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O Sullivan (2016) Psychological Interventions For Children and Young People Affected
O Sullivan (2016) Psychological Interventions For Children and Young People Affected
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
142
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O’Sullivan et al.
of local or outside support that aims to protect or Literature detailing interventions for con-
promote psychosocial wellbeing and/or prevent £icted a¡ected youths suggest some promis-
or treat mental disorder’ (IASC, 2007, p.17). ing ¢ndings. However, this research is in
Psychological interventions for this popu- need of an in-depth evidence base. The aim
lation are widely used by state led health of this review is to provide evidence for the
services, nongovernmental organisations e¡ectiveness of interventions employed
(NGOs) and local community based organ- among youths a¡ected by ongoing con£ict.
isations (CBOs), and are strongly recom-
mended by the World Health Organization
(2010). Despite this consensus, gaps exist Method
between the needs of youths and the avail- Search strategy
ability of evidence based interventions, with Four databases were searched; Pubmed, PI-
the majority of these informed by trauma LOT, Psyc Info and Medline. Search terms
based research in non con£ict a¡ected areas, included: (_child_ or _adolescent_) and (_war_
particularly western Europe and North or _armed con£ict_ or _community violence_
America (Morris, van Ommeren, Belfer, or _ political _ violence _) and (_intervention_
Saxena, & Saraceno, 2007). The suitability or _treatment_ or _ therapeutics) and (_psycho-
of such interventions for the issues facing social_ or _mental health_).The search covered
con£ict a¡ected youths is questionable and, publication dates between 1806 and 2014,
where impact has been noted, almost no and was performed on16 July 2014, including
longitudinal follow-ups have been conducted past and present con£ict a¡ected areas.
(Summer¢eld, 2001). A grey literature search was conducted
Three literature reviews exist for psychologi- through websites of key organisations in
cal interventions within this population this ¢eld, and a survey was conducted to
(Jordans, Tol, Kompore & de Jong, 2009; inform the inclusion criteria, highlighting
Peltonen & Punamaki, 2010; Persson & any further grey literature not already
Rousseau, 2009). These reviews recommend screened. Results of the survey informed
improving scienti¢c research and insight inclusion criteria detailed below.
into the causality and strength of reported Articles were included for full review
changes on the range of outcomes. Addition- if they met the following criteria: a) the
ally, by including outcomes related to methodology was described as an RCTor a
optimal functioning and development, cluster randomised trial (CRT); b) primary
intervention outcomes can be expanded participants were youths living in countries
beyond symptom reduction. These reviews with protracted armed con£ict or political
were conducted over ¢ve years ago, and glo- violence; c) interventions aimed at reducing
bal contexts assessed ranged widely. Other psychosocial or mental health e¡ects of
randomised control trials (RCTs) have since armed con£ict; and d) the publication
been published (e.g. McMullen et al., 2013). detailed the impact on psychosocial and
Across these reviews, only three RCT’s mental health outcomes.
relevant to interventions for war a¡ected Studies were excluded if target populations
youths were detailed, including one study were asylum seekers or refugees who had
in northern Uganda (Bolton et al., 2007) crossed an international border as the
and two in Bosnia and Herzegovina (Layne experiences of making the journey to a
et al., 2001; Dybdahl, 2001). Consequently country of perceived safety, and the experi-
no comprehensive meta-analyses have ence of living outside of the home country
been completed, and key questions remain of con£ict presents experiences and variables
unanswered relating to the e¡ectiveness that are di¡erent to those experienced by
of interventions. those who remain living in con£ict or
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Psychological interventions for children and young people affected by armed conflict or political violence: a
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
post-con£ict zones. Studies were also Collaboration, 2014) was used for meta-
excluded if they focused on single event analytic calculations. A narrative synthesis
exposure, such as a terrorist attack in an of outcomes that were not eligible for
otherwise stable country, or if the population meta-analyses was completed.
were exposed to interpersonal or internal
familial con£ict. Critical appraisal
The Downs and Black quality assessment
Procedure scale (QAS) measured study quality (Downs
Two reviewers (COS andTB) independently & Black, 1998). This QAS consists of 27
screened studies using the title/abstract, with criteria that determine the quality of report-
those selected being screened by full text. ing, and external and internal validity.
