Evidence based mental health interventions for children in fragile and conflict affected settings: expanding reach and system strengthening

Abstract

Theresa S Betancourt and colleagues argue that implementation and systems strengthening are urgently needed to integrate mental health and psychosocial support interventions across health, education, and social protection platforms to reach children affected by conflict

Millions of children and adolescents living through armed conflict and displacement face heightened risks of post-traumatic stress reactions, depression, anxiety, and behavioural problems.¹ Decades of research show that evidence based mental health and psychosocial support (MHPSS) interventions can reduce mental distress even in active fragile and conflict affected settings.² However, despite growing evidence of effectiveness, interventions are often relegated to short term research or pilot projects with short funding cycles, external management, and poor coordination, rarely translating into sustainable, high quality MHPSS systems in fragile and conflict affected settings. In war torn and displacement settings—such as internally displaced people or refugee camps and informal settlements—national health and social care systems often cannot meet the rising mental health demand. For example, among Syrian refugee children in Lebanon, a telephone delivered common elements treatment approach showed promising reductions in anxiety, depression, and trauma symptoms but reached only a fraction of those in need.³ The challenge is not just what works but delivering effective support at scale with quality and continuity.

In this article, part of a BMJ Collection on Child Mental Health in Conflict Settings, we argue that the research agenda should shift from standalone randomised controlled trials of single interventions towards implementation and systems research that tests how to integrate, finance, supervise, and sustain evidence based MHPSS within routine health, education, and social and child protection platforms. The focus is on practical strategies for scaling with quality, including task sharing, cross sector integration, and fit-for-context adaptation, alongside policy and workforce investments that enable delivery at scale.

MHPSS integration into existing systems

Evidence based MHPSS interventions have been developed for humanitarian settings, but a persistent “evidence-to-practice gap” limits their impact. Implementation science, “the scientific study of methods to promote the systematic uptake of evidence-based practices into routine use and improve service quality and effectiveness,”⁴ provides tools to identify strategies for embedding evidence based MHPSS interventions for children, adolescents, and families into real world, conflict affected contexts and scaling them with quality. Although randomised trials show what works, they rarely answer systems questions about reach, relevance, quality, and sustainment. For example, the Sawa Aqwa Family Intervention showed efficacy for individual families in Lebanon; however, group delivery for scale-up lost gains,⁵ necessitating modality testing and further adaptations for Jordan and Iraq. Effective interventions thus need adaptations in training, delivery, and evaluation to maintain fidelity and feasibility when scaled up in the same context or scaled out to new fragile and conflict affected settings.⁶

Implementation frameworks include Exploration, Preparation, Implementation, Sustainment (EPIS)⁷; Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM); and Consolidated Framework for Implementation Research (CFIR).⁸ These can be used to structure and strengthen implementation research in fragile and conflict affected settings. These tools guide country or regional level plans by mapping and leveraging local resources and tackling deficits. Such initiatives could be strengthened by incorporating effective elements from other successful global health systems strengthening strategies used by the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria and the Global Vaccine Initiative. These include country led plans, flexible financing mechanisms, and targeted support for local research and implementation capacity.⁹

In many low resource settings, persistent barriers include limited skilled personnel, underinvestment in task sharing and non-specialist workforce development, and inadequate access to evidence based MHPSS treatments.¹⁰ As a result, MHPSS programmes in fragile and conflict affected settings often rely on temporary staff or external teams, with limited local ownership and accountability to affected populations. Investing in the workforce, including both mental health professionals and non-specialist extension workers, and embedding continuous quality improvement processes can enable actors to track service delivery, measure outcomes, and make real time adjustments that enhance scalability and quality of evidence based MHPSS. Global agencies, including the World Health Organization (WHO) and United Nations Children's Fund (Unicef), promote MHPSS models with layered services following the Inter-Agency Standing Committee’s pyramid, which integrates promotive, preventive, and care level support across health, education, and social protection systems.¹¹ These same principles are reflected in the minimum service package for MHPSS, which outlines the integration of MHPSS into multiple sectors and was developed by WHO, Unicef, the United Nations Population Fund, and the UN High Commissioner for Refugees.¹²

Building sustainable MHPSS systems for children, adolescents, and families in fragile and conflict affected settings requires deliberate implementation science to test scaling strategies for evidence based interventions with quality. This includes identifying barriers and facilitators to embedding evidence based interventions in alternative delivery systems such as education and social protection, adapting them culturally and contextually, overcoming mental health stigma, and closing equity, financing, and workforce gaps. Cross sectoral integration can transform MHPSS from isolated initiatives into a comprehensive approach to promoting child health and wellbeing.

