Dec 10, 2016 - 1Research Program for Children and Global Adversity, Department ... The Netherlands; 4International Rescue Committee, New York, NY, USA.
Journal of Child Psychology and Psychiatry **:* (2016), pp **–**
doi:10.1111/jcpp.12671
Annual Research Review: Breaking cycles of violence – a systematic review and common practice elements analysis of psychosocial interventions for children and youth affected by armed conflict Felicity L. Brown,1,2 Anne M. de Graaff,1,3 Jeannie Annan,4 and Theresa S. Betancourt1 1
Research Program for Children and Global Adversity, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; 2War Child Holland, Amsterdam; 3Faculty of Social and Behavioral Sciences, Leiden University, Leiden, The Netherlands; 4International Rescue Committee, New York, NY, USA
Background: Globally, one in 10 children live in regions affected by armed conflict. Children exposed to armed conflict are vulnerable to social and emotional difficulties, along with disrupted educational and occupational opportunities. Most armed conflicts occur in low- and middle-income countries (LMICs), where mental health systems are limited and can be further weakened by the context of war. Research is needed to determine feasible and cost-effective psychosocial interventions that can be delivered safely by available mental health workforces (including nonspecialists). A vital first step toward achieving this is to examine evidence-based psychosocial interventions and identify the common therapeutic techniques being used across these treatments. Methods: A systematic review of psychosocial interventions for conflict-affected children and youth living in LMICs was performed. Studies were identified through database searches (PsycINFO, PubMed, Cochrane Central Register of Controlled Trials, PILOTS and Web of Science Core Collection), hand-searching of reference lists, and contacting expert researchers. The PracticeWise coding system was used to distill the practice elements within clinical protocols. Results: Twenty-eight randomized controlled trials and controlled trials conducted in conflict-affected settings, and 25 efficacious treatments were identified. Several practice elements were found across more than 50% of the intervention protocols of these treatments. These were access promotion, psychoeducation for children and parents, insight building, rapport building techniques, cognitive strategies, use of narratives, exposure techniques, and relapse prevention. Conclusions: Identification of the common practice elements of effective interventions for conflict-affected children and youth can inform essential future treatment development, implementation, and evaluation for this vulnerable population. To further advance the field, research should focus on identifying which of these elements are the active ingredients for clinical change, along with attention to costs of delivery, training, supervision and how to sustain quality implementation over time. Keywords: Armed conflict; war; violence; developing countries; children; adolescents; youth; mental health; well-being; psychosocial treatment; systematic review.
Introduction The context of war and the impact on child and youth mental health Globally, it is estimated that one in 10 children – nearly 250 million – live in areas affected by armed conflict (UNICEF, 2016). War-related fatalities have increased sharply in recent years (IISS, 2015; Pettersson & Wallensteen, 2015), alongside a trend of increasing intensity of the killing, maiming, recruitment into armed forces, and other grave violations of children (United Nations Office of the Special Representative of the Secretary-General for Children and Armed Conflict, 2016). Through 2015, global conflicts contributed to an estimated 65.3 million forcibly displaced people; thus, we are witnessing the highest overall rates and sharpest increases in displacement on record (UNHCR, 2015, 2016). Half
Conflict of interest statement: No conflicts declared.
