Interventions for Children Affected by War: An Ecological

REVIEW

Interventions for Children Affected by War: AnEcological Perspective on Psychosocial Support andMental Health Care

From thPublicand HuOhki);Charroof MenTol); H

Originato revis2012.

CorresHealthAve., B

©2013

DOI: 1

70

Theresa S. Betancourt, ScD, MA, Sarah E. Meyers-Ohki, BA, Alexandra P. Charrow, BA,and Wietse A. Tol, PhD

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 mentalhealth needs in these groups.Aims: To provide an overview of peer-reviewed psychosocial and mental health interventions designed to addressmental health needs of conflict-affected children, and to highlight areas in which policy and research needstrengthening.Methods: We used standard review methodology to identify interventions aimed at improving or treating mentalhealth problems in conflict-affected youth. An ecological lens was used to organize studies according to the individ-ual, family, peer/school, and community factors targeted by each intervention. Interventions were also evaluated fortheir orientation toward prevention, treatment, or maintenance, and for the strength of the scientific evidence ofreported effects.Results: Of 2305 studies returned from online searches of the literature and 21 sources identified through bibliographymining, 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 inter-ventions 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 strengthen-ing. Postconflict development agendas must be retooled to target the vulnerabilities characterizing conflict-affectedyouth, and these approaches must be collaborative across bodies responsible for the care of youth and families.

Keywords: ecological, interventions, mental health, psychosocial, war-affected youth

INTRODUCTIONIn the midst of war, images of children and families caught inthe crossfire disturb and motivate action. However, as con-flicts subside and media attention turns to the latest breakingemergency, little attention is paid to the longer-term mental

e Department of Global Health and Population, Harvard School ofHealth (Dr. Betancourt); François-Xavier Bagnoud Center for Healthman Rights, Harvard University (Dr. Betancourt and Ms. Meyers-Perelman School of Medicine, University of Pennsylvania (Ms.w); Global Health Initiative, Yale University (Dr. Tol); Departmenttal Health, Johns Hopkins Bloomberg School of Public Health (Dr.ealthNet TPO, Amsterdam, the Netherlands (Dr. Tol).

l manuscript received 3 July 2012, accepted for publication subjection 24 September 2012; revised manuscript received 19 November

pondence: Theresa S. Betancourt, ScD, MA, Department of Globaland Population, Harvard School of Public Health, 651 Huntingtonoston, MA 02115. Email: Theresa_ [email protected]

President and Fellows of Harvard College

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health and psychosocial sequelae plaguing conflict-affectedchildren and families. In general, mental health receives lim-ited attention from policymakers and funding agencies, andit is rare for countries under conflict to emerge with a post-conflict development agenda that includes robust attentionto mental health services.

Evidence-based intervention principles are vital to ade-quately address the needs of populations affected by disastersand mass violence.1,2 Experts have pinpointed the followingfive intervention principles as “essential elements” of imme-diate and midterm mass trauma interventions, which needto promote (1) a sense of safety, (2) calming, (3) a sense ofself-and-community efficacy, (4) connectedness, and (5) hope.Inadequate responsiveness to these issues is especiallyconcerning in view of the body of research documentingincreased risk of mental health problems in war-affectedchildren and families.1,3–8

An ecological framework is useful for considering howmultilevel interventions can improve long-term mental

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Interventions for War-Affected Children

health and psychosocial well-being. Often cited in thiscontext is the work of Uri Bronfenbrenner. Although helater revised the emphasis of his work, his most cited pub-lication9 emphasizes the importance of the environment inwhich children grow up, and conceptualizes environmentalinfluences at different nested levels—for example, the indi-vidual (ontogenic system), the meso-system, exo-system,and macro-system—depending, for instance, on the amountof direct interaction that a child has with these social sys-tems. Current applications of this theoretical frameworkwith children in adversity have focused on transactionstaking place between risk and protective factors at differentsocio-ecological levels—that is, the family, peer, school,and wider-community levels.10,11 When resources at anylevel are compromised, the risk of poor developmental out-comes and poor mental health adjustment increases; forexample, among children and youth exposed to conflict, ad-verse mental health outcomes triggered by exposure to hor-rific events are compounded by war-related damage to theextended support systems (family, social, economic, politi-cal) that usually foster healthy child development.3,10,12–17

When resources across the social ecology are more robust(e.g., family and community acceptance, access to school),children can achieve more positive outcomes, even inthe face of extreme hardship.18,19 It follows that layersof comprehensive supports, coupled with interventionsaimed at rebuilding or strengthening such resources, havethe potential to improve children’s capacity for resilienceand to mitigate the effects of conflict experiences.5,10,18–20

Despite consensus from the Inter-agency Standing Com-mittee Reference Group on Mental Health and Psychoso-cial Support in Emergency Settings1 on the importance of aprotective environment, this model of holistic interventionis often challenged. Debate continues in both the researchand programmatic communities about the prioritizationof clinical interventions—that is, psychotherapeutic andpharmacological treatments for people suffering from identi-fied mental disorders and associated impairment20—overpsychosocial programming—that is, preventive interven-tions and programming to strengthen protective factorsand bolster social contributors to well-being.21,22 Althoughguidelines commonly argue that the integration of theseparadigms can provide services better suited to a continuumof mental health adjustment, a false dichotomy between thetwo domains persists.20,23 In truth, combined interventionstrategies that attend to both prevention/mental health pro-motion and clinical approaches (targeting individuals withidentified mental disorders with evidence-based practices)have consensus support.5

In this article we review the peer-reviewed literatureon psychosocial and mental health interventions targeting

1The Inter-agency Standing Committee, http://www.humanitarianinfo.org/IASC/, was established by the United Nations in 1992 as “the primary mechanismfor inter-agency coordination of humanitarian assistance,” including between“key UN and non-UN humanitarian partners.”

Harvard Review of Psychiatry

Copyright @ 2013 President and Fellows of Harvard Colle

children and adolescents affected by conflict. To address ser-vice gaps resulting from the clinical-psychosocial dichot-omy, it is useful to examine the range of existinginterventions using an ecological lens. By organizing inter-ventions according to each ecological level’s focus, we cangain insight into the similarities and inconsistencies be-tween same-level programs, as well as into the complemen-tarity of interventions across levels. Where available, werefer to research or evaluation efforts that provide an evi-dence base for intervention effectiveness. Furthermore,we organize interventions according to their orientationtoward prevention (i.e., upstream intervention to addressrisk and protective factors prior to onset of problems),treatment, or maintenance (i.e., interventions to reduceeither distress and symptoms or the chance of relapse,respectively).24,25 By organizing the literature accordingto this framework, we offer a snapshot of current knowl-edge while highlighting existing gaps.

METHODSUsing Preferred Reporting Items for Systematic Reviews andMeta-analyses criteria (http://www.prisma-statement.org),we searched PubMed, PsycINFO, and EMBASE for allpeer-reviewed publications from 1990 to 2011 that pertainto mental health and psychosocial interventions for conflict-and war-affected children and adolescents. Returns werelimited to those that contained keywords within a matrixof relevant terminology identified in the study title or ab-stract. To this end, the following search terms were utilized:(child(ren) or youth(s) or adolescent(s)) and (war or conflict)and (intervention or program or therapy or treatment) and(mental health or psychosocial or depression or anxiety orposttraumatic stress). Sensitivity of searches was refined byusing keywords and the bibliographies of eligible studiesidentified in the early stages of the search. In addition, wecomplemented our searches with results from related reviews.

Articles subject to full review were those that adhered tothe following criteria: (1) the publication described a psy-chosocial or mental health intervention (preventive, treat-ment, or maintenance), (2) children or adolescents werespecified as primary recipients of the intervention, (3) men-tal health and psychosocial outcomes served as the primaryoutcomes of interest, and (4) the intervention was adminis-tered in a postconflict setting or a setting with protractedpolitical violence. Database queries returned a total of2305 unique studies. Three team members working inde-pendently screened each of the abstracts for relevance andexcluded those not meeting inclusion criteria (with 95%concordance between team members). Additional recordswere identified through bibliography mining. Full-text arti-cles were then assessed for eligibility, and a final sampleof 40 peer-reviewed studies was identified (see Figure 1).

