interventions for children affected by armed conflict: a ...interventions for children affected by...

CHILD AND FAMILY DISASTER PSYCHIATRY (B PFEFFERBAUM, SECTION EDITOR)

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

Mark J. D. Jordans1,2 & Hugo Pigott1,3 & Wietse A. Tol4

Published online: 14 January 2016# The Author(s) 2016. This article is published with open access at Springerlink.com

Abstract Over one billion children under the age of 18 live incountries affected by armed conflict. This systematic reviewreplicates an earlier study, aiming to provide a comprehensiveupdate of the most current developments in interventions forchildren affected by armed conflict. For the period 2009–2015, a total of 1538 records were collected from PubMed,PsycINFO, and PILOTS. Twenty-four studies met the inclusioncriteria, and the included interventions involve data from 4858children. Although the number of publications and level of ev-idence has improved since the previous review, there is still ageneral lack of rigor and clarity in study design and reportedresults. Overall, interventions appeared to show promising re-sults demonstrating mostly moderate effect sizes on mentalhealth and psychosocial well-being. However, these positiveintervention benefits are often limited to specific subgroups.There is a need for increased diversification in research focus,with more attention to interventions that focus at strengtheningcommunity and family support, and to young children, andimprovements in targeting and conceptualizing of interventions.

Keywords Armed conflict . Children . Evidence base .

Systematic review . Violence .War

Introduction

Over one billion children under the age of 18 live in countriesaffected by armed conflict [1]. In 2013, 33 armed conflictswere recorded, with the majority in Africa (39 %), Asia(39 %), and the Middle East (12 %) [2]. These conflicts takeplace principally in Blower and middle-income countries^(LMIC), where 90 % of the world’s population of childrenand adolescents live.

Mental health and psychosocial well-being in settings ofarmed conflict are threatened by exposure to violence andother risk factors for mental health such as increased povertyand lack of access to basic services for example healthcare,education, housing, water, and sanitation [3]. In an armedconflict situation, the population is affected in various waysand consequently requires different kinds of support.International consensus guidelines, such as the Inter-AgencyStanding Committee (IASC) guidelines for mental health andpsychosocial support (MHPSS) in emergencies, agree on theneed for a multi-layered system of support that is delivered atdifferent levels of social and health systems [4]. The frame-work emphasizes integrating different forms of support, rang-ing from activities for the population as a whole (for example,providing general humanitarian support with respect to digni-ty and in a participatory manner), non-specialized activitiesthat strengthen protective factors (for example, with a focuson strengthening informal social supports and existing copingmechanisms), and programs that address a smaller percentageof the population displaying significant psychological distressor mental disorders, for whom more specialized support isneeded [5]. In public health terms, these interventions can be

This article is part of the Topical Collection onChild and Family DisasterPsychiatry

* Mark J. D. [email protected]

1 Center for Global Mental Health, Institute of Psychology, Psychiatry& Neuroscience, King’s College London, London, UK

2 Research and Development Department, War Child Holland,Amsterdam, the Netherlands

3 Center for Global Mental Health, London School of Hygiene andTropical Medicine, London, UK

4 Department of Mental Health, Johns Hopkins Bloomberg School ofPublic Health, Baltimore, USA

Curr Psychiatry Rep (2016) 18: 9DOI 10.1007/s11920-015-0648-z

http://crossmark.crossref.org/dialog/?doi=10.1007/s11920-015-0648-z&domain=pdf

divided into promotion (i.e., activities aimed at strengtheningpositive aspects of mental health and well-being), prevention(i.e., activities aimed at making sure mental health problemsdo not develop, for example through action on the social de-terminants of mental health), and treatment (i.e., activities toreduce symptoms and improve functioning in people withidentified mental disorders) [6].

Despite an increase in efforts to evaluate MHPSS for chil-dren and adolescents in areas of armed conflict, there remainimportant gaps in evidence [7]. A previous systematic reviewon psychosocial and mental health interventions for childrenin areas of armed conflict was published in 2009. That reviewconcluded that there is a paucity of rigorous studies. Existingstudies focused predominantly on PTSD as an outcome ofinterventions, and outcomes of evaluations were mixed.Given the time passed since this review, an update is timely[8]. Such an update may be useful in determining where thecurrent focus of interventions lies and whether there arechanges in types of interventions that are commonly imple-mented, as well as their effectiveness. For example, severalauthors have called in the past for paradigm shifts in MHPSSinterventions for populations affected by armed conflict [9,10]. Existing consensus guidelines broadly endorse proposedshifts away from a single focus on treatment of psychologicalsymptoms to contextually appropriate multi-layered systemsof support that build on existing resources. However, we pre-viously did not find such broadening of interest reflected in thepublished peer-reviewed literature.

The purpose of this current systematic review is to assess theevidence of interventions since 2009, providing a current stateof the art overview. The objective is to examine the type andeffectiveness of psychosocial and mental health interventionsfor conflict-affected children. All study designs were assessedin order to broadly summarize the evidence for MHPSS.

Method

Study Selection

The inclusion and exclusion criteria for studies are listed indetail in Appendix 1. In summary, the review includes allstudies that describe, and evaluate the effect of, psychosocialand mental health interventions for children affected by armedconflict in LMIC. The composite term MHPSS is used todescribe any type of local or outside support that aims toprotect or promote psychosocial well-being and/or preventor treat mental disorder [4].

Data Sources and Searches

The search was restricted by language, publication status, anddate. The following electronic databases were used: PubMed/

MEDLINE, PsycINFO, and PILOTS from January 1, 2009 toJuly 20, 2015. The following search terms were used: (child*OR adolescent*) AND (war* OR Bcommunity violence^ ORBarmed conflict^) AND (mental health OR psychosocial)AND (intervention OR treatment). In addition, bibliographiesof eligible papers were manually examined for relevant cita-tions our searches missed. The authors of included studieswere contacted in the event of missing data. After conductingthe searches, we first screened all titles and abstracts for meet-ing inclusion and exclusion criteria outlined above (by HP andcross-checked by MJ). The remaining papers were fully readby two authors to check for papers including MHPSS inter-ventions that assessed an outcome for children affected byarmed conflict in LMIC.

Data Extraction and Risk of Bias Assessment

Data from these selected papers was obtained by using a pre-viously developed [8] standard data extraction form. Thestudy characteristics extracted were theoretical framework,specification of target groups and descriptions of interven-tions, treatment modalities, methodologies, and outcomes.The methodological quality of included studies was assessedby one person using the Cochrane risk of bias tool [11]. Riskof bias was assessed at both study and outcome levels.