Achieving this integrated vision requires sustained investment in policies, budgets, workforce, and management infrastructure, including digital systems for case management and the use of technological innovation for improving training, supervision, and other elements of quality in the support of the local MHPSS workforce. Systems strengthening and quality depend on collaboration with local governments, communities, mental health providers, researchers, and donors. Strengthening the capacity of frontline workers—teachers, nurses, and social workers—is essential to ensure that evidence based and trauma informed MHPSS becomes a central and routine component of health systems strengthening in fragile and conflict affected settings.

From fragmented to coordinated MHPSS responses: experiences from Lebanon

Lebanon illustrates how multiple overlapping crises have created a complex landscape for delivering MHPSS care. The country, now classified by the World Bank as lower-middle income, hosts 2.2 million displaced people—more than one third of its six million residents—amid prolonged political and economic collapse, the 2020 Beirut explosion, and the 2024 war with Israel. These crises have increased mental health conditions, particularly among children and adolescents,¹³ while historically private sector dominated mental health services have limited access for much of the population.

Within this challenging context, the National Mental Health Programme—via the technical working group, chaired by the Ministry of Public Health (with WHO/Unicef support)—coordinates MHPSS delivery. Key initiatives include the 2015 National Mental Health Policy (updated 2024) and the Greentree Acceleration Plan,¹⁴ initiated by the UN deputy secretary general and co-funded by the Wellcome Trust.

The Greentree Acceleration Plan aims to scale evidence based MHPSS interventions for children, adolescents, and care givers. In Lebanon, this initiative integrates scalable digital interventions, such as a parenting support app, with community based programmes, including play based mental health interventions for children, ensuring continuity of care and age appropriate support across the country.¹⁴ This layered approach aims to embed evidence based MHPSS within family and community systems, strengthening Lebanon’s mental health system for people affected by war. These delivery models not only reduce costs and increase reach, but they also promote localisation. Community based providers remain embedded in the contexts they serve, enabling better alignment with cultural norms and long term continuity and pathways to professional advancement as part of systems building.

Lebanon’s experience reflects the broader struggles of conflict affected countries, underscoring the urgent need to move beyond short term “emergency” interventions towards systemic, sustainable care structures that can tackle the prolonged nature of conflict and displacement in the lives of children, adolescents, and families.

Task sharing and community involvement

Even the best designed interventions cannot be scaled up without effective and feasible delivery models. Task sharing—delegating care from specialists to trained paraprofessionals as part of a broader continuum of care and collaboration—offers a practical, transformative solution in fragile and conflict affected settings with limited human resources. A large individual participant data meta-analysis found that psychosocial interventions mainly delivered by paraprofessionals improved coping skills and hope among children in humanitarian contexts.² With adequate training and supervision, paraprofessionals can provide high quality support to children, adolescents, and families and serve as one critical building block for mental health systems strengthening.

However, task sharing alone is insufficient and must be accompanied by other elements of MHPSS systems strengthening. These include intentional strategies to train mental health specialists and provide them with credentials, supervision, functional referral pathways linking all elements of the mental health workforce in fragile and conflict affected settings, and planning for the management of severe or complex cases, along with robust quality assurance mechanisms.¹⁵ Initiatives, such as the WHO-Unicef EQUIP toolkit framework, provide evidence based guidance for implementing MHPSS training and supervision at scale.¹⁶ For example, in Sierra Leone, task sharing models tested in an implementation effectiveness hybrid type II study examined the use of weekly remote supervision of trained community based facilitators by licensed psychologists, fostering clinical oversight and sustained support.¹⁵ Without investment in quality improvement, scaling without quality risks undermining the effectiveness of evidence based MHPSS interventions, diluting their impact or even causing harm.