of those displaced (51%) are estimated to be under the age of 18 years (UNHCR, 2016). Beyond direct exposure to violence, death, loss, and other atrocities, armed conflict disrupts the life trajectories of children and their families, by limiting their basic opportunities to pursue an education or occupation long into the postconflict period (Betancourt, 2015; Tol, Kohrt, et al., 2010). With the changing nature of modern warfare, conflicts are no longer confined to distinct battlefields, but often specifically target civilian populations and essential infrastructure such as schools and hospitals (Betancourt & Khan, 2008). Damage to social and community support networks, lack of access to services, increased daily stressors in the postconflict setting, shifting of behavioral norms including increases in other forms of violence, disrupted family environments, and the intergenerational transmission of trauma can exacerbate and perpetuate the social, emotional, and economic consequences of war for young people (Betancourt, 2015; Betancourt,
© 2016 Association for Child and Adolescent Mental Health. Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
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McBain, Newnham, & Brennan, 2015; Newnham, Pearson, Stein, & Betancourt, 2015; Panter-Brick, Grimon, & Eggerman, 2014; Slone & Mann, 2016). The global development community is increasingly recognizing the significance of mental health problems as leading causes of illness and disability that affect the lives of young people worldwide (Davidson, Grigorenko, Boivin, Rapa, & Stein, 2015; Erskine et al., 2015; Gore et al., 2011). Indeed, the newly launched Sustainable Development Goals (SDGs; Interagency Expert Group on SDG Indicators, 2016) acknowledge mental health and well-being as integral components of overall health, and specifically aim to enhance services and reduce exposure of children to violence and other adversities. The impacts of war on youth mental health and wellbeing are immense; high rates of traumatic stress reactions and posttraumatic stress disorder (PTSD), symptoms of depression and anxiety, psychosomatic symptoms, functional impairments, social difficulties, and risky behaviors all have consequences for the immediate well-being as well as life course opportunities of children and adolescents exposed to armed conflict (Attanayake et al., 2009; Betancourt, Newnham, McBain, & Brennan, 2013; Fazel, Reed, Panter-Brick, & Stein, 2012; Okello, NakimuliMpungu, Musisi, Broekaert, & Derluyn, 2013; Slone & Mann, 2016). Thus, in order to advance human development globally, it is essential that effective services are developed and implemented to prevent and respond to distress, and promote well-being in this vulnerable and rapidly growing group.
The challenge of improving access to quality services in conflict-affected settings Tremendous care gaps exist in access to mental health services globally, particularly in situations of armed conflict. In low- and middle-income countries (LMICs), it is estimated that over 80% of individuals requiring mental health services do not receive the care they require (WHO, 2012). With armed conflicts more common in LMICs (Kim & Conceicao, 2010), increased mental health needs frequently emerge in the context of health systems that are ill-equipped to cope with the burden (WHO, 2013). The growing trend of limited humanitarian access in conflict-affected settings further prevents provision of essential mental health services (Collinson & Elhawary, 2012). Calls to action from the Lancet Global Mental Health series have underscored that in order to truly make progress toward the SDGs, explicit evidence-based indicators of mental health outcomes and service provision must be specified, and strategies for reducing this vast treatment gap implemented (Gureje & Thornicroft, 2015; Izutsu et al., 2015; Kieling et al., 2011). Yet access to quality mental health care and other social services in conflict-affected settings, especially for children and youth, currently remains an urgent and poorly addressed issue.
A growing body of research has documented that evidence-based interventions developed in highincome countries can be effective across cultures in LMICs (Barry, Clarke, Jenkins, & Patel, 2013; Patel, Araya, et al., 2007) and in conflict-affected areas (Betancourt, Meyers-Ohki, Charrow, & Tol, 2013; Jordans, Pigott, & Tol, 2016; OʼSullivan, Bosqui, & Shannon, 2016; Tol et al., 2011). Two recent systematic reviews of children and adolescents affected by armed conflict have highlighted promising effects of interventions, particularly trauma-focused cognitive behavioral therapy (CBT) for clinical populations (Jordans et al., 2016; OʼSullivan et al., 2016). Yet there is less consistent evidence for other intervention modalities and for nonclinical populations. Furthermore, treatment benefits are often limited to specific subgroups of youth, and methodological limitations remain (Jordans et al., 2016; OʼSullivan et al., 2016). Moreover, an overwhelming key barrier in realworld implementation of such interventions and the advancement of child and youth mental health globally is the scarcity of mental health specialists in LMICs and conflict-affected settings (Lancet Global Mental Health Group, 2007; Patel, Flisher, Hetrick, & McGorry, 2007), with an estimated shortage of 1.2 million health workers required to meet global needs (Kakuma et al., 2011). Recent innovations have been implemented to address this challenge of scaling up care for mental health disorders in LMICs. These have involved simplified treatments and task-shifting and task-sharing approaches, whereby nonspecialist lay interventionists are trained to deliver psychological interventions (van Ginneken et al., 2013; WHO, 2010). Intervention models involving nonspecialist providers have also shown promise in high-income countries (Fuhr et al., 2014). Therefore, an ongoing core research priority is to develop and evaluate effective and costeffective treatments for delivery by nonspecialists with minimal training to respond to the high burden of mental health needs, unique risk and protective factors, and service delivery challenges in conflictaffected settings (Collins et al., 2011; Lancet Global Mental Health Group, 2007; Tol et al., 2011).
