Table 3.

Outline of mechanisms of change for interventions aimed at improving the wellbeing, mental health and resilience of children and adolescents affected by war and armed conflict

Mechanisms		Cited reviews	Outcomes	Evidence Quality
Basic services and security
1	Creating safety and protection from harm	Ager et al. [17]	Protection outcomes (sense of safety, exual exploitation and rape, physical injuries, referrals, reporting); social and emotional wellbeing	Low: Program evaluations
2	Playing	Apfel and Simon [1]; Betancourt et al. [14]	Resilience; wellbeing; self-confidence; emotional regulation	Low: Case or cross-sectional studies
Strengthening family and community support
3	Community capacity building	Apfel and Simon [1]; Ager et al. [17]; Peltonen & Punamäki [6]	Knowledge of protection systems; sense of order and sanity; PTSD; improved psychosocial wellbeing	Low: Program evaluations
4	Increasing social support	Apfel and Simon [1]; Peltonen & Punamäki [6]	Resilience; PTSD; improved psychosocial wellbeing	Low: Program evaluation and clinical experience
5	Family and caregiver capacity building	Apfel and Simon [1]; Jordans, Pigott and Tol [36]	Ability of caregivers to provide consistent and reliable care; depression; PTSD; anxiety symptoms; hope	High: Statistical testing of mechanism
6	Family and caregiver relationship strengthening.	Apfel and Simon [1]; Betancourt et al. [14]; Jordans, Pigott and Tol [36]	Further traumatic experience; psychosocial functioning; mental health; maternal mental health; depression; PTSD; anxiety symptoms; hope	High: Statistical testing of mechanism
7	Engaging with values, traditions, religious and non-religious beliefs, and ideologies	Apfel and Simon [1]; Betancourt et al. [14]; Tol, Song and Jordans [11]	Morale and healing; maintaining the right to be alive despite suicidal despair; drive to survive; community and personal restitution; empowerment; reintegration into communities; wellbeing	Low: Qualitative studies or clinical experience
Focused non-specialist support
8	Learning about the presenting problem, medication, and how to access services (psychoeducation)	Betancourt et al. [14]	Medication compliance; access to services; distress	Moderate: Statistic testing but of intervention not mechanism
9	Learning stress management skills	Peltonen & Punamäki [6]	PTSD; psychosocial wellbeing	Moderate: Statistic testing but of intervention not mechanism
10	Emotional regulation and bearing negative emotions	Apfel and Simon [1]; Peltonen & Punamäki [6]	Chances of survival; resilience	Low: Program evaluation and clinical experience
11	Problem solving	Jordans, Pigott and Tol [36]	Depression; PTSD; anxiety symptoms; hope	High: Statistical testing of mechanism
12	Learned helpfulness	Apfel and Simon [1]; Betancourt et al. [14]	Helplessness; wellbeing	Moderate: Statistical testing but of intervention not mechanism
Specialist support
13	Adverse mechanism: Pathologising normal reactions	Apfel and Simon [1]	Alienating participants	Low: Clinical experience
14	Trauma processing through narratives, exposure, dreaming or play	Apfel and Simon [1]; Betancourt et al. [14]; Jordans, Pigott and Tol [36]; Peltonen & Punamäki [6]	Memory integration; PTSD; depression; PTSD; anxiety symptoms; hope; psychosocial wellbeing	Moderate: Statistical testing but of intervention not mechanism
15	Restructuring unhelpful cognitions and appraisals	Peltonen & Punamäki [6]	PTSD; psychosocial wellbeing	Moderate: Statistical testing but of intervention not mechanism
16	Therapeutic rapport	Jordans, Pigott and Tol. [36]	PTSD; anxiety symptoms; hope	High: Statistical testing of mechanism