Systematic Review of Evidence and
Treatment Approaches: Psychosocial and
Mental Health Care for Children in War
Mark J.D. Jordans
1,2
, Wietse A. Tol
1,2
, Ivan H. Komproe
1
& Joop V.T.M.
de Jong
2,3
1
Healthnet TPO, Department of Public Health and Research, Amsterdam, the Netherlands.
E-mail: mjordans@healthnettpo.org
2
VU University Medical Center, Amsterdam, the Netherlands
3
Boston University School of Medicine, United States of America
Background: There is a growing body of literature on interventions addressing psychosocial wellbeing and
mental health of children affected by violence in low- and middle-income countries. Methods: This systematic
review of PubMed, PsychINFO, and PILOTS identified 500 publications (1991–2008) on interventions. Results:
Sixty-six publications (12 treatment outcome studies and 54 intervention descriptions, covering a range of
treatment modalities) met inclusion criteria. Most interventions are evaluated positively, while some studies
lack evidence for efficacy and effectiveness. Conclusion: Scarcity of rigorous studies, diversity of interventions,
and mixed results of evaluations demonstrate a need to identify evidence-based interventions. The literature
presents consensus on a number of treatment-related issues, yet the application remains limited across
interventions.
Key Practitioner Message:
• There is a serious lack of rigorous studies evaluating psychosocial care for children affected by war.
• Though some treatment evaluation studies are promising, effect sizes of controlled studies are moderate
and several studies have methodological flaws.
• Despite the PTSD bias of evaluation studies, papers describing treatment approaches support a paradigm
shift from tertiary to primary care, with the main focus on community-based approaches.
• Most descriptive papers lack a comprehensive presentation of treatment modalities and either report
single interventions or are limited to position statements.
Keywords: Systematic review; children; low- and middle-income countries; war; psychosocial; mental health;
treatment; effectiveness; efficacy
Introduction
There is increasing evidence for the effectiveness of
psychosocial and mental health treatment in low- and
middle-income countries. A review by Patel and col-
leagues (2007) demonstrates that there is evidence for
the effects of treatment for depression, antipsychotic
drugs for schizophrenia, and brief interventions deliv-
ered by primary care staff for substance abuse. However,
while the review highlights community-based rehabili-
tation models as a low-cost and integrative framework for
care, it also points out the lack of evidence about effec-
tiveness of such interventions (Patel et al., 2007). Other
reviews echo the dearth of evidence for affordable child
psychosocial and mental health interventions in low- and
middle-income countries and complex emergencies
(Morris et al., 2007; Barenbaum, Ruchkin, & Schwab-
Stone, 2004; Patel et al., 2008). For example, a worldwide
systematic review on evidence-based primary prevention
programs includes only studies in high-income countries
(Flament et al., 2007).
Child mental health problems are a significant con-
tributor to the global burden of disease (Remschmidt et
al., 2007). Especially within low- and middle-income
countries, there is a vast gap between child and ado-
lescent mental health needs and the availability of re-
sources, as well as lack of program development and
policy to address the gap (Belfer, 2008; Patel et al.,
2008). Additionally, considering the ample research on
the harmful impact of armed conflicts and violence on
children, the importance of psychosocial and mental
health care for children cannot be overestimated
(Stichick, 2001; Barenbaum et al., 2004; Williams,
2006). Though there is increasing consensus on mental
health and psychosocial interventions in complex
emergencies (IASC, 2007), there is a gap between child
mental health needs and availability of evidence-based
interventions (Morris et al., 2007; Patel et al., 2007).
Child and Adolescent Mental Health Volume 14, No. 1, 2009, pp. 2–14 doi: 10.1111/j.1475-3588.2008.00515.x
2008 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
A small number of recent reviews have addressed the
issue of children in complex emergencies, with partic-
ular attention paid to children in areas of armed conflict
(Barenbaum et al., 2004; Kalsma-van Lith, 2007; Moss
et al., 2006; Williams, 2006; Morris et al., 2007). These
reviews emphasize (a) the lack of available assistance
for children exposed to war and the need for develop-
ment of assessment and interventions in their home
countries (Moss et al., 2006; Barenbaum et al., 2004);
(b) the need for combined attention to childrenÕs resil-
ience and risk factors for developing severe mental
health problems (Williams, 2006; Barenbaum et al.,
2004) combined with a division between a curative
mental health care approach and a developmental
preventative approach (Kalsma-van Lith, 2007); (c) the
scarcity of formulated specific therapy techniques and
intervention effectiveness research for war-affected
children (Barenbaum et al., 2004; Morris et al., 2007);
and (d) the need for accessible, low-cost, systematic
interventions (Moss et al., 2006; Williams, 2006;
Barenbaum et al., 2004; Morris et al., 2007). In her
review of community based mental health care in low-
and middle-income countries Wiley-Exley (2007) calls
for a further review of interventions targeting children.