Data Synthesis and Analysis

In accordance with our study aims, we conducted two types ofanalysis. First, for an account of intervention descriptions, weused thematic analysis to summarize themes, with a specificfocus on cultural adaptations. Second, all evaluation studiesreporting quantitative data were categorized into level of evi-dence (1 = randomized controlled trials, all types; 2 = quasi-experimental design and controlled studies; 3 = non-controlled design; 4 = case studies; adapted from Morris)[12]. Also, interventions were categorized according to thedifferent levels of the pyramid of the IASC guidelines formental health and psychosocial support in emergencies (i.e.,social considerations in basic services and security, strength-ening community and family supports, focused non-specialized support, specialized services) [4]. To summarizequantitative evaluation studies, Cohen’s d effect size calcula-tions were used to obtain an indication of strength of interven-tion benefits and allow for a comparison of the strength ofintervention benefits (or harms) across interventions. Effectsizes were not adjusted for effects of clustering in cluster ran-domized trials. Effect sizes were graded as less than 0.30small, 0.30 to 0.60 moderate, and above 0.60 large [13]. Thevalidity of the quantitative evaluation studies was assessedusing the Cochrane risk of bias tool [11]. It includes categor-ical variables 1–7 to quantify selection bias consisting of ran-dom sequence generation and allocation concealment (1–2,

9 of 15 Curr Psychiatry Rep (2016) 18: 9

respectively), performance bias comprising of blinding of par-ticipants and personnel (3), detection bias consisting ofblinding of outcome assessment (4), attrition bias detailingincomplete outcome data (5), reporting bias comprising ofselective reporting (6), and other sources of bias consistingof uncovered problems (7). These categorical variables werescored by low risk, high risk, and unclear risk. The methodol-ogy and results are presented according to the PRISMA state-ment for reporting systematic reviews [14].

Results

Figure 1 shows the screening and selection procedure for thisreview. A total of 1538 records were collected from threedatabases. Twenty-four studies met the inclusion criteria.Four studies used the same data set [15-18]. Table 1 providesan overview of all included studies.

Delivery and MHPSS Approach1

The collection of publications focuses on armed conflicts innine countries, with 46% (n=11) of the studies taking place inAsia, 46 % (n=11) in Africa, 4 % (n=1) in Europe, and 4 %(n=1) in a collection of countries. The included 24 publica-tions identified in peer-reviewed journals had the followingstudy designs: five individually randomized controlled trials(RCTs), nine cluster randomized controlled studies, three con-trolled studies, four non-controlled studies, and three casestudies. One case study summarized results of a collection ofstudies and reported high levels of client satisfaction, moder-ate post-treatment problem reductions, and significant levelsof distress for service providers [19]. It was included in theanalysis but excluded from calculating percentages below.

The included quantitative evaluation studies interventionsinvolved data being collected with 4858 children, with justunder two thirds (60 %, n=12) using a school as a deliveryplatform and over a third (40 %, n=8) implemented in com-munity settings. The interventions consisted of 30 % (n=6)MHPSS level 2 activities, 65 % (n=13) level 3, and 5 %(n=1) level 4 initiatives. A non-specialist (a service providerwho did not receive years of training is specialized care) de-livered 90 % of these interventions. The duration varied with55 % (n=11) implemented in 15 sessions or more, 5 % (n=1)had ten to 14 sessions, 30 % (n=6) less than ten sessions, and10% (n=2) did not record the number of sessions. Training ofa delivery agent was stated in 95 % (n=19) of interventions.Eight programs included less than 1 month’s training for the

delivery agent; however, these were for individuals with ex-tensive prior experience working with the study population.Three interventions included 3 months of training. Of all pro-grams, 55 % (n=11) included supervision in order to supportthose implementing interventions and ensure fidelity to theprogram. There were seven interventions (35 %) that imple-mented MHPSS regardless of children’s symptoms (univer-sally), and 13 used a context-sensitive screener (65 %), prin-cipally for those demonstrating traumatic stress reactions.

The interventions targeted post-traumatic stress symptoms(PTSS), internalizing symptoms (depression, anxiety), andbehavioral and emotional problems more generally (e.g., con-duct problems). Eighteen publications (78 %) reported resultson multiple outcome indicators. Of the 11 publications (48 %)that have PTSS as a primary outcome, ten included multipleindicators for internalizing symptoms and behavioral andemotional problems. Two case studies examined potentialmechanisms of effective counseling and were delivered onan individual basis [20, 21]. Almost all programs were groupbased (n=18, 90 %), except for two interventions that includ-ed both group and individual elements [22••, 23••]. A multi-level multi-country program that took a public health ap-proach was reported in eight publications [19-21, 24, 25••,26-28]. This multi-level multi-country program targeted chil-dren with elevated psychosocial distress upon primary screen-ing who were offered a classroom-based intervention. Thosein need of more individualized or specialized care were re-ferred for counseling and psychiatric care if available. Teninterventions involved the family or community in any capac-ity [21, 22••, 23••, 25••, 29-34].

Evidence Base

All publications reported positive promotion, prevention, andtreatment effects on a range of indicators. Eighteen studies(78 %) reported positive effects on their primary outcomes[16, 18, 22••, 23••, 25••, 26-35, 36••, 37, 38], and eight(44 %) of these 18 showed positive impacts on specific sub-groups [16, 18, 26-28, 30, 31, 36••]. Therefore, only ten pub-lications (43 %) reported positive overall promotion, preven-tion, and treatment effects on symptom reduction and im-proved well-being for their primary outcomes.

Improvements were shown on multiple outcome indicatorsfor 16 (70 %) studies [15-18, 22••, 23••, 24, 25••, 26-28,33-35, 37, 38]. Most positive effects were small or moderatein size, with a few studies reporting large effect sizes. Trauma-focused cognitive behavioral therapy (TF-CBT) was used toalleviate distress, for both sexually exploited girls and war-affected boys in Democratic Republic of the Congo, and dem-onstrated large effect sizes (d=2.13 to 2.75 [22••], d=0.64 to2.01 [23••]). A traumatic grief psychotherapy in Palestine re-sulted in significant improvements in PTSS and depressionsymptoms also with large effect sizes (d=0.62–2.38) [38].

1 When calculating percentages of interventions, we have used n= 20 asfour publications report on the same intervention and one case studyreported multiple interventions. For the calculation of percentages ofpublications, n= 23 is used, not including the one with multiple resultson multiple interventions.

