The impact of structured activities among Palestinian children in a time of conflict

Growing Up on the Edge: A Community-Based Mental Health Intervention for Children in Gaza

The Gaza Strip is a notoriously high-conflict area, but few large-scale studies have examined the rates of psychiatric distress and emotional/behavioral problems among Gaza youth, and there are few trauma-informed, scaleable intervention options. Studies in existence have used smaller samples or have examined focal problems such as posttraumatic stress disorder (PTSD) or aggression. Here, we examine the mental health burden of young individuals (ages 8-13) in Gaza across a broad range of symptoms, and demonstrate the impact of a community-based, trauma-informed program, Eye to the Future. At the outset of this supportive youth program, over 2000 children and adolescent youth and their parents reported on child well-being using standardized measures with established global norms (the Child Behavior Checklist and Youth Self Report). These measures examine symptoms broadly (e.g. anxiety, depression, social problems, attention problems, aggression, etc.). Relative to U.S. population estimates, children in Gaza had between 2.5- and 17-times higher point prevalence of clinical mental health problems. The most significant clinical concern was anxiety, but overall, their symptoms were not confined to posttraumatic stress as a disorder and were instead broadly dispersed. However, these concerns were responsive to intervention: over the course of a six-month community psychosocial program, symptoms ameliorated, with approximately 50-70% showing reliable improvement at post-program (varying by measure). These gains were maintained in a 9-month follow-up. Future work should consider the broader mental health impact, beyond PTSD and aggression, and incorporate community supports into addressing mental health among children in the region.

Resilience processes among Ukrainian youth preparing to build resilience with peers during the Ukraine-Russia war

The war in Ukraine significantly impacts the mental health and well-being of its youth. Like other communities affected by war, Ukraine's youth are at risk of developing psychopathological symptoms, and there is a shortage of mental health and psychosocial support services to address this. Resilience-building initiatives present an alternative approach to supporting the well-being of young people by promoting protective processes to enhance the likelihood of positive development in the context of adversity. Emerging research findings suggest that young people themselves can serve as powerful facilitators of such initiatives with one another. Yet, evidence about culturally and contextually relevant protective processes is needed to guide such interventions, especially among young people experiencing the war and working to boost resilience within their communities. In this study, we identified key protective processes Ukrainian youth depend on as they adapt to the conflict while also preparing to implement a resilience-building intervention as a facilitator. Through thematic analysis of transcripts of three training sessions with Ukrainian youth (n = 15, 100% female; aged 18-22), we identified the following themes: positive thinking, sense of control, emotion awareness and regulation, close personal relationships, and community support. Findings also highlighted the cultural and contextual nuance of these protective processes, as well as individual differences in the ways they co-occurred and manifested within each youth. Results have implications for developing tailored yet flexible resilience-building interventions that can be delivered by lay people, including youth with their peers, in Ukraine and other cultures and contexts.

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.

Community perspectives on the implementation of a group psychological intervention for adolescents with depression: A qualitative study in rural Nepal

Group-based psychological interventions could help to close the treatment gap for depression in low-resource settings, but implementation barriers exist. In Nepal we sought community members' perspectives on how to implement group interpersonal therapy for adolescents. We conducted qualitative interviews with 25 adolescents with depression (aged 13-18) and seven health and non-governmental organization workers, and four focus groups with non-depressed adolescents, four with parents/guardians, and two with teachers (126 participants total). Data were analyzed using the Framework Method. Participants recommended same-sex groups. School was the preferred location because it is accessible for adolescents and acceptable to parents. Adolescents wanted facilitators from their own community with good communication skills. They did not want parents or teachers to participate in groups but emphasized the need to inform parents and obtain their permission. Community members supported group psychological intervention. School-based psychological interventions facilitated by local people could be an acceptable option in rural Nepal.

Mental Health Prevention and Promotion-A Narrative Review

Extant literature has established the effectiveness of various mental health promotion and prevention strategies, including novel interventions. However, comprehensive literature encompassing all these aspects and challenges and opportunities in implementing such interventions in different settings is still lacking. Therefore, in the current review, we aimed to synthesize existing literature on various mental health promotion and prevention interventions and their effectiveness. Additionally, we intend to highlight various novel approaches to mental health care and their implications across different resource settings and provide future directions. The review highlights the (1) concept of preventive psychiatry, including various mental health promotions and prevention approaches, (2) current level of evidence of various mental health preventive interventions, including the novel interventions, and (3) challenges and opportunities in implementing concepts of preventive psychiatry and related interventions across the settings. Although preventive psychiatry is a well-known concept, it is a poorly utilized public health strategy to address the population's mental health needs. It has wide-ranging implications for the wellbeing of society and individuals, including those suffering from chronic medical problems. The researchers and policymakers are increasingly realizing the potential of preventive psychiatry; however, its implementation is poor in low-resource settings. Utilizing novel interventions, such as mobile-and-internet-based interventions and blended and stepped-care models of care can address the vast mental health need of the population. Additionally, it provides mental health services in a less-stigmatizing and easily accessible, and flexible manner. Furthermore, employing decision support systems/algorithms for patient management and personalized care and utilizing the digital platform for the non-specialists' training in mental health care are valuable additions to the existing mental health support system. However, more research concerning this is required worldwide, especially in the low-and-middle-income countries.

