give more attention to community-level interventions. Community-level supports such as person-to-person support, solidarity groups, and dialogue groups stand to reach large numbers of children and families.

The culturally and contextually sensitive assessment of mental health using a structured diagnostic interview (MINI Kid) for Syrian refugee children and adolescents in Lebanon: Challenges and solutions

Elevated rates of mental health difficulties are frequently reported in conflict-affected and displaced populations. Even with advances in improving the validity and reliability of measures, our knowledge of the performance of assessment tools is often limited by a lack of contextualization to specific populations and socio-political settings. This reflective article aimed to review challenges and share lessons learned from the process of administering and supervising a structured clinical interview. We administered the MINI International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) and used the Clinical Global Impression (CGI) severity scale with N = 119 Syrian refugee children (aged 8-17) resident in ITSs in Lebanon. Qualitative data were derived from supervision process notes on challenges that arose during assessments, analyzed for thematic content. Five themes were identified: (1) practical and logistical challenges (changeable nature of daily life, competing demands, access to phones, temporary locations, limited referral options); (2) validity (lack of privacy, trust, perceptions of mental health, stigma, false positive answers); (3) cultural norms and meaning (impact of different meanings on answers); (4) contextual norms (reactive and adaptive emotional and behavioral responses to contextual stress); and (5) co-morbidity and formulation (interconnected and complex presentations). The findings suggest that while structured assessments have major advantages, cultural and contextual sensitivity during assessments, addressing practical barriers to improving accessibility, and consideration for inter-connected formulations are essential to help inform prevalence rates, treatment plans, and public health strategies.

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

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.

Mental health in refugee children

Almost half of the world's forcibly displaced population are children, most commonly originating from Syria, Iraq, and Afghanistan. Health disparities are well documented, especially for mental health, but not consistent across groups, time or context. Despite high exposure to trauma and stress, refugee children also show remarkable resilience. An ecological model of refugee health including both risk and resilience factors is therefore recommended. The model also includes the dynamic inter-relationship of past traumatic experiences, ongoing daily stressors and the disruptions of basic systems affecting both the individual and families as a whole, offering a framework to better understand the health disparities and appropriate interventions for refugee children.

Implementation of Mental Health Policies and Reform in Post-Conflict Countries: The case of post-genocide Rwanda

The global burden of mental illness is rising, with populations in post-conflict countries contributing significantly to the numbers. Governments in these countries face the dual challenge of responding to increased mental health needs and implementing this response with institutions and economies weakened by war. This research studies the process, successes, and challenges of implementing mental health reform in a low-resource, post-conflict country, a subject that is rarely studied. Based on fieldwork conducted in Rwanda in 2019, the study focuses on the implementation of this African country's post-genocide mental health policy, which relies primarily on strategies of decentralization and integration into the primary healthcare system. The results are based on thirty interviews conducted in Kigali and Ngoma with primary stakeholders including government officials, representatives from Non-Governmental Organizations, service providers, and academics. These stakeholders held a positive view of the main strategies of the policy as they resulted in increased accessibility and availability of care for Rwandans. However, they also noted the institutionalization and individualization of mental health care as gaps in the implementation that do not respond to the Rwandan context. Building on complexity theory, the analysis found that many of these gaps, as well as opportunities to address them, are missed by the government due to top-down implementation and a lack of collaboration with local organizations and service providers working in the domain. The research results suggest that although it is possible to prioritize mental health in low-resource, complex settings, the implementation of such reform requires collaborative, adaptive, and horizontal approaches in order to adequately address and respond to citizen needs and ensure quality mental health care for all.

Editorial Perspective: How can we help the children of Ukraine and others affected by military conflict?

Parents and caregivers play a key role in protecting children from the stresses of war. Their own experiences, changes they see in children in their care and the nature of the parenting they provide can have a profound effect on childrens' reactions. The adoption of a pyramid of resources from universally available psychoeducational materials to specialised forms of trauma-informed interventions allows for screening and provision of appropriate levels of assistance. The importance of consideration of the family's context, the evidence base and the capacity of informal and professional networks to support caregiving is discussed. Resources available through the United Nations Office on Drugs and Crime are provided to share experiences of building a pyramid of interlinked, evidence-based, trauma-informed interventions which have been developed in collaboration with families and practitioners experiencing life through the contexts of military conflict, displacement and resettlement.

Factors Influencing Improvement of Trauma-Related Symptoms Among Somali Refugee Youth in Urban Kenya

Somali refugee youth present with a heightened risk for common mental disorders (CMDs), and yet few studies have discussed factors influencing mental health outcomes after psychosocial interventions. This study aimed to identify key factors that contribute to the improvement of CMD symptoms among Somali youth displaced in urban Kenya. Logistic regression analyses revealed that trauma exposure and emotional coping predict overall symptom improvement, pointing to a differential intervention effect on those with differing levels of religious belief and attitudes toward violence. This study provides insights into how psychosocial factors likely contribute to positive intervention outcomes in Somali refugee youth.