Given large gaps in the peer-reviewed literature—oncommunity-based interventions, in particular—a selec-tion of reviews and reports was also included to provide

www.harvardreviewofpsychiatry.org 71

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http://www.humanitarianinfo.org/IASC/

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Betancourt et al.

background information on promising, but untested, inter-ventions of interest. Some programs were also found tohave multiple aims (e.g., prevention and treatment) andwere therefore listed in different sections of Table 1.

RESULTSOf the 1888 unique abstracts identified in the initial search,58 were agreed upon by team members as meriting full re-view. Of these, 5 were excluded for failing to meet thestudy criteria. The remaining studies are reviewed and sum-marized in Table 1.

Overall, we found diverse forms of psychosocial inter-vention for conflict-affected children, youth, and families,ranging from individualized narrative exposure therapy tobroad-based community-sensitization campaigns. Below,we discuss each intervention in further detail. A discussionof trends and gaps in the literature, along with recommen-dations for directions in future research, follows.

Figure 1. Systematic review following PRISMA standards.

72 www.harvardreviewofpsychiatry.org


Individual-Level Interventions: PreventionHUGGY-PUPPY INTERVENTION This review identified onlyone intervention in the peer-reviewed literature aimed atpreventing mental health symptoms in war-affected chil-dren. In Israel, researchers investigated the effects of thehuggy-puppy intervention among young children (ages 2–7)living in refugee camps during active conflict.26 In this briefintervention derived from theories on child developmentand psychopathological processes, children are presentedwith a stuffed puppy doll that is “far away from his homeand does not have any friends . . . He likes to be huggedbut has no one to take care of him.” Participating chil-dren who agree to befriend the puppy are taught how tohug the doll and encouraged to focus on being a responsiblecaretaker.

In randomized trials of the huggy-puppy interventionin Israel, pre/post-intervention parent-report assessmentsindicated that it had strong positive effects on symptoms oftraumatic stress reactions.26 Significant correlations between



Table1

Interven

tions

Organ

ized

According

toEcolog

ical

Levela

ndAim

Leve

lAim

sProgram

Referen

ces

Design

Sample

size

(boys/girls/to

tal)

Control

group

Reg

ion

Additional

commen

ts&

notesoncu

ltural

adap

tatio

n

Individual

Preve

ntio

nHugg

y-puppy

interven

tion

Sadeh

etal.(2008)26

RCT

106/85/191

Yes

Israel

Brief

interven

tionfor

youngch

ildren(age

s2–

7)liv

ingin

midstof

activ

eco

nflict

Intended

tofacilitate

activ

eco

pingwith

stress

&war

experience

s&

toprevento

nsetof

symptom

sMinim

altim

erequ

ired

onpartof

physicians/clinicians

Psych

ologica

lfirstaid

Aulagnier

etal.(20

04)27

Descriptiv

en/a

n/a

n/a

Modularap

proac

hto

strengthen

ingmen

tal

hea

lthin

immed

iate

afterm

athofdisaster

orco

nflict

Trea

tmen

tTrau

ma-focu

sed

CBT

Task

Forceon

Community

Preve

ntiv

eSe

rvices

(2008)28

Descriptiv

en/a

n/a

n/a

CBTtrau

ma-focu

sed

trea

tmen

tsarerare,

give

nlim

itedresources

forone-on-onetrea

tmen

t

Narrativ

eex

posure

therap

y

Neu

neretal.(20

08)29

Catan

ietal.(201

0)30

Pilo

t14/12/26

Yes

Rwan

dan

&So

malirefuge

esin

Uga

nda

Primarily

focu

sedon

traum

atic

stress

reactio

nsSh

ortn

umbe

rof

sessions

&de

liveryby

layp

ersons

reco

mmen

dedfor

sustaina

bility

Interven

tionco

mpo

nents

originally

develope

dfor

violen

ce-affected

popu

latio

nsin

Chile

Onyu

tet

al.(2005)31

Pilo

t3/3/6

No

Rwan

dan

&So

malirefuge

esin

Uga

nda

Testim

onial

psych

otherap

yLu

stig

etal.(2004)32

Descriptiv

e3boys

No

Sudan

ese

refuge

esin

Boston

Feasibility

ofinterven

tion

exploredwith

focu

sgroupspriorto

implemen

tatio

n;

feed

bac

kwas

inco

rporatedinto

interven

tionprotoco

l

Contin

ued

onnextpage


Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 73

Copyright @ 2013 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.

Table1

Con

tinue

d

Leve

lAim

sProgram

Referen

ces

Design

Sample

size

(boys/girls/to

tal)

Control

group

Reg

ion

Additional

commen

ts&

notesoncu

ltural

adap

tatio

n

Individual

Maintenan

ceNarrativ

eex

posure

therap

y

Neu

ner

etal.(2008)29

Pilo

t14/12/26

Yes

Rwan

dan&

Somalirefug

ees

inUgand

a

Inve

stigationsofprogram

’slong-term

effectiven

ess

show

enco

uragingresults

Onyu

tet

al.(2005)31

Pilo

t3/3/6

No

Rwan

dan&

Somalirefug

ees

inUgand

a

Family

Preventio

nChild

tracing

Hep

burn

(2006)33

Mac

hel

(2000)34

Descriptiv

en/a

n/a

n/a

Family

reunifica

tion&

child

trac

inghelpto

preve

ntvu

lnerab

ility

toriskssuch

ashunge

r,ex

ploita

tion,&

violence

Use

oftrad

itional

clea

nsingce

remonies&

strongintegrationwith

loca

lservices

contribute

tosucc

essful

reintegrationofyo

uth

Involvem

ento

flocalstaff

&commun

ityleaders

criticalinreintegrationefforts

Verhey

(2001)35

Verhey

(2002)36

Rep

ort

n/a

n/a

Ango

la&

ElSa

lvad

or

Williamson(2005)37

Descriptiv

en/a

n/a

Sierra

Leone

Trea

tmen

tDya

dpsych

osocial

support/

trea

tmen

t

Dyb

dah

l(2001)38

Pre/post

39/48/97

Yes

Bosnia

Interven

tionco

mponen

tswerederived

from

(1)

succ

essfultech

niques

usedpreviouslyin

this

populatio

n&

(2)

theo

ry-drive

ntrea

tmen

tsusedcross-cultu

rally

indiverse

settings

Multiple-fam

ilygroup

interven

tion

Weineet

al.(2005)39

Pre/post

30families

No

Kosovo

Leve

rage

dthetrad

itional

Kosova

rfamily

structure

tobuild

onstrengths

Strongloca

lco

llaboratio

ns

improve

dcu

ltural

acce

ptability/relev

ance

ofinterven

tion

Collabo

rations

strengthened

loca

lserviceca

pac

ities

Maintenan

ceNone

––

––

––

Betancourt et al.

74 www.harvardreviewofpsychiatry.org Volume 21 • Number 2 • March/April 201


3

Table1

Con

tinue

d

Leve

lAim

sProgram

Referen

ces

Design

Sample

size

(boys/girls/to

tal)

Control

group

Reg

ion

Additional

commen

ts&

notesoncu

ltural

adap

tatio

n

Pee

r/school

Preve

ntio

nStructured

activ

ities

atNGO

sites

Loug

hryetal.(20

06)40

Pre/post

150/150/400

Yes

Palestin

eEm

ploye

dloca

l,yo

ung

volunteersas

providers

Emphasisgive

nto

cultu

ral

&recrea

tional

activ

ities

Universal

school-based

interven

tions

Age

ret

al.(2011

)41

Cross-sec

tional

follo

w-up

210/202/403

Yes

Uga

nda

Administeredbyteac

hers

inaclassroom

settingto

increa

sefeasibility

&affordab

ility,&

toreduce

stigma

Universalinterven

tions

may

beusedto

iden

tify

child

renin

nee

dofmore

targeted

interven

tions

Exam

inationoflong-term

effectiven

essis

warranted

Further

integrationin

multisectoralinterventions

&addressing

multiple

layersof

thesocialecology

may

increase

effectiveness

(see

Agere

tal.20

11)41

Berge

r(2007)42

Quasi-RCT

77/65/142

Yes

Israel

Gelko

pfet

al.(20

09)43

Pre/post

114/0/114

Yes

Israel

Slone&

Shoshan

i(2008)44

Pre/post

84/97/181

Yes

Israel

Selectiveor

indicated

school-based

program

s

Constan

dinides

etal.