Distilling the common elements of effective psychosocial treatments in conflict-affected settings With the growing progress in the global mental health field, it is now possible to take stock of the cumulative evidence and begin to shift from a focus on pure efficacy and effectiveness research, to thinking systematically about treatment mediators and moderators, and utilizing dismantling approaches to identify necessary and sufficient active treatment components for effective interventions for children and youth affected by war. As in broader fields of psychosocial interventions, treatments are commonly implemented and evaluated as comprehensive © 2016 Association for Child and Adolescent Mental Health.
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manualized packages, and treatment content and fidelity are often poorly specified in outcome reports. Yet without an understanding of the specific techniques delivered within a psychosocial intervention package, it is impossible to draw adequate conclusions about the existing evidence-base, and use these to inform clinical practice. In order to develop feasible treatments for delivery by nonspecialist providers, it is essential to first identify the key treatment components that must be included and implemented with fidelity in order to effect change. In an attempt to improve understanding of the key ingredients of effective mental health interventions for different patient groups and presenting problems, Chorpita, Daleiden, and Weisz (2005) developed a distillation and matching approach to empirically identify profiles of common elements of interventions. During the distillation process, key characteristics of intervention trials and patient groups and the corresponding intervention protocols are systematically coded to identify the common ‘practice elements’ across intervention protocols. During the matching process, data mining procedures are used to determine specific profiles of common components included in evidence-based treatments and to determine where these profiles of included elements may vary between particular patient groups and settings. Rather than considering the effectiveness of comprehensive intervention packages, this approach aims to drill down to individual therapeutic techniques commonly found in effective treatments, in order to obtain a more finegrained understanding of the current evidence-base (Chorpita et al., 2005). Such an approach cannot identify whether specific components are ‘active ingredients’ in producing the observed treatment effects. However, a focus at the level of specific common practice elements used in efficacious interventions, rather than at the level of comprehensive multicomponent treatment packages, can improve coordination and reduce waste in research efforts. It can also inform later dismantling studies to determine active ingredients, and may enable improved integration of specific treatment elements into a treatment package to target particular symptom domains or functional impairments in a given population at risk for mental health problems (Chorpita et al., 2005; Michie et al., 2013). Identification of common practice elements can complement and enhance efforts to develop interventions that can be used across multiple different disorders. These approaches are gaining interest in high-resource settings (e.g. Ellard, Fairholme, Boisseau, Farchione, & Barlow, 2010; Hayes, Strosahl, & Wilson, 2003; Weisz, Bearman, Santucci, & JensenDoss, 2016; Weisz et al., 2012) and low-resource settings (e.g. Betancourt, McBain, et al., 2014; Epping-Jordan et al., 2016; Murray, 2014; Sijbrandij et al., 2015). Treatment approaches incorporating © 2016 Association for Child and Adolescent Mental Health.
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core components of psychosocial interventions that are safe and effective for delivery by lay interventionists and can be applied across a range of commonly co-occurring mental health problems have the potential to reduce the burden of training in multiple, discrete intervention packages and limit the number of referral points required before receiving treatment (Murray & Jordans, 2016). This has particularly important implications in emergency or postconflict settings where human resources, access to specialists, and training and supervision opportunities are extremely limited. Given the growth in implementation and evaluation of psychosocial treatments in conflict-affected settings, the unprecedented numbers of people displaced by armed conflicts globally, and the heightened demand for targeted, flexible, and affordable intervention options, an analysis of common practice elements in this setting is valuable and timely as a first step to inform ongoing research and treatment efforts. To date, this approach has not been applied specifically to conflict-affected youth, nor has it been applied to the broad range of psychological problems and treatment modalities present in such settings.