Supporting Youth and Families in Gaza: A Randomized Controlled Trial of a Family-Based Intervention Program

Background: A total of 450 million children are now living in active conflict zones. The negative consequences for children are significant and long lasting. In response to the urgent need for sustainable interventions for children and families, the current study evaluated a brief (12 hr, 8 session) family-based coping and support program, Promoting Positive Family Futures (PPFF), in Gaza. Methods: Families (n = 68, mother/father/adolescent triads) were randomized into the PPFF intervention or another lengthier (50 hr, 25 session) locally well-established psychosocial support program (treatment as usual; TAU). Results: Improvements were found for both conditions for paternal and maternal depression, emotion regulation using cognitive reappraisal, family-wide emotional security, and adolescent adjustment. Effect sizes were medium to large (d = 0.35–1.27). Fathers in the PPFF condition reported lower depression and higher emotion regulation using cognitive reappraisal at post-test than did fathers in the TAU condition. Mothers in the PPFF condition reported higher levels of emotion regulation using cognitive reappraisal at post-test than did mothers in the TAU condition. PPFF was also indirectly associated with improved depression at post-test for both mothers and fathers via improvements in emotion regulation using cognitive reappraisal and with adolescent adjustment at six months via improvements in maternal emotion regulation using cognitive reappraisal. Conclusions: These findings suggest that the PPFF intervention has many benefits comparable with a longer and locally well-established program. PPFF was also associated with unique positive implications for family-wide adjustment over time. Support was also identified for transdiagnostic processes of improvement associated with the PPPF intervention consistent with the theoretical models informing the approach.

Community-Based Interventions for the Treatment and Management of Conflict-Related Trauma in Low-Middle Income, Conflict-Affected Countries: a Realist Review

Where low- and middle-income countries have limited economic resources to provide individualized mental health services to people exposed to conflict, community-based interventions may be more appropriate. We aimed to evaluate community level interventions for improving mental health outcomes in Low- and Middle-income countries (LMIC). A realist review of community-based interventions (CBIs) to improve mental health for people in LMIC following conflict. Five databases (Cochrane, PubMed, PsychINFO, Medline, and CINAHL) and a manual search of individual papers. We found 1318 articles, of which 29 were selected. Out of the 29 primary articles, 19 showed successful results, 4 showed mixed results, 1 showed inconclusive results, and 1 showed unsuccessful results. After analyzing the results, we found 3 mechanisms that may influence the effectiveness of these CBIs: the use of lay community members as intervention deliverers, the application of transdiagnostic approaches, and customized outcome assessment tools. Community-based approaches to improve mental health in LMICs are rare and evidence for their effectiveness is limited. Interventions that have a wide scope, train lay mental health workers, and use contextually adapted outcome assessment tools show promise.

Trauma-focused cognitive behavioral therapy for children and youth in low and middle-income countries: A systematic review

BACKGROUND

Trauma-focused cognitive behavioral therapy (TF-CBT) has been identified as a gold standard treatment for childhood posttraumatic stress disorder (PTSD) in Western countries. More recently, TF-CBT has emerged in the literature as an area of interest for children and youth affected by conflict and war in low- and middle-income countries (LMIC).

METHODS

The present systematic review assesses the current evidence base of TF-CBT for children and youth in LMIC, with a focus on conflict-affected countries. A total of 143 articles were identified, of which 11 articles, representing 1,354 participants, met the proposed inclusion criteria.

RESULTS

Results showed that the majority of the studies identified were conducted in low-resource community settings in East or Central Africa (n = 8). It was also found that cultural considerations were taken into account in TF-CBT delivery to meet the needs of local populations. Additionally, measures were translated and validated for local use.

CONCLUSIONS

Findings of outcome data indicated that TF-CBT was effective in treating trauma-related symptoms and improving psychosocial functioning in children and adolescents in LMICs. Given the limited number of published literature available in this area, further studies are needed to conclude when and for whom trauma-focused interventions are most relevant.

Mental Health and Positive Development Prevention Interventions: Overview of Systematic Reviews

CONTEXT

Previous reviews of mental health interventions have focused on adolescents (10-19 years), with a paucity of comprehensive evidence syntheses on preventive interventions for school-aged children (5-10 years).

OBJECTIVE

To summarize and synthesize the available evidence from systematic reviews of mental health and positive development interventions for children aged 5-14.9 years in both high-income (HIC) and low- and middle-income countries (LMIC), with a focus on preventive and promotive strategies.

DATA SOURCES

This overview includes all relevant reviews from OVID Medline, The Cochrane Library, and Campbell Systematic Reviews through December 2020.

STUDY SELECTION

We included systematic reviews that synthesized empirical studies using experimental or quasi-experimental designs to evaluate the effectiveness of interventions in children aged 5-14.9 years.

DATA EXTRACTION

Data extraction and quality assessment were completed independently and in duplicate by two review authors. The AMSTAR2 tool was used to assess methodological quality.

RESULTS

We included 162 reviews. The greatest evidence was found in support of school-based universal and anti-bullying interventions in predominantly HIC. Moderate evidence was found for the use of substance abuse prevention, and early learning and positive development interventions in mixed settings. In LMIC-only contexts, the most promising evidence was found for positive youth development programs.

LIMITATIONS

The review was primarily limited by paucity of high-quality research due to methodological issues and high heterogeneity.

CONCLUSIONS

This overview of reviews highlights the need for further research to consolidate findings and understand the specific criteria involved in creating positive mental health and development outcomes from the various interventions considered.

School-based MHPSS interventions in humanitarian contexts: a realist review

OBJECTIVE

The aim of this review is to elucidate the characteristics of school-based mental health and psychosocial support (MHPSS) interventions in humanitarian contexts and the hypothesised mechanisms by which they influence well-being or learning outcomes.

METHODS

We conducted a realist review and searched PubMed, Embase, Global Health, CINAHL, PsychInfo, PILOTS and grey literature through January 2022. Eligible studies included children age 6-12 years, were conducted in humanitarian contexts in low-income or middle-income countries, and focused on universal MPHSS prevention in an educational setting, using any study design. Data were extracted and analysed using narrative synthesis and realist analysis techniques to create 'context-mechanism-outcome' configurations that were iteratively developed to modify, refine and substantiate programme theories.