Although resourceful, the available reviews are neither
rigorous nor systematic and/or are focused on the
impact of armed conflict or the immediate response
after emergencies. The current study is therefore the
first to systematically review the literature on psycho-
social and mental health interventions for children
during and after war in low- and middle-income
countries. The two aims of the review were (1) to provide
an overview of the evidence-base for mental health and
psychosocial treatment for children and adolescents in
areas affected by violence and (2) to synthesize
treatment descriptions and recommendations in order
to summarise trends, including the non-researched,
practical and grassroots context.
Method
The following databases were searched: PubMed, Psy-
chINFO and PILOTS with the following search terms:
(ÔchildÕ or ÔadolescentÕ) and (ÔwarÕ or Ôarmed conflictÕ or
Ôcommunity violenceÕ) and (ÔinterventionÕ or ÔtreatmentÕ)
and (ÔpsychosocialÕ or Ômental healthÕ). In addition, a
number of authors were approached for relevant pub-
lications. The search was limited to publication dates
between 1991 and 2008. An initial search was per-
formed on 15 August 2006, and repeated on 20 Feb-
ruary 2008 to update results.
Articles were included for full review if they adhered
to the following criteria: (a) publication involved
description of, or recommendations for, psychosocial or
mental health treatment or intervention programs with
children specified as primary or secondary beneficia-
ries; (b) the article focused on low- and middle-income
countries following definitions of the World Bank
(2007), thereby excluding publications focusing on ref-
ugees in high-income countries; and (c) the publication
was focused on protracted violence and long-term
complex emergencies.
A four-step procedure for reviewing the search out-
comes was followed. First, based on the above inclusion
criteria, all search outcomes were assessed by title and/
or abstract. Second, if these criteria were met, or if the
review of title and abstract was insufficient to exclude
the study, the publication was selected for full review.
Third, after full review, a final number of articles were
included in the study. Fourth, all included articles were
cross-referenced.
Actual review and analyses of the selected publica-
tions were conducted in several steps. First, articles
were read by two authors of this paper (MJ and WT)
and summarised in a pre-defined format. Second,
information from the completed formats was trans-
ferred into a table with the following categories: inter-
vention/treatment modalities (approach, focus,
content/techniques, implementation steps), specifica-
tion of target group and location, recommendations,
cultural adaptations, classification as a clinical paper
if describing an actual implemented intervention
component, and a position paper if otherwise. Third,
all treatment descriptions were categorised as target-
ing general well-being, psychosocial distress, psycho-
pathology, or a combination. Interventions per
category were subsequently grouped based on their
primary treatment focus. Fourth, for the outcome
studies the following categories were added: study
(sample, design, instruments), outcomes and level of
evidence (1 = randomised controlled trial; 2 = quasi-
experimental design; 3 = non-controlled design;
4 = case studies; adapted from Morris et al., 2007). All
studies with an outlined methodology for evaluation,
and reported results, were included in the treatment
outcome table. Fifth, effect sizes (CohenÕs d) were used
to standardise the differences in outcome variables
and allow for comparison of the different statistical
measures. Effects sizes greater than 0.60 were classi-
fied as large, 0.30 to 0.60 as moderate, and less than
0.30 as small (Cohen, 1988). Finally, we summarised
all entries on specific mention of (a) cultural adapta-
tions and (b) evaluation components (for non outcome
studies).