The present review We conducted a systematic literature review of randomized controlled trials (RCTs) and controlled trials of psychosocial interventions addressing the mental health and well-being of conflict-affected children and youth in LMICs, and an analysis of common practice elements across efficacious intervention protocols. Previous reviews have considered the evidence-base for children and adolescents in LMICs or conflict settings (Barry et al., 2013; Betancourt, Meyers-Ohki, et al., 2013; Jordans, Tol, Komproe, & De Jong, 2009; Jordans et al., 2016; OʼSullivan et al., 2016; Tol et al., 2011); however, we broadened our inclusion criteria to include youth up to 24 years (UNESA, 2010). As a well-functioning family environment may mitigate the detrimental effects of violence on children (Betancourt & Khan, 2008; Slone & Mann, 2016), family interventions where the well-being of children was addressed indirectly via parents were also included. This is the first study to distill the practice elements included in efficacious interventions specifically for youth in conflict-affected settings. It is an important extension of existing work distilling the practice elements for interventions with children more broadly (Chorpita & Daleiden, 2009), given the realities of low resources, cultural considerations, typically nonspecialist workforces, and health system strains in these settings. It can inform future research into active therapeutic techniques, which will in turn guide development of intervention models that are maximally targeted to improve functioning and reduce distress even in the challenging context of humanitarian emergencies.
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Methods The methodology and results for the review are presented according to the PRISMA standards for reporting systematic reviews (Moher, Liberati, Tetzlaff, & Altman, 2009).
to identify additional studies. In addition, we contacted authors of included studies to identify additional articles not yet retrieved.
Inclusion criteria Search strategy A systematic literature search was conducted on the following databases: PsycINFO (1840 – August 2015), PubMed (1951 – August 2015), Cochrane Central Register of Controlled Trials (1974 – August 2015), PILOTS (1871 – August 2015) and Web of Science Core Collection (all Citation Indexes; 1900 – August 2015). Limits were not applied to searches in terms of language or publication date. The searches used exploded Medical Subject Headings (MeSH) terms where relevant and the comprehensive list of keywords is shown in Box 1. Hand-searches of the reference lists of two relevant journals in the field (Intervention and Journal of Traumatic Stress Studies) as well as relevant review papers were also conducted
Inclusion and exclusion criteria are shown in Box 2. The full search yield was initially reviewed for inclusion by two independent reviewers (FB and AdG) on the basis of title and abstract. Both reviewers then assessed the full text of the remaining articles for adherence to the inclusion criteria. At both points, discrepancies were resolved by discussion, and remaining queries were discussed with a third reviewer (TB).
Box 2 Inclusion and exclusion criteria for studies in this systematic review Inclusion criteria:
Box 1 Search terms used for systematic database searches Population: Child* OR Adolescen* OR Preadolescen* OR Youth* OR “Young people” OR “Young person*” OR Infant* OR Family OR Families OR Pediatric* OR Paediatric* OR Parent* AND Population: War OR Genocide OR “prisoners of war” OR “mass violence” OR “community violence” OR “mass conflict*” OR “post-conflict*” OR “post conflict*” OR “political conflict*” OR “political violence” OR “armed conflict*” OR “Armed violence” OR “ethnic cleansing” OR “child soldier*” OR “child combatant*” OR “children associated with armed forces and armed groups” OR “CAAFAG” OR terrorism AND Intervention: treatment* OR intervention* OR therapy OR psychotherapy OR counseling OR counselling OR training OR psychoeducation OR promotion OR prevention OR Program* OR “Home visiting” OR Support AND Outcome: Behavior OR Behaviour OR Function* OR Externalizing OR Externalising OR Conduct OR “Mental Health” OR “Mental-Health” OR Psychosocial OR Psycholog* OR resilienc* OR “posttraumatic growth” OR “post-traumatic growth” OR “post traumatic growth” OR “Posttraumatic stress” OR “Post traumatic stress” OR “Posttraumatic stress” OR Trauma OR Internalizing OR Internalising OR PTSD OR PTSS OR Depression OR “Depressive Disorder*” OR MDD OR Anxiety OR “Anxiety disorder*” OR Stress OR Distress OR Emotion* OR Suffering OR “Depressive symptom*” OR “anxiety symptom*” OR wellbeing OR “well being” OR well-being OR coping OR psychopathology OR “Quality of life” OR Suicid* OR “Mental Disorder*
1. Participants were children or youth (24 years and younger) of both sexes who lived or are living in an area affected by recent or ongoing conflict (post-World War II), including former child soldiers. We also included interventions where the parents of youth participated in an intervention related to youth outcomes. 2. Treatment was a psychosocial intervention, including group, individual, self-help, family-based, or community-based interventions. As described by the Inter-Agency Standing Committee for Mental Health and Psychosocial Support in Emergencies (2007), we included specialized services, focused nonspecialized services, and strengthening community and family supports, but excluded interventions focused solely on basic needs and services and security. 3. The treatment was delivered in an LMIC 4. Design was randomized controlled trial (RCT) or controlled trial (i.e. a comparison of a psychosocial intervention condition with either another active intervention, standard care, waitlist, or no treatment). 5. Outcomes included internalizing symptoms (e.g. depression, anxiety, distress, stress, trauma, posttraumatic stress), externalizing symptoms (e.g. conduct problems), mental disorders, functioning. Exclusion criteria: 1. Pre- and postintervention data were not collected for each group, or no betweengroup comparison was conducted. 2. Included youth affected by conflict who now lived in high-income countries. 3. Included youth affected by single incidents of terrorism.