RESULTS

Twenty-seven articles, representing 19 studies, were included in the review. We analysed data from 26 articles. Eleven evidenced-informed programme theories were developed at the levels of the child (n=4), teacher (n=3), caregiver (n=2), school environment (n=1) and school managers/administrators (n=1). At the child level, mechanisms related to strengthening coping skills, emotion regulation, interpersonal relationships led to improved psychosocial well-being or learning outcomes. At the teacher level, coping skills and the provision of support to students were linked to psychosocial well-being and learning outcomes. At the caregiver level, strengthening interpersonal bonds trigger improved psychosocial well-being, and at the school environment level, fostering feelings of security was linked to psychosocial well-being and learning outcomes. We did not find any evidence supporting the programme theory at the school managers/administrators level. We found limited evidence of positive impacts of the included interventions to support these programme theories.

CONCLUSIONS

These programme theories are a promising start towards ensuring school-based MHPSS interventions in humanitarian contexts better address the well-being and learning needs of children. Future research is needed to support these programme theories and enhance the evidence base.

PROTOCOL: Child and adolescent mental health and psychosocial support interventions: An evidence and gap map of low- and middle-income countries

This is the protocol for a Campbell review. The objective of this evidence and gap map is to provide an overview of the existing evidence on the effectiveness of interventions aimed at promoting mental health and reducing or preventing mental health conditions among children and adolescents in low- and middle-income countries.

Effectiveness of psychosocial school interventions in Finnish schools for refugee and immigrant children, "Refugees Well School" in Finland (RWS-FI): a protocol for a cluster randomized controlled trial

BACKGROUND

Schools are natural environments in which to enhance young people's social and emotional skills, mental health, and contact between diverse groups, including students from refugee and immigrant backgrounds. A layered or tiered provision of services is recommended as it can be effective to meet the needs of war-affected adolescents who variably show mental health problems (such as posttraumatic stress disorder (PTSD)). The current protocol describes the study design for a multi-layered intervention model. The study will test the effectiveness of two interventions: a teacher-training intervention In-Service Teacher Training (INSETT) combined with targeted cognitive-behavioral treatment-based Teaching Recovery Techniques (TRT) and a classroom-focused preventive intervention Peer Integration and Enhancement Resources (PIER). We analyze, first, whether the interventions are effective in decreasing psychological distress and increasing positive resources, i.e., prosocial behavior and resilience among refugee and immigrant students. Second, we analyze which student-, school-, and parent-related factors mediate the possible beneficial changes. Third, we look at which groups the interventions are most beneficial to.

METHODS

A three-arm cluster RCT with parallel assignment, with a 1:1:1 allocation ratio, is applied in 16 schools that agreed to participate in the Refugees Well School interventions and effectiveness study. Schools were randomized to three conditions of two active interventions and a waiting list control condition. Students, their parents, and teachers in intervention and control schools participated in the study at baseline before the interventions, after the interventions, and at 6 to 12 months after the interventions. The primary effectiveness criterion variables are psychological distress (SDQ) symptoms, resilience (CYRM-12), and prosocial behavior (SDQ).

DISCUSSION

The current study presents a recommended universal approach of layered interventions aiming to reduce psychological distress and increase resilience among refugee and immigrant students. A combination of promotive, preventive, and targeted interventions may offer a holistic, ecological intervention package for schools to better address the needs of the whole group.

TRIAL REGISTRATION

ISRCTN ISRCTN64245549 . Retrospectively registered on 10 June 2020.

Advancing and translating knowledge: a systematic inquiry into the 2010-2020 mental health and psychosocial support intervention research evidence base

BACKGROUND AND STUDY OBJECTIVES

MHPSS is increasingly seen as a critical component to effective and responsible humanitarian programming. This review examines the extent to which MHPSS research generated since 2010 has contributed to the public health evidence base and how this has influenced and impacted programming and policy in humanitarian settings.

METHODS

This mixed-method study included a scoping literature review (n = 50) and a consultation process with qualitative key informant interviews (n = 19) and online survey responses (n = 52) to identify the facilitating and inhibiting factors for the two areas of inquiry and to understand the broader context in which knowledge is generated and taken up. The interviews were thematically analysed and the survey responses were descriptively analysed.

RESULTS

The review identified a rapidly growing evidence base that has evaluated a range of MHPSS interventions. However, few studies examined long-term impacts of interventions, there was limited direct evidence on outcomes for children and adolescents and whole family approaches, and there were minimal replications of the same approach that could test efficacy across settings and population groups. A general shift was identified in the consultation process away from a focus on disorder towards the more positive aspects of wellbeing. However, there remained a mismatch in many studies included in the literature review, whereby the interventions were broad, community-based but the outcome measures used still focused on changes in symptoms of mental disorders.

CONCLUSION

The evidence base for MHPSS has grown significantly over the last 10 years. However, several knowledge gaps remain, as does the divide between research and practice. Moving forward, MHPSS intervention research needs to be more responsive to the needs on the ground.

Families and Collective Futures: Developing a Program Logic Model for Arts-Based Psychosocial Practice With South African Rural Communities

Aim: This aim of this study is to describe the development of a program logic model to guide arts-based psychosocial practice delivered in rural South African farming communities affected by transgenerational traumas. Background: The rationale for developing a program logic model for arts-based psychosocial practice in South Africa was based on the lack of evidence for effective community arts-based psychosocial interventions for collective trauma, unknown consensus about best practices and the need for developing cogent collective psychosocial practices. Further to this, the aims and benefits of the practice required clarity given the psychosocial complexity of the environment within which the practices for this population are being offered. The logic model offers a valuable resource for practitioners, participants and funders to understand the problem being addressed, how practice is defined, as well as the impact of practice and on intermediate and longer term goals. Methods: The authors used a systematic iterative approach to describe the operationalization of arts-based psychosocial practice. This resulted in the design of the logic model being informed by data from focus groups, an overview of the literature regarding transgerenational trauma in this population, operational policies and organizational documents. The development of the logic model involved actively investigating with practitioners their work with remote farming communities. We thematised practitioners practice constructs to identify salient practice elements and their relationship to perceived benefits and lastly feedback from practitioners and participants following implementation to make adjustments to the logic model. Results: The results were clearly identified in the form of visual mapping using the design of a program logic model. The logic model was divided into 5 parts and was verified by practitioners following implementation. The parts of the program logic model are (Part 1) main presenting problem, (Part 2) operational processes, (Part 3) practice elements, (Part 4) benefits, and impact and (Part 5) review.

