Care for depression, anxiety helps war-exposed children long-term

Sierra Leonian kids pose in Kailahun, about 19kms (12 miles) away from the Liberian border in Sierra Leone July 21, 2005. (Michael Dalder / Reuters)

Treating depression and anxiety in youngsters affected by war may have lasting benefits for their mental health and ability to function in society, new findings suggest.

The study, of former child soldiers and other young people affected by Sierra Leone's civil war, found that those with higher levels of anxiety and depression two years after the end of the conflict had the highest levels of these “internalizing symptoms” four years later. They also had worse post-traumatic stress symptoms and exhibited more anti-social behavior.

The findings suggest that treating anxiety and depression in war-affected youth could have multi-faceted effects on their future mental health, attitudes, and behavior, the researchers write in Pediatrics.

“We were surprised to see the large role that targeting symptoms of hopelessness and depression played across many years of observing war-affected youth,” Theresa Betancourt of Harvard T.H. Chan School of Public Health in Boston, the first author of the new study, told Reuters Health via email.

“As a result,” she said, “we have amplified the elements of the intervention models we are developing and testing to address self-efficacy and elements of grief and loss given all the loss and life change that war-affected youth have experienced.”

Armed conflict has devastating, long-lasting effects on young people's social and physiological well-being, and there has been little research on how to best to help children and adolescents affected by war, Betancourt and her colleagues write.

“Mental health interventions are increasingly being made available to war-affected youth, but very few of them are evidence-based,” Betancourt said in an interview.

To investigate how these interventions could have the most benefit, the researchers looked at 529 war-affected youth who ranged in age from 10 to 17 when they enrolled in the study, in 2002. One-quarter of the study participants were female. Sixteen percent of the study participants said they had been raped or sexually assaulted during the conflict, while about one-third had killed or injured another person, and about one third had lost a parent or caregiver.

The investigators interviewed the study participants when they joined the study, and again in 2004 and 2008.

To identify where interventions should focus, the researchers took note of potentially modifiable factors that were present in the youngsters in 2004 - including externalizing behaviors such as hostility and aggression, internalizing behaviors like depression and anxiety, community acceptance, social behaviors, school participation, and social support.

Then they looked at how these factors affected the children’s mental health outcomes in 2008, after taking into account their baseline mental health, exposure to trauma, and other factors.

Levels of internalizing behaviors in 2004 predicted internalizing symptoms, social behaviors and attitudes, and post-traumatic stress symptoms in 2008, the researchers found. None of the other potential intervention targets were significantly associated with the 2008 outcomes.

“Our findings emphasize the need for low-cost, group-based, trauma-informed mental health interventions grounded in evidence-based techniques, which can be implemented in low- and middle-income countries by mental health workers with strong training and supervision, reserving the scarcest resources for youth with the greatest need,” the researchers say.

Last year, Betancourt and her colleagues reported on a randomized trial of a cognitive-behavioral group therapy-based program, “the Youth Readiness Intervention,” in war-affected 15- to 24-year-olds.

The intervention was linked to better emotion regulation, social attitudes and behaviors, and social support as well as improved day-to-day functioning, Betancourt said. The improvements spilled over into school functioning, she said, with participants more likely to stay in school, with better attendance and classroom behavior.

“When offering health and other services for war-affected youth, we cannot leave mental health out of the equation,” Betancourt concluded. “Integrated mental health interventions that attend to key symptoms and impairments in war-affected youth, such as internalizing or depression-like problems, may have spillover effects on other domains of life functioning and are an important part of the big picture of caring for children affected by war.”