Discrepancies were discussed with a third This tool has high internal consistency, good
reviewer (CS) and agreed. Interrater test^retest (r ¼ 0.88), inter-rater (r ¼ 0.75)
reliability for article selection was good reliability, and good face and criterion
(Kappa ¼ 84%). Reference lists of included validity (0.90).
studies were also screened. Finally, grey lit-
erature was screened by reviewers COS Results
and TB. Study selection
Of 649 publications and 4,276 grey literature
items, 17 studies were ultimately included
Data synthesis and analysis
(Figure 1). Exclusion criteria consisted of:
methodology
inappropriate methodology; no interven-
Interventions were categorised according to
tion; no evaluation; refugees, asylum seekers
the target populations, as either non clinical
or adult participants; participants exposed
or clinical. Studies were categorised as ‘non
to interpersonal con£ict, urban violence, or
clinical’ if the interventions targeted youths
a single event.
at risk of developing psychosocial and men-
tal health di⁄culties through exposure to
continued violence. Studies were categorised Intervention features
as ‘clinical’ if the interventions targeted Table 1 provides an overview of intervention
participants whose symptoms met a clinical features. First, the eight interventions studies
threshold. for non clinical populations are detailed, fol-
Meta-analyses were conducted on post lowed by the nine interventions studies for
intervention scores for treatment and con- clinical populations.
trol groups only when comparable interven-
tions and outcomes were present. For all Setting and sample size
meta-analyses, studies were weighted by Contexts ranged from displacement after
sample size. Random e¡ects modelling were violent con£ict in Uganda, to exposure to
used due to the inherent heterogeneity ongoing armed con£ict in the occupied
across studies. Standard mean di¡erences Palestinian territories. Sample size in the
(SDM) were utilised when the same out- studies ranged from 50 participants to larger
comes were measured using di¡erent scales, community studies of 1127 war a¡ected
and means di¡erences (MD) were utilised youths (McMullen et al., 2013; Khamis,
when outcomes were measured on the same Macy, & Coignes, 2004).
scales. All results represented in the meta-
analysis are short-term outcomes, as there Participants
was insu⁄cient data for long-term out- In 14 of the 17 studies, youths were the only
comes. RevMan 5.3 (The Cochrane participants in the interventions. Three
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O’Sullivan et al.
14 studies included
1 grey lierature included
2 studies identified in reference
included
17 included
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146
Table 1. Intervention features
Sample size Type of Primary
Author & participants Evidence control Primary outcome
country exclusion Age Intervention quality group outcomes measures E¡ectiveness
Non clinical
populations
Ager et al., 403 internally 7^12 Psychosocial CRT; Pre Wait list Wellbeing Wellbeing scale Wellbeing
2011; Uganda displaced structured and 12 developed for d ¼ 0.72 to 1.12
youths; No activities months post study
exclusion
criteria detailed
Day & 62 war a¡ected 10^12 Bensons RCT; Pre, Active Anxiety GAS-C Anxiety d ¼ 0.175
Sadek, youths relaxation post and
1982; exposed to con- technique 3 month
Lebanon tinued follow-up
con£ict. No
exclusion
criteria detailed
Diab et al., 428 war a¡ected 10^13 Teaching CRT; Pre, Wait list Peer /sibling Youths loneliness Loneliness
2014; youths recovery post and relations scale; Friendship d ¼ 0.14; Peer
Palestine living in Gaza 3.5 techniques 6 month qualities scale relations d ¼ 0.12;
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
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148
Table 1. (Continued)
Sample size Type of Primary
Author & participants Evidence control Primary outcome
country exclusion Age Intervention quality group outcomes measures E¡ectiveness
O’Callaghan 159 war a¡ected 7^15 Family focused RCT; Pre, Wait list PTSD; Conduct CRIES-8; AYPA PTSD symptoms
et al., 2014; youths and their psychosocial post and problems; d ¼ 0.40
DRC caregivers intervention 3 month Prosocial
facing current follow-up behaviour
risk. Global
developmental
delay
Slone et al., 179 adolescents; 16^17 Mobilisation of CRT; Pre Wait list Psychological SDQ; SEQ-C Self-e⁄cacy
2013; Israel No exclusion support and and post distress; Self d ¼ 0.43;
criteria noted self-e⁄cacy e⁄cacy Psychological
symptoms
d ¼ 0.20^0.40
Clinical
populations
Bolton et al., 314 war a¡ected 14^17 a) Group RCT; Pre Wait list and Depression; AYPA Depression; IPT:
2007; Acholi adoles- Interpersonal; and post Active Anxiety; d ¼ 0.57; CP:
Uganda cents living in Psychotherapy Conduct d ¼ 0.20
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
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150
Table 1. (Continued)
Sample size Type of Primary
Author & participants Evidence control Primary outcome
country exclusion Age Intervention quality group outcomes measures E¡ectiveness
O’Callaghan 52 war-a¡ected 12^17 GTF^CBT RCT; Pre, Wait list PTSD; Anxiety; UCLA-PTSD Reduced PTS
et al., 2013; girls exposed to post and Depression; RI; AYPA symptoms
DRC rape and 3 month Conduct d ¼1.92; Reduced
inappropriate follow-up problems; depression/
sexual touch; Prosocial anxiety d ¼1.98;
Intellectual behaviour Reduced conduct
disability, problems d ¼1.09;
psychosis, severe Improved
emotional & psychosocial
behavioural behaviours;
problems d ¼1.35
Tol et al., 495 war-a¡ected 8^17 CBIR CRT; Pre, Wait list PTSD; CPSS; DSRS PTSD symptoms
2008; youths post and Depression; SCARED-5; d ¼ 0.55;
Indonesia with clinically 3 month Anxiety; Hope; CHS FIS Depression
signi¢cant symp- follow-up General d ¼ 0.07;
toms of PTSD/ functioning Anxiety d ¼ 0.14;
depression.; Hope
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
Violent d ¼ 0.29
behaviour/
Severe
psychiatric
symptoms
Psychological interventions for children and young people affected by armed conflict or political violence: a
151
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Psychological interventions for children and young people affected by armed conflict or political violence: a
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
and PTS symptoms (Ager et al., 2011; Day & Eight studies utilised locally developed out-
Sadek, 1982; Diab, Punamki, Palosaari & come measures (Ager et al., 2011; Bolton
Qouta, 2014; Dybdahl, 2001; Jordans et al., et al., 2007; McMullen et al., 2013;
2010; Khamis et al., 2004; O’Callaghan O’Callaghan et al., 2013; O’Callaghan
et al., 2014). et al., 2014; Tol et al., 2008, 2012, 2014).
Eight of the nine interventions for clinical
populations measured at least three out-
Theoretical frameworks
comes. Depression and PTSD were
Theoretical frameworks ranged from cogni-
measured by eight studies, and anxiety
tive behavioural therapy (CBT), mind^body
was included in six. Grief, stigma, guilt
(e.g. meditation, breathing techniques,
and suicidal ideation were identi¢ed once
guided imagery), and narrative exposure
across the nine studies (Ertl, Pfei¡er,
therapy to interventions informedbyaneclec-
Schauer, Elbert, & Neuner, 2011). Prosocial
tic range of therapeutic models (Table 2).
behaviour was included in two studies and
hope in three studies (McMullen et al.,
2013; O’Callaghan et al.,2013;Tol, Komproe, Quality assessment
Susanty, Jordans, Macy & De Jong, 2008; Quality of studies was assessed using the
Tol et al., 2012, 2014). Downs and Black quality assessment scale
Non clinical Ager et al., 2011; Jordans et al., 2010; CBT, creative expressive (art) and
Khamis et al., 2004 experiential
(drama) therapy
Day et al.,1982 Biofeedback assisted relaxation
training
Diab et al., 2014 CBT principles
Dybdahl 2001 Contemporary developmental
theories
O’Callaghan et al., 2014 Systemic, family focused,
community based
psychosocial intervention
Slone et al., 2013 Resilience enhancement: self-
e⁄cacy and
mobilisation of social support
Clinical Bolton et al., 2007 Interpersonal psychotherapy;
Resilience enhancement
though verbal and non-verbal play
Ertl et al., 2011 Narrative exposure therapy
Gordon et al., 2008 Mind^body skills training
Layne et al., 2001; McMullen TF^CBT
et al., 2013; O’Callaghan et al., 2013
Tol et al., 2008, 2012, 2014 CBT, creative expressive and
experiential therapy
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O’Sullivan et al.
Jordans et al., 2010 17.71 4.83 164 18.62 5.26 161 31.7% –0.18 [–0.40, 0.04]
Khamis et al., 2004 (12–16) 30.69 12.37 347 29.85 13.01 122 32.8% 0.07 [–0.14, 0.27]
Khamis et al., 2004 (6–11) 31.21 11.04 496 28.96 10.87 162 35.5% 0.20 [0.03, 0.38]
(QAS, Downs & Black, 1998). Average study Classroom Based InterventionR (CBIR),
quality washigh,meeting83.4%ofthecriteria di¡erent scales were used to measure out-
(range: 70^93%). Potential adverse events comes (Table 1).
were not detailed in all 17 studies. Criteria
commonly unful¢lled included not reporting
Symptoms of PTS
exact P values and the absence of power
For symptoms of PTS, Figure 2 illustrates
calculations (Day & Sadek,1982; Diab et al.,
that the pooled estimate of random
2014; Dybdahl 2001; Gordon, Stales & Blyta,
e¡ects model found no overall e¡ect for
2008; Jordans et al., 2010; Khamis et al.,
either CBIR [SMD ¼ 0.04; 95% CI (con¢-
2004; Layne et al., 2001; McMullen et al.,
dence interval) 0.18 to 0.026, P ¼ 0.74].