Developing a Culturally Relevant Measure of Resilience for War-Affected Adolescents in Eastern Ukraine

Psychosocial support in education that is provided during emergencies frequently aims to support children's resilience, but strong, contextual measures of resilience are in short supply in Eastern Europe. In this article, our aim is to describe the development and psychometric properties of the first measure of resilience for war-affected adolescents in Eastern Ukraine. We used qualitative methods to identify the main cultural characteristics of resiliency and then used these constructs to develop the measure. We used exploratory structural equation modeling to extract five factors that showed high internal consistency: family support (ω=0.89), optimism (ω=0.87), persistence (ω=0.87), health (ω=0.86), and social networking (ω=0.87). Confirmatory factor analysis suggested that a concise model of resiliency fit the data almost as well as the exploratory structural equation modeling model. The measure demonstrated good test-retest reliability. In this article, we also discuss the importance of development, validation, and the use of culturally relevant measures of resilience for strengthening psychosocial support programs in schools, particularly in Ukraine.

Cultural adaptation of a scalable psychological intervention for Burundian refugee adolescents in Tanzania: a qualitative study

Background

There is an urgent need for evidence-based, scalable, psychological interventions to improve the mental health of adolescents affected by adversity in low-resource settings. Early Adolescents Skills for Emotions (EASE) was developed by the WHO as a brief, transdiagnostic, group intervention for early adolescents exhibiting internalising problems, delivered by trained and supervised lay providers. This study describes the cultural adaptation of EASE for Burundian adolescents living in Mtendeli refugee camps in Tanzania.

Methods

A phased approach to adaptation of the EASE intervention and its implementation, was adopted and comprised of: (1) a desk review to synthesize existing research on mental health issues in conflict-affected Burundian communities, (2) a rapid qualitative assessment involving free listing and key informant interviews with multiple stakeholders, (3) cognitive interviews with end users, and (4) a two-part adaptation workshop involving the implementing partner staff, members of the refugee community and mental health experts. We applied the Bernal framework to systematically document and track adaptations across eight dimensions of the intervention.

Results

Problems associated with worry, stress, sadness, shame and fear were identified as amongst the most critical mental health concerns, alongside a range of experiences of different forms of violence (such as gender-based violence, violence when fleeing from their homes) and associated problems. Problems associated with violence that included past experiences of fleeing as well as ongoing problems of gender-based violence in the camp. The most significant adaptations that were required included providing options for low literacy of participants, safety planning to address the high prevalence of sexual violence, simplification of strategies for the benefit of the end users and of lay facilitators, and implementation changes to consider involvement of refugee incentive workers. A majority of changes were across dimensions of language, people, metaphors, content, methods and context, while there were fewer changes regarding the goals and concepts of EASE.

Conclusions

The approach to adaptation of a psychological intervention suggested both minor and major required changes. Adaptations based on the findings of this study are anticipated to enhance relevance and acceptability of the EASE intervention and its delivery for camp-residing Burundian refugees in Tanzania.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00391-4.

Mental health consequences of armed conflicts in children and adolescents: An overview of literature reviews

Introduction: Armed conflicts affect the mental health of children and adolescents. Their outcomes in these populations have been documented identifying vulnerability and significant biopsychosocial damage as the most common factors. Objective: To identify and synthesize the mental health consequences of armed conflicts in children and adolescents. Materials and methods: We carried out a comprehensive and systematic search of reviews published until July 2019 in the MEDLINE (Ovid), EMBASE, Cochrane Central Register of Controlled Trials, and LILACS databases, as well as in additional sources. The information was retrieved and analyzed narratively by describing the characteristics and objectives of the studies and the mental health consequences of armed conflicts in three periods of time: pre-armed conflict, during the armed conflict, and post-conflict. Results. Out of 587 potentially relevant studies, we finally selected 72. In the pre-armed conflict period, we described in detail the psychological experiences and the anticipatory somatic symptoms. During the conflict, we identified regressive, behavioral, and cognitive symptoms such as enuresis, fear, sadness, aggression, hyperactivity, and inattention, among others. Direct mental health consequences such as adjustment disorders, depression, anxiety, and post-traumatic stress were also identified. Finally, in the postconflict period, we referred to the transmission of mental health consequences and resilience processes. On the other hand, we reviewed in depth the potential consequences of armed conflicts on biopsychosocial development, morality, identity, culture, education, and society. Conclusion. The development of mental health consequences due to the exposure to armed conflicts in these populations is a complex process that depends on the stage of the exposure, the length of the conflict, and contextual factors.