(2011

)45

Cross-sec

tional

follo

w-up

476/401/877

Yes

Palestin

eSe

lectiveorindicated

scho

ol-based

preven

tion

prog

ramsareaimed

atspecificat-riskgrou

ps&

oftenha

veov

erlapp

ing

aimswith

treatm

ent

interven

tions

Hasan

ovicet

al.

(2009)46

Cross-sec

tional

follo

w-up

141/276/408

Yes

Bosnia

Karam

etal.(2008)47

Cross-sec

tional

follo

w-up

99/95/194

Yes

Leban

on

Youth

clubs

Ispa

novic-Rad

ojko

vic

etal.(20

04)48

Pre/post

813/293/1,106

Yes

Serbia

Youthclub

smay

contribu

teto

thehe

aling

proc

ess,bu

tadd

ition

alinterven

tionmay

bene

eded

insome

individu

alcases

Contin

ued

onnextpage




Table1

Con

tinue

d

Leve

lAim

sProgram

Referen

ces

Design

Sample

size

(boys/girls/to

tal)

Control

group

Reg

ion

Additional

commen

ts&

notesoncu

ltural

adap

tatio

n

Pee

r/school

Trea

tmen

tGroup

interpersonal

psych

otherap

y&

crea

tiveplay

Bolto

net

al.(2007)49

RCT

134/180/314

Yes

Uga

nda

Innova

tivein

itsuse

of

loca

llydev

eloped

mea

suresforassessing

men

talhea

lthoutcomes

Interpersonalp

sychotherapy

trea

tmen

tman

ual

adap

tedforlocalu

se;

creativeplay

originally

develope

dforusewith

war-affe

cted

youth

Dan

ce&

move

men

ttherap

y

Harris(2007)50

Pre/post

12/0/12

No

S.Sudanese

&Sierra

Leonea

ndiaspora

inthe

Unite

dStates

Provides

ausefultherap

yforsettings

whereve

rbal

emotio

nal

expressionis

notem

phasized

Mind-body

tech

niques

Stap

leset

al.(2011

)51

Pre/post

81/48/129

No

Palestin

eDidac

ticco

ursefocu

sed

onmed

iatio

n,

biofeed

bac

k,drawings,

autoge

nic

training,

guided

imag

ery,

genogram

s,move

men

t,breathingtech

niques

Administrationby

nonspec

ialistteac

hers

reco

mmen

dedfeasibility

inapilotstud

y(G

ordo

net

al.,20

04)53

andused

inRCT

Gordo

netal.(20

08)52

RCT

20/62/82

Yes

Kosovo

School-based

program

sfor

child

ren

exhibiting

distress

Entholdt

etal.(20

05)54

Pilo

t17/9/26

Yes

Unite

dKingd

om

Classroom-based

form

at&

deliveryby

parap

rofessionalsmay

bemore

cost-effe

ctive,

feasible,&

easily

integrated

with

inthe

social-eco

logicalc

ontext

Tolet

al.(2008)14

Tolet

al.(2010)55

Tolet

al.(2012)56

RCT

Intrea

tmen

t:545

Control:607

Yes

Burundi,

Indonesia,

SriLa

nka

Jordan

set

al.(2010)57

Cluster

RCT

167/158/325

Yes

Nep

al

Betancourt et al.



Table1

Con

tinue

d

Leve

lAim

sProgram

Referen

ces

Design

Sample

size

(boys/girls/to

tal)

Control

group

Reg

ion

Additional

commen

ts&

notesoncu

ltural

adap

tatio

n

Pee

r/school

Trea

tmen

tSk

ills+

psychotherapeutic

interven

tion

Coxet

al.(2007)58

Qualita

tive

n/a

No

Bosnia

Attend

edto

peer,fam

ily,&

commun

ity-le

velinteractio

nsthroug

hsensitizatio

nwork

Collabo

ratedwith

local

coun

terpartsto

revise

&ad

aptp

rogram

tolocaln

eeds

Qua

litativean

alysisprov

ided

iterativefeedback

onprogram

acceptability&sustainability

Successfullyscaled

upin

manyscho

ols

Layn

eet

al.(2001)59

Layn

eet

al.(2008)60

RCT

43/84/127

Yes

Bosnia

Voca

tional

training+

psych

osocial

support

Ban

nink-Mbaz

zi&

Lorsch

iedter

(2009)61

Descriptiv

e51/39/90

No

Uga

nda

Provides

psycho

socialsupp

ort

asneeded

toanyyouth

enrolledin

livelihoo

dtraining

Representsamoreintegrated

approach

thatavoids

singling

outspecificcategoriesof

confl

ict-affected

youth

Rea

dinessvia

grouptherap

y+

educa

tion

Betan

courtet

al.62

RCT

Pilo

tsample:

16/16/32

No

Sierra

Leone

Interven

tionde

velopm

ent

entaileduseof

anexploratory,sequ

ential,

mixed

-metho

dsstud

yde

sign

Group

-based

interven

tion

linking

youthto

educ

ationa

l&em

ploy

men

topp

ortunities

was

reco

mmen

ded

TheYRIisafeasible

&acceptab

leinterven

tionfor

war-affected

youth;

larger

RCTs

arene

eded

toexam

ine

effectiven

essan

dim

pacton

emotionregulation,

pro-social

skills,&daily

functioning

Teac

her-led

trau

ma/grief

psych

otherap

y

Woodsideet

al.

(1999)63

RCT

126/125/151

Yes

Croatia

Close

collabo

rationwith

local

agencies

ledto

developm

ent

ofaculturally

relevant

trainingprogram

&manual

Feedback

from

teachers

appliedto

intervention

revision

s&refinements

Contin

ued

onnextpage




TABLE

1

Con

tinue

d

Leve

lAim

sProgram

Referen

ces

Design

Sample

size

(boys/girls/to

tal)

Control

group

Reg

ion

Additional

commen

ts&

notesoncu

ltural

adap

tatio

n

Pee

r/school

Trea

tmen

tNonform

aled

uca

tion&

trau

mahea

ling

Gupta

&Zim

mer

(2008)64

Pre/post

167/148/315

No

Sierra

Leone

Athorough

,multistag

etran

slationproce

ssattended

tocu

lturalsensitiv

ityLo

cally

produce

dliterac

y&

numerac

ymodules

ensuredcu

ltural

appropriaten

ess

Participa

ntfeed

back

prov

ided

further

inform

ationon

interven

tionac

ceptability

Short-term

groupcrisis

interven

tion

Thab

etet

al.(2005)65

Pre/post

60/51/111

Yes

Palestin

eInno

vativeattempt

totre

attra

umareactio

nsdu

ring

ongo

ingco

nflict

Furth

erad

aptatio

nof

treatmen

ttechn

ique

sto

increase

cultu

ralrelevan

cemay

bewarranted

Integrationof

more

cogn

itive

oractivetasks

reco

mmen

dedby

authors

Maintenan

ceUniversal

school-based

interven

tions

Constan

dinides

etal.

(2011

)45

Cross-sec

tional

follo

w-up

476/401/877

Yes

Palestin

ePrelim

inaryresults

indicate

atleastfou

ryears

durabilityof

effectsin

Palestinestud

y

Community

Sensitiz

ation

campaign

sBaren

bau

met

al.

(2004)3

Descriptiv

en/a

n/a

n/a

Com

mun

ityou

treachmay

help

preven

tstigma&

improv

eco

mmun

ityacceptan

ceof

confl

ict-a

ffected

child

ren

Massmed

iaLa

mberg(2004)66

Wessells

(1996)67

Bonati(1997)68

Tam-Baryo

h(2009)69

Descriptiv

e/report

n/a

n/a

n/a

Med

iaprogram

s/radio

used

broad

lyto

deliver

psychoeducationtocommunities

New

research

shouldinvestigate

effectso

ftheseinterventions

onpsychosocialwell-being

Purifica

tion

rituals&

addressing

evilspirits

Stark(2006)70

Rey

nolds(1996)71

Honwan

a(1998)72

Descriptiv

e/report

n/a

n/a

n/a

Collabo

ratio

nwith

relig

ious

&traditionalhealersmay

help

bridge

thegapbetweencultural

norm

s&Western-derived

treatments

Betancourt et al.