2013; Slone, Shoshanie & Lobel, 2013).
Heterogeneity was statistically signi¢cant
(I2 ¼72%, P ¼ 0.03).1
E¡ectiveness of interventions
Intervention e¡ectiveness is divided into two
sections, 1) non clinical populations, and 2) Anxiety
clinical populations. Both sections include For anxiety, Figure 3 illustrates that the
meta-analyses for eligible studies and brief pooled estimate of random e¡ects model
narrative synthesis for the remaining studies. found no overall e¡ect for CBIR
(SMD ¼ 0.65; 95% CI 0.56 to 0.187,
Interventions for non clinical P ¼ 0.29). Heterogeneity was statistically sig-
populations ni¢cant (I2 ¼ 99%, P < 0.001).
Meta-analyses of Classroom Based
InterventionR for posttraumatic General psychological functioning
stress symptoms, anxiety, depression Figure 4 illustrates that for general psycho-
and hope logical functioning the mean di¡erence
Three studies met meta-analyses criteria for for random e¡ects model found no overall
the outcomes: PTS symptoms, anxiety, e¡ect for CBIR (MD ¼1.69; 95%
general psychosocial functioning and hope CI 3.82 to 0.44, P ¼ 0.12), as measured on
(Jordans et al., 2010; Khamis et al., the SDQ. Heterogeneity was statistically
2004a; b). For the studies employing the signi¢cant (I2 ¼ 92%, P < 0.001).
Experimental Control Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Khamis et al., 2004 (12 -16) 12.84 5.12 136 13.03 6.14 122 33.3% −0.03 [−0.28, 0.21]
Khamis et al., 2004 (6-11) 14.08 5.98 244 4.87 2.11 162 33.3% 1.91 [1.67, 2.14]
Jordans et al., 2010 3.84 1.53 164 3.71 1.23 161 33.4% 0.09 [−0.12, 0.31]
153
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Psychological interventions for children and young people affected by armed conflict or political violence: a
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
Khamis et al., 2004 (12 -16) 12.85 4.59 136 13.3 5.63 122 32.2% −0.45 [−1.71, 0.81]
Khamis et al., 2004 (6-11) 13.64 5.57 224 17.49 4.73 162 33.4% −3.85 [−4.88, −2.82]
Jordans et al., 2010 14.97 4.4 164 15.71 3.17 161 34.4% −0.74 [−1.57, 0.09]
Figure 4: E¡ectiveness of CBIR for general psychosocial functioning within a non clinical population.
154
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O’Sullivan et al.
O'Calllaghan et al., 2013 18.38 10.53 24 42.93 13.67 28 44.3% −24.55 [−31.14, −17.96]
McMullen et al., 2013 10.6 9.2 25 34.8 11.6 24 55.7% −24.20 [−30.08, −18.32]
O'Calllaghan et al., 2013 13.96 10.3 24 40.04 15.18 28 41.9% −26.08 [−33.05, −19.11]
McMullen et al., 2013 7 5.8 24 29.3 13.6 24 58.1% −22.30 [−28.22, −16.38]
155
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Psychological interventions for children and young people affected by armed conflict or political violence: a
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
156
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O’Sullivan et al.