Improving mental health in low-resource settings: A feasibility randomized controlled trial of a transdiagnostic psychological intervention among Burundian refugee adolescents and their caregivers

There is a paucity of evidence regarding interventions that can improve the mental health of adversity-affected young adolescents living in low-resource settings. We evaluated the feasibility, acceptability, relevance, and safety of the World Health Organization's Early Adolescent Skills for Emotions (EASE) intervention among Burundian refugee adolescents and their caregivers in Tanzania. This study consisted of a feasibility cluster randomized controlled trial (cRCT) and a process evaluation. The feasibility cRCT included 82 young adolescents and their 64 caregivers, with two clusters randomized to EASE and two to an enhanced control condition. EASE was delivered by adult refugees without prior training in mental health. The process evaluation consisted of 36 semi-structured qualitative interviews with key stakeholders, including adolescents, caregivers, and facilitators. EASE participants and facilitators gave positive feedback about its format, accessibility, and content. Trained non-specialist refugee facilitators were able to deliver EASE with high fidelity. The research protocol functioned well in terms of balanced randomization, limited loss to follow-up, and psychometrically promising measures, but discordance was observed between the short screener and psychological distress symptom checklist. This formative study suggests the potential of EASE in targeting psychological distress among displaced young adolescents and lays the groundwork for a future definitive trial.

The effect of dancing interventions on depression symptoms, anxiety, and stress in adults without musculoskeletal disorders: An integrative review and meta-analysis

OBJECTIVE

To examine the effect of dancing interventions on depression symptoms, anxiety, and stress in adults with and without musculoskeletal disorders, and to determine the duration of the effectiveness of a dancing intervention.

METHODS

Five electronic databases, CINAHL, MEDLINE, SPORTDiscus, Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO were searched from January 2010 to March 2021. Data were extracted for a quality synthesis and meta-analysis, and GRADEpro software was used to rate the quality of evidence.

RESULTS

Twenty-eight randomized controlled trials involving 2249 eligible subjects were selected. They were found to be of satisfactory quality (fair n = 12, good n = 16). These studies revealed that dance interventions had a significant effect on relieving depression symptoms (SMD = -0.69, 95 % CI -0.91 to -0.35, p < 0.001), anxiety (SMD = -0.99, 95 % CI = -1.92 to -0.05, p < 0.05), and stress (SMD = -1.0, 95 % CI = -1.83 to -0.17, p < 0.05). Exposure to a dancing intervention for at least 150 min per week was found to have reduced depression symptoms (SMD = -0.72, 95 % CI -0.20, -0.25, p < 0.01). The quality of evidence ranged from very low to low.

CONCLUSIONS

This review indicates that dancing interventions significantly reduce depression symptoms, stress, and anxiety; and adults with or without musculoskeletal disorders would benefit from engaging in a dancing intervention for at least 150 min per week. Dancing interventions are recommended to be incorporated in health promotion activities to promote psychological wellbeing.

A bioecocultural approach to supporting adolescent mothers and their young children in conflict-affected contexts

An estimated 12 million girls aged 15-19 years, and 777,000 girls younger than 15 give birth globally each year. Contexts of war and displacement increase the likelihood of early marriage and childbearing. Given the developmentally sensitive periods of early childhood and adolescence, adolescent motherhood in conflict-affected contexts may put a family at risk intergenerationally. We propose that the specifics of normative neuroendocrine development during adolescence, including increased sensitivity to stress, pose additional risks to adolescent girls and their young children in the face of war and displacement, with potential lifelong consequences for health and development. This paper proposes a developmental, dual-generational framework for research and policies to better understand and address the needs of adolescent mothers and their small children. We draw from the literature on developmental stress physiology, adolescent parenthood in contexts of war and displacement internationally, and developmental cultural neurobiology. We also identify culturally meaningful sources of resilience and provide a review of the existing literature on interventions supporting adolescent mothers and their offspring. We aim to honor Edward Zigler's groundbreaking life and career by integrating basic developmental science with applied intervention and policy.

Nursing Interventions in Children Living Under Armed Conflict Situations and Quality of Life: A Scoping Review

PROBLEM

Today, one in four children in the world lives in an area of conflict or disaster, and more than 30 million have been displaced, enslaved or trafficked, abused, and exploited. However, there is little recognition of nursing interventions in this context and their impact on the quality of life.

ELIGIBILITY CRITERIA

Studies that (1) Described nursing interventions in children under situations of armed conflict. (2) Identified the impact of the interventions in the Quality of Life. (3) identify research trends in the field by nursing professionals. (4) Summarized concepts associated and nursing interventions proposed in armed conflict to address this problem.

SAMPLE

From June to November 2019, electronic databases such as Embase, MEDLINE, LILACS, BIREME library, CINAHL, and ProQuest were accessed. Eleven papers were included in the review.

RESULTS

The studies described the positive effects of nursing interventions on mental health and mortality. No studies were found reporting the impact of the interventions on quality of life. The topics of significant research in nursing focus on mental health. Care practices based on leadership, health management, advocacy, and intermediation in public policies should be a matter of interest for nurses.

CONCLUSIONS

Future research is required to generate a comprehensive and accurate understanding of the nursing interventions in children under armed conflict situations.

IMPLICATIONS

Recognizing the applied interventions and proposing a frame of reference justifies present and future research to children's attention under armed conflict situations.

Tutor of Resilience: A Model for Psychosocial Care Following Experiences of Adversity

This article describes a model for training service providers to provide interventions that build resilience among individuals who have experienced adversity. The Tutor of Resilience model emphasizes two distinct dimensions to training: (1) transforming service providers' perceptions of intervention beneficiaries by highlighting their strengths and capacity for healing; and (2) flexibly building contextually and culturally specific interventions through a five-phase model of program development and implementation. Tutor of Resilience has been employed successfully with child and youth populations under stress in humanitarian settings where mental health and psychosocial support professionals are required to design and deliver interventions that enhance resilience among vulnerable children.

Process evaluation of TeamUp: a movement-based psychosocial intervention for refugee children in the Netherlands

BACKGROUND

Nearly 60,000 people applied for asylum in the Netherland in 2015, confronting the governmental structures and services with great administrative, logistical and service provision challenges. Refugee children's psychosocial needs and wellbeing are often overlooked, and post-migration support is of pivotal importance.