Curr Psychiatry Rep (2016) 18: 9 of 15 9

Five (22 %) publications identified negative outcomes.Gender and abduction history interacted to moderate theeffectiveness of group interpersonal psychotherapy (G-IPT) with a small negative outcome on male non-abducted subjects in regards to depression [36••]. Therewere increased PTSS in the experimental group com-pared to control, post-intervention in the student media-tion program in Palestine [37]. A BTeaching RecoveryTechnique^ aiming to improve emotion regulation (ER)and coping abilities actually established that a decreasein ER was associated with improved mental health andpsychosocial well-being [17]. Gender-specific outcomesdemonstrated that girls had greater reduction in PTSSin the waitlist control, compared to the experimentalgroup in a classroom-based intervention in Sri Lanka[28]. The same intervention implemented in Burundi also

reported negative effects for subgroups of children (de-pending on age, household composition, exposure, anddisplacement), with a better outcome for hope and func-tioning in the waitlist control compared to the experi-mental group [27].

Intervention Modalities

Figure 2 outlines the range of intervention modalities mappedon to the multi-layered approach as advocated by the IASCguidelines. The most frequently mentioned modalities werecreative expressive, psycho-educational, and cognitive behav-ioral strategies. Creative expressive approaches emphasizedinteractive activities such as drama, music, role-playing, anddrawing. They aim to build better relationships and improvewell-being. Three interventions had a core (as opposed to

1538 Records identified throughdatabase search641 PubMed660 PsycINFO237 PILOTS

1538 Records screened for criteria basedon title/abstract

1459 Records excluded

79 Full text articles assessed for eligibility

58 Excluded14 Ineligible population33 Ineligible intervention11 Ineligible publication type

21 Articles included

3 Articles included from bibliographies

24 Articles included in systematic review

Fig. 1 Study flowchart


Tab

le1

Evidencebase

(n=24,consistingof

20interventio

ns)

Reference,

country

Age

(years),

gender,sam

ple

Modality

(level),

focus

Delivery

Level

Bias

Training(T)and

supervision(S)

Culturaladaptations

Prim

aryoutcom

e(PO)

andcomponents(C)

Results(R)andeffectsize

(d)

Ager(2011)

[29],

Uganda

7–12,50%

Mand50

%F,

N=403

Level2,well-being

15groupsessions

for5weeks

deliv

ered

bynon-specialist

(teacher)

21=high

T=yes

S=notstated

Interventio

nincorporates

needsof

child

andlocal

community

Instrumentscreated

throughFG

Dwith

child

ren,parents,and

teachers

PO=well-being

C=school-based

recrea-

tionaland

connectiv

ityactiv

ities

R=well-beingim

proved

morein

experimental

groupcomparedtocontrol.

Predictorsforwell-being

weregroupassignments

andage.

d=0.18–0.64(w

ell-being)

2=unclear

3=high

4=high

5=high

6=unclear

7=high

Barron(2012)

[35],P

alestin

e11–14,59

%M

and41

%F,

N=140

Level3,PT

SS/

depression/grief

5groupsessions

for5weeks

deliv

ered

bynon-specialist

(counselor)

11=low

T=counselor3

days

S=observed

classes

Interventio

ntranslated

inArabic

Instrumentadaptations

notstated

PO=PT

SSanddepression

C=school-based

TF-CBT

R=significantd

ecreases

across

allindicatorsin

experimentalg

roup

comparedto

control.

Studentsreported

their

experiencesas

very

positiv

e.d=0.76

(PTSS

)d=1.24

(depression)

d=0.90–0.96(emotionand

behavior)

2=unclear

3=unclear

4=unclear

5=high

6=unclear

7=high

Betancourt(2012)

[36],U

ganda

14-17,43

%M

and57

%F,

N=304

Level3,depression

16groupsessions

for16

weeks

deliv

ered

bynon-specialist

(facilitators)

11=low

T=facilitator

2weeks

S=weekly

Interventio

nadaptedand

tested

andqualitative

workshow

scompatib

ility

with

targetgroup

Instrumentsbasedon

previous

qualitativ

eworkon

samesites

PO=moderatorsof

depression

C=community

-based

G-

IPTfocusedon

triggers

andgrouprelatio

nships

R=gender

andabduction

moderated

the

effectivenessof

G-IPT

ondepression.F

emalenon-

abducted

greatestim

-provem

entand

malenon-

abducted

hadanegativ

eim

pact.

d=1.06

(fem

alenon-

abduction)

d=−0

.02(m

alenon-

abduction)

2=high

3=low

4=low

5=high

6=unclear

7=low

Claessens

(2012)

[30],U

ganda

10–15,not

stated,

N=510

Level2,well-being

Group

sessions

for

17weeks

deliv

ered

bynon-specialist

(socialw

orker)

31=high

T=socialworker

1day

S=notstated

Interventio

nspecifically

forconflict-affected

areasbutadaptations

notstated

Instrumentsused

not

clinical,m

ixed-

methods

approach

PO=well-being

C=school-based

recreatio

naland

connectiv

ityexercises

R=54.3%

child

renachieved

theirgoal.T

hemed

quiz

child

rengot8

7%

answ

ers

correct.Interactionhelped

build

betterrelationships

andreported

improved

well-being.

d=N/A

2=high

3=high

4=high

5=high

6=unclear

7=high

Diab(2014)

[17],

Palestine

10–13,51

%M

and49

%F,

N=482

Level3,social

supportimpacting

PTSS

/depression

Tim

efram

enot

stated,

deliv

ered

bynon-specialist

(counselor)

11=low

T=yes

S=weekly

Interventio

npreviously

foundto

beeffective

inPalestin

echild

ren

butadaptations

not

stated

Instrumentsused

insetting

before

but

adaptatio

nsnotstated

PO=peer

andsibling

relatio

nsC=school-based

TF-CBT

R=gender-specificresults.

Lonelinessinpeerrelations

reducedam

ongboys

and

siblingrivalryam

onggirls.