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS

PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

Effectiveness of a School-Based Intervention on the Students' Mental Health After Exposure to War-Related Trauma

BACKGROUND

After the war, which was conducted against Palestinian civilians in the Gaza Strip, the prevalence of posttraumatic stress disorder (PTSD) among children and adolescents has increased. The counselling department at the Ministry of Education in the Gaza Strip applied a counselling program in schools in order to alleviate the effect of exposure to war. The aim of the study is to investigate the effectiveness of the counselling program after exposure to war-traumatic events among Palestinian children and adolescents in the Gaza Strip.

METHODS

The sample consists of 572 students aged 12-18 years old. Of them, 331 (57.9%) were female and 241 (42.1%) were male. Traumatic events were measured by War-Traumatic Events Checklist (W-TECh). PTSD was measured by the Post-Traumatic Stress Disorders Symptoms Scale (PTSDSS). Anxiety symptoms were adapted from The Anxiety Symptoms Scale, and depression symptoms were measured by Child Depression Inventory. Repeated measures design was employed as the counselling program was applied in all the schools at the same time. Specifically, the data were collected from the participants before the application of the counselling program and 2 months later.

RESULTS

After applying the school-based counselling program, the prevalence of PTSD (according to DSM-V) decreased from 57.5% to 45.6% among the children and adolescents who were exposed to war-traumatic events. In addition, PTSD symptoms, and emotional, somatic and cognitive functional impairment symptoms has decreased after the implementation of the counselling program especially amongst girls.

CONCLUSIONS

The school-based counselling program was effective in decreasing the PTSD symptoms among children and adolescents after the exposure to war-traumatic events.

Delivering mental health and psychosocial support interventions to women and children in conflict settings: a systematic review

Background

Over 240 million children live in countries affected by conflict or fragility, and such settings are known to be linked to increased psychological distress and risk of mental disorders. While guidelines are in place, high-quality evidence to inform mental health and psychosocial support (MHPSS) interventions in conflict settings is lacking. This systematic review aimed to synthesise existing information on the delivery, coverage and effectiveness of MHPSS for conflict-affected women and children in low-income and middle-income countries (LMICs).

Methods

We searched Medline, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Psychological Information Database (PsycINFO)databases for indexed literature published from January 1990 to March 2018. Grey literature was searched on the websites of 10 major humanitarian organisations. Eligible publications reported on an MHPSS intervention delivered to conflict-affected women or children in LMICs. We extracted and synthesised information on intervention delivery characteristics, including delivery site and personnel involved, as well as delivery barriers and facilitators, and we tabulated reported intervention coverage and effectiveness data.

Results

The search yielded 37 854 unique records, of which 157 were included in the review. Most publications were situated in Sub-Saharan Africa (n=65) and Middle East and North Africa (n=36), and many reported on observational research studies (n=57) or were non-research reports (n=53). Almost half described MHPSS interventions targeted at children and adolescents (n=68). Psychosocial support was the most frequently reported intervention delivered, followed by training interventions and screening for referral or treatment. Only 19 publications reported on MHPSS intervention coverage or effectiveness.

Discussion

Despite the growing literature, more efforts are needed to further establish and better document MHPSS intervention research and practice in conflict settings. Multisectoral collaboration and better use of existing social support networks are encouraged to increase reach and sustainability of MHPSS interventions.

PROSPERO registration number

CRD42019125221.

