Figure 1 shows the screening and selection procedure for this review. A total of 1538 records were collected from three databases. Twenty-four studies met the inclusion criteria. Four studies used the same data set [15-18]. Table 1 provides an overview of all included studies.
Delivery and MHPSS Approach
The collection of publications focuses on armed conflicts in nine countries, with 46 % (n = 11) of the studies taking place in Asia, 46 % (n = 11) in Africa, 4 % (n = 1) in Europe, and 4 % (n = 1) in a collection of countries. The included 24 publications identified in peer-reviewed journals had the following study designs: five individually randomized controlled trials (RCTs), nine cluster randomized controlled studies, three controlled studies, four non-controlled studies, and three case studies. One case study summarized results of a collection of studies and reported high levels of client satisfaction, moderate post-treatment problem reductions, and significant levels of distress for service providers . It was included in the analysis but excluded from calculating percentages below.
The included quantitative evaluation studies interventions involved data being collected with 4858 children, with just under two thirds (60 %, n = 12) using a school as a delivery platform and over a third (40 %, n = 8) implemented in community 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 provider who did not receive years of training is specialized care) delivered 90 % of these interventions. The duration varied with 55 % (n = 11) implemented in 15 sessions or more, 5 % (n = 1) had ten to 14 sessions, 30 % (n = 6) less than ten sessions, and 10 % (n = 2) did not record the number of sessions. Training of a 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 extensive prior experience working with the study population. Three interventions included 3 months of training. Of all programs, 55 % (n = 11) included supervision in order to support those implementing interventions and ensure fidelity to the program. There were seven interventions (35 %) that implemented MHPSS regardless of children’s symptoms (universally), and 13 used a context-sensitive screener (65 %), principally for those demonstrating traumatic stress reactions.
The interventions targeted post-traumatic stress symptoms (PTSS), internalizing symptoms (depression, anxiety), and behavioral and emotional problems more generally (e.g., conduct problems). Eighteen publications (78 %) reported results on multiple outcome indicators. Of the 11 publications (48 %) that have PTSS as a primary outcome, ten included multiple indicators for internalizing symptoms and behavioral and emotional problems. Two case studies examined potential mechanisms of effective counseling and were delivered on an individual basis [20, 21]. Almost all programs were group based (n = 18, 90 %), except for two interventions that included both group and individual elements [22••, 23••]. A multi-level multi-country program that took a public health approach was reported in eight publications [19-21, 24, 25••, 26-28]. This multi-level multi-country program targeted children with elevated psychosocial distress upon primary screening who were offered a classroom-based intervention. Those in need of more individualized or specialized care were referred for counseling and psychiatric care if available. Ten interventions involved the family or community in any capacity [21, 22••, 23••, 25••, 29-34].
All publications reported positive promotion, prevention, and treatment 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 subgroups [16, 18, 26-28, 30, 31, 36••]. Therefore, only ten publications (43 %) reported positive overall promotion, prevention, and treatment effects on symptom reduction and improved well-being for their primary outcomes.
Improvements were shown on multiple outcome indicators for 16 (70 %) studies [15-18, 22••, 23••, 24, 25••, 26-28, 33-35, 37, 38]. Most positive effects were small or moderate in size, with a few studies reporting large effect sizes. Trauma-focused cognitive behavioral therapy (TF-CBT) was used to alleviate distress, for both sexually exploited girls and war-affected boys in Democratic Republic of the Congo, and demonstrated large effect sizes (d = 2.13 to 2.75 [22••], d = 0.64 to 2.01 [23••]). A traumatic grief psychotherapy in Palestine resulted in significant improvements in PTSS and depression symptoms also with large effect sizes (d = 0.62–2.38) .
Five (22 %) publications identified negative outcomes. Gender and abduction history interacted to moderate the effectiveness of group interpersonal psychotherapy (G-IPT) with a small negative outcome on male non-abducted subjects in regards to depression [36••]. There were increased PTSS in the experimental group compared to control, post-intervention in the student mediation program in Palestine . A “Teaching Recovery Technique” aiming to improve emotion regulation (ER) and coping abilities actually established that a decrease in ER was associated with improved mental health and psychosocial well-being . Gender-specific outcomes demonstrated that girls had greater reduction in PTSS in the waitlist control, compared to the experimental group in a classroom-based intervention in Sri Lanka . The same intervention implemented in Burundi also reported negative effects for subgroups of children (depending on age, household composition, exposure, and displacement), with a better outcome for hope and functioning in the waitlist control compared to the experimental group .