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Data extraction for study characteristics Data were extracted independently from each study by two reviewers (FB and AdG) using a coding scheme based on the PracticeWise coding manual (2005). Data extracted included study design (RCT or controlled clinical trial), participant characteristics (sample size, age, gender, inclusion and exclusion criteria), study methods (recruitment and sampling strategies), intervention protocol characteristics (therapist, session format, number and duration of sessions), relevant outcomes measured (outcome, tool used), and treatment effects (significant between-group differences, significant within-group differences). We made adaptations to the PracticeWise coding structure to suit the purpose of this review, and the postconflict and LMIC context. For example, we coded: country of origin rather than ethnicity; war experiences in terms of whether the conflict was ongoing or past; whether the study included children associated with armed forces or armed groups (CAAFAGs) or orphans; cadre of therapist (peer, lay health worker, teacher, counselor, social worker, psychologist, medical doctor, psychiatrist); and whether therapist was local or nonlocal to the country of implementation. We also added Internally Displaced Person (IDP) Camp or Refugee Camp as potential intervention settings, and where group sessions were held, we coded the group size when available. When reported, we also collected descriptive information on therapist training and supervision, and cultural adaptations made to the intervention. There was 97% initial agreement on characteristics of studies and 95% initial agreement on treatment effects. Discrepancies in coding of treatment studies were resolved by discussion. As described by Chorpita and Daleiden (2009), ‘study groups’ were defined as a group of participants who received a specified protocol; a ‘protocol’ was defined as the treatment procedures in which members of that group participated. A ‘winning treatment’ was defined as a psychosocial treatment protocol received by a study group, which was superior to another study group within the study (e.g. a comparison psychosocial treatment, waitlist condition, no-treatment, or other control group) on at least one outcome measured. A winning treatment was indicated via a significant betweengroup treatment effect (p < .05), whereby either the winning group improved while the comparison group did not, both groups improved but the winning group improved significantly more, or the comparison group deteriorated while the winning group did not. If a control condition consisted of a psychosocial treatment and showed greater improvement on outcomes than another condition in the study (e.g. a second control condition, or the primary treatment condition), this would also be considered a winning treatment. The protocol for each winning treatment was subjected to further coding to identify the practice elements included. Nonwinning protocols (i.e. a psychosocial treatment delivered to a study group that did not show greater improvement in outcome when compared to a study group receiving a comparison psychosocial treatment, waitlist condition, no-treatment, or another control condition) were not coded for their practice elements (in line with standard procedures; Chorpita & Daleiden, 2009). Where moderator effects were examined in a study and significant treatment effects were only found for a specific subgroup on given outcomes, these effects are specified in Table S1, available online. In order to classify a treatment as a winning treatment for that outcome, it was required that either there was an overall treatment effect, or a treatment effect for a specific subgroup by age or gender (the two most common and relevant moderators). Other moderation effects are reported, but these effects were not sufficient for a treatment to be included as a winning treatment. Where a cluster RCT design was employed, analyses adjusted for clustering were considered when available. © 2016 Association for Child and Adolescent Mental Health.
