Mental health and psychosocial support for children in areas of armed conflict: call for a systems approach.

This paper focuses on the question of whether separate attention to children who have faced specific conflict-related events is justified, or whether the scarce resources for mental health should be spent on the development of services for children more broadly in low- and middle-income countries (where most contemporary armed conflicts are taking place). It is argued that a systems approach to mental health and psychosocial support for children is warranted.

Mental health problems affect 10–20% of children and adolescents worldwide (Kieling et al, 2011). Especially in low- and middle-income countries (LMICs), there is a substantial gap in the available resources to meet the mental health needs of children (Belfer, 2008). Among these LMICs, there are currently 23 countries where armed conflict results in grave acts committed against children (United Nations, 2014). Armed conflicts have a negative impact on the mental health and psychosocial well-being of individuals, including psychological distress and mental disorders, as well as negative impacts on the families and communities in which children grow up (Barenbaum et al, 2004).

In response, psychosocial and mental health interventions for children affected by armed conflict have been developed. Types of interventions vary widely, with respect to both aim (from promotion, prevention and treatment approaches) and modality (spanning creative and recreational group activities; dance and movement therapy; parental support; individual psychotherapy) (Jordans et al, 2009b). School-based interventions are most often represented in the literature (Betancourt et al, 2013). Research on resilience in children and adolescents affected by armed conflict converges on the importance of supports across socio-ecological levels, of which parental support and parental monitoring are most consistently associated with desired mental health outcomes (Tol et al, 2013b). Recent years have seen a rise in the number of trials for interventions targeting young people in humanitarian settings, but the evidence base is still weak, with mixed results (Tol et al, 2011).

Given the range of potential stressors that children in areas of armed conflict in LMICs are exposed to, a pertinent question is whether separate attention to children who have faced specific conflict-related events is justified, or whether the scarce resources for mental health should be spent on the development of services for children more broadly in LMICs (where most contemporary armed conflicts are taking place). This paper focuses on this question, starting with giving arguments for and against such special attention.

Whether and how to target services

The most compelling and most straightforward reason to argue in favour for services specific to conflict-affected children concerns their increased risk of mental health problems as a result of the exposure to violence. Studies suggest there are higher prevalence rates of mental disorders among children exposed to conflict compared with the general population, including post-traumatic stress disorder, anxiety and depression (Kohrt et al, 2008; Attanayake et al, 2009). In addition, exposure to violence affects children’s views of the world, their social networks and relationships, and family functioning (Stichick, 2001; Williams, 2006). Furthermore, one could argue that precisely because of the limited resources it is better to target a smaller at-risk group rather than watering down resources by spreading them over the entire population. This pragmatic argument is based on the notion that a well defined sub-population is easier to cover. In addition, because of the obvious urgency of needs, funding specifically for children affected by armed conflict is commonly more readily available. Finally, psychotherapies targeting traumatic stress are among the few in LMICs that have a relatively strong evidence base.

On the other hand, there are many groups vulnerable to higher rates of mental health problems (e.g. children in caregiver roles; children facing child abuse and neglect; trafficked children; children with chronic physical illnesses or disabilities). Instead of focused attention on one group, a population-wide mental healthcare system can encompass multiple vulnerable groups – rather than having them compete for the scarce resources. Also, the simple argument that mental health problems are present in any child population, regardless of the presence or absence of armed conflict, supports such a broad approach. An additional argument for broader targeting comes from epidemiological research. Recent studies with conflict-affected populations have shown the importance of chronic daily stressors for mental health that most children in all LMICs are exposed to (i.e. poverty, social exclusion, domestic violence), in addition to past exposure to specific conflict events (Betancourt et al, 2010; Miller & Rasmussen, 2010; Jordans et al, 2012). Such data further complicate tough questions on targeting.

Maybe the more appropriate question is how these two positions can be combined. A two-pronged approach that works towards a population-wide mental healthcare system, within which the special needs of conflict-affected children are explicitly addressed, may reconcile these positions. This principle, also called proportionate universalism, entails that actions to support mental health should be universal yet calibrated proportionally to the level of vulnerability, because an exclusive focus on the most vulnerable will fail to receive the support of the whole population. An exclusive focus on one group will also fail to reduce the magnitude of social determinants of mental ill-health, which are felt across a gradient of vulnerability (World Health Organization & Calouste Gulbenkian Foundation, 2014). This two-pronged approach should build on the evidence that is available, and combine a universal approach geared towards promoting resilience within families and communities (Tol et al, 2013b) with more targeted attention to families and individuals with specific vulnerabilities (Jordans et al, 2011).

