Solving Single G L Lambert Epub 80
Badomero Schoulund
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. Mdecins Sans Frontires 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 (
The limitations of this research and the difficulty in applying intervention-specific findings in low-resource settings has resulted in a large theory-practice gap [20]. Part of the difficulty in applying research findings in the field is the tendency for intervention research to focus on quantifiable effectiveness for specific manualised interventions, which tends to neglect the wealth of less quantifiable, but valuable, field experience and interventions at different levels, in different cultures and by non-specialist practitioners. Reviews of interventions in the field, both academic and clinical, frequently report on the mechanisms of change employed by the reviewed interventions; the theoretical and operational process by which the targeted outcome is thought to be achieved. For example, many reviews cite the importance of the narration of experience, trauma processing and memory integration and the correction of self-blaming appraisals (e.g. [14]), secure and consistent caregiving (e.g. [13]), and traditional rituals such as for grief or forgiveness (e.g. [10]), as well as highlighting key adverse effects such as the pathologising of normal reactions (e.g. [21]). Reviewing underlying mechanisms of change in these populations, rather than intervention specific effectiveness, could help to connect theory to practice by identifying key therapeutic processes that transcend the diversity of models, approaches and techniques, that could be applied across service settings and socio-political and cultural contexts.
This review of reviews included children, adolescents and young people aged 25 or younger, who have experienced or continue to experience war, armed conflict or political violence, and any psychological or psychosocial intervention that aims to improve the wellbeing, mental health and/or resilience of children and adolescents, in any format, and at every level of the IASC (Inter-Agency Standing Committee) 4-tiered pyramid model for mental health and psychosocial support in emergencies [24]. For the purposes of this review, intervention aims were categorised as prevention, promotion, and/or treatment. Prevention refers to interventions that aim to prevent mental ill health or distress, such as universal psychoeducation. Promotion refers to interventions that aim to promote wellbeing, resilience and optimal development, such as targeted school-based interventions. Treatment refers to interventions that aim to treat mental ill health and psychiatric disorders, such as Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) [25] and Narrative Exposure Therapy for children (KidNET) [26, 27]. Some interventions may also have mixed aims, particularly given the interaction between the prevention of distress and promotion of wellbeing.
Children affected by single terrorism-related events in non-war affected countries were excluded, as well as displaced populations in non-war affected countries. Displaced populations that continued to live in their, or another, country affected by war were included. Reviews that had a wider scope but provided sub group analysis of children or adolescents affected by war were also included.
Included reviews were screened by the first author and all sentences or paragraphs that referred to mechanisms of change relating to any of the included interventions were extracted, along with data on the number and ages of participants, the countries and settings, the types of conflict, the types of interventions, outcome measures, and the type and quality of evidence supporting the mechanisms. Sentences or paragraphs that referred to impediments to change, such as intervention adverse effects, were also extracted. Mechanisms were cited in reviews as part of a synthesis of findings drawn from their included studies.
To further explore the scope and quality of research, two additional analyses were conducted. The first to identify the global coverage of the identified research, using a map derived from the Global Peace Index, from 2007 when data was first available, until the most recent publication in 2016. The Index categorises countries based on 23 indicators of internal violent conflict, international war, political insecurity and militarisation [32]. The map was amended to display countries affected by conflict (a score of 2.38 or more (low or very low peace) in any year of the index period), and countries in which at least 1 study has been conducted on psychological interventions for children, according to the results of this review of reviews. Some reviews included studies on refugee populations in high-income countries (e.g. Kosovan and Roma refugees in Germany, [14]) or single terrorist attacks (e.g. 9/11 in the United States, [6]), and these countries were excluded from the map. Copyright for use of the original map was granted by the Institute for Economics and Peace. Secondly, in order to support and inform the qualitative interpretations of data, citations for each identified mechanisms of change were counted and organised into prevention, promotion and treatment intervention categories, stratified by mechanism quality of supporting evidence ratings.
The quality of each included review was assessed using the AMSTAR Checklist (A Measurement Tool to Assess Systematic Reviews, Copyright 2015 AMSTAR All Rights Reserved, [33]). This tool assesses reviews based on quality criteria, including duplicate study selection and publication bias, and provides a quality rating (low, moderate and high).
The quality of supporting evidence for the mechanisms of change was also assessed. Extracted data on the type of supporting evidence was compiled for each mechanism. A rating scale was developed based on the recommendations of Kazdin [28]. The quality of evidence was rated as low if the mechanism was described based on case studies, qualitative research, clinical experience, cross-sectional research, or program evaluations. A moderate quality rating was assigned if the mechanism was supported by quantitative data from intervention controlled trials. A high quality rating was given when the mechanism was supported by quantitative data specifically testing the mechanism, such as through mediational analysis.
The database and grey literature search produced a total of 2359 records from which 13 reviews were included (for details of the review process see Additional file 1: Figure S1). Details of the included reviews are displayed in Table 1 (for excluded studies see Additional file 2: Table S1). Within the included reviews, 7 were systematic reviews of quantitative studies, 3 were systematic reviews of quantitative and qualitative studies and 3 were unsystematic narrative reviews. The reviews included studies up until 2017 and covered a diversity of countries, age groups and war settings, with pooled sample sizes ranging from 730 to 32,046.
The AMSTAR quality assessment results are displayed in Table 2. The assessment shows that 5 reviews were of low quality, 6 of moderate quality and 2 of high quality. Studies were most commonly marked down for not providing protocols, not providing a list of excluded studies, and not assessing publication bias.
Two reviews [1, 36] cited the need to support families, caregivers and practitioners in order to improve their ability to support children, through psychoeducation, dialogue, and through self-care. Caregivers are affected by the same war and violence affecting the children they care for, with the addition of containing the distress of children and their own childhood traumatic experiences. Statistical testing in two studies cited by Jordans, Pigott and Tol [36] provides high quality evidence for this mechanism.
Three reviews [1, 14, 36] cited the strengthening of family and therapeutic relationships, of involvement in interventions, and of improved consistency of caregiving, particularly during periods of active conflict, for the long term wellbeing of children. This was also cited within the context of looking beyond traumatisation to the daily experience of children within the context of collectivist cultures, where family relationships are a core resource. Statistical testing in two studies cited by Jordans, Pigott and Tol [36] provides high quality evidence for this mechanism.
These mechanisms with their respective quality ratings are displayed in Fig. 2. Overall, the quality of evidence is poor, with few studies testing mechanisms statistically. High quality evidence was found only for family capacity building, relationship strengthening, problem solving, and therapeutic rapport. Mechanisms at lower levels of the IASC pyramid (basic services and security, and strengthening family and community support) such as protection from harm, play, and capacity building had the poorest quality of evidence. Trauma processing was the most cited mechanism, and was included at least once for each intervention type.
Researcher reflective notes showed three core considerations. Firstly, the utility of interventions (and intervention research) aiming to treat children for post-traumatic stress disorders was raised because of the reliance on post trauma literature and its application to populations experiencing ongoing and indefinite terror. Secondly, the eighth mechanism of engaging with traditions was worded carefully due to concern raised about cultural biases and norms around traditional healing, particularly as most reviews were conducted by authors based in European or North American countries. Finally, the difficulty in differentiating mechanisms from techniques and protective factors was noted. Reviews often highlighted this lacking detail and clarity on underlying processes in their included studies.
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