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Coding of practice elements As specified by Chorpita and Daleiden (2009), a ‘practice element’ is a discrete clinical technique or strategy (e.g. exposure, relaxation) included in a larger intervention protocol (e.g. a manualized anxiety treatment). Written requests to access the manuals for treatment protocols were sent to all authors of papers reporting winning treatments, or developers of winning treatments, and one follow-up request was sent. Where actual manuals were available and it was clear that these were the exact protocols followed in the study, these were used for coding of practice elements along with any additional information presented in the journal article (n = 16; indicated in table). However, in other cases where the treatment manual was not available (n = 9; four manuals unavailable, five manuals not exact protocol delivered), coding of practice elements was conducted on the description of the treatment protocol provided in the text of the journal article. Using the PracticeWise (2005) coding system, we coded the protocols of all winning treatments for the presence or absence of 73 practice elements codes. One critique of the practice of identifying discrete practice elements is that the process tends to favor CBT-based approaches, and other modalities are less represented (Swartz, 2015). To compensate for this, we undertook an additional two steps. First, we reviewed the 59 common elements for evidence-based trauma treatment identified recently (Strand, Hansen, & Courtney, 2013) and added two additional relevant codes – ‘homework’ and ‘interventions for grief and loss’ – to our coding system. Second, as recommended by the PracticeWise manual (2005), additional treatment components not captured by existing codes were recorded as free text and reviewed for frequently occurring practice elements. Through this process, we added three additional codes – ‘safe place techniques,’ ‘parenting skills’ (this was included to capture provision of broader training in parenting skills that were not specific codes in the PracticeWise coding system; e.g. parenting psychoeducation, child rights education, strategies for improving interactions with youth, or parental supervision), and ‘expressive therapies’ (e.g. drama, movement, or art). Coding was conducted independently by two raters (FB and AdG) and this resulted initially in 92% agreement between raters. Discrepancies were reviewed by a third expert rater (JA) and were resolved by discussion until the two original raters and the expert rater were in agreement. As an additional control, coding was compared across studies that used conceptually similar treatments to check for consistency in ratings across the manuals. This resulted in the identification of 12 additional discrepancies, and these were again reviewed and resolved by an expert rater (JA). We had planned to undertake matching analysis where profiles are created to match a given treatment to a patient population (Chorpita et al., 2005); however, due to the small yield of studies, and small yield of winning treatments on the different outcomes measured in particular, this was not considered an appropriate analysis.
Methodological quality assessment Two authors (FB and AdG) assessed the methodological quality of the included studies using a modified version of the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies (Jackson & Waters, 2005). This tool was selected as the reviewed studies included both RCTs and controlled trials. Discrepancies were solved through discussion.
Results Descriptions of studies The search strategy yielded 9,390 unique references (see Figure 1). Of these papers, 9,319 were excluded
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Original articles found through electronic searches and screened on title and abstract by 2 reviewers (duplicates deleted) (n = 9,374)
Total original articles (n = 9,390)
Articles retrieved for detailed examination by 2 reviewers (n = 71)
Articles included (n = 33)
Original articles found through hand searching reference lists of relevant articles and hand searching issues of 2 key journals (n = 16)
Articles excluded based on title and abstract (n = 9,319)
Articles excluded (n = 38) Reasons for exclusion: • Not original study: conference abstract (n = 3); article review (n = 3) • Wrong population: adults (n = 13); study in HIC (n = 2); population not war-affected (n = 1) • Not psychological intervention: HIV prevention intervention (n = 2); music/sport program (n = 2) • Study design: no comparison group (n = 7); not intervention study (n = 1); retrospective study (n = 1); no baseline data collected (n = 1); no betweengroup comparison (n = 2)
Figure 1 Flow diagram of search strategy of systematic review of psychological interventions for war-affected children, adolescents, and youth in LMIC
on examination of the title and abstract. The remaining 71 papers were accessed for detailed review, of which 33 met inclusion criteria, describing 28 studies. Of these, 20 studies were randomized controlled trials, while eight were controlled trials (i.e. prepostevaluation trials with a control group, but without randomization). Pertinent details are described below and presented in Table S1.
Setting and participant characteristics Included studies involved a range of participants from varying settings and regions. Classifying the location of the trials by WHO regions, 13 were conducted in Africa, eight in the Eastern Mediterranean, four in South East Asia, and three in Europe. While 12 studies were conducted in a region where the conflict had ceased, 16 were conducted in a region with ongoing conflict. Six studies were conducted within camps for refugees or IDP. Several studies specifically targeted (n = 2) or included (n = 5) CAFAAGs, and several targeted (n = 2) or included (n = 5) orphans; however, generally the samples were children more broadly affected by conflict in their region. Six studies included young adults (defined as aged between 19 and 24 years) as well as children and/or adolescents. None of the reviewed studies included children