Figure 2 outlines the range of intervention modalities mapped on to the multi-layered approach as advocated by the IASC guidelines. The most frequently mentioned modalities were creative expressive, psycho-educational, and cognitive behavioral strategies. Creative expressive approaches emphasized interactive activities such as drama, music, role-playing, and drawing. They aim to build better relationships and improve well-being. Three interventions had a core (as opposed to inclusive) focus on creative expressive activities [29-31]. The case studies that investigated counseling mechanisms used face-to-face engagement and supportive strategies centered on empowering the participant to reduce psychological and mental health problems [20, 21]. Other publications reported psycho-education and psychotherapies as strategies to improve the mental health and psychosocial well-being of children affected by armed conflict. Psycho-educational activities were implemented in five studies that focused on resilience, stress management, and conflict resolution [25••, 32-34, 37]. The psychotherapies targeting specific psychopathology reported: trauma-focused CBT [15-18, 22••, 23••, 35], interpersonal psychotherapy [36••], traumatic grief psychotherapy , and combined creative expressive activities with CBT [24, 26-28].
As can be seen in Fig. 2, there are no interventions in the dataset that focused on social considerations in basic humanitarian services and security, and a large majority of the programs investigated focused non-specialized support. Most mental health and psychosocial promotion interventions were school based. Only one study focused on the top level that represents the treatment of subgroups of children diagnosed with a mental health disorder who required more focused individualized care. A grief psychotherapy in Palestine as reported above aimed to treat those who were diagnosed with PTSD .
There were also two case studies evaluating treatment mechanisms of counseling in Burundi and South Sudan for children in need of individual-level care; however, counseling was provided by a non-specialist (hence included in the focused care level) [20, 21]. Positive results were associated with an explicit trust formation and disclosure, active problem solving, structural trauma-focused exposure, family involvement, and parental support. Both studies reported displaying a moralistic attitude in counseling had a negative impact on a child’s mental health and psychosocial well-being.
Within Study Bias
The RCT(s) implemented in the Democratic Republic of the Congo were the only interventions to have low risk for both subsections of selection bias [22••, 23••, 33]. High risk and unclear risk of bias for blinding of the participants and personnel (performance bias) were coded in 50 % (n = 10) and 40 % (n = 8) of the interventions, respectively. Three publications (15 %) scored low for risk on blinding of outcome assessment (detection bias). Incomplete data representing loss to follow-up was coded as high risk in 45 % (n = 9) and unclear risk in 15 % (n = 3) of the interventions. Determining whether statistical results were selectively withheld from the publication was problematic to establish; consequently, reporting bias was coded as 100 % unclear risk. Other sources of bias such as contamination of controls were determined to be 60 % (n = 12) high risk. Of the possible 140 high, low, and unclear risks of bias scores, 40 % (n = 56) were unclear and 39 % (n = 55) of scores were considered as high risk.
Cultural Modifications and Key Themes
With interventions delivered in nine different countries, it is important to review cultural adaptations. Instrument adaptations by translation and back translation, focus group discussions (FGD), and piloting were outlined in 60 % (n = 12) of the studies [20, 21, 22••, 23••, 24, 25••, 26-29, 33, 38]. Promotion, prevention, and treatment approaches were culturally modified in 40 % (n = 8) of the interventions [22••, 23••, 29, 32-35, 36••]. However, few gave detailed accounts of any actual adaptations made. The publications appeared to mainly report minor changes for instance translation of the manual and small alterations to session themes, making no changes to the overall structure of interventions. The interventions detailing their cultural adaptations such as culturally applicable analogies and examples throughout the modified program manual had the largest effect sizes of the review [22••, 23••]. Both were randomized controlled trials.
Although 70 % (n = 16) of studies reported specific intervention effects in certain subgroups, only one study tailored their intervention by splitting groups by age and gender . Fifty-two percent of the publications recommended that future interventions should apply multi-levelled approaches [15, 17, 20, 22••, 23••, 24, 25••, 26-28, 33, 36••]. Eight studies used intervention approaches with a focus beyond children’s individual symptomology, incorporating community/caregiver aspects [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 ceremony attended by key figures in the community, and the creation of a community advisory board to assist with implementation. Feedback on treatment quality and satisfaction were only ascertained from children in 13 % (n = 3) of publications [30, 31, 35]. The delivery agent’s relationship with the participant was described as integral to positive treatment effects in both publications on mechanisms of counseling [20, 21]. However, only one study gave a rationale for their recruitment strategy [23••].