Tol et al., 2014 1.4 4.9 153 1.12 5.67 176 32.3% 0.05 [−0.16, 0.27]
Tol et al., 2012 2.9 3.7 198 1.19 4.5 199 33.8% 0.41 [0.22, 0.61]
Tol et al., 2008 1.44 4.27 182 1.16 4.23 221 34.0% 0.07 [−0.13, 0.26]
researchers for each study. Figure 13 indicates Three studies that were not included in the
that for functional impairment, CBIR did meta-analyses examined the e¡ectiveness of
not yield any overall signi¢cant e¡ect with a various interventions for PTSD. Gordon
mean increase of 0.07 (95% CI 0.13 to 0.26, et al. (2008) employed a mind^body skills
P ¼ 0.13). Heterogeneity was statistically sig- programme, ¢nding a large treatment e¡ect
ni¢cant (I2 ¼75%; P ¼ 0.02). favouring the intervention group (Cohen’s
d ¼1.13). The e¡ectiveness of narrative
Hope exposure therapy (NET) and an academic
Hope was measured on the Child Hope catch-up group for PTSD were examined
Scale (Synder et al., 1997). Figure 14 illus- by Ertl, Pfei¡er, Schauer, Elbert & Neuner
trates that CBIR did not yield any overall sig- (2011). NET produced a larger treatment
ni¢cant e¡ect for hope, with a mean e¡ect (Cohen’s d ¼ 0.76) than the academic
increase of 0.33 (95% CI 1.51 to 0.13 to catch up group (Cohen’s d ¼ 0.66), both being
1.21, P ¼ 0.51). Heterogeneity was not statisti- favoured over the control condition. Trauma
cally signi¢cant (I2 ¼ 0%; P ¼ 0.33). and grief component therapy (TGCT, Smith
& Saunders, 2005), produced a larger e¡ect
Narrative synthesis of remaining size (Cohen’s d ¼1.66) for the treatment
interventions for clinical populations group who received the intervention earlier
E¡ect sizes for the remaining interventions than the control, suggesting earlier interven-
indicate some evidence to suggest that these tion is more e¡ective than delayed interven-
may prove bene¢cial (Table 1). tions (Layne et al., 2001).
Tol et al., 2014 1.98 6.53 153 1.15 6.42 176 48.6% 0.83 [−0.57, 2.23]
Tol et al., 2008 0.95 6.84 183 1.1 7.11 221 51.4% −0.15 [−1.51, 1.21]
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Psychological interventions for children and young people affected by armed conflict or political violence: a
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
For depression within clinical populations, systemic, narrative and interpersonal thera-
Bolton et al. (2007) found that Group Inter- peutic frameworks (e.g, Bolton et al., 2007;
personal Therapy (Cohen’s d ¼ 0.52) was Dybdahl, 2001; Gordon et al., 2008; O’Calla-
more e¡ective than creative play (Cohen’s ghan et al., 2014). However, as these are all
d ¼ 0.2), compared to a comparison group, one-o¡ studies no conclusive evidence exists
but no signi¢cant e¡ects were identi¢ed for on the e¡ectiveness of these interventions.
anxiety nor conduct di⁄culties.
Although these ¢ndings point to potentially
e¡ective interventions for PTSD and depres- Synthesis of intervention features
sion within clinical populations, the true Seventeen studies were included in this
clinical e¡ectiveness remains unquanti¢ed review and although research in the area
without meta-analytic calculations. has increased (the number of controlled
studies increasing from three in 2009 and
to 17 in 2014) this is still low relative to the
Discussion number of con£ict a¡ected youths. How-
Key ¢ndings ever, the high rating across the QAS evi-
Research in this area does not provide a rig- dences that there have been advances in
orous evidence base to inform practice. research. Six of the studies included CRTs
Within clinical cohorts of con£ict a¡ected and the remaining eleven were RCTs, a
youths, meta-analyses found GTF^CBT to marked improvement from the three RCTs
be e¡ective in reducing symptoms of, identi¢ed in a review ¢ve years ago (Jor-
anxiety, conduct problems and increasing dans et al., 2009).
pro-social behaviour however, only three There is a continued focus on clinical out-
studies were included in this analysis. For comes, even within non clinical populations.
non clinical populations, CBIR was the only Although there is a movement to incorporat-
intervention eligible for meta-analyses and ing more psychosocial outcomes, it is clear
was found to be e¡ective for the sole out- from the results of this review that clinical
come, hope. Overall, from meta-analytic outcomes (e.g. PTSD, depression etc.) out-
calculations, it is evident that interventions weigh non clinical outcomes (e.g. pro-social
which are comprised of core elements of behaviour). The limited e¡ectiveness of
CBT, such a GGTF-CBT for clinical cohorts, interventions for non clinical cohorts may
are bene¢cial. be a result of the use of clinical measures
It is also apparent from this review that inter- for non clinical populations. The use of such
ventions that are comprised of core elements measures may result in £oor-e¡ect results,
of CBT have secured more RCTs, and that with the resultant missed opportunity to
this may result in a skewed evidence base in examine changes which may occur at a sub
favour of such interventions. Importantly, clinical level.