Interventio

ndecreased

mentalh

ealth

problemsby

improvingpeer

relatio

ns.

d=N/A

2=unclear

3=unclear

4=unclear

5=high

6=unclear

7=high


Tab

le1

(contin

ued)

Reference,

country

Age

(years),

gender,sam

ple

Modality

(level),

focus

Delivery

Level

Bias

Training(T)and

supervision(S)

Culturaladaptations

Prim

aryoutcom

e(PO)

andcomponents(C)


(d)

Diab(2015),[15]

Palestine

10–13,51

%M

and49

%F,

N=482

Level3,social

supportimpacting

resiliency

Tim

efram

enot

stated,

deliv

ered

bynon-specialist

(counselor)

11=low

T=yes

S=weekly

Interventio

nfoundto

beeffectivein

Palestine

child

renpreviously

butadaptations

not

stated

Instrumentsused

insetting

before

but

adaptatio

nsnotstated

PO=resilienceand

moderatingroleof

family

factors

C=school-based

TF-CBT

R=didnotincreaseresilience

(defined

asprosocial

behavior

andwell-being)

butimproved

quality

ofpeer

andsiblingrelatio

ns.

d=N/A

2=unclear

3=unclear

4=unclear

5=high

6=unclear

7=high

Eiling

(2014),

[31]

South

Sudan

8–16,60%

Mand40

%F,

N=122

Level2,well-being

19groupsessions

for4–6months

deliv

ered

bynon-specialist

(com

munity

worker)

31=high

T=community

worker3days

S=notstated

Interventio

nspecifically

forconflict-affected

areasbutadaptations

notstated

Instrumentsused

not

clinical,m

ixed-

methods

approach

PO=well-being

C=school-based

recrea-

tionaland

connectiv

ityexercises

R=48

%respondentsstated

they

noticed

significant

personalim

provem

ents.

Mainchangesreported

weredecreasedfightin

gandim

proved

relatio

nships.

d=N/A

2=high

3=high

4=high

5=high

6=unclear

7=high

Hasanovic

(2009),[32]

Bosniaand

Herzegovina

12–15,32

%M

and68

%F,

N=408

Level3,PT

SS20

groupsessions

for20

weeks

deliv

ered

bynon-specialist

(student,teach-

er,parent)

21=high

T=students15

h,teachers15

h,parents14

hS=notstated

Interventio

nmodifiedto

match

participants

needs

Instrumentsadaptations

notstated

PO=PT

SSC=school-based

psycho-

educativeandexpressive

classes

R=PT

SSdecreased

significantly

inexperimentalg

roup

comparedto

control.

Indicatio

nPT

SSmay

betransm

itted

through

caregivers.

d=0.14

(PTSS

)

2=high

3=high

4=unclear

5=low

6=unclear

7=high

Jordans(2010),

[24]

Nepal

11–14,51

%M

and49

%F,

N=325

Level3,PT

SS/

depression/

behavioraland

emotional

problems

15groupsessions

for5weeks

deliv

ered

bynon-specialist

(intervention-

ists)

11=low

T= interventio

nists

15days,local

researcher

3weeks

S=regularly

Interventio

nadaptatio

nsnotstated

Instrumentstranslated

andtested

for

reliabilitywith

subgroup

PO=PT

SSanddepression

C=school-based

creativ

eexpressive

focusedCBT

with

distincttraumafo-

cus

R=no

maineffectsfound,but

severalm

oderatesubgroup

effectson

prosocial

behavior,sense

ofhope,

aggression,and

psychologicald

ifficulties.

The

interventionim

proved

genericpsychosocial

problems.

d=0.1(PTSS

)d=0.46

(depression)

2=unclear

3=high

4=high

5=low

6=unclear

7=unclear

Jordans(2011),

[19]

Burundi/

Indonesia/Sri

Lanka/Sudan

7–15,N

/A,N

/ALevel2/3,N/A

Differentdurations

deliv

ered

bynon-specialist

(com

munity

workers,facili-

tators,counsel-

or)

41=N/A

T=community

worker1/2

weeks,facilita-

tor3weeks,

counselor4

months

S=notstated

N/A

PO=N/A

C=presentsamulti-layered

modelforcommunity

-basedcare

follo

wing

publichealth

approach

R=multi-layeredsystem

isfeasible,highlevelsof

cli-

entsatisfaction;

post-

treatm

entp

ositive

changes

reported.R

elativelyhigh

distress

toservicepro-

viders

d=N/A

2=N/A

3=N/A

4=N/A

5=N/A

6=N/A

7=N/A


Tab

le1

(contin

ued)

Reference,

country

Age

(years),

gender,sam

ple

Modality

(level),

focus

Delivery

Level

Bias

Training(T)and

supervision(S)

Culturaladaptations

Prim

aryoutcom

e(PO)

andcomponents(C)


(d)

Jordans(2012),

[21]

Burundi

11–14,18

%M

and82

%F,

N=11

Level3,mechanism

sof

counseling

8individual

sessions

for8

weeks

delivered

bynon-

specialist

(counselor)

41=high

T=counselor3

months,local

researcher

4weeks

S=notstated

Interventio

nadaptatio

nsnotstated


andscales

created

throughqualitativ

ework

PO=treatm

entm

echanism

sC=community

-based

counselin

gfocuson

indi-

vidualem

powerment

R=Po

sitiv

eresults

associated

with

counselor

demonstratin

greflectiv

einvolvem

ent,absence

moralistic

behavior,

opportunity

toexpress

emotions

andinclusionof

family.

d=N/A

2=high

3=high

4=high

5=low

6=unclear

7=high

Jordans(2013),

[25]

Burundi

10–14,49

%M

and51

%F,

N=97

Level3,depression/

behavioralprob-

lems/socialsup-

port

2groupsessions

deliv

ered

toparentsby

non-

specialist

(counselor)

21=high

T=counselor3

months,local

assessor

2days

S=notstated

Interventio

nadaptatio

nsnotstated

Instrumentstranslated,

back

translated

and

FGDsused

PO=depression

and

aggression

C=community

-based

men-

talh

ealth

problem

man-

agem

entstrategiesfocus

psycho-education

R=reducedaggression

comparedto

control,

especially

amongboys.