Table1

Con

tinue

d

Leve

lAim

sProgram

Referen

ces

Design

Sample

size

(boys/girls/to

tal)

Control

group

Reg

ion

Additional

commen

ts&

notesoncu

ltural

adap

tatio

n

Community

Social

dialogu

eWessells

(2004)73

Wessells

(2007)23

Rep

ort

n/a

n/a

n/a

Usedpa

rticipa

tory

metho

dsto

enco

uragedialog

ueab

out

traditio

nalh

ealin

gWorkedwith

participan

tsto

blen

dWestern

&tra

ditio

nal

approa

ches

totra

umahe

aling

Rec

oncilia

tion

committee

sSw

artz

&Drennan

(2000)74

Richterset

al.(20

05)75

Pouligny

etal.(2007)76

Descriptiv

e/report

n/a

n/a

n/a

Further

research

isnee

ded

toinve

stigatethepreve

ntiv

eeffectsofreco

ncilia

tion

committee

sonyo

uth

Com

munity-based

rehab

ilitatio

nInternational

Labour

Organ

isationet

al.

(200

4)77

Rep

ort

n/a

n/a

n/a

Enga

gesco

mmunities,

families,&

organizatio

nsin

attend

ingto

the

physical

&men

tal

capa

citie

sof

disabled

commun

itymem

bers

May

serveas

auseful

mod

elforfuture

research

Multileve

lStep

ped

care

Carepac

kage

Jordan

set

al.(201

1)78

Monito

ring&

evaluation

CBI:24,690

Counselin

g:1705

Referrals:571

No

Burun

di,Sud

an,

SriLanka,

Indo

nesia

Five

leve

ls:

Men

talhea

lthpromotio

nfor

populatio

nat

large

Preven

tive,resilienc

e-focu

sed

groupac

tivities

Classroom

-based

interven

tion

forsubgroups

Counselin

gofsubgroups

byparap

rofessionals

Spec

ializ

edindividual

psych

iatric

trea

tmen

t

Multileve

linterven

tion

Mohlenet

al.

(2005)79

Pre/post

6/4/10

No

Kosovan

&Rom

arefugees

inGermany

Uniqu

eblen

dof

individu

al,

grou

p,&family-le

vel

activities

Deliveryby

layp

ersons

shou

ldbe

investigated

CBT,

cogn

itive

-beh

avioraltherap

y;NGO,nongo

vernmen

talorgan

ization;RCT,

rand

omized

,co

ntrolle

dtrial;YRI,Yo

uthRea

dinessInterven

tion.




Betancourt et al.

child adherence to the intervention, child attachment to thedoll, and improvements in well-being were observed. Addi-tional research is needed to examine intervention mechanisms,but initial results suggest that the intervention may be imple-mented early on during conflict as a preventive measure.

PSYCHOLOGICAL FIRST AID Recently, growing attention hasbeen given to individual psychological first aid, whichis an intervention aimed at strengthening mental healthoutcomes in the immediate aftermath of a disaster orconflict. Recently, the World Health Organization has pub-lished guidelines on psychological first aid. In essence, thisguide focuses on the intervention as a supportive, nonintru-sive form of interaction that aims to provide practical assis-tance where possible, connect people with existing supports,and identify those in need for more specialized services.Although psychological first aid is recommended by inter-national consensus-based humanitarian guidelines,80 no rig-orous (i.e., systematically evaluated) evidence is availableconcerning this form of psychological support for useamong children and adolescents affected by war.81 Impor-tantly, this intervention is separate from the trauma-focusedpractice of psychological debriefing, which has been demon-strated to be ineffective and, in adults, even harmful insome cases.27,28

Individual-Level Interventions: TreatmentTRAUMA-FOCUSED COGNITIVE-BEHAVIORAL THERAPY In high-income settings, individual trauma-focused cognitive-behavioraltherapy is one of the interventions with a sufficient evi-dence base to be a recommended practice.28 In war zones,however, such individualized treatment approaches are notcommonly implemented, given the resources required, thelack of specialized mental health professionals, the lowprioritization of mental health, and the stigma that is as-sociated with mental health problems.

NARRATIVE EXPOSURE THERAPY Narrative exposure ther-apy for the treatment of posttraumatic stress disorder(PTSD) is typically delivered as a short-term individual treat-ment by experienced mental health clinicians. This form oftherapy is an intervention based on cognitive-behavioral ex-posure therapy for treating PTSD symptoms. It adapts theclassical form of exposure therapy to meet the needs of trau-matized survivors of war and torture. Instead of defining asingle event as a target in therapy, the patient constructsa narration about his whole life from birth up to the pre-sent situation while focusing on the detailed explorationof the traumatic experiences and traumatic memories. Nar-rative exposure therapy has been adapted for war-affectedadolescents and children aged 12 to 17 years (KidNET) pre-senting with multiple war trauma exposures and meet-ing moderate to severe criteria for PTSD.82 In a study inGermany, significant improvements in PTSD symptoms weredemonstrated among eastern European refugee children



enrolled in KidNET.30 Lasting and strong effects of KidNEThave been observed in research with war-affected youthorphaned in the Rwandan genocide; in this trial, KidNETperformed as well as flexible trauma counseling administeredat the discretion of lay counselors.29 Significant reductionsin PTSD symptoms and improvements in functioning werealso observed in a small trial of KidNET with war-affectedchildren in Sri Lanka (KidNET performed similarly tomeditation therapy).30

Few studies have investigated the maintenance of indi-vidual treatment gains over time. In a small pilot study ofKidNET, participants demonstrated sustained treatmenteffects at a nine-month follow-up,31 but further researchis needed on the efficacy of KidNET in treating PTSD; inother settings, long-term results of narrative exposure ther-apy with adults have been mixed.83 Further, while KidNETmay have long-term effects in alleviating PTSD symptoms,more research is needed on maintenance interventions thatinvolve ongoing treatment rather than on the potentiallysustained benefits of prior interventions.

TESTIMONIAL PSYCHOTHERAPY In testimonial psychother-apy, patient narratives of past traumatic events are re-corded and then reviewed by the patient and a clinicianfor links between personal experiences and the social andpolitical aspects of trauma. Case studies of the interven-tion as used with Sudanese refugees indicate that testi-monials may serve as a useful alternative to traditionalpsychotherapy approaches, which may be stigmatizing, un-common, or culturally irrelevant among some popula-tions.32 Evidence of intervention efficacy or effectivenesswith war-affected children has not been published.

Family-Level Interventions: PreventionA strong evidence base supports the claim that secure andconsistent caregiving relationships are critical in order forchildren to weather the extreme stressors of war and con-flict.84–91 As a result, a number of psychosocial interventionsare oriented toward the family, with the aim of strengtheningparent-child relationships and connection.

For some children, war may impose prolonged separa-tions from, and loss of, loved ones.92,93 Although few child-tracing interventions have been formally evaluated foreffectiveness in improving mental health outcomes, reunifi-cation of separated families is often an important first stepin promoting mental health in war zones.94,95 A number ofinterventions are available for preventing separation (e.g., uni-versal registration at birth, registration during movements,computer-assisted databases), providing interim and dura-ble care options (e.g., foster care, peer-group care),33,34 andreunifying families (e.g., tracing separated children, reinte-grating child soldiers).35–37,96,97 To date, however, studiesdemonstrating significant associations between child trac-ing, family reunification, and psychosocial adjustment havenot been published in the peer-reviewed literature.




Family-Level Interventions: TreatmentDYAD PSYCHOSOCIAL SUPPORT A five-month trial in Bosniacompared effects of a short-term, group-based psychosocialtreatment for mother-child dyads to a control condition com-prising free medical care only.38 The intervention, designedby the International Child Development Programme,98 in-cluded treatment components derived from successful techni-ques used previously in the Bosnian population as well astheory-driven treatments used in a number of other settings.Pre/post-intervention results suggested modest positive ef-fects on maternal mental health, children’s weight gain,and children’s psychosocial functioning and mental health.Study limitations included lack of involvement of male care-givers, a small intervention sample size (n = 87 dyads), anddifficult environmental conditions that posed challenges forintervention delivery.

MULTIPLE-FAMILY GROUP INTERVENTION A multiple-familygroup intervention that also included individual home visitswas piloted with 30 families living with severe mental illnessin postwar Kosovo.39 Families participated in seven sessionsof psychoeducation about chronic mental illness—led by alocal psychiatrist and nurse and supervised by trained localservices teams and American study consultants. The therapyaimed to increase compliance with psychiatric medicationamong war-affected individuals in treatment and to im-prove mental health service use among families. Discus-sions in group sessions addressed the following topics:psychoeducation; medication use and side effects; psycho-social causes and effects of relapse; problem solving inresponse to symptoms; responding to crises; accessing pro-fessional mental health services; and building resilience.Findings indicated positive effects on both outcomes,although additional information related to child mentalhealth outcomes would have strengthened the study de-sign. This study used a collaborative approach to delivery,including close work with Kosovar partners.

