Psychosocial Care for Children in Armed Conflict Mark Jordans, Healthnet-TPO Wietse Tol, Healthnet-TPO Ivan Komproe, Healthnet-TPO Joop de Jong, Vrije Universiteit Amsterdam

Acknowledgement This project and research was conduct with financial assistance from PLAN Netherlands

Content of presentation Introduction Systematic literature review –Methods –Results –Conclusion Comprehensive psychosocial support system –Rationale/objectives –CTP Model and implementation –Outputs –Conclusion

1. Introduction Weak evidence base for affordable child psychosocial and mental health intervention in LAMIC (Morris et al, 2007; Belfer, 2008) Burden of child mental health problems on society has been reported, as well as increased mental health problems among children in areas of conflict (Belfer et al, 2008) Vast gap between child and adolescent mental health needs and the availability of resources (Patel et al, 2008) Increasing consensus on mental health and psychosocial intervention in complex emergencies (IASC, 2007) Several reviews have been published related to psychosocial and mental health of children in complex emergencies, but these have not been systematic or focus on acute emergencies (Barenbaum et al, 2004; Kalsma-vanLith, 2007; Moss, 2006; Morris et al, 2007)

2. Systematic Literature Review Systematically review the published literature on psychosocial and mental health interventions for children in areas of armed conflict, for: –Evidence base of treatment –Treatment modalities utilized

2.1 Methods We performed a systematic review of studies in psychological & medical databases –PubMed; PsychInfo; Pilots and cross referencing Key words related to –treatment/ intervention –war/armed conflict –psychosocial/ mental health For children and adolescents in LAMIC, focusing on protracted and longer term complex emergencies

2.2 Results

2.2.1 Results Evaluation Studies 12 treatment evaluations –2 RCT’s –4 quasi-experimental –5 non-controlled –1 case study Primary treatment focus –PTSD (n=8) –Depression (n=4) –Generic problems (n=4) 10 studies evaluate group interventions, 1 individual and 1 parent-child

2.2.2 Results Evidence Base 11 intervention demonstrate positive effects –8 with multiple indicators –2 with sustained long term effects demonstrated 3 intervention demonstrate mixed results 3 interventions demonstrate no treatment effects Outcomes Trials: -Efficacy of group interpersonal therapy in reducing depression symptoms among girls in Uganda and non-efficacy of creative workshops (Bolton et al, 2007) -Small positive impact of a mother-child intervention in Bosnia on mothers’ mental health, children’s weight gain and psychological functioning (Dybdahl, 2001)

2.3 Conclusion - evidence Evaluations are promising But scarcity of rigorous studies, diversity of studied interventions and mixed results call for more research Effect studies are skewed geographically and towards a primary PTSD-focus

2.4 Growing Consensus Findings are compatible with the increasingly advocated paradigm shift from tertiary to primary care and adopting a public health approach –The PTSD focus is not applicable for the non- evaluation studies –An even representation of focus between targeted levels of distress –Overwhelming majority report a community approach –More nuanced then dichotomization between curative and preventative –Multi-focus intervention mainly holistic/ ecological

Yet… Scarcity of tested/described treatment models –very few studies elaborate on what a community approach entails (e.g. Wessels & Monteiro, 2004; de Berry, 2004) –very few actual multi-tiered systems described (Salzman et al, 2003) –many position papers

3. Comprehensive Psychosocial Support System Development Development of a comprehensive care package –Translating common principles and guidelines into a replicable delivery framework –Multiple-levelled curative and preventative interventions –Community-oriented on different ecological levels Development of a toolkit for implementation –Developed within a LAMIC setting Development of an evidence base for child oriented interventions

3.1 Project information Period: September CBI capacity building with Center for Trauma Psychology Sites: –Burundi/ Healthnet TPO –Sudan/ Healthnet TPO –Sri Lanka/ Shantiham –Indonesia/ Church World Services

3.2 Model

3.3 Results Service Delivery – > children and caretakers reached with community-, group-, and individual support Instrument development outputs –Replicable package of 11 step-by-step modules –Screening procedure Strengthened evidence base –Impact of war on children –Efficacy of CBI (multi-site) –Validation of psychosocial distress screening instrument –Single case studies of counselling –Procedure for development of contextual functioning assessment instrument

4. Conclusion Evidence base –Paucity of research-supported recommendations –High standard research is possible in unstable settings A comprehensive psychosocial care package is possible in LAMIC/conflict settings –Care system has been developed, adapted and implemented –A delivery system that can be replicated Further development is needed –To increase effectiveness, extent of services and outreach –To increase a multi-sectoral focus and primary prevention –To increase contextualization of interventions and indicators per setting is prerequisite

Thank you!