this should not be taken as lack of evidence Few studies were identi¢ed that utilised
for interventions informed by other theoreti- locally validated outcome measures. As
cal frameworks, rather it indicates a lack of symptom expression can di¡er across con-
studies examining e¡ectiveness of interven- texts, evaluating intervention e¡ectiveness
tions other than CBT-type protocols. based on measures that are not culturally
Examining individual e¡ect sizes for studies germane may result in inaccurate ¢ndings.
not included in meta-analyses, it is arguable Sample sizes ranged between 50 to larger
that some of these interventions may be community studies of 1127 war a¡ected
bene¢cial for this population. For example, youths (McMullen et al., 2013; Khamis
moderate to large e¡ect sizes were identi¢ed et al., 2004). Although these are adequate
for interventions grounded in mind^body, sample sizes, not all studies explicitly
158
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O’Sullivan et al.
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Psychological interventions for children and young people affected by armed conflict or political violence: a
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
The e¡ectiveness of CBIR across both non interventions were promising, as indicated
clinical and clinical groups was restricted, by moderate e¡ect sizes.
with signi¢cant improvements identi¢ed in Two interventions couched within the
the non clinical group being limited to hope. mind^body framework were indenti¢ed in
One potential cause was the extremely large this review, one in both the universal and
sample size. Although the studies report ade- indicated category, for anxiety and PTSD
quate procedures for treatment ¢delity, one respectively, (Day & Sadek, 1982; Gordon
could question its reliability given the large et al., 2008). Results from Gordon et al.
numbers of lay facilitators and teachers pro- (2008) suggest promise, as indicated by the
viding the intervention. large e¡ect size.
Within the clinical population, e¡ects near- NET informed an intervention within the
ing signi¢cance were identi¢ed for anxiety, indicatedcategoryandpromising resultswere
whereas in the non clinical population found for PTSD, however, as only one study
signi¢cant e¡ects were identi¢ed on the out- was informed by this theoretical framework,
come hope. In exploring this di¡erence, the true e¡ectiveness could not be analysed.
questions arise relating to the outcomes Despite these ¢ndings, the lack of replication
measured. While outcomes of interest for and missing data within research is heavily
non clinical populations are predominantly in£uenced by CBT-type interventions which
clinical, an important question is whether have been subjected to meta-analyses.
using clinical methods within a non clinical
population may result in reduced sensitivity Future research
to changes in symptoms that do not meet This review demonstrates a movement
the clinical threshold. towards quality trials. However, continued
Despite guidance on the importance of emphasis on well designed trials is needed
holistic interventions from the IASC Refer- to address factors that have limited study
ence Group on Mental Health and Psycho- eligibility for meta-analyses. Key consider-
social Support in Emergency Settings, it is ations in future research are the use of theor-
apparent that evidence for interventions etically grounded interventions and the use
informed by CBT collectively outweighs of appropriate outcomes (e.g. less focus on
interventions informed by other theoretical clinical outcomes within non clinical popu-
frameworks (IASC, 2007). Evidently, these lations). Additionally, replication of existing
interventions do exist in smaller numbers, interventions^which have proven quality
but the lack of replication limits examining design and evidence of utility^may broaden
e¡ectiveness. the evidence base in this area.
There is a strong evidence base to suggest A particular area of concern is the lack of evi-
secure and trusting relationships counteract dence supporting interventions delivered to
stressors, and this has been extended to inter- youths who do not meet clinically signi¢cant
ventions within this population (Bowby, thresholds. Results of a survey conducted
1969; Sveass & Reichett, 2001). To address by the authors, prior to this review, high-
the e¡ects of war exposure two non clinical lighted this as a key area for further research.
interventions focused on enhancing inter- This is re£ected in the ¢ndings of this
personal and social relations (O’Callaghan review. Such studies may bene¢t from
et al., 2014; Slone et al., 2013). Among clinical employing interventions that are ¢rmly
interventions, improving interpersonal based in theoretical frameworks.
relations was also a key focus in Bolton It may be important for future research to
et al. (2007a) in which IPT-G (group inter- focus on younger age groups; this is parti-
personal therapy) was the intervention of cularly true for interventions for clinical
choice. Across both groups, results for such cohorts.
160
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O’Sullivan et al.
161
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Psychological interventions for children and young people affected by armed conflict or political violence: a
systematic literature review, Intervention 2016, Volume 14, Number 2, Page 142 - 164
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a¡ected children? Impact and mediating analyses chosocial intervention in con£ict-a¡ected Nepal:
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ment, 23, 215-231. Child Psychology and Psychiatry and Allied Disciplines,
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