Results
The searches resulted in a total of 500 publications;
PubMed returned 156 articles, PsychINFO 176, and
PILOTS 86, 32 articles from cross-referencing and 50
articles through experts. Ninety-seven articles were
selected for full review; 31 were excluded as not meeting
the study criteria, leaving 66 for study inclusion (see
Table 1). The articles describe activities in 18 countries
Table 1. Search outcomes
Databases
All outcomes:
Review, title
and abstract Duplication
Selected:
Review full
article Included
Pubmed 156 0 13 11
PsychInfo 176 5 31 17
PILOTS 86 13 16 6
AuthorsÕ
database
50 26 11 7
Cross refs 32 - 27 25
Total 500 44 97 66
Note: Books may be referenced as 1 entry in Ôall outcomesÕ
column, but individual chapters as separate entries in the
ÔselectedÕ or ÔincludedÕ columns
Psychosocial and Mental Health Care for Children in War 3
(Croatia, Uganda, Bosnia, West-Bank and Gaza, Ethi-
opia, Sierra Leone, Chechnya, Azerbaijan, Mozam-
bique, Sri Lanka, Afghanistan, Iraq, Kosovo,
Guatemala, Mexico, Rwanda, Zimbabwe, Angola) with
25.8% of the total publications and 41.6% of the out-
come studies focusing on countries formerly part of
Yugoslavia. Results are presented in order of the
objectives outlined in the introduction.
To review the evidence base for treatment, publica-
tions describing an outcome study (with outlined
methodology as a minimum criterion) are depicted in
Table 2. In total 12 studies have been published with
different levels of evidence. Two studies report rando-
mised controlled trials (RCTs), 3 report non-randomised
controlled studies, 6 report non-controlled studies, and
1 presents a case study. The interventions target
symptoms of post-traumatic stress disorder (PTSD)
and depression, and generic emotional, social and
behavioral problems, as well as stressors. One study
evaluates an intervention for individual children (Onyut
et al., 2005) and one focuses on the parent-child dyad
(Dybdahl, 2001a). All other studies evaluate group
interventions. The majority of outcome studies focus on
PTSD symptoms (8 studies, 66.7%).
Eleven studies show patterns of positive treatment
effects primarily reported as symptom reduction and/or
increased protective factors (Stichick-Betancourt,
2005; Woodside, Santa Barbara, & Benner, 1999; Bol-
ton et al., 2007; Dybdahl, 2001a; Gordon et al., 2004;
Layne et al., 2001; Cox et al., 2007; Loughry et al.,
2006; Onyut et al., 2005; Paardekooper, 2002; Gupta &
Zimmer, 2008). Eight of these show improvements on
multiple indicators, and two report sustained long-term
effects at 9 months (Onyut et al., 2005) and 12 months
(Woodside et al., 1999) post-treatment. Three of the
studies also note negative outcomes: the risk of
undermining the need for normality through interven-
tion participation (Stichick-Betancourt, 2005), reduc-
tion of hope compared to control group (Loughry et al.,
2006), and increased avoidance symptoms (Gupta &
Zimmer, 2008). One qualitative study failed to replicate
positive quantitative findings when examining the same
intervention (Cox et al., 2007). Three studies present no
significant treatment effects of an emotion-focused
coping group intervention, a creative workshop
approach for depression, and a group crisis interven-
tion for PTSD and depression symptoms (Paardekooper,
2002; Bolton et al., 2007; Thabet, Vostanis, & Karim,
2005, respectively). The two reported RCTs give differ-
ent results: Bolton and colleagues (2007) show the
efficacy of group interpersonal therapy in reducing
depression symptoms among 14 to 17-year-old ado-
lescent girls in Uganda, whereas a mother-child inter-
vention in Bosnia has moderate positive effects on
mothersÕ mental health, childrenÕs weight gain, and
childrenÕs psychological functioning (Dybdahl, 2001a).