METHODS

An easy accessible movement-based psychosocial intervention, called TeamUp, was developed for children aged 6-17 living in refugee reception centres. A mixed-method process evaluation was conducted of (1) implementation process, assessing attendance (n = 2183 children, and n = 209 children); (2) implementation quality, using structured observations at two time points to evaluate facilitator's (2a) individual-level fidelity (n = 81 facilitators); (2b) team-level fidelity (n = 22 teams); (2c) facilitators' competencies (n = 81); (2d) trainee perceived self-efficacy pre-post training (n = 73); and (3) perceptions on implementation and outcomes, employing a survey (n = 99), focus group discussions and key informant interviews with children (n = 94), facilitators (n = 24) and reception centre staff (n = 10).

RESULTS

Attendance lists showed a mean of 8.5 children per session, and children attending 31.3% of sessions. Structured observations demonstrated 49.2% and 58.2% individual-level fidelity, 72.5% and 73.0% team-level fidelity, and 82.9% and 88.4% adequacy in competencies, each at T1 and T2 respectively. The main reported challenges included managing children's energy regulation (e.g. offering settling moments) and challenging behaviour. Training participation significantly improved perceived self-efficacy for trainees. The facilitator survey demonstrated on average, high satisfaction and self-efficacy, low experienced burden, and high perceived capacity-building support. Qualitatively, TeamUp was positively perceived by all stakeholders and was regarded as contributing to children's psychosocial outcomes.

CONCLUSION

(1) Attendance and group size were lower than expected. (2) The intervention's facilitator fidelity ranged from moderate to adequate-exhibiting a need for specific fidelity and capacity strengthening-while facilitator competencies were high. Trainee's perceived self-efficacy improved significantly following a 2-day training. (3) Facilitators expressed high levels of satisfaction, self-efficacy and support, and low burden. The intervention was positively perceived by all stakeholders and to have a positive impact on children's psychosocial learning and wellbeing.

A Critical Review of Effective Child Mass Trauma Interventions: What We Know and Do Not Know from the Evidence

Over the last 20 years, numerous interventions have been developed and evaluated for use with children exposed to mass trauma with six publications reporting meta-analyses of randomized controlled trials of child mass trauma interventions using inactive controls to examine intervention effects on posttraumatic stress, depression, anxiety, and functional impairment. The current report reviews the results of these meta-analytic studies to examine the status of the evidence for child mass trauma mental health interventions and to evaluate potential moderators of intervention effect and implications for practice. The meta-analyses reviewed for the current report revealed a small to medium overall effect of interventions on posttraumatic stress, a non-statistically significant to small overall effect on depression, a non-statistically significant overall effect on anxiety, and a small overall effect on functional impairment. The subgroup analyses suggest that interventions should be matched to the populations being served and to the context. Additional research is needed to tailor future interventions to further address outcomes other than posttraumatic stress including depression, anxiety, and functional impairment.

A call for greater conceptual clarity in the field of mental health and psychosocial support in humanitarian settings

AIMS

When the Interagency Standing Committee (IASC) adopted the composite term mental health and psychosocial support (MHPSS) and published its guidelines for MHPSS in emergency settings in 2007, it aimed to build consensus and strengthen coordination among relevant humanitarian actors. The term MHPSS offered an inclusive tent by welcoming the different terminologies, explanatory models and intervention methods of diverse actors across several humanitarian sectors (e.g., health, protection, education, nutrition). Since its introduction, the term has become well-established within the global humanitarian system. However, it has also been critiqued for papering over substantive differences in the intervention priorities and conceptual frameworks that inform the wide range of interventions described as MHPSS. Our aims are to clarify those conceptual frameworks, to argue for their essential complementarity and to illustrate the perils of failing to adequately consider the causal models and theories of change that underlie our interventions.

METHODS

We describe the historical backdrop against which the term MHPSS and the IASC guidelines were developed, as well as their impact on improving relations and coordination among different aid sectors. We consider the conceptual fuzziness in the field of MHPSS and the lack of clear articulation of the different conceptual frameworks that guide interventions. We describe the explanatory models and intervention approaches of two primary frameworks within MHPSS, which we label clinical and social-environmental. Using the examples of intimate partner violence and compromised parenting in humanitarian settings, we illustrate the complementarity of these two frameworks, as well as the challenges that can arise when either framework is inappropriately applied.

RESULTS

Clinical interventions prioritise the role of intrapersonal variables, biological and/or psychological, as mediators of change in the treatment of distress. Social-environmental interventions emphasise the role of social determinants of distress and target factors in the social and material environments in order to lower distress and increase resilience in the face of adversity. Both approaches play a critical role in humanitarian settings; however, the rationale for adopting one or the other approach is commonly insufficiently articulated and should be based on a thorough assessment of causal processes at multiple levels of the social ecology.

CONCLUSIONS

Greater attention to the 'why' of our intervention choices and more explicit articulation of the causal models and theories of change that underlie those decisions (i.e., the 'how'), may strengthen intervention effects and minimise the risk of applying the inappropriate framework and actions to a particular problem.

Effectiveness of the Super Skills for Life programme in enhancing the emotional wellbeing of children and adolescents in residential care institutions in a low- and middle-income country: A randomised waitlist-controlled trial

BACKGROUND

The present study examined the effectiveness of a transdiagnostic prevention programme, Super Skills for Life (SSL), among children and adolescents with emotional problems in residential care institutions (RCIs) in the low- and middle-income country of Mauritius using a randomised waitlist-controlled trial (RCT). SSL is based on the principles of cognitive behavioural therapy, behavioural activation, social skills training, and uses video-feedback and cognitive preparation as part of the treatment.