Did

notshowim

pacton

depression

symptom

sand

parentsevaluatedthe

interventio

npositiv

ely.

d=0.08

(depression)

d=0.60

(aggression)

2=unclear

3=unclear

4=unclear

5=low

6=unclear

7=high

Jordans(2013),

[20]

South

Sudan

10–15,33

%M

and67

%F,

N=6

Level3,mechanism

sof

counseling

8individual

sessions

for8

weeks

delivered

bynon-

specialist

(counselor)

41=high

T=counselor3

months,local

researcher

4weeks

S=notstated

Interventio

nadaptatio

nsnotstated


andscales

created

throughqualitativ

ework

PO=treatm

entm

echanism

sC=community

-based

counselin

gfocuson

indi-

vidualem

powerment

R=positiv

eresults

associated

with

quality

ofrelatio

nship,levelo

fclient

activ

ation,andability

ofcounselorto

match

treatm

enttoproblems.

d=N/A

2=high

3=high

4=high

5=low

6=unclear

7=high

McM

ulle(2013),

[22]

Dem

ocratic

Republic

ofthe

Congo

13–17,100%

M,N

=50

Level3,PT

SS/

internalizing

symptom

s/behav-

ioralp

roblem

s

15groupandone-

to-one

sessions

deliv

ered

byspecialistand

non-specialist

(counselor,au-

thor)

11=low

T=daily

S=evaluatio

nsessions

held

daily

Interventio

nadaptedand

modifiedincluding

culturally

applicable

analogiesand

exem

plars

throughout


andFGDsused

PO=PT

SS,depression,and

anxiety

C=community

-based

TF-

CBTincorporatingcop-

ingandprocessing

skills

R=highly

significant

decreasesacross

all

indicatorsin

experimental


Treatmentg

ains

maintainedat3-month

fol-

low-up.

d=2.75

(PTSS

)d=2.13

(depression/anxiety)


behavior)

2=low

3=unclear

4=unclear

5=low

6=unclear

7=unclear

O’Callaghan

(2013),[23]

Dem

ocratic

Republic

ofthe

Congo

12–17,100%

F,N=52

Level3,PT

SS/

internalizing

symptom

s/behav-

ioralp

roblem

s

15groupandone-

to-one

sessions

bynon-

specialist(so-

cialworker,

evaluator)

11=low

T=yes

S=evaluatio

nsessions

held

daily

I nterventio

nadaptedand

modifiedthrough

daily

meetin

gswith

community

involvem

ent


FGDsused

and

piloted

PO=PT

SS,depression,and

anxiety

C=community

-based

TF-

CBTincorporatingcop-

ingandprocessing

skills

R=highly

significant

decreasesacross

all

indicatorsin

experimental


Contin

ualimprovem

ents

after3months.

d=2.01

(PTSS

)d=2.01



behavior)

2=low

3=unclear

4=low

5=low

6=unclear

7=unclear


Tab

le1

(contin

ued)

Reference,

country

Age

(years),

gender,sam

ple

Modality

(level),

focus

Delivery

Level

Bias

Training(T)and

supervision(S)

Culturaladaptations

Prim

aryoutcom

e(PO)

andcomponents(C)


(d)

O’Callaghan

(2014),[33]

Dem

ocratic

Republic

ofthe

Congo

7–18,55%

Mand45

%F,

N=159

Level2,PT

SS/

internalizing

symptom

s/behav-

ioralp

roblem

s

8groupsessions

for3weeks,

deliv

ered

bynon-specialist

(locallay

workers)

11=low

T=locallay

worker2days

S=evaluatio

nsessions

held

daily

Interventio

nadapted

with

community

leadersand

facilitatorsto

assess

impactandmake

cultu

ralchanges


back

translated

and

piloted

PO=PT

SS,depression,and

anxiety

C=community

-based

psy-

cho-educativeclassesfo-

cuson

communication

andresolutio

n

R=Moderatereductions

across

allindicatorsin

experimentalg

roup

comparedto

control.

Similarresults

3month

follo

w-up.

d=0.40

(PTSS

)d=0.09



behavior)

2=low

3=low

4=low

5=low

6=unclear

7=unclear

Peltonen(2012),

[37]

Palestine

10–14,64

%M

and36

%F,

N=225

Level2,PT

SS/

internalizing

symptom

s/behav-

ioralp

roblem

s

Individual

sessions

for8

months

deliv

ered

bynon-specialist

(students)

11=low

T=yes

S=monthly

workshops

and

sessions

Interventio

nshow

ntobe

effectivein

Palestine

Instrumentsshow

ntobe

reliablewith

Palestinechild

ren

Adaptations

notstated

forinterventio

nor

instruments

PO=PT

SS,depression,and

distress

C=school-based

psycho-

educativefocuson

com-

municationandresolu-

tion

R=sm

allreductio

nsacross

indicatorsin

experimental


How

ever,increaseinPT

SSin

experimentalg

roup

but

notcontrol.

d=0.12

(PTSS

)d=0.32

(depression)

d=0.01–044

(emotionand

behavior)

2=unclear

3=unclear

4=unclear

5=high

6=unclear

7=high

Punamaki(2014),

[17]

Palestine

10–13,51

%M

and49

%F,

N=482

Level3,em

otion

regulatio

nim

pactingmental

health

8groupsessions

for4weeks

deliv

ered

bynon-specialist

(counselor)

11=low

T=yes

S=weekly

meetin

gs

Interventio

nfoundto

beeffectivein

Palestine

children

Instrumentsused

insetting

before

Adaptations

notstated

forinterventio

nor

instruments

PO=em

otionregulatio

nC=school-based

TF-CBT

R=noteffectivein

changing

emotionregulatio

n(ER),

andERdidnotm

ediatethe

interventio

neffectson

child

ren’sMH.A

decrease

inERwas

associated

with

bettermentalh

ealth

.d=N/A

2=unclear

3=unclear

4=unclear

5=high

6=unclear

7=high

Qouta(2012),

[18]

Palestine

10–13,51

%M

and49

%F,

N=482

Level3,PT

SS/

depression/

distress

8groupsessions

for4weeks

deliv

ered

bynon-specialist

(counselor)

11=low

T=yes

S=weekly

meetin

gwith

author

Interventio

neffectivein

child

rentraumatized

inwar

Instrumentsused

insetting

before

Adaptations

notstated

forinterventio

nor

instruments

PO=PT

SS,peri-traumatic

dissociatio

n,anddepres-

sion

C=school-based

TF-CBT

R=subgroup

effectswith

reductionPT

SSam

ong

boys,girlshadreductions

inPT

SSifthey

show

edlowperi-traum

aticdissoci-

ation.

d=0.13

(PTSS

)d=−0

.09(depression)

2=unclear

3=unclear

4=unclear

5=high

6=unclear

7=high

Staples(2011),

[38]

Palestine

8–18,63%

Mand37

%F,

N=129

Leve l4,PT

SS/

depression

10groupsessions

for5weeks

deliv

ered

byspecialist

(mentalh

ealth

professional)

31=high

T=notstated

S=notstated

Interventio

nadaptatio

nsnotstatedbutp

roven

tobe

effectivein

Kosovo


andback

translated

PO=PT

SSanddepression

C=community

-based

trau-

maticgriefpsychothera-

py

R=significantly

reduced

PTSS

anddepression

and

decreasedsenseof

hopelessness.W

ithgains

maintainedat7months

follo

w-up.