Comparisons of effect sizes provide a more nuanced
picture of positive trends (see Table 2). Results from the
RCTs demonstrate moderate treatment effects (d = 0.53
in Bolton et al., 2007; between d = 0.33–0.54 in
Dybdahl, 2001a). The study by Loughry and colleagues
(2006) shows small effect sizes for CBCL change
(d = 0.27) and a moderate effect size for hope in the
control group ( d = 0.40). The studies of Paardekooper
(2002) and Layne and colleagues (2001) give unclear
findings in terms of effect sizes. The former demon-
strates that if a cut-off threshold is used to evaluate
treatment, no effect is detected despite reporting mod-
erate to large effect sizes (d = 0.54–1.42). Layne and
colleagues (2001) report large effect sizes for symptom
change (d = 1.31–2.07) but no significant interaction
effect for group membership (partial or full treatment
participation). The results section of the study by
Woodside and colleagues (1999) only allows for calcu-
lating the (small) effect size of one of the indicators for
which treatment effect is stated (d = .27 for social dis-
tance). In the non-controlled studies, effect sizes are
generally large (d = 0.6–2.4 for Gordon et al., 2004;
d = 2.25 for Gupta & Zimmer, 2008; 2.78 for Onyut
et al., 2005). However, it should be noted that these are
effect sizes of change not of treatment efficacy due to the
lack of comparison of change scores with a control
group.
Treatment focus and recommendations of the 66
studies were grouped in categories and subcategories
(see Table 3 for detailed division of the publications over
all categories and the 12 sub-categories). Category 1
comprises interventions targeting general well-being
(18.6% of the publications) with primary intervention
foci including resilience (8.6%), the childÕs social con-
text (4.3%), education (4.3%), and reconciliation (1.4%).
Category 2 comprises interventions targeting psycho-
social distress (30% of the publications) with psycho-
logical (22.9%), social (5.7%), and traditional healing
(1.4%) as sub-categories. Category 3 comprises inter-
ventions targeting psychopathology (18.6% of the pub-
lications) with primary intervention foci including PTSD
(12.9%), depression (1.4%), or general mental health
disorders (4.3%). Seventeen publications (24.3%) report
interventions with multiple foci, which can be divided
into two categories: multi-sectoral (also targeting issues
other than psychosocial distress, e.g. reconstructing
infrastructure) (18.6%), and multi-levelled (simulta-
neously targeting different levels of distress) (5.7%).
The remaining six publications are not included in the
categorization, five because they are reviews (Baren-
baum et al., 2004; Morris et al., 2007; Kalsma-van Lith,
2007; Moss et al., 2006; Williams, 2006), and one
because it does not fit in any of the categories (Hepburn,
2006).
A wide range of treatment modalities is reported (see
Table 3). The most frequently mentioned treatment
modalities used across the different categories are cre-
ative-expressive, recreational, and psycho-educational
activities. Creative-expressive approaches include
techniques such as story telling, drawing, writing,
playing, role-playing, singing, dancing, playing music
and performing psychodrama. Other treatment modal-
ities are specific for the level of distress targeted such as
counselling and family care targeting psychosocial dis-
tress, and psychotherapies targeting specific psycho-
pathology such as PTSD. Few explicit therapies are
reported: narrative exposure therapy (Schauer et al.,
2004; Onyut et al., 2005), trauma/grief-focused group
psychotherapy (Layne et al., 2001); dance and move-
ment therapy (Harris, 2007), cognitive behavioural
therapy (Jones et al., 2003), group interpersonal ther-
apy (Bolton et al., 2007) and parent-child interaction
therapy (Dybdahl, 2001a,b). Only one publication
mentions the use of psychopharmacology (Jones et al.,
4 Mark J.D. Jordans et al.
Table 2. Evidence base (n = 12)
Authors: (year)
and country
Target group
(age range)
Intervention, duration
and/or sessions
Core intervention
focus Sample Outcomes
Evidence
level Effect size
Bolton et al. (2007)
Uganda
Adolescents
(14–17)
Group interpersonal therapy;
16 weekly sessions
Creative workshops;
16 weekly sessions
Depression 209 Reduction of depression
symptoms among girls. Creative
workshops showed no effect
compared to the control group.