The adaptation of interventions to culture and context is essential for the scaling of evidence based MHPSS interventions for children and families affected by war. Structured approaches, such as the ADAPT-ITT framework,¹⁷ help practitioners to systematically adapt interventions for new settings while maintaining core elements. For example, the Family Strengthening Intervention for Early Childhood Development and Violence Prevention (FSI-ECD+VP),¹⁸ originally developed in post-genocide Rwanda, was adapted for conflict affected Venezuelan and Colombian families by using ADAPT-ITT combined with the FRAME reporting standards to ensure cultural fit and document how cultural adaptation was done while maintaining core evidence based elements.^{19 20} Such culturally grounded adaptation can improve uptake and impact by leveraging local cultural strengths to help to engage beneficiaries and mitigate psychological distress. Community based participatory methods further ensure that adaptations are not top-down but shaped by lived experience.²¹

Ignoring cultural adaptation risks perpetuating evidence hierarchies that privilege external models over local wisdom. Truly sustainable and responsive MHPSS systems in fragile and conflict affected settings must value both scientific evidence and knowledge of local strengths, practices, and cultural norms. Partnering with affected communities and individuals with lived experience enhances cultural relevance and acceptability—factors critical to overcoming mental health stigma and improving engagement with mental health services across diverse settings.¹⁵

Digital technologies as a support, not a replacement

Digital innovation is often viewed as a key innovation factor for scaling MHPSS in fragile and conflict affected settings. Apps, SMS platforms, and artificial intelligence (AI) powered technologies can expand reach and improve efficiency, especially in fragile contexts with limited human resources. For example, in Lebanon, “Step-by-Step,” a guided self-help intervention, trained non-specialists (“e-helpers”) to provide psychological support to adults affected by adversity. When paired with weekly supportive calls from e-helpers, the programme showed significantly higher effectiveness than usual care in reducing depression and anxiety and improving functioning among displaced people in Lebanon.²²

By contrast, a similar self-guided intervention implemented among Syrian refugees in Egypt, which offered contact with e-helpers “on demand” rather than scheduled follow-up by a real person, showed low effectiveness.²³ These findings highlight that digital mental health technologies may be most effective when combined with active human engagement.

Another example is the Ahlan Simsim programme, the largest humanitarian intervention for early childhood development in the Middle East and North Africa region, run by Sesame Workshop and the International Rescue Committee in partnership with educational media, which showed in a randomised controlled trial that children who participated in an 11 week remote learning programme—with Ahlan Simsim videos supported by local teachers via cell phones—showed developmental progress across social-emotional skills as well as other core areas of child development.²⁴ Similarly, the Coping Together intervention—a virtual family strengthening programme aimed at enhancing family resilience processes and promoting mental health—delivered didactic instruction, communication practice, and multimedia components across eight sessions. A mixed methods study conducted during the covid-19 pandemic showed promising preliminary results, including improved family communication and relationship closeness. Quantitative pre-post changes were small, supporting further evaluation of similar interventions.²⁵

However, challenges remain. For instance, a randomised trial testing a self-guided, app based calming skills programme for Ukrainian children found no significant reduction in anxiety or trauma symptoms compared with controls.²⁶

This contrast underscores a fundamental point: technology can support MHPSS delivery but is not a standalone solution. Digital methods using AI have great potential to expand training and supervision and tailor evidence based MHPSS interventions to local cultures, languages, and individualised needs, increasing access to evidence based services. However, caution is needed as digitalised interventions may reduce genuine human contact and connection, contributing to further fragmentation and social isolation of communities already disrupted by violence and displacement. These technologies should enhance the available workforce case management and competency building, not replace human care. Practical challenges in fragile and conflict affected settings, such as limited electricity, smartphones, internet access, and private spaces, as well as ethical concerns, including bias, data security, and cultural relevance in AI enabled mental health technologies, need careful consideration. Therefore, even if digital technologies may be—or become—powerful allies in systems strengthening and scale-up efforts, they should be used as complementary supports to human workforce investments.