Community-Based Mental Health Intervention Skills: Task Shifting in Low- and Middle-Income Settings

There is a global need to provide human resources for health in low- and middle-income countries. To increase access to care, task shifting has been implemented in community-based rehabilitation (CBR) programs where skills and responsibilities are transferred to local people with shorter and more focused training. Through realist review and synthesis, this research aimed to consolidate the literature when considering (a) what skills CBR workers are reportedly using and/or being trained in relating to mental health, (b) how different settings affect how these task shifting programs work, and (c) the evidence of effectiveness when community health workers come from within the community itself. A total of 11 databases (PubMed, ABI/Inform Global, CINAHL, Cochrane, Emerald, Google Scholar, PsycINFO, SAGE, Science Direct, Scopus, and Web of Science) were systematically searched for specific terms relating to mental health, CBR, and low- and middle-income country. A total of 27 publications were identified as fitting the criteria (4 qualitative, 20 quantitative including 10 randomized controlled trials, and 3 noninvestigatory editorials). Core skills have been identified along with themes that affect how programs work in particular contexts. The use of task shifting in this area may be a potentially viable option for increasing access to mental health care. This resulted in the development of a theory to explain the outcomes being observed. When Task-shifting mental health intervention skills collaboration, harnessing resources available within the community, and the provision of ongoing supervision interact to influence awareness gains, social bonding, the building of trust, and the development of skills and understanding within the community itself. This effects intervention buy-in, overall effectiveness and sustainability, mental health symptoms and local empowerment. These findings can be considered when developing training programs for CBR mental health workers, as well as policy and intervention program design.

Child mental health in Jordanian orphanages: effect of placement change on behavior and caregiving

BACKGROUND

To assess the mental health and behavioral problems of children in institutional placements in Jordan to inform understanding of current needs, and to explore the effects of placement change on functioning and staff perceptions of goodness-of-fit.

METHODS

An assessment was completed of 134 children between 1.5-12 years-of-age residing in Jordanian orphanages. The Child Behavior Checklist was used to assess prevalence rates of problems across externalizing and internalizing behavior and DSM-IV oriented subscales. Also included was caregiver perceived goodness-of-fit with each child, caregiving behavior, and two placement change-clock variables; an adjustment clock measuring time since last move, and an anticipation clock measuring time to next move.

RESULTS

28% were in the clinical range for the internalizing domain on the CBCL, and 22% for the externalizing domain. The children also exhibited high levels of clinical range social problems, affective disorder, pervasive developmental disorder, and conduct problems. Internalizing problems were found to decrease with time in placement as children adjust to a prior move, whereas externalizing problems increased as the time to their next age-triggered move drew closer, highlighting the anticipatory effects of change. Both behavioral problems and the change clocks were predictive of staff perceptions of goodness-of-fit with the children under their care.

CONCLUSIONS

These findings add to the evidence demonstrating the negative effects of orphanage rearing, and highlight the importance of the association between behavioral problems and child-caregiver relationship pathways including the timing of placement disruptions and staff perceptions of goodness-of-fit.

Mental health services for children exposed to armed conflict: Médecins Sans Frontières' experience in the Democratic Republic of Congo, Iraq and the occupied Palestinian territory

BACKGROUND

Armed conflict has broad-ranging impacts on the mental health and wellbeing of children and adolescents. Mental health needs greatly exceed service provision in conflict settings, particularly for these age groups. The provision and targeting of appropriate services requires better understanding of the characteristics and requirements of children and adolescents exposed to armed conflict.

METHODS

Routine patient and programme monitoring data were analysed for patients <20 years of age attending mental health services provided by Médecins Sans Frontières (MSF) in three countries affected by armed conflict: the Democratic Republic of Congo (DRC), Iraq and the occupied Palestinian territory (oPt). The demographic characteristics, presenting mental health complaint, attributed precipitating event, services provided and short-term outcomes for mental health services users in each country are described.

RESULTS

Between 2009 and 2012, 3025 individuals <20 years of age presented for care in DRC and Iraq, and in 2012 in oPt, constituting 14%, 17.5% and 51%, respectively, of all presentations to MSF mental health services in those three countries. The most common precipitating event was sexual violence in DRC (36.5%), domestic violence in Iraq (17.8%) and incarceration or detention in oPt (33%). Armed conflict-related precipitants were reported by 25.9%, 55.0% and 76.4% of youths in DRC, Iraq and oPt, respectively. The most common presenting complaints in children and adolescents were anxiety-related, followed by mood-related, behaviour-related and somatisation problems; these varied according to country and precipitating event. Although a high proportion (45.7%) left programmes early, 97% of those who completed care self-reported improvement in their presenting complaint.

CONCLUSIONS

Brief trauma-focused therapy, the current MSF mental health therapeutic intervention, appears to be effective in reducing symptoms arising from the experience of trauma. Although inferences on outcomes are limited by high default rates, this provides a feasible tool for addressing the mental health needs of children exposed to armed conflict. Priorities for future research include understanding why children and adolescents constitute a small proportion of patients in some programmes, why many leave care early and how to address these issues, but this research must occur within the context of efforts to provide access to mental health services for children.

