Child and caregiver mental health in conflict affected settings

Abstract

Interventions that support caregiver wellbeing and families should be a priority

One in five children worldwide live in settings affected by conflict or violence, a twofold increase compared with the mid-1990s.¹ Conflicts in Gaza, Ukraine, and Sudan, together with protracted crises elsewhere, are exposing around half a billion children globally to armed violence and related harms.¹ At the same time, global politics is becoming more unstable, with weaker international cooperation and fewer effective protections for civilians.²

The BMJ Collection on Child Mental Health in Conflict Settings (https://www.bmj.com/collections/child-mental-health) clarifies three main points. First, children living in conflict affected settings experience raised rates of mental health problems, driven not only by direct exposure to violence but also by the broader disruption of daily life, including poverty, hunger, displacement, and the breakdown of essential services, with interrupted schooling and restricted access to healthcare.³ Second, to reach more children, mental health support must move beyond small, short term projects and become part of regular health, school, and social services.⁴ Third, real progress will happen only if governments and global leaders commit, and honour their commitment, to protecting children in conflict settings, providing steady funding and working together across humanitarian, development, and peace efforts.⁵

Additionally, it is vital to remember that even the best mental health programmes will work suboptimally if the root causes of children’s distress are not tackled. Programmes that ignore basic needs such as livelihoods, food security, access to school, and stable, caring families are unlikely to produce lasting recovery. Supporting caregivers’ mental health and their ability to earn a living must go hand in hand with protecting children from further harm.⁶ In addition, more support is needed for locally led solutions, especially in low income countries; when local systems are not strengthened, progress can quickly unravel when funding is cut or political priorities shift.⁷

Family support

Humanitarian responses that tackle the difficult conditions families face as they cope and recover are essential. One way to support caregivers alongside children is group support psychotherapy. In post-conflict Uganda, for example, group support psychotherapy delivered within communities by trained lay facilitators⁸ improved adults’ mental and physical health, strengthening families and creating more supportive environments for children.⁹ Adaptations, including play based components¹⁰ and telephone or remote delivery,¹¹ show that this locally rooted intervention can provide ongoing support for children and young people in low resource settings. For research, greater emphasis is needed on understanding how and for whom family centred interventions work, including the mechanisms through which supporting caregivers and household conditions lead to better child outcomes.¹²

Current humanitarian responses to conflict are often fragmented, with many short term mental health projects run by different organisations that are poorly integrated with each other and with local systems. Better sharing of evidence based approaches, stronger country level coordination, and sustained investment in skilled frontline workers can reduce this fragmentation. For example, the Wellcome Trust is supporting communities of practice that bring together researchers, implementers, and local partners to share learning, strengthen capacity, and coordinate the scaling of evidence based mental health interventions across settings.¹³ Such longer term financing, clearer national leadership, and deliberate design of interventions that fit within routine services can tackle barriers, including weak links between emergency responses and longer term services.¹³

Evidence based implementation

To strengthen future scale-up efforts, priority should be given to interventions that align closely with proved mechanisms of change. Although many psychosocial interventions show benefits for specific outcomes such as post-traumatic stress symptoms, effects on depression, anxiety, and functional outcomes are more variable.¹⁴ This heterogeneity highlights the need to move beyond broad intervention labels and focus on identifying which components drive change, for whom, and under what conditions.

Implementing this approach requires evidence based steps. First, interventions should be chosen for scale-up because of the ways they are known to work, such as reducing stigma, strengthening care giver and peer support, and improving emotional coping, rather than simply because they reduce symptoms. This means routinely using implementation studies alongside effectiveness trials to identify which components matter most, for whom, and in which settings.¹²

Second, scale-up should move away from standalone projects and instead work through family support programmes within routine services using “task sharing”—that is, training non-specialist frontline workers such as teachers, community health workers, or social workers to deliver structured mental health support under regular supervision. Such approaches allow care to be delivered consistently over time within existing systems instead of relying on scarce specialists. Evidence from low resource and humanitarian settings shows that task sharing can improve continuity, feasibility, and access. For example, in the group support psychotherapy study in post-conflict Uganda, about 99% of participants who met criteria for depression at baseline were no longer depressed six months after treatment and remained depression-free two years later,⁸ showing how community delivered care can achieve sustained recovery when embedded within local systems.

Third, better coordination at national and local levels is needed so that organisations use the same screening tools, training standards, and reporting indicators and plan services together instead of duplicating small projects in the same areas. For example, Uganda integrated group support psychotherapy into national HIV care and its national HIV treatment guidelines.¹⁵ The Ministry of Health agreed on simple, standardised screening tools for depression to be used across facilities and rolled out a national training cascade: national trainers were trained first, who then trained regional trainers, who in turn trained primary care staff. This approach aligned policy, tools, supervision, and workforce development under one national strategy, reducing fragmentation and embedding mental health within routine care.¹⁶ A similar model could be adapted in humanitarian settings. Taken together, these reforms could support a shift from scaling faster to scaling more carefully, by aligning how interventions are designed, delivered, and funded with what actually drives children’s mental health in conflict settings.