Ensuring expanded and sustainable MHPSS systems

To develop sustainable, high quality MHPSS interventions for children, adolescents, and families in fragile and conflict affected settings at scale, moving beyond isolated interventions and short term emergency responses that fail to translate into systems building initiatives is essential. Governments must be supported to integrate evidence based MHPSS programmes into long term policy planning and financing frameworks. Rather than treating MHPSS services as temporary emergency services, they need to be considered core elements of trauma informed health, education, social, and child protection systems during and after conflict and displacement.

MHPSS systems strengthening in fragile and conflict affected settings requires active engagement and concrete action from local governments and communities, researchers, humanitarian agencies, and donors. Workforce capacity building includes career pathways for non-specialist providers, teachers, social workers, and mental health professionals through accreditation, supervision, and compensation structures that ensure retention, quality, and accountability.

In the years ahead, in the face of declining global investment in fragile and conflict affected settings and the humanitarian system, ensuring that the services envisioned are effective and efficient is all the more imperative. Humanitarian actors and donors must shift from fragmented programmatic funding in acute crises to coordinated, multi-year efforts that accompany local actors and strengthen sustainable public sector infrastructure. Instead of creating short term parallel systems, development and humanitarian actors would contribute more by supporting governments (where functional) and local institutions to lead implementation whenever possible, measure and evaluate health and related outcomes, and institutionalise effective practices.²⁷ Where local government leadership is limited, local non-governmental agencies can be supported by international non-governmental organisations and UN agencies to build sustainable capacity for delivering evidence based MHPSS to children, adolescents, and families, including adaptive social protection approaches and workforce strategies as advocated by the World Bank.²⁸

Research institutions must collaborate with local community partners to bridge gaps between knowledge and practice. Collaborations between high income and local research institutions should extend beyond effectiveness studies to focus on implementation science questions investigating the best strategies for scaling, sustaining, and ensuring quality of evidence based MHPSS services in fragile and conflict affected settings. Affected communities should be involved from the beginning, co-designing interventions to ensure cultural and contextual fit as well as mechanisms for systems strengthening and sustainment.

What can and should be done

Scaling evidence based MHPSS for children, adolescents, and families in fragile and conflict affected settings is feasible if integrated into existing systems. Randomised controlled trial evidence shows growing effectiveness, but challenges remain in achieving reach, quality, and sustainment amid short funding cycles, workforce gaps (especially with supervision and task sharing), sector fragmentation, and poor measurement focused on children’s mental health outcomes as well as the quality of service delivery. Insecurity, political changes, displacement, and infrastructure gaps further disrupt continuity of care, especially for the children with the highest need.

Two critical steps can help the field to advance from pilots to sustainable coverage: Firstly, phased integration of minimum evidence based intervention packages into existing platforms that reach children, such as primary care, schools, and social protection, with upfront supervision, referrals, and quality assurance. Secondly, learning partnerships among implementers, researchers, ministries, and communities using routine data to test service delivery strategies, ensure equity, and track quality of implementation (coverage, fidelity/competence, acceptability) plus child mental health outcomes that reflect functioning and development.

When implementation research focuses on these real world delivery questions, evidence based MHPSS is more likely to become locally owned, scalable, and resilient in fragile and conflict affected settings rather than short term and unsustainable.

Key messages.

• Evidence based interventions for mental health and psychosocial support (MHPSS) can effectively reduce distress and enhance functioning among children, adolescents, and families in fragile and conflict affected settings

• However, most evidence based and trauma informed interventions do not reach many people in need and are insufficiently integrated into existing national systems

• Scalable and sustainable MHPSS systems in fragile and conflict affected settings can be built upon in innovative ways by integrating them into existing health, education, and social protection platforms, with genuine engagement of conflict affected communities in design and delivery

• Cross sector collaboration among governments, civil society, researchers, humanitarian actors, and donors is essential to strengthen MHPSS systems and local ownership in fragile and conflict affected settings

• Applying implementation science, task sharing, digital innovation, and community driven approaches can expand reach and systems strengthening and ensure the lasting impact of MHPSS interventions in fragile and conflict affected settings