Extracurricular interest as a resilience building block for children affected by parental HIV/AIDS

Parental illness and death due to human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) impose challenges to children's psychological adjustment. Positive psychology emphasizes individual's resilience in the face of adversity, trauma, and tragedy. Limited data are available regarding the factors that can cultivate resilience of children affected by HIV/AIDS. This study aims to examine the role of extracurricular interest in strengthening resilience among children affected by HIV/AIDS. Participants included 755 children orphaned by parental HIV/AIDS, 466 vulnerable children living with HIV-positive parent(s), and 404 comparison children from HIV-free families in the same community in rural China. The measures include extracurricular interest (i.e., reading, sports, music, painting, science, and playing chess) and indicators of psychological adjustment (i.e., depression, loneliness, and self-esteem). Having extracurricular interest was positively associated with self-esteem and negatively associated with depression and loneliness. Having extracurricular interest attenuated the negative effect of parental HIV/AIDS on children's self-esteem and loneliness, after controlling for children's age, gender, and family socioeconomic status. The findings underscore the importance of nurturing extracurricular interest and make available of such activities to promote resilience for children affected by HIV/AIDS in resource-limited settings.

A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries

BACKGROUND

This systematic review provides a narrative synthesis of the evidence on the effectiveness of mental health promotion interventions for young people in low and middle-income countries (LMICs). Commissioned by the WHO, a review of the evidence for mental health promotion interventions across the lifespan from early years to adulthood was conducted. This paper reports on the findings for interventions promoting the positive mental health of young people (aged 6-18 years) in school and community-based settings.

METHODS

Searching a range of electronic databases, 22 studies employing RCTs (N = 11) and quasi-experimental designs conducted in LMICs since 2000 were identified. Fourteen studies of school-based interventions implemented in eight LMICs were reviewed; seven of which included interventions for children living in areas of armed conflict and six interventions of multicomponent lifeskills and resilience training. Eight studies evaluating out-of-school community interventions for adolescents were identified in five countries. Using the Effective Public Health Practice Project (EPHPP) criteria, two reviewers independently assessed the quality of the evidence.

RESULTS

The findings from the majority of the school-based interventions are strong. Structured universal interventions for children living in conflict areas indicate generally significant positive effects on students' emotional and behavioural wellbeing, including improved self-esteem and coping skills. However, mixed results were also reported, including differential effects for gender and age groups, and two studies reported nonsignficant findings. The majority of the school-based lifeskills and resilience programmes received a moderate quality rating, with findings indicating positive effects on students' self-esteem, motivation and self-efficacy. The quality of evidence from the community-based interventions for adolescents was moderate to strong with promising findings concerning the potential of multicomponent interventions to impact on youth mental health and social wellbeing.

CONCLUSIONS

The review findings indicate that interventions promoting the mental health of young people can be implemented effectively in LMIC school and community settings with moderate to strong evidence of their impact on both positive and negative mental health outcomes. There is a paucity of evidence relating to interventions for younger children in LMIC primary schools. Evidence for the scaling up and sustainability of mental health promotion interventions in LMICs needs to be strengthened.

Interventions for children affected by war: an ecological perspective on psychosocial support and mental health care

BACKGROUND

Children and adolescents exposed to armed conflict are at high risk of developing mental health problems. To date, a range of psychosocial approaches and clinical/psychiatric interventions has been used to address mental health needs in these groups.

AIMS

To provide an overview of peer-reviewed psychosocial and mental health interventions designed to address mental health needs of conflict-affected children, and to highlight areas in which policy and research need strengthening.

METHODS

We used standard review methodology to identify interventions aimed at improving or treating mental health problems in conflict-affected youth. An ecological lens was used to organize studies according to the individual, family, peer/school, and community factors targeted by each intervention. Interventions were also evaluated for their orientation toward prevention, treatment, or maintenance, and for the strength of the scientific evidence of reported effects.

RESULTS

Of 2305 studies returned from online searches of the literature and 21 sources identified through bibliography mining, 58 qualified for full review, with 40 peer-reviewed studies included in the final narrative synthesis. Overall, the peer-reviewed literature focused largely on school-based interventions. Very few family and community-based interventions have been empirically evaluated. Only two studies assessed multilevel or stepped-care packages.

CONCLUSIONS

The evidence base on effective and efficacious interventions for conflict-affected youth requires strengthening. Postconflict development agendas must be retooled to target the vulnerabilities characterizing conflict-affected youth, and these approaches must be collaborative across bodies responsible for the care of youth and families.