d=2.38

(PTSS

)d=0.74

(depression)

d=0.62

(hopelessness)

2=high

3=high

4=unclear

5=high

6=unclear

7=high


Tab

le1

(contin

ued)

Reference,

country

Age

(years),

gender,sam

ple

Modality

(level),

focus

Delivery

Level

Bias

Training(T)and

supervision(S)

Culturaladaptations

Prim

aryoutcom

e(PO)

andcomponents(C)


(d)

Thabet(2009),

[34]

Palestine

6–16,87%

Mand13

%F,

N=304

Level2,behavioral

problems

Group

sessions

deliv

ered

bynon-specialist

(student)

31=low

T=yes

S=notstated

Interventio

ntranslated

into

Arabic

Instrumentsdeveloped

andvalidated

inPalestine

Adaptations

notstated

forinstruments

PO=behavioralproblems

C=school-based

psycho-

educativefocuson

com-

municationandresolu-

tion

R=sm

allreductio

nsin

behavior

anddepression,

decreasesin

hyper-activ

ityreported

bychild

ren.Par-

entsreported

decrease

inobsessiveandoveranxious

symptom

s.d=0.06–0.17(behavior)

d=0.03–0.11(depression)

2=unclear

3=high

4=high

5=unclear

6=unclear

7=high

Tol(2010),[26]

Indonesia

7–15,51%

Mand49

%F,

N=403

Level3,social

supportm

ediatin

gandmoderating

PTSS

15groupsessions

for5weeks

deliv

ered

bynon-specialist

(counselor)

11=low

T=counselor3

weeks

S=yes

Interventio

nadaptatio

nsnotstated

Instrumentstranslation

andstatistical

techniques

used

PO=hope

andsocial

support

C=school-based

creativ

eexpressive

techniques

combining

CBT

R=treatm

entshowed

maintainedhope

and

increasedsocialsupport.

Play

socialsupport

associated

with

smaller

reductions

inPT

SS.G

irls

show

edlarger

treatm

ent

benefitsin

PTSS

.d=N/A

2=high

3=high

4=high

5=unclear

6=unclear

7=unclear

Tol(2012),[28]

SriL

anka

9–12,61%

Mand39

%F,

N=399

Level3,PT

SS/

depression/

behavioraland

emotional

problems

15groupsessions

for5weeks

bynon-specialist

(counselo r)

11=low

T=yes

S=yes

Bothfor1year

priorto

study

Interventio

nadaptatio

nsnotstated


FGDs,andinterviews

used

PO=PT

SSanddepression

C=school-based

creativ

eexpressive

techniques

combining

CBT

R=maineffecton

conduct

problems.Several

subgroup

benefits

identified.Negativeresults

PTSSforgirls

d=−0

.05(PTSS

)d=0.10

(depression)

2=unclear

3=unclear

4=unclear

5=unclear

6=unclear

7=unclear

Tol(2014),[27]

Burundi

8–17,52%

Mand48

%F,

N=329

Level3,PT

SS/

depression/

behavioraland

emotional

problems

15groupsessions

for5weeks

bynon-specialist

(counselor)

11=low

T=yes

S=yes

Bothfor1year

priorto

study

Interventio

nsadaptatio

nsnotstated


FGDs,andinterviews

used

PO=PT

SSanddepression

C=school-based

creativ

eexpressive

techniques

combining

CBT

R=no

maineffects.Six

favorableandtwo

unfavorablesubgroup

effectsidentified,

moderated

byage,

householdcompositio

n,exposure,and

displacement

d=−0

.02(PTSS

)d=−0

.03(depression)

2=unclear

3=unclear

4=unclear

5=high

6=unclear

7=unclear

Modality

andlevelwerecategorizedaccordingto

theInter-AgencyStandingCom

mittee

mentalhealth

andpsychosocial

supportpyramid

(level

1=socialconsiderations

inbasichealth

services

and

security,level2=strengtheningcommunity

andfamily

supports,level3=focusednon-specialized

care,level4=specialized

services)[19].L

evelistheevidence

levelo

fstudydesign

[12]

Mmale,Ffemale,Nsamplesize,P

TSS

post-traum

aticstress

symptom

s,FGDsfocusedgroupdiscussions,TF

-CBTtrauma-focusedcognitive

behavioraltherapy,G-IPTgroupinterpersonaltherapy


inclusive) focus on creative expressive activities [29-31]. Thecase studies that investigated counseling mechanisms usedface-to-face engagement and supportive strategies centeredon empowering the participant to reduce psychological andmental health problems [20, 21]. Other publications reportedpsycho-education and psychotherapies as strategies to im-prove the mental health and psychosocial well-being of chil-dren affected by armed conflict. Psycho-educational activitieswere implemented in five studies that focused on resilience,stress management, and conflict resolution [25••, 32-34, 37].The psychotherapies targeting specific psychopathology re-ported: trauma-focused CBT [15-18, 22••, 23••, 35], interper-sonal psychotherapy [36••], traumatic grief psychotherapy

[38], and combined creative expressive activities with CBT[24, 26-28].

As can be seen in Fig. 2, there are no interventions inthe dataset that focused on social considerations in basichumanitarian services and security, and a large majority ofthe programs investigated focused non-specialized sup-port. Most mental health and psychosocial promotion in-terventions were school based. Only one study focused onthe top level that represents the treatment of subgroups ofchildren diagnosed with a mental health disorder who re-quired more focused individualized care. A grief psycho-therapy in Palestine as reported above aimed to treat thosewho were diagnosed with PTSD [38].

Specialised

services

n=1 (5%)

Focused non-specialised supports

n=13 (65%)

Strenghtening community and family supports

n=6 (30%)

Social consideraions in basic services and security

n=0 (0%)

Specialised servicesEg, Mental health care by mental health specialist (psychologists, psychiatrist, mental health nurse etc) Intervention delivered:

Traumatic grief psychotherapy (1 NCCT)38

Focused non-specialised supportsEg, basic mental health care by primary health-care doctors, basic emotional support by community workers.Intervention delivered:

School and community based, group trauma focused-CBT (3 RCT)22, 23,

35

Classroom based intervention, creative expressive focused-CBT (4 CRCT)24, 26-28

Group interpersonal psychotherapy (1 RCT)36

Reconciliation in education (1 CCT)32

Psycho-education and management strategies for parents (1 CCT)25

Group trauma focused-CBT (1 CRCT- four publications)15-18

Individual counseling (2 CS)20, 21

Strengthening community and family supportsEg, activating social networks, communal traditional supports, supportive child-friendly spacesInterventions delivered:

Communication and resolution in education (1 RCT, 1 CRCT, 1 NCCT)33, 34, 37

Recreational and connectivity activities (1 CCT, 2 NCCT)29-31

Fig. 2 Included interventionsmapped onto care framework


There were also two case studies evaluating treatmentmechanisms of counseling in Burundi and South Sudanfor children in need of individual-level care; however,counseling was provided by a non-specialist (hence in-cluded in the focused care level) [20, 21]. Positive resultswere associated with an explicit trust formation and dis-closure, active problem solving, structural trauma-focusedexposure, family involvement, and parental support. Bothstudies reported displaying a moralistic attitude incounseling had a negative impact on a child’s mentalhealth and psychosocial well-being.