A comprehensive systems-of-care approach

In addition to prevention, such systems should focus on community-based mental health treatments for a range of mental disorders. This is based on the widely advocated idea that the best way to provide population-wide mental health services in LMICs is by integrating them into non-specialised health settings. Evidence-based guidelines have been drawn up that cover a spectrum of psychological and pharmacological treatments (World Health Organization, 2010). Specific attention to violence-affected children can be embedded, for example by including psychological treatments with proven efficacy to deal with post-traumatic stress disorder (e.g. cognitive–behavioural therapy with a trauma focus, eye movement and desensitisation reprocessing) (Catani et al, 2009; Betancourt et al, 2013; Tol et al, 2013a), or by population-based community screening for at-risk children (Jordans et al, 2009a).

Merging such approaches into one service-delivery framework is critical in order to address both preventive and treatment needs in humanitarian settings (Inter-Agency Standing Committee, 2007). Promoting resilience at different ecological levels to address long-term damaged social fabric as a result of conflict can be best achieved by targeting locally identified risk and protective factors, at the family, peer-group and community levels (Tol et al, 2013b). Families may be particularly relevant for selective preventive interventions, such as parenting support, whereas schools have been shown to be promising venues for mental health promotion and universal prevention (Barry et al, 2013), for example classroom management support for teachers. The integration of mental health within non-specialised healthcare is a possible strategy to make targeted interventions sustainable. Overall, prevention and treatment should take into account a life-course approach that responds to the risk and protective factors for the overall well-being of children in a way that is sensitive to their developmental stage. Armed conflict clearly poses additional stressors for children and their environment, necessitating adjustments at all parts of the spectrum, which include promoting a sense of safety, calming, a sense of self-efficacy and community efficacy, connectedness and hope (Hobfoll et al, 2007) (e.g. normalising daily life by re-initiating safe schooling, strengthening parent– child relations, stress management).

Feasibility and sustainability

The comprehensive systems-of-care approach we propose clearly raises questions with regard to feasibility and sustainability. Especially in post-conflict settings where systems are devastated and weak, the development and continuation of a system of care will be challenging. However, this lack of a care infrastructure also provides opportunities. Experience has shown that mental health reform is realistic as part of post-emergency recovery, because of the increased recognition of donors and governments of the importance of mental health in humanitarian settings. Initiatives to (re)build mental health services are successful when they address the broad mental health needs of the population rather than set up vertical programmes (World Health Organization, 2013). This entails that psychosocial and mental health programmes in conflict-affected countries, which are often brief and consist of single-intervention approaches funded outside of existing health and social systems, need to systematically integrate a longer-term perspective into their work and employ multi-level or stepped-care packages with entry points in community and non-specialised healthcare settings (Jordans et al, 2009b; Betancourt et al, 2013). The feasibility of a multi-layered care system for children has been demonstrated in several conflict-affected settings, with schools as the entry point (Jordans et al, 2011). At the healthcare level, task-sharing mental healthcare with primary healthcare workers appears a feasible strategy based on existing studies (van Ginneken et al, 2011), also in post-conflict settings (Mendenhall et al, 2014).

Calls to widen the focus of treatment to a broader group of mental disorders seem daunting. However, a promising direction in this regard is a trans-diagnostic modular approach, in which different components of evidence-based treatments for specific disorders are combined to cater for a variety of mental health problems (e.g. rather than only addressing post-traumatic stress disorder, especially given the very high comorbidity rates). These different components can subsequently be combined to form the building blocks of a larger care package.

Conclusion

Clearly, this paper is not a call to neglect the potentially devastating impact of ongoing political violence on children in areas of armed conflict. In contrast, we argue that a broader systems approach is better capable of addressing the variety of needs of both this group of children and other vulnerable groups in LMICs affected by armed conflict. With millions of children living in areas of war, continued attention to their plight and mental health needs has to continue, and subsequently be channelled to establishing a mental healthcare approach that has the ability to address specific psychosocial sequelae of conflict-affected children and families. This can be achieved within a multi-level system that promotes mental health, prevents mental ill-health and strengthens access to evidence-based treatments in the population at large.