Based on these key findings, we propose a mental health service model for Burundian families living in the refugee camps. In line with the Inter-Agency Standing Committee (IASC) Guidelines for Mental Health and Psychosocial Support (2007) and related stepped care models for refugee and conflict-affected children (Eruyar et al., 2018; Jordans et al., 2010), the model aims to provide mental health care to children and adolescents across multiple layers and different ecological contexts (individual, family, community). However, in view of the low prevalence of mental health problems among youth in the camps and the important role of both trauma exposure and family-related factors for youth`s mental health, we argue that identifying youth with clinically relevant mental health problems and providing them with trauma- and family-focused interventions needs to be prioritized over broad-scale psychosocial interventions. This does not imply that interventions targeting contextual and social factors, the pyramid`s base in the original multi-layered model, should be neglected. In contrast, displacement-related stressors should be addressed as they have direct and indirect impacts on families and children (Miller & Rasmussen, 2017). However, stronger focus should be placed on identifying those children suffering from severe mental health problems, who should then receive focused mental health care. Although this model refers to the specific context of Burundian refugees in Tanzanian camps, it may also be applicable to other conflict-affected and resource-poor settings with rather low prevalence rates of mental disorders among youth, e. g. in North Uganda (3.3% for PTSD and 9.6% for emotional and behavioral problems; Saile et al., 2016).
Considering the limited specialist resources for mental health care in the camps, a crucial element on all layers of the proposed model is task-shifting, i.e. the transfer of skills from mental health professionals to trained non-specialists, such as community workers, teachers and nurses (Hodes & Vostanis, 2018; Silove et al., 2017). This approach is cost-effective, sustainable and increases the potential for broad dissemination of interventions (Fazel, 2018; Silove et al., 2017). Moreover, given the important role of parental factors for children`s mental health, the involvement of parents or caregivers at all levels is another essential feature of the model. The model is graphically displayed in Figure 1. The individual layers of the model and possible interventions at each layer are described in more detail in the following.
Identification and targeting
The base layer comprises all activities that aim at identifying those children who are suffering from severe mental health problems. This requires a broad approach and a close-meshed collaboration between different organizations and services, e.g. education, child protection, physical and mental health care. The most important activity in this layer is screening children for mental health problems including PTSD symptoms, internalizing and externalizing problems, which can be conducted by trained para-professionals such as teachers, community mobilizers, nurses and social workers in their respective settings. It is crucial that screening instruments are locally validated (Hall et al., 2014). Youth who are screened positive can then be interviewed by a trained counsellor to establish a diagnosis and be referred to an appropriate intervention. For instance, Catani et al. (2009) followed such an approach in a treatment study with Sri Lankan youth who had been affected by war and tsunami: After an initial screening in schools, trained local counsellors conducted clinical interviews to assess the presence of PTSD among youth and delivered Narrative Exposure Therapy for children (KIDNET) or a meditation-relaxation intervention to those with a diagnosis.
The findings of the survey further point to the importance of increasing youth`s awareness of services and reducing barriers to access particularly in parents who are mainly responsible for initiating contact with organizations on behalf of their children. For example, providing psychoeducation to the community may help to increase awareness of mental health problems, learn about existing services and reduce possible stigma. These broad community sensitization activities can be easily disseminated as they can be carried out by trained non-professionals from the refugee communities, ideally widely respected community leaders. The consideration of cultural idioms and expressions of distress can increase communities` understanding and make it easier for them to identify children suffering from problems. Moreover, working together with existing informal resources providing psychosocial support, e.g. traditional healers, religious groups or community elders, can be helpful in identifying and referring children in need of treatment.
The identification of children and adolescents in need of intervention enables an effective and efficient allocation of available resources on the next layer of interventions. Our studies revealed youth`s trauma exposure and family-related factors, i.