Family-Level Interventions: MaintenanceNone of the research on family-based interventions forconflict- and war-affected populations has investigated themaintenance of effects over the longer term. This topicremains an important target for future research efforts.

Peer- and School-Based Interventions: PreventionAlthough many schools in high-resource settings haveimplemented programs with the primary aim of preven-tion, few such interventions have been implemented andevaluated in low-and middle-income settings affected byarmed conflict.99 Within the school setting, interventionscan be aimed at preventing mental health problems in allchildren in the school (i.e., a universal approach) or aimedat specific at-risk groups (i.e., selective and indicated pre-vention, which often have overlapping aims with treatmentinterventions). Our search identified only a handful ofprevention-oriented studies.



STRUCTURED ACTIVITIES AT NONGOVERNMENTAL ORGA-

NIZATION SITES In a yearlong, nonrandomized trial involv-ing a sample from the Palestinian Territories, researchersassessed the effects that structured activities at nongovern-mental organization sites had on child mental health (inter-nalizing and externalizing), child hopefulness, and parentalsupport.40 Structured activities included traditional dance,art, sports, drama, and puppetry. This combination of activ-ities was hypothesized to (1) assist emotional adjustment inhostile environments by providing routine, constructive en-gagement and opportunities for attachment and expression,(2) positively affect parent-child relations by providing safe,shared outdoor activities, and (3) increase children’s futureorientation. Special emphasis was placed on ensuring a cul-turally appropriate community focus, which entailed thetranslation of all materials to the local language, the em-ployment of local volunteers as providers, the implementa-tion of cultural activities, and the use of the communitycenter as the focal location for all activities. Child partici-pants demonstrated improved internalizing/externalizing out-comes when compared to a small control arm; improvementsin hopefulness were not observed; improvements in paren-tal support were reported at one of the sites involved.

UNIVERSAL SCHOOL-BASED PROGRAMS Universal school-based programs for war-affected children have been pilotedin several contexts, although intervention effects have beenlargely evaluated through cross-sectional follow-up studies.

In Uganda, researchers investigated effects of a school-based intervention that progresses through 15 structuredsessions, incorporating play therapy, drama, art, andmovement to increase feelings of stability and to improveemotional outcomes.41 Notably, psychosocial structuredactivities are integrated with community service oppor-tunities and parental engagement in order to attend tomultiple levels of ecological needs. In a cross-sectionalfollow-up study of intervention participants versus com-munity controls, researchers observed that improvementsin child well-being were significant among those assignedto the intervention arm, with group assignment and agereported as significant predictors of child-reported well-being. Parent and teacher reports suggested that girls maybenefit more from the intervention than boys.

A similar school-based intervention (named Oversha-dowing the Threat of Terrorism) to reduce PTSD, functionalimpairment, somatic complaints, and anxiety was testedamong children whose schools had sustained repeated terrorattacks in Israel.42 This universal intervention involvescognitive-behavioral components, art therapy techniques,body-oriented strategies, and narrative approaches to docu-ment children’s experiences. The quasi-randomized designassigned 70 students to the intervention and 72 to a wait-listed control, andwas implemented by trained teachers overeight 90-minute sessions. Parents and families participatedvia homework assignments and during two psychoeducation



Betancourt et al.

sessions. Positive treatment effects were found on all out-comes of interest.

Finally, we identified two preventive school-based inter-ventions (both piloted in Israel) that focused on developingresiliency as a mechanism for addressing mental health.The first (named ERASE-Stress) uses psychoeducation andskill training with meditative and narrative practices tore-process traumatic experiences and boost self-esteem andaccess to social supports.43 The second is a primary preven-tion intervention that focuses on amplifying three factors—social support, self-efficacy, and meaning attribution—tomoderate psychological distress.44 In research trials, bothinterventions were implemented as universal, classroom-based programs. Significant intervention effects in moder-ating psychological distress were observed as compared tocontrol groups in both studies.

SELECTIVE OR INDICATED SCHOOL-BASED PROGRAMS Cross-sectional analyses of a school-based psychosocial interven-tion implemented with children in Gaza during an activeconflict period focused on positive aspects of well-being,such as good family and community relationships, trust,problem solving, and hope.45 Results from this study indi-cated significant positive effects of the intervention, with du-rability of at least four years (despite lower effectiveness inone subgroup assessed two years post-intervention).

In Bosnia, a cross-sectional follow-up study found thatsymptom severity and cluster symptoms—especially in re-experiencing and avoidance—were significantly reducedamong students who participated in a schoolwide trauma-reduction project, as compared to controls.46

By contrast, in a cross-sectional follow-up study com-paring intervention participants to community controls inLebanon, no positive effects were observed among childrenwho received a school-based intervention combining cognitive-behavioral treatment strategies with activities like drawing,creative play, and group discussion.47

YOUTH CLUBS In Serbia, youth clubs have been widelyimplemented in boarding schools and youth hostels, andinclude a wide range of participant-directed activities, in-cluding communal games, poetry, guest speakers, drama,and group debate. In one study of youth from a boardinghigh school where youth clubs are active, researchersevaluated the impact of clubs on psychological symptomsin 128 youth club participants as compared to 978 con-trols.48 Significant increases in self-respect were registeredin youth club participants, as were decreases in with-drawal and anxiety in boys and withdrawal and social prob-lems in girls.Non-refugees reported improvements in traumaticstress (this effect was not observed among refugees).

Peer- and School-Based Interventions: TreatmentGROUP INTERPERSONAL PSYCHOTHERAPY AND CREATIVE

PLAY In a three-arm, randomized, controlled trial (RCT)to reduce depression symptoms in war-affected youth from



northern Uganda, researchers compared outcomes amongadolescents enrolled in (1) an adapted group interpersonalpsychotherapy, (2) a creative play intervention, and (3) await-list control group.49 All participants were screenedfor high depression scores and some impairment at base-line using locally derived and validated mental health assess-ments. Results from this randomized design indicated thatthe adapted group interpersonal psychotherapy had posi-tive effects on locally relevant mood disorders, particularlyamong young women. Creative play was not associated withimprovements in mental health or functioning, althoughthe authors indicated that the timing of the assessmentsmay have limited the ability to see longer-term improve-ments in functioning. Though not part of the study, anassessment of broader psychosocial outcomes such as inter-personal skills, self-esteem, or problem solving may havebeen better aligned with the goals of the creative condition.

SCHOOL-BASED PROGRAMS FOR CHILDREN EXHIBITING DIS-

TRESS School-based cognitive-behavioral therapy (CBT) forchildren exhibiting mental health symptoms has been usedin trials with groups of war-affected refugees and asylumseekers in the United Kingdom.54 When compared to con-trols, children enrolled in CBT showed significant im-provements in PTSD, behavioral problems, and emotionalsymptoms, although gains were not retained at two monthspost-intervention.

Positive effects of a classroom-based intervention havebeen observed in several rigorous cluster, randomized trialswith war-affected children aged 8 to 12 years.14 Implemen-ted by trained community paraprofessionals, this interven-tion is delivered in 15 manualized, school-based sessionsover five weeks. Sessions included trauma-processing activ-ities, cooperative play, and creative expressive elements. InIndonesia, a promising level of effectiveness was demon-strated among participants screened for PTSD and anxiety.Female participants exhibited improved PTSD symptomsand reduced functional impairment. Both males and femalesmaintained their levels of hope. No effects on anxiety, depres-sion, or PTSD-like symptoms were observed among male orfemale participants.14 Larger improvements in play social sup-port (social support for emotional problems through playingwith others) were associated with smaller improvements inPTSD symptoms.55

In Nepal, the same classroom-based intervention wasnot associated with any main effects, but girls receivingthe intervention improved on pro-social behavior, boys im-proved on psychological difficulties and aggression, andolder children displayed an increased sense of hope com-pared to those in a wait-list control group.57 In Burundiand Sri Lanka, treatment effects were less robust.12,56

DANCE AND MOVEMENT THERAPY The effects of danceand movement therapy have been studied in war-tornSierra Leone among males aged 15 to 18 years.50,100 In this




therapy, sixteen 2–3 hour sessions of therapy combinedwith improvisational dance to Sierra Leonean pop musicaimed to build self-confidence and improve emotionalregulation in participants. The therapy culminated in a pub-lic, 25-minute role-play in which the capture, perpetration,and suffering of children and their communities during thewar were reenacted. Assessments of traumatic histories,posttraumatic psychosocial problems (aggressive behavior,depression, anxiety, intrusive recollections, and elevatedarousal) were conducted at the time of enrollment and atfour points thereafter (one, three, six, and twelve months).Data on sustained effects of dance and movement therapyon the outcomes investigated have yet to be published, butqualitative reports have indicated good feasibility in thispostwar context.

MIND-BODY TECHNIQUES Positive effects of mind-body tech-niques for reducing PTSD were investigated among childrenand adolescent Kosovar refugees inGaza51 and in high-schoolstudents in postwar Kosovo.52 In this treatment, a six-week (three hours weekly) intervention is administered bytrained, nonspecialist teachers. Treatment components in-clude meditation, biofeedback, drawing, autogenic training(a self-relaxation technique to produce a psychophysiolog-ically determined relaxation response), guided imagery,genograms, movement, and breathing techniques as tac-tics for reducing PTSD symptoms. In an RCT of the inter-vention, 82 adolescents meeting criteria for PTSD wererandomly assigned to an immediate-intervention group ora delayed-intervention (wait-list control) group. Significantdecreases in PTSD symptoms were found across the sam-ple at post-test, with those students in the immediate-intervention group reporting more dramatic positive effects.While the RCT conducted among high-school students inpostwar Kosovo did have a wait-list control group, a signif-icant limitation of the study conducted among childrenand adolescent Kosovo refugees in Gaza was the lack of acontrol group.

SKILLS + PSYCHOEDUCATION INTERVENTION A structured,17- session psychoeducation and skills program was pilotedwith promising effects among war-traumatized Bosnianadolescents.58–60 In an RCT, this school-based psycho-therapeutic group intervention was implemented bylocal school counselors. One hundred twenty-seven war-exposed secondary school students participated in the study.Significant reductions in PTSD and depressive symptoms,as well as improvements in maladaptive grief, were per-ceived among intervention participants as compared toan active-treatment comparison group that did not partici-pate in the intervention. Results from the study suggestthat classroom-based programs that combine psychoeduca-tion, skills building, and supportive counselor contact maybe adequate to reduce distress in war-exposed youths livingin low-resource settings.



VOCATIONAL TRAINING + PSYCHOSOCIAL SUPPORT INTER-

VENTION In northern Uganda, an educational interventionto provide vocational training and as-needed psychosocialsupport has been evaluated through qualitative inquiry.61

In this program, psychosocial support is provided to youthwho score above threshold on an assessment of psychosocialdistress. The psychosocial support includes counseling incoping strategies and in cognitive and behavioral methods,as well as facilitating referrals for youth who require ad-ditional follow-up. The intervention aims to provide anintegrated approach for all war-affected youth desiringlivelihood opportunities, including youth with increasedneed for mental health support. Findings from the interven-tion showed that most psychological distress for youth—including sleeping problems, psychosomatic symptoms,and worries about family, future, and income—can be ame-liorated by providing psychosocial support for students andteachers, in this case by counselors with a wide range oftraining backgrounds, from short-term certificate trainingfrom local organizations to full university master’s degrees.Mental health support, such as counseling vulnerable youthand training teachers to provide psychosocial support tostudents, should be incorporated into general health ser-vices and programs.

READINESS VIA GROUP THERAPY + EDUCATION In Sierra Leone,an RCT is presently taking place to assess the ability ofa Youth Readiness Intervention to decrease problems withemotion regulation/anger and general psychological dis-tress and to improve pro-social/adaptive skills and dailyfunctioning among war-affected male and female youth(ages 15–24, per the UN definition of youth). The interven-tion integrates common practice elements derived mainlyfrom CBT (i.e., psychoeducation, behavioral activation, cog-nitive restructuring, and sequential problem solving) andgroup interpersonal psychotherapy (i.e., addressing inter-personal deficits and building social support). Initial re-sults of an open trial indicate reliable change across alloutcomes investigated.62 Limitations of the study includethe lack of a control group; however, a larger RCT thatincludes a wait-list control group is currently under way.Future iterations of this research also plan to investigatethe degree to which the intervention facilitates success-ful transitions to educational and employment programsfor troubled youth in postconflict settings.

TEACHER-LED TRAUMA/GRIEF PSYCHOTHERAPY A school-based curriculum to reduce psychosocial trauma and pro-mote social healing in war-affected children from Croatiaalso demonstrated positive results.63 In this study, teachersreceived training in the form of trauma/grief-focusedpsychotherapy developed in partnership with local socialworkers and psychologists. Weekly group sessions were con-ducted with the intervention group over a four-month pe-riod. Pre/post-assessments, including a one-year follow-up,



Betancourt et al.

examined levels of PTSD, self-worth, conflict resolution, so-cial skills, psychosocial well-being, ethnic bias, and academicachievement. Results revealed a small, but significant, re-duction in ethnic bias and a reduction of stress symptomsin the intervention group as compared to two control groups,with more positive effects on self-esteem observed amonggirls. Participants exhibited an increased positive perceptionof Serbs. No significant correlations were found betweentrauma exposure, trauma symptoms, and social distance(also called ethnic bias: the degree of one’s acceptance ofthe actions of other ethnic groups). Investigators proposedthat future studies account for measures of parental atti-tudes. They also suggested that ethnic reconciliation maybegin in school but is likely tempered by the degree of com-munity buy-in. Potential confounding variables such as par-ticipant maturation, exposure to media, parental attitudestoward reconciliation, and the gender of trainers (all ofwhom were female) were cited as study limitations. Theselimitations suggest that the study could be improved byclear delineation and planning of variables to be controlledfor in this context.

NONFORMAL EDUCATION + TRAUMA HEALING Rapid-Edis a four-week intervention targeting both educationalneeds and trauma healing. It was used in a trial of SierraLeonean war-affected youth, aged 8 to 18 years, 9–12 monthsafter the 1999 invasion of the capital city by the Revolu-tionary United Front rebel group. A total of 315 displacedchildren from two camps for internally displaced personsparticipated in Rapid-Ed. The intervention includes non-formal educational activities such as literacy and numeracymodules and a trauma-healing module that includes groupsharing about past war experiences, psychoeducation re-garding responses to trauma, discussion of positive memoriesbefore the war, and recreational activities.64 A noncontrolledpilot study of Rapid-Ed was conducted in Sierra Leone overfour weeks with biweekly, hourlong sessions. The treat-ment, designed in close consultation with Sierra Leone’sMinistry of Education, was implemented by camp teacherswho received six hours of training in the program. At post-test, participants displayed decreased intrusion and arousalsymptoms, but increased avoidance symptoms. Study inves-tigators hypothesized that this increase could be attributed toa temporary defense mechanism for dealing with daily stres-sors in an acute postconflict situation. However, the lack ofa control group remains an important limitation of the study.

SHORT-TERM GROUP CRISIS INTERVENTION In a trial usinga robust design among children affected by conflict in theGaza Strip, participants aged 9 to 15 years presenting withPTSD symptoms were assigned without randomization toone of three study arms: (1) a seven-session group inter-vention that included drawing, free play, storytelling, andexpression of feelings, (2) a four-session education interven-tion, and (3) a control group.65 At a three-month follow-up,



neither intervention was found to have significant effects onchildren’s PTSD or depression symptoms. Study limitationsincluded a small sample size (total n = 147), the lack of ran-domization, an absence of parental involvement in theinterventions, and failure to account for war events experi-enced during the intervention period. Investigators hypothe-sized that the lack of significant effects could also partially beexplained by the intervention’s use of “non-active” compo-nents, which do not necessarily help children explore andcome to terms with difficult experiences or emotions.

Peer- and School-Based Interventions: MaintenanceWe did not identify any studies that sought to reducerelapses or recurrences of conflict- or war-related psychoso-cial and mental health problems in a peer- or school-basedsetting. One study of a school-based psychosocial interven-tion in Gaza observed long-term positive effects at up tofour years post-intervention, but study authors identifieda need for more research on the intervention’s longitudinaleffects beyond this point of follow-up.45

Community-Level InterventionsA number of studies suggest that the degree to whichcommunity support increases over time plays an impor-tant ameliorative role for conflict- and war-affectedchildren.16,97,101,102 This review did not identify any eva-luations of community-level interventions whose primarygoal was to reduce psychological distress and prevent ortreat mental disorders in children. However, given the im-portance of community support, we describe here severalprocesses that activate and strengthen social networks, bol-ster traditional supports, and create child-friendly spaces,as such interventions may help to promote individual well-being and may prevent, or even provide some elements ofeffective treatment for, mental disorders in children.

SENSITIZATION CAMPAIGNS AND PROGRAMMING Sensitiza-tion campaigns about war-related mental health difficul-ties and community outreach to advocate good preventivepractices have been incorporated into some psychosocialprograms for children.3 These interventions have the po-tential to raise awareness of mental health at the communitylevel and to reduce stigma around mental health problemsin youth.103 In Angola, researchers have piloted a grass-roots program to restore social structures and practicesin the communities affected by war.73 The interventionincluded sensitization dialogues with community groupsaround children’s problems, training seminars for commu-nity leaders who subsequently advocated for children’sneeds, activities to encourage emotional expression in asupportive group context, and physical reconstruction ofvillage buildings (e.g., schools, community huts). Partici-pating adults felt that the project helped strengthen thecommunity’s local protective processes, but no systematic,quantitative evaluation was conducted.




MASS MEDIA Mass media, including radio and television,have been innovatively applied to deliver messages of heal-ing and reconciliation to large numbers of people.66 InAngola and Mozambique, radio programs have been usedto deliver psychoeducation to the public through narrating,in a series of chapters, the stories and experiences of war-affected children.67,68 In other countries, media programshave been developed and broadcast by young people. Forinstance, in postconflict Sierra Leone, the “Talking DrumStudio” prepares weekly, youth-led radio broadcasts thatcontain music, news stories, and other information of inter-est to youth listeners. They are intended to model positiveyouth leadership and to help guide youth struggling to nav-igate the difficult postconflict environment.69

As social media networks expand in low-and middle-income countries, many opportunities will develop for exam-ining the psychosocial impact of online programming.

COMMUNITY-LEVEL EFFORTS TO ADDRESS HEALING In manysettings, traditional healing practices make critical contri-butions to social healing in the context of war.70,104–106 Forinstance, in Zimbabwe, Zezuru healers are known toengage family and community members in groups, drawout concerns over children’s problems, facilitate reconcil-iation in and between families, and create a restorative cli-mate.71 Similarly, in Angola, researchers have observed howtraditional cleansing rituals facilitate the reintegration ofwar-affected youth through forgiveness of past transgres-sions.72 Such research emphasizes the importance of inter-ventions already in use within affected communities.13,104–107

To date, however, most research on traditional healing/cleansing ceremonies has been descriptive. No systematicevaluations have examined the degree to which commu-nities and traditional healing interventions are associatedwith improvements in mental health in war-affected chil-dren and adolescents.

RECONCILIATION COMMITTEES Modern warfare goes handin hand with mass human rights violations within civilianpopulations.108,109 Consequently, increased attention is beingplaced on reconciliation efforts that can address damaged so-cial relations and human rights violations through judicialprocesses, and thus promote psychological healing at a macrolevel.74 Truth and reconciliation commissions have been apart of national reconciliation efforts in a number of set-tings, including East Timor, Peru, Sierra Leone, and SouthAfrica. In Rwanda, a state-orchestrated attempt at reconcilia-tion between ethnic groups employed traditional gacaca jus-tice mechanisms.75

Unfortunately, the meager evidence available suggeststhat reconciliation processes are not necessarily associ-ated with improvedmental health status.110–112 In addition,such approaches have been critiqued for their lack of en-gagement with social change at the grassroots level.76 Furtherresearch that attempts to address the possible preventive



effects of transitional justice mechanisms on social relation-ships and population mental health is clearly needed.

COMMUNITY-BASED REHABILITATION Although our reviewfound no community interventions aimed at maintainingwell-being or preventing relapse in war-affected children,community-based rehabilitation—a consensus strategy sup-ported by the International Labour Organization, WorldHealth Organization, and the United Nations EducationalScientific and Cultural Organization—may serve as a usefulmodel for future research. This broad intervention is in-tended to promote teamwork between families, organizations,and communities to ensure that people with disabilities canmaximize their physical and mental capacities and contributeto community life.77 Because disability can serve as a unifyingforce among opposing factions, community-based rehabilita-tion has particular relevance to peace building in conflictscharacterized by entrenched divisions based on racial, ethnic,and religious differences.113 For example, in Sri Lanka, thisapproach was used to bring together warring Sinhalese mili-tary and Tamil groups in educational workshops on child de-velopmental disabilities such as polio, blindness, and stroke.These programs exposed both groups to the commonalitiesof the disability experience and promoted mutual assistancebetween them. Such community-level interventions aimed atraising awareness, building empathy, and combating stigmaabout mental and cognitive disabilities have significant po-tential to benefit war-affected children, families, and commu-nities, and merit much more effort in program evaluation.

Multilevel InterventionsIn this review, only two multilevel interventions wereidentified in the peer-reviewed literature. The first used acomprehensive monitoring and evaluation framework toassess a multilevel, stepped-care package in four war-affectedcountries (Burundi, Indonesia, Sri Lanka, and Sudan).78 Thecommunity-based package included interventions ranging frompopulation-level psychoeducation to specialized referrals forchildren in need of psychiatric services. Primary preventionactivities included building social support through groupactivities; a secondary preventive, classroom-based interven-tion was aimed at children with distress; individual psycho-social counseling was offered to those with more severeproblems; and available psychiatric services were mappedto facilitate referrals. Across all settings, almost 30,000child beneficiaries expressed high levels of satisfaction; theauthors recommended that reducing costs and the burdensupon therapists may help to increase sustainability.

In a pilot study with child and adolescent Kosovan refu-gees in Germany, researchers evaluated effects of a treat-ment that blended individual sessions, group sessions, familysessions, and parent-only sessions.79 Both past traumatic ex-periences and current daily hardships were addressed. Crea-tive techniques and psychoeducation were also incorporated.Post-intervention results showed significant declines in PTSD,



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depression, and anxiety symptoms among participants;nine out of ten scored higher on psychosocial functioningmeasures. Although no control group was used in thissmall trial, preliminary results are promising and shouldprovoke further analysis of blended, multilevel interven-tions and more use of robust evaluation designs, includ-ing the use of control groups.

DISCUSSIONFrom our review, it is clear that—despite promising progressin the rigorous evaluation of programs—large gaps existin our knowledge regarding the effectiveness of psychoso-cial and mental health interventions for war-affected chil-dren, adolescents, and youth. Here, we discuss a number ofkey themes characterizing the existing evidence base and pro-vide recommendations for future research.

Research on Prevention and Maintenance Is LackingAcross the different levels of children’s social ecology—from the individual to the family, peer, and communitylevels—insufficient evidence is available to guide interven-tionists in designing preventive and maintenance interven-tions. Preventive interventions have a high potential forincreasing the productivity of countries emerging from con-flict and have received increased attention for use in high-risk groups such as children of depressed caregivers or thoseliving in extreme poverty.25,114–116 That said, the inter-ventions highlighted in this review—psychological first aid,family reunification, and structured recreational activitieswith peers—represent a mere fraction of the possible preven-tive efforts that may be implemented in war-affected settings.In such settings, although individual approaches to preventionmay be limited because of their resource-intensive nature, in-terventions that leverage existing protective constructs relatedto social support, coping, supporting healthy parenting,and other resources hold promise.117 In particular, growingattention is being given to early childhood development pro-grams for young children in adversity. Such investmentshave demonstrated the capacity, in the long run, to im-prove productivity and reduce social problems among at-risk groups.118

Similarly, the available research is characterized by a lackof attention to the preservation, over time, of treatmenteffects. Although many studies have focused on reducingdistress—for example, in the forms of symptoms of PTSD,depression, and anxiety—little is known about the longer-term effectiveness of psychotherapeutic approaches. Lon-gitudinal research on children affected by war indicatesthat recovery from the trauma of ecological disruption,loss, and exposure to violence is a developmental processand that interventions initiated at one time point may needto be revisited as the children grow older.16,119–121 However,although the Inter-agency Standing Committee guidelinesprescribe sustained care for individuals with mental health



issues,5 the degree to which initial benefits are retained andto which relapses occur in war-affected, low-resource set-tings is not known. For instance, in one study of a school-based group intervention based on CBT, intervention effectswere not maintained in the absence of treatment, even twomonths post-intervention.54