METHODS

The RCT involved 100 children and adolescents aged 9 to 14 years, from six RCIs, randomly allocated to either an SSL intervention group (IG) or a waitlist-control (WLC) group. A set of questionnaires measuring internalising and externalising problems, emotion regulation and self-esteem, and experimental tasks measuring attentional bias and inhibitory control, were completed at baseline, post-intervention and 3-month follow-up. Participants also completed a 2-min video speech task during the first and final sessions of the SSL intervention.

RESULTS

Children and adolescents in the IG showed significant improvements in internalising symptoms (e.g. anxiety and depression), externalising symptoms (e.g. conduct problems and hyperactivity), and inhibitory control, and an increase in adaptive (except putting into perspective strategy) and decrease in maladaptive emotion regulation strategies, at both post-intervention and follow-up. These findings were not replicated among children in the WLC.

LIMITATIONS

The small sample size and lack of an active control group were the major limitations of this study.

CONCLUSIONS

This study provides evidence for the effectiveness of a transdiagnostic prevention programme for emotional problems in RCIs in a low- and middle-income country.

Assessment of service provider competency for child and adolescent psychological treatments and psychosocial services in global mental health: evaluation of feasibility and reliability of the WeACT tool in Gaza, Palestine

BACKGROUND

There is a scarcity of evaluated tools to assess whether non-specialist providers achieve minimum levels of competency to effectively and safely deliver psychological interventions in low- and middle-income countries. The objective of this study was to evaluate the reliability and utility of the newly developed Working with children - Assessment of Competencies Tool (WeACT) to assess service providers' competencies in Gaza, Palestine.

METHODS

The study evaluated; (1) psychometric properties of the WeACT based on observed role-plays by trainers/supervisors (N = 8); (2) sensitivity to change among service provider competencies (N = 25) using pre-and-post training WeACT scores on standardized role-plays; (3) in-service competencies among experienced service providers (N = 64) using standardized role-plays.

RESULTS

We demonstrated moderate interrater reliability [intraclass correlation coefficient, single measures, ICC = 0.68 (95% CI 0.48-0.86)] after practice, with high internal consistency (α = 0.94). WeACT assessments provided clinically relevant information on achieved levels of competencies (55% of the competencies were scored as adequate pre-training; 71% post-training; 62% in-service). Pre-post training assessment saw significant improvement in competencies (W = -3.64; p < 0.001).

CONCLUSION

This study demonstrated positive results on the reliability and utility of the WeACT, with sufficient inter-rater agreement, excellent internal consistency, sensitivity to assess change, and providing insight needs for remedial training. The WeACT holds promise as a tool for monitoring quality of care when implementing evidence-based care at scale.

Resiliency process and socialization among Palestinian children exposed to traumatic experience: Grounded theory approach

PURPOSE

The conflict in Palestine is known to be one of the longest ongoing conflicts in the world affecting children with harmful psychological consequences. The purpose of this study was to explore the process of resilience among Palestinian children exposed to psychological trauma due to detention experiences.

METHOD

A qualitative approach utilizing grounded theory design was used. Data collected by a semi-structured interview format from 18 Palestinian children aged 12-18 years were exposed to detention.

RESULTS

The study revealed four main categories with focus and initial coding subcategories. Major categories were: revering and honoring the prisoners, normalizing the abnormal situations (positive adaptation), awareness and political socialization during childhood, and developing identity and belonging to the homeland. The results indicated that Palestinian children exposed to political detention had their own positive perception of the trauma and had a high level of posttraumatic maturation.

PRACTICE IMPLICATION

The study concluded that early childhood political awareness, family and community support, sociocultural perception of prisoner children, and sense of belonging improved the ability of detained children to normalize abnormal situations and successfully cope with psychological trauma. So, the study has significant implications for nursing practice in the field of childhood trauma and intervention, it can help nurses working with traumatized children to assess and intervene according to the child's perception about the trauma and ability to cope.

Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries

BACKGROUND

Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming.

OBJECTIVES

The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs).

METHODS

Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017).

RESULTS

We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups.

CONCLUSION

Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.

Disseminating evidence-based research on mental health and coping to adolescents facing adversity in Lebanon: a pilot of a psychoeducational comic book 'Somoud'

Background

Despite advances in the evidence base and scaling up of mental health and psychosocial interventions for children and adolescents affected by conflict and adversity, a theory-practice gap remains, with limited translation of research findings to affected communities.

Methods

In order to disseminate findings from a review on mental health and coping for children and adolescents, a psychoeducational comic book ‘Somoud’ was developed and piloted with adolescents and their caregivers in Lebanon, using a qualitative Grounded Theory approach.

Results

In total, 10 participants (5 adolescents, 5 parents), took part in the study. Using Thematic Content Analysis, 6 themes were identified; 1) psychoeducation versus misinterpretation, 2) balancing depth with accessibility, 3) aesthetic appeal, 4) contextual relevance and realism, 5) daily stressors, and 6) parental and social relationships.

Conclusions

The findings demonstrate the importance of cultural and contextual piloting of psychoeducational content, and the potential usefulness and accessibility of a comic book format to disseminate information to adolescents. Data from the pilot was used to inform the development of a new version of ‘Somoud’ for sharing with adolescents in Lebanon. Further research is required to establish the effectiveness of the psychoeducational book as a ‘self-help’ tool, and to further improve knowledge exchange between researchers and communities.

