Mechanisms of change for interventions aimed at improving the wellbeing, mental health and resilience of children and adolescents affected by war and armed conflict: a systematic review of reviews

Abstract

Despite increasing research and clinical interest in delivering psychosocial interventions for children affected by war, little research has been conducted on the underlying mechanisms of change associated with these interventions. This review aimed to identify these processes in order to inform existing interventions and highlight research gaps. A systematic review of reviews was conducted drawing from academic databases (PubMed, PILOTS, Cochrane Library for Systematic Reviews) and field resources (e.g. Médecins Sans Frontières and the Psychosocial Centre of the International Federation of Red Cross and Red Crescent Societies), with extracted data analysed using Thematic Content Analysis. Thirteen reviews of psychosocial or psychological interventions for children and adolescents (< 25 years old) affected by war, armed conflict or political violence were identified, covering over 30 countries worldwide. Qualitative analysis identified 16 mechanisms of change, one of which was an adverse mechanism. Themes included protection from harm, play, community and family capacity building, strengthening relationships with caregivers, improved emotional regulation, therapeutic rapport, trauma processing, and cognitive restructuring; with the adverse mechanism relating to the pathologising of normal reactions. However, only 4 mechanisms were supported by strong empirical evidence, with only moderate or poor quality evidence supporting the other mechanisms. The poor quality of supporting evidence limits what can be inferred from this review’s findings, but serves to highlight clinically informed mechanisms of change for existing and widely used non-specialist interventions in the field, which urgently need rigorous scientific testing to inform their continued practice.Electronic supplementary materialThe online version of this article (10.1186/s13031-018-0153-1) contains supplementary material, which is available to authorized users.

Disseminating Evidence-based Research on Mental Health and Coping to Adolescents Facing Adversity in Lebanon: A Pilot of a Psychoeducational Comic Book ‘Somoud’

“…Unfortunately, mechanisms related to wide family and community interventions, and to basic needs like safety and play, are poorly represented in research. The systematic review of reviews on which 'Somoud' is based found low quality evidence for mechanisms at this level, predominantly based on case studies and clinical experience [15]. Reviews of MHPSS have consistently highlighted a lack of research on systemic and community interventions [38,4,39], and this gap was well highlighted by our participating families.…”

“…In addition, books are generally aimed only at children, and not to the parent-child dyad or triad. This is particularly problematic in the context of communities facing adversity, where parental support and relationships have been found to be a strong protective mechanism for child and adolescent mental health [15].…”

Mediators of focused psychosocial support interventions for children in low‐resource humanitarian settings: analysis from an Individual Participant Dataset with 3,143 participants

“…This would suggest that the mediating pathway of focused psychosocial interventions is different from the mechanism of more specialized clinical interventions, which are firstly directed to psychological symptoms and may subsequently generate an improvement in other outcomes including functional impairment (Kohrt & Song, ). From this perspective, the process may be explained from a ‘demoralization’ point of view: a first explanation could be that the interventions help children to reverse a sense of ‘learned helplessness’, that is they provide children with a general sense that the world can be positively improved, and that children are not helpless to deal with the human consequences of humanitarian crises (Bosqui & Marshoud, ). A second explanation, possibly more consistent with our findings, is that the improvement can be measured as an improved ability to engage in daily activities, that generates and/or reinforces a sense of competency.…”

“…This more general subjective satisfaction subsequently translates into reductions in specific symptoms. These mechanisms of change have been recently described in a systematic review of reviews, designed with the aim of exploring the key mechanisms of change intrinsic across interventions aimed at improving resilience and well‐being in children exposed to war and armed conflicts (Bosqui & Marshoud, ). Factors like helpfulness, engagement in social and daily activities, and an internal locus of control have been considered within those that might improve strength (Bosqui & Marshoud, ).…”

Fostering Resilience in Children: The Essential Role of Healthcare Professionals and Families

“…The scientific literature in this area is expanding, however, there is limited integration of the findings into proactive strategies designed to relieve the impact of adverse experiences suffered by individuals during their developmental years. 3,4 The process of developing resilience in children and adolescents has progressively become of particular interest to healthcare professionals and families because of its implications for the health of children and adolescents they care for. The authors of this commentary are part of a working group on social pediatrics supported by European national pediatric societies, members of the European Paediatric Association/Union of National European Paediatric Societies and Associations.…”