Mental health and psychosocial support in humanitarian settings: linking practice and research

This review links practice, funding, and evidence for interventions for mental health and psychosocial wellbeing in humanitarian settings. We studied practice by reviewing reports of mental health and psychosocial support activities (2007-10); funding by analysis of the financial tracking service and the creditor reporting system (2007-09); and interventions by systematic review and meta-analysis. In 160 reports, the five most commonly reported activities were basic counselling for individuals (39%); facilitation of community support of vulnerable individuals (23%); provision of child-friendly spaces (21%); support of community-initiated social support (21%); and basic counselling for groups and families (20%). Most interventions took place and were funded outside national mental health and protection systems. 32 controlled studies of interventions were identified, 13 of which were randomised controlled trials (RCTs) that met the criteria for meta-analysis. Two studies showed promising effects for strengthening community and family supports. Psychosocial wellbeing was not included as an outcome in the meta-analysis, because its definition varied across studies. In adults with symptoms of post-traumatic stress disorder (PTSD), meta-analysis of seven RCTs showed beneficial effects for several interventions (psychotherapy and psychosocial supports) compared with usual care or waiting list (standardised mean difference [SMD] -0·38, 95% CI -0·55 to -0·20). In children, meta-analysis of four RCTs failed to show an effect for symptoms of PTSD (-0·36, -0·83 to 0·10), but showed a beneficial effect of interventions (group psychotherapy, school-based support, and other psychosocial support) for internalising symptoms (six RCTs; SMD -0·24, -0·40 to -0·09). Overall, research and evidence focuses on interventions that are infrequently implemented, whereas the most commonly used interventions have had little rigorous scrutiny.

Integrating mental health services into humanitarian relief responses to social emergencies, disasters, and conflicts: a case study

Utilizing lessons learned from development and implementation of "Project Liberty" in New York City, created in response to the attacks of September 11, 2001, this paper explores the importance of integrating structured mental health services with community-based social service programs offered in large-scale humanitarian relief responses. Relevant international research studies illustrating similar integrated programs are also reviewed. The primary approach is community-based and resilience-enhancement focused, offering structure, stability, support, and community cohesion, with an added integrated screening component to identify persons with severe treatable mental health conditions. Because there is thus far little evidence that resilience-enhancing programs are effective for severe mental health conditions, a secondary program initiated in parallel would be staffed with more specialized providers offering services for those referred from the primary program. The key implication supports the establishment of more effective links between programs and professionals from different disciplines, who then can more effectively implement integrated program responses to large-scale disasters.

Sierra Leone's former child soldiers: a follow-up study of psychosocial adjustment and community reintegration

This is the first prospective study to investigate psychosocial adjustment in male and female former child soldiers (ages 10-18; n = 156, 12% female). The study began in Sierra Leone in 2002 and was designed to examine both risk and protective factors in psychosocial adjustment. Over the 2-year period of follow-up, youth who had wounded or killed others during the war demonstrated increases in hostility. Youth who survived rape not only had higher levels of anxiety and hostility but also demonstrated greater confidence and prosocial attitudes at follow-up. Of the potential protective resources examined, improved community acceptance was associated with reduced depression at follow-up and improved confidence and prosocial attitudes regardless of levels of violence exposure. Retention in school was also associated with greater prosocial attitudes.

Effectiveness and specificity of a classroom-based group intervention in children and adolescents exposed to war in Lebanon

The purpose of this study was to examine the effectiveness and specificity of a classroom-based psychosocial intervention after war. All students (n=2500) of six villages in Southern Lebanon designated as most heavily exposed to war received a classroom-based intervention delivered by teachers, consisting of cognitive-behavioural and stress inoculation training strategies. A random sample of treated students (n=101) and a matched control group (n=93) were assessed one month post-war and one year later. Mental disorders and psychosocial stressors were assessed using the Diagnostic Interview for Children and Adolescents - Revised with children and parents. War exposure was measured using the War Events Questionnaire. The prevalence of major depressive disorder (MDD), separation anxiety disorder (SAD) and post-traumatic stress disorder (PTSD) was examined pre-war, one month post-war (pre-intervention), and one year post-war. Specificity of treatment was determined by rating teachers' therapy diaries. The rates of disorders peaked one month post-war and decreased over one year. There was no significant effect of the intervention on the rates of MDD, SAD or PTSD. Post-war MDD, SAD and PTSD were associated with pre-war SAD and PTSD, family violence parameters, financial problems and witnessing war events. These findings have significant policy and public health implications, given current practices of delivering universal interventions immediately post-war.