The modules of mental health programs implemented in schools in low- and middle-income countries: findings from a systematic literature review

BACKGROUND

Secondary schools in low- and middle-income countries (LMICs) provide health promotion, preventive, and early intervention services. Nevertheless, literature indicates that the modules of these services are either adapted or modified from existing mental health programs in developed countries. The literature also highlights the provision of non-comprehensive services (mental health promotion, prevention, and early intervention), in LMICs. These findings inform the need for undertaking this systematic literature review. The aim of this review was thus to identify the modules of school-based mental health programs (SBMHP) that have been implemented in LMICs to guide the development of a culturally sensitive comprehensive mental health program for adolescents in a LMIC country.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was used to guide this review. The following databases were searched in September 2018, to identify the relevant literature: PubMed, CINAHL, Scopus, Web of Science, PsycINFO, and ERIC. The search was conducted by the first author and reviewed by the authors.

RESULTS

Following the screening process, a total of 11 papers were identified and reviewed for quality. The systematic review highlighted that the mental health programs provided in schools included: an introduction module, a communication and relationship module, a psychoeducation module, a cognitive skills module, a behavioral skills module, establishing social networks for recovery and help seeking behavioral activities and a summary/conclusion module.

CONCLUSION

This review sheds light on the characteristics of the programs in LMICs. Two programs were found to be universal in nature. Five programs were directed at key risk factors or at-risk groups, and four were early intervention programs. The review also revealed that only one program out of the 11 programs included modules for parents. The synthesis indicated that all the identified programs were adapted or modified from existing programs. The dearth of comprehensive programs in LMICs was also revealed. Lastly, the review revealed seven modules that can be useful for developing a SBMHP.

Social-Ecological Resilience Moderates the Effectiveness of Avoidant Coping in Children Exposed to Adversity: An Exploratory Study in Lithuania

Background

Against the high prevalence of adverse childhood experiences in Lithuania, the government testified a lack of effective ways to address the problem. A crucial endeavor for intervention planners is to identify the risk and protective factors whose interaction may lead at risk children to achieve greater levels of functioning. Internal qualities and external resources can act independently or interactively to reduce the damaging effects of adversities, and to enhance resilience process. In particular, both coping strategies and social resources have been shown to have a consistent influence on trauma-related outcomes.

Objective

The aim of this study was to investigate the potential interaction of coping strategies with external resources in predicting trauma-related outcomes in children exposed to adversities.

Participants and Setting

A sample of 372 Lithuanian children (mean age = 13.03; range: 7-17) with a history of traumatic experiences has been involved.

Methods

The Child and Youth Resilience Measure-Revised (CYRM-R), the Children Coping Strategy Checklist (CCSC), and the Trauma Symptom Checklist for Children (TSCC) have been administered to participants. A moderation analysis was performed to test whether social-ecological resilience moderate the relationship between each coping strategy and trauma-related outcomes. Results: When controlling for sex, age, other coping strategies, and social-ecological resilience, only active coping was found to significantly predict each of the trauma-related symptoms. Furthermore, social-ecological resilience has a negatively moderating effect on the relationship between avoidant coping strategies and depression.

Conclusion

MHPSS professionals who design and implement interventions to enhance the likelihood of resilience among vulnerable children, should take in considerations the multiple interaction between social-ecological resilience and avoidant coping strategies in the children adjustment.

Refugee and Migrant Children’s Mental Healthcare: Serving the Voiceless, Invisible, and the Vulnerable Global Citizens

Millions of children are on the run worldwide, with many unaccompanied children and adolescents undertaking risky journeys to flee war, adverse circumstances, and political persecution. The grueling journey and multiple stressors faced by the refugee children, both accompanied and unaccompanied during the pre-migration, migration, and in the country of destination, increase their risk for psychiatric disorders and other medical conditions. Unaccompanied refugee migrant children have higher prevalence of mental health disorders than accompanied refugee peers. Long after reaching the host country, the refugee, migrant, and asylum-seeking juveniles continue to face adversities in the form of acculturation. In assessing medical fitness and healthcare mediations for refugees and migrant children, special consideration should be given to certain areas such as their distinct history, whether they are with their family or separated or unaccompanied, and whether they have been peddled or have been left behind.

Supporting Syrian families displaced by armed conflict: A pilot randomized controlled trial of the Caregiver Support Intervention

BACKGROUND

The impact of armed conflict and displacement on children's mental health is strongly mediated by compromised parenting stemming from persistently high caregiver stress. Parenting interventions for refugees emphasize the acquisition of parenting knowledge and skills, while overlooking the deleterious effects of chronic stress on parenting. War Child Holland's Caregiver Support Intervention (CSI) aims to strengthen parenting by lowering stress and improving psychosocial wellbeing among refugee parents, while also increasing knowledge and skill related to positive parenting. The CSI is a nine-session group intervention delivered by non-specialist providers.

OBJECTIVE

We describe the findings of a two-arm pilot randomized controlled trial of the CSI with Syrian refugees in Lebanon. The primary aim was to test the feasibility of our study methodology prior to conducting a definitive RCT.

METHODS

We recruited 78 families (151 parents), who were randomized to the CSI or a waitlist control group. Data were collected at baseline and post-intervention.

RESULTS

Randomization was successful, retention was high (99 %), as was intervention completion (95 % among women, 86 % among men). Implementation fidelity was excellent. Blinding was largely, though not completely effective. The CSI group showed significantly increased parental warmth and responsiveness, decreased harsh parenting, lowered stress and distress, improved psychosocial wellbeing, and improved stress management. CSI parents reported increased child psychosocial wellbeing. Control families showed no significant change on any variable.

CONCLUSIONS

Findings demonstrate the feasibility of our methodology for a definitive RCT, and suggest that the CSI shows promise as a scalable approach to strengthening parenting in refugee communities. Trial registration # ISRCTN33665023.