Neither group showed effect
on anxiety or functioning
1 d = 0.53
Dybdahl (2001a)
Bosnia
Mothers and
children
(5–6)
Parent-child interaction;
weekly sessions for 5 months
Parent-child interaction;
child psychosocial functioning
and maternal mental health
87 Intervention had a small positive
effect on mothersÕ mental health,
childrenÕs weight gain and
childrenÕs psychological functioning
1 d = 0.33 – 0.54
Loughry et al. (2006)
Palestine
Children
(6–17)
Recreational and connectivity
activities; activities spread
out over 12 months
Emotional and behavioral
problems, parental support
and hope
400 Intervention associated with
reduced emotional and behavioral
problems among girls, compared
to control group. No evidence for
change on hope, and increased
perceived parental support within
geographic sub-group
2 d = 0.27
(CBCL; treatment group)
d = 0.40
(hope; control group)
Thabet et al. (2005)
Gaza
Children
(9–15)
Group crisis intervention;
7 weekly sessions (CISM-
based; expressive creative)
PTSD-, Depression symptoms 111 No significant reduction in PTSD
and depression symptoms compared
to control and alternative
intervention groups
2N/A
Paardekooper (2002)
Sudan
Refugees
(7–12)
Psycho-dynamic group support
groups; 7 weekly sessions
Contextual group support
groups; 7 weekly sessions
Emotional and behavioral
problems, PTSD symptoms,
Coping, Social support
105 Problem-focused coping, contextual,
approach associated with moderate
reductions in emotional, behavioral
and post-traumatic symptoms, coping
and daily stressors but not for
participants of a emotion-focused
coping, psychodynamic, approach
2 d = 0.54 – 1.42
Woodside et al. (1999)
Croatia
Children
(10–14)
Psycho-educative and expressive
classes; 4 months of
weekly sessions
PTSD symptoms; Conflict
resolution
251 Reduction in PTSD symptoms and
ethnic bias (retained after 12
months follow-up), increased girl
self-esteem and quality of
social connections
3 d = 0.28
(social distance)
Layne et al, (2001)
Bosnia
Adolescents
(15–19)
School-based trauma/grief-
focused group psychotherapy;
20 weekly sessions
PTSD-, grief-, depression
symptoms
87 Significant reductions of PTSD,
depression and grief symptoms;
changes in scores associated with
school and peer variables
3 d = 1.31 – 2.07
(symptoms change)
No significant
treatment effect
Cox et al. (2007)
Bosnia
Idem Idem Idem 66 Qualitative data demonstrate positive
changes among participantsÕ attitudes
and skills (hope, self-esteem, problem-
solving, open communication).
The study does not confirm decreased
distress as found in Layne et al. (2001).
Increased stigmatisation was
reported among participants
3N/A
Psychosocial and Mental Health Care for Children in War 5
Table 2. Continued
Authors: (year)
and country
Target group
(age range)
Intervention, duration
and/or sessions
Core intervention
focus Sample Outcomes
Evidence
level Effect size
Stichick-Betancourt
(2005)
Chechnya
IDP
Adolescents
(11–18)
Emergency education and
structured (recreational)
activities; ongoing
Physical, emotional and
social stressors
57 Intervention benefits participants
by increased social support,
meaningful activity and hope,
but risks undermining
needs for normality
3 N/A
Gordon et al. (2004)
Bosnia
Adolescents
(12–19)
Mind-body skill experiential
and psycho-educative groups;
6 weekly sessions
PTSD symptoms 139 Intervention associated with
reduction in PTSD symptoms
3 d = 0.60 – 2.40
(symptom change)
Gupta & Zimmer (2008)
Sierra Leone
Children
(8–18)
Trauma healing and recreational
activities; 8 sessions over 4 weeks
Psychological impact of
events, PTSD symptoms
306 Intervention is associated with
reduction in intrusion and
arousal symptoms, as well as
increased avoidance symptoms;
participants also reported
increased optimism, concentration
and reduced nightmares.
3 d = 2.25
(symptom change)
Onyut et al. (2005)
Uganda
Refugee
Adolescents
(12–17)
Narrative exposure therapy
(KIDNET); 4–6 weekly sessions
PTSD symptoms 6 Reduction of PTSD symptoms,
retained at 9-months follow-up,
and reduced functional impairment;
attribution of causality limited
4 d = 2.78
(symptom change)
Note: Levels of evidence 1 = Randomised controlled trial or systematic review; 2 = Quasi-experimental design; 3 = Non-controlled or cohort; 4 = Case studies
PTSD = Post Traumatic Stress Disorder; IDP = Internally Displaced Persons; CISM = Critical Incident Stress Management; d = CohenÕs effect size (Cohen, 1988)
6 Mark J.D. Jordans et al.