Within Study Bias2

The RCT(s) implemented in the Democratic Republic ofthe Congo were the only interventions to have low riskfor both subsections of selection bias [22••, 23••, 33].High risk and unclear risk of bias for blinding of theparticipants and personnel (performance bias) were cod-ed in 50 % (n= 10) and 40 % (n= 8) of the interven-tions, respectively. Three publications (15 %) scoredlow for risk on blinding of outcome assessment (detec-tion bias). Incomplete data representing loss to follow-up was coded as high risk in 45 % (n= 9) and unclearrisk in 15 % (n= 3) of the interventions. Determiningwhether statistical results were selectively withheld fromthe publication was problematic to establish; conse-quently, reporting bias was coded as 100 % unclearrisk. Other sources of bias such as contamination ofcontrols were determined to be 60 % (n= 12) high risk.Of the possible 140 high, low, and unclear risks of biasscores, 40 % (n= 56) were unclear and 39 % (n= 55) ofscores were considered as high risk.

Cultural Modifications and Key Themes

With interventions delivered in nine different countries, it isimportant to review cultural adaptations. Instrument adapta-tions by translation and back translation, focus group discus-sions (FGD), and pilotingwere outlined in 60% (n=12) of thestudies [20, 21, 22••, 23••, 24, 25••, 26-29, 33, 38]. Promotion,prevention, and treatment approaches were culturally modi-fied in 40 % (n=8) of the interventions [22••, 23••, 29, 32-35,36••]. However, few gave detailed accounts of any actual ad-aptations made. The publications appeared to mainly reportminor changes for instance translation of the manual and smallalterations to session themes, making no changes to the

overall structure of interventions. The interventions detailingtheir cultural adaptations such as culturally applicable analo-gies and examples throughout the modified program manualhad the largest effect sizes of the review [22••, 23••]. Bothwere randomized controlled trials.

Although 70 % (n=16) of studies reported specific inter-vention effects in certain subgroups, only one study tailoredtheir intervention by splitting groups by age and gender [33].Fifty-two percent of the publications recommended that futureinterventions should apply multi-levelled approaches [15, 17,20, 22••, 23••, 24, 25••, 26-28, 33, 36••]. Eight studies usedintervention approaches with a focus beyond children’s indi-vidual symptomology, incorporating community/caregiver as-pects [21, 22••, 23••, 25••, 29, 30, 32, 33]. The community/caregiver aspects included helping the elderly, planting trees,psycho-educational classes for parents, a graduation ceremo-ny attended by key figures in the community, and the creationof a community advisory board to assist with implementation.Feedback on treatment quality and satisfaction were onlyascertained from children in 13 % (n=3) of publications[30, 31, 35]. The delivery agent’s relationship with the partic-ipant was described as integral to positive treatment effects inboth publications on mechanisms of counseling [20, 21].However, only one study gave a rationale for their recruitmentstrategy [23••].

Discussion

The results of this systematic review, covering the period2009–2015, illustrate the current modalities and evidence ofpsychosocial and mental health interventions for children af-fected by armed conflict in LMIC.

Summary

All 24 identified publications reported positive benefits(i.e., promotion, prevention, or treatment) associated withevaluated interventions. However, under half (43 %) ofthese demonstrated an overall positive impact on theirprimary outcomes, and five studies (22 %) displayed neg-ative effects. Therefore, the interventions may have im-proved some children’s mental health but underminedthe natural recovery of others. Most mental health andpsychosocial interventions were school based, which asa group demonstrated mixed results. The evidence sug-gests that interventions often resulted in specific subgroupeffects. The school-based interventions mainly reportedsmaller effect size impacts on symptom reduction of pri-mary outcomes and more positive effects on secondaryoutcomes (mostly not disorder-specific outcomes, for ex-ample behavioral problem, or protective factors such ashope and social support). Nine different countries were

2 Four studies used one data set; study bias was recorded from the originalpublication [18]; therefore, percentages are based on n = 20 (publicationwith multiple interventions excluded).


included in the review; however, few cultural adaptationswere made. Adapting interventions to the cultural contextmay lead to added impact, for example inviting commu-nity leaders and stakeholders in helping to design pro-grams, thus being empowered with a voice in the designof the intervention that will match the communities’ needs[39]. Although numerous publications detailed moderatorsand mediators of MHPSS, children and adolescents wererarely consulted for their experiences. Effects of individ-ual counseling for children were moderated by the rela-tionship the client had with their counselor, the structureand components of care, and family involvement andsupport.

Comparison

This updated systematic review detailed both differencesand similarities to the previous systematic review con-ducted 5 years prior. There is a greater quantity of inter-ventions evaluated in the updated review, with 24 studiesidentified over a 5-year period compared to a previous 12studies (for the period 2009 and before). Using the classesof evidence by Morris that have been adapted, interven-tions were levels 1 or 2 for 70 % (n = 14) of studies,where previously it was 42 % (n= 5) [12]. This suggestsan encouraging improvement in evidence for efficacy andeffectiveness of MHPSS for children affected by armedconflict. The inclusion of stronger study designs assistsin establishing causality between intervention approachand positive outcomes. However, only two of the currentstudies had majority low risk of bias scores; this reducesthe potential validity of reported results from the includedinterventions [23••, 33]. Although the level of evidencefrom study design appears to have improved, there is stilla lack of rigor for many of the evaluations. The process inwhich interventions are implemented also needs greaterdescription, particularly with regards to cultural adapta-tion. There is a lack of clarity in reported study design,implementation, and results.