These realities have implications for partnerships andentail the development of medium- and long-term plans forproviding care outside of short-term humanitarian inter-ventions.81 In higher-resource settings, researchers haveobserved positive effects of phased approaches for disaster-affected children; for example, in Hawaii, treatment “non-responders” (defined as children demonstrating sustained,clinical levels of PTSD in the year following their comple-tion of a brief psychosocial intervention) were enrolled inadditional sessions of eye movement desensitization and re-processing therapy, with significant positive improvementsin PTSD, depression, and anxiety following treatment.122

Studies like this one highlight the potential of approachesthat begin with broad-based stabilizing interventions forall war-affected children but that move toward increasinglyspecialized treatments for those children who do not re-spond to general treatment approaches (i.e., a stepped-caremodel; see Table 1). An additional promising element ofinterventions to maintain improvements over time is thatthey provide an ongoing opportunity to build capacity andstrengthen systems. Depending on how emergency inter-ventions are delivered, these programs can help to build oraugment sustainable systems of care and to establish mech-anisms for training, supervision, and sustained employmentof mental health workers serving war-affected youth. Whensystems used are ad hoc and incapable of being sustained be-yond the emergency period, an opportunity is lost.81,123,124

Few Treatments Integrate Individual, Family, Peer, andCommunity ComponentsPromising evidence of intervention efficacy is emerging withregard to treatment, especially in school-based interventionsand peer-to-peer processes. These findings reflect trends inhigh- and middle-income settings, where school-based in-terventions (specifically, group-based cognitive-behavioralprograms) have become increasingly popular.28,125 It is im-portant to recognize, however, that school-based interven-tions alone might not be sufficient to address the full rangeof psychological and social problems associated with con-tinued political instability, poverty, and limited access toschool in conflict settings.14,49,121 Since the gains made topsychosocial well-being in a short, school-based programmay not be sustainable without additional changes in fa-milial, peer, and community supports, further integrationof these interventions within family- and community-basedmodels is well warranted, as are strategies to reduce pov-erty and social/political conflict and to improve employ-ment opportunities and educational access.12,13,126




PTSD Interventions May Not SufficientlyAddress ComorbidityThe reality of polyvictimization and the resultant comor-bidity of mental health problems among war-affected chil-dren must be recognized. Because war brings with it ahost of stressors—resulting from direct injury, exposure toloss, and even active involvement in perpetuating vio-lence—the presentation of emotional, behavioral, and so-cial consequences can be complex.127 Treatments focusedon single disorders may therefore have limited applica-tion; what is likely needed, instead, is a stepped-care modelthat entails treatment components for multiple types ofpsychological problems,59,88,128 including acute psychiat-ric problems.

Epidemiological work on child mental health in conflict-and war-affected settings can provide a deeper understand-ing not only of equifinality—the processes by which differentwar exposures may manifest in a similar set of symptomsand impairments—but of key outcome mediators (e.g., so-cial supports, coping skills, emotion-regulation skills) andtreatment moderators (e.g., age, gender, ongoing insecu-rity). A better understanding of these factors can help toguide future intervention research and also to create better-targeted interventions, including the selection of treatmentor prevention components with cross-cutting applicabilityto common symptoms (e.g., traumatic stress reactions, hope-lessness, and social deficits).129

Sustainability and Cost-Effectiveness Are ImportantConsiderationsThe findings of this review imply that task-shifting and cost-saving innovations can be applied at multiple levels of in-tervention for war-affected children, youth, and families.Such models, if carefully crafted with high-quality trainingand supervision, may go a long way in overcoming some ofthe human-resources problems that characterize low-incomeand conflict-affected settings. In the reviewed studies, group-based interventions demonstrated better cost-effectivenessand potential for sustainability in school and community set-tings.130 In Kosovo, evenmultiple-family groupswere shownto be feasible, which has tremendous promise for futurecost-effective interventions that may be made across the so-cial ecology.39

Highly trained mental health professionals, where avail-able, can play an important role in developing a continuumof care by providing training and supervision, and by man-aging the more complex and acute cases. In many war-affected countries, however, this professional workforcealone is insufficient for addressing mental health needs.Several of the studies reviewed here highlight how para-professionals and lay facilitators may be successfullymobilized to deliver mental health and psychosocial inter-ventions.29,50–53,58,59,63 Additional research to examine howfamilies and communities can be trained to address themental health consequences of war would be useful for



extending the continuum of care beyond clinical or schoolsettings to ensure more community-based resources. Moreresearch is also needed to assess how locally developedmodels of healing and spiritual guidance may provide a nat-ural base for building robust, culturally resonant, locallydelivered interventions.70

Differential Effects of Interventions Are Under-studiedA number of studies in our review have demonstratedstronger intervention effects in girls than in boys.14,49,131

Few studies to date, however, are of sufficient power to ex-plain such gender effects. In future research, much more at-tention is needed to understand these differential effectsby gender.

Treatment-intervention research will also benefit from amore detailed (and at the same time, broader) examinationof how intervention effects are achieved and maintained—and not simply in terms of the efficacy of specified treat-ments in reducing a defined range of disorder-specific symp-toms over a specified time. The need for this paradigm shiftis exemplified by findings from cross-cultural applicationsof the classroom-based intervention that was associatedwith varying degrees of efficacy in Burundi, Indonesia, andSri Lanka.12,56,126 Researchers from the study hypothesizedthat results reflect the varying degree of contextual stressorsfacing children and youth; for instance, in Indonesia, thehigher rates of cohesiveness within families and communi-ties (increasingly segregated by religion following the con-flict) were hypothesized to have positively influenced childoutcomes.126 In Burundi and Sri Lanka, children exposedto ongoing challenges related to armed conflict and socialdisruption (e.g., poverty and violence in the home and neigh-borhood) did not benefit as strongly from intervention.132

Holistic research to investigate how individual, family, andcommunity strengths work in tandem with interventions tosupport children has the potential to (1) identify active in-gredients, which may help strengthen the size of treatmenteffects, and (2) provide interventionists with a toolbox ofnaturally occurring processes that can be flexibly targetedand optimized to address context-specific needs.

Measurement Tools for Cross-cultural Use Are LackingIn the studies reviewed here, very few used locally validatedmental health assessments to perform pre/post-interventionevaluations.49,133 Since symptom expression can vary widelybetween social and cultural contexts,121,127,134,135 evaluatingintervention effects based on culturally insensitive measuresmay produce inaccurate or meaningless results. Integratedqualitative and quantitative (“mixed-methods”) research oncontext- or culture-specific mental health problems and re-sources can contribute to refining the suite of assessmentand monitoring tools available for cross-cultural use.121 Theuse of improved measurement tools with strong psychomet-ric properties and cultural acceptability may help to im-prove future longitudinal research and also research onmaintenance interventions.



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Mental Health Systems Strengthening and SustainabilityAre CriticalFrom our review, it is evident that interventions to preventrelapse in children needing mental health services due towar-related exposures are currently limited. Humanitarianorganizations supporting psychosocial and mental healthprograms in conflict- and war-affected countries need tosystematically integrate a longer-term perspective into theirwork. Budgetary support, technical assistance, and incen-tives from the international community can deliver im-mediate and emergency psychosocial support and mentalhealth care, but political will is needed to galvanize the ac-tual reforms that would build and strengthen systems atthe local level. Overall, a dramatic paradigm shift mustoccur from the deployment of short-term “Band-Aids” tolasting investments, staffing, and technical support. Concur-rently, interdisciplinary strategies should be culled from thehealth, business, and management sectors to guide futurepolicy analyses and implementation research in globalmental health, thereby enabling children, adolescents,and their families to be more effectively targeted.

The evidence base for mental health and psychosocial-support interventions for children and adolescents in areasof armed conflict is increasing, and promising interventioneffects have been identified through rigorous research (asdetailed in this article). Still, considerable gaps in knowl-edge remain. Our hope is that the overview provided herecan serve as a foundation for motivating a shift in attentionand for positioning mental health and psychosocial issuessquarely at the heart of global humanitarian and postcon-flict development agendas.

Declaration of interest: The authors report no conflicts ofinterest. The authors alone are responsible for the contentand writing of the article.

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Interventions for Children Affected by War: An Ecological

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