The results demonstrate moderate effect sizes in alarge majority of the publications and a major focuson PTSD; this was also the case in the 2009 review.However, the current review also includes studies withlarge effects and most studies also assessed depressionand/or behavioral problems. This may have been theresult of the ongoing debate about interventions thatsolely focus on the individual’s conflict exposure andPTSD symptoms, without also addressing broader riskand protective systems factors [7, 9, 10]. Per illustra-tion, in Kabul, war exposure accounted for only 15 %of the variance in PTSD symptom levels, and in Sri

Lanka, it was 8 %. Similarly, direct exposure accountedfor 2 % of the variance in distress levels in Palestinianyouth and only 1 % of the variance in PTSD symptomlevels was attributable to the violence experienced inSudan for Darfurian refugees in Chad [10]. A dailystressors model to outline these results indicated a needto incorporate environmental and societal factors whendesigning interventions. Multi-levelled interventions thatincorporated a community-based approach were advocat-ed in the previous review. Although a multi-levelledcare package was included in the current review, fewstudies implemented an intervention that aimed to inte-grate into the existing local health or social systems (astrategy advocated to promote sustainability [40]).Multi-level interventions were much more representedin the current review; however, these publications allstem from one multi-country program [19-21, 24, 25••,26-28].

Implications

There are continuing gaps in the literature that exploreseffectiveness of mental health and psychosocial supportinterventions for children affected by armed conflict.First, while most of the interventions being implementedin humanitarian settings are geared towards strengtheningcommunity support (e.g., activating social networks, sup-portive child-friendly spaces—level 2 in Fig. 2), mostresearch attention still goes to focused interventions, es-pecially CBT. More diversification in research focus istherefore called for. Few publications focus on parentsand families. Given existing evidence of parenting inter-ventions in high-income setting, and the promising resultsfrom the brief parenting psycho-education intervention inBurundi [25••], family-oriented interventions should befurther explored. Specifically, as a focus on young chil-dren (below 6 years of age) is entirely lacking in thecurrent review. Also, the role of physical activities in in-terventions may be further explored. Several systematicreviews have reported an association between physicalactivity and improved self-esteem, social interaction, andlower levels of depression and anxiety for children[41-43].

Second, although we find that there are overall pos-itive benefits of evaluated intervention for subgroups ofchildren, we also identified studies with negative im-pacts. In our opinion, this calls for better targeting andimproved conceptual development of interventions. Thedescribed interventions often consisted of multiple ele-ments and often focused on children in settings ofarmed conflict broadly. Nevertheless, publications rarely


outlined how specific intervention elements were aimedat addressing specific paths of a causal pathway. Fewintervention descriptions described a theory of changethat outlined how interventions may affect different sub-groups of children, even though interventions were im-plemented in complex and dynamic environments withongoing adversity threatening mental health and well-being. Similarly, we found that interventions that hadvery different goals (ranging from promotion, to preven-tion, to treatment) often applied the same outcome mea-sures, rather than select outcome measures that matchedintervention goals. We feel that further sophistication intailoring interventions to specific socio-cultural contextsand conflict settings could help mitigate the negativeeffects that were identified in the identified studies.

Limitations

A few limitations of the systematic review methodologyshould be noted. The review searched three databases andonly peer-reviewed articles were included, excluding any grayliterature. Primary outcomes were often not stated thereforethey were assigned to categories based on the core interven-tion focus. Furthermore, publications targeting children andadults simultaneously were excluded if the majority of thesample was adult at the time of intervention, yet they stillmay yield important findings for the review. For example, acommunity-implemented intervention using narrative expo-sure therapy demonstrated positive results on former childsoldiers even after a 1-year follow-up period [44]. TheCohen’s d effect sizes are established from a single post-intervention time point, neglecting natural recovery and base-line differences between groups. Cohen’s d effect sizes cantherefore be an under- or overestimate of the interventioneffect.

Conclusion

Although the number of publications and level of evidencehave improved, there is still a general lack of rigor and clarityin study and intervention design and reported results. Someinterventions show promising results demonstrating mostlymoderate effect sizes on mental health and psychosocialwell-being, albeit often for subgroups. CBT-based interven-tions, and the school as the delivery platform, are the mostcommonly reported. There is a need for increased diversifica-tion in research focus, withmore attention to interventions thatfocus at strengthening community and family support, and toyoung children, and improvements in targeting and conceptu-alizing of interventions.

Compliance with Ethical Standards

Conflict of Interest Mark J.D. Jordans, Hugo Pigott, andWietse A. Toldeclare that they have no conflict of interest.

Human and Animal Rights and Informed Consent This article doesnot contain any studies with human or animal subjects performed by anyof the authors.

Appendix 1

Table 2 Inclusion and exclusion criteria for review

Included Excluded

Publication type Date (1 January 2009) to(20 July 2015)

Only lower and middle-income countries(LAMIC)

Only studies reported inEnglish peer-reviewed journals

Study design All study designs

Study population Child and adolescentpopulation affectedby armed conflict

Adult refugees in high-income countries(HIC)

Definition mentalhealth

State of well-being inwhich every individ-ual can cope with thestresses of life, canwork productively,and is able to make acontribution to theircommunity [45]

Definition of mentalhealth andpsychosocialsupport (MHPSS)

MHPSS is used todescribe any type oflocal or outsidesupport that aims toprotect or promotepsychosocial well-being and/or preventor treat mental disor-der [4]

Interventions notevaluated MHPSSnot specific to studypopulation

Definition of childand adolescent

A person of age 18 orbelow

Definition of armedconflict

Whenever there is aresort to armed forcebetween states orprotracted armedviolence betweengovernmentalauthorities andorganized armedgroups or betweensuch groups within astate [46]

Non-war-relatedviolence

Natural disasters

Outcome Clinical outcomesPsychosocial outcomes


Open Access This article is distributed under the terms of the CreativeCommons At t r ibut ion 4 .0 In te rna t ional License (h t tp : / /creativecommons.org/licenses/by/4.0/), which permits unrestricted use,distribution, and reproduction in any medium, provided you giveappropriate credit to the original author(s) and the source, provide a linkto the Creative Commons license, and indicate if changes were made.

References

Papers of particular interest, published recently, have beenhighlighted as:• Of importance•• Of major importance

1. United Nations International Children’s Emergency Fund(UNICEF), United Nations. Office of the Special Representativeof the Secretary-General for Children Armed Conflict. Machelstudy 10-year strategic review: children and conflict in a changingworld. New York: UNICEF; 2009.

2. Themner L, Wallensteen P. Armed conflicts, 1946–2013. J PeaceRes. 2014;4(51):541–54.

3. World Bank. Mental health and conflicts: conceptual frameworkand approaches. Washington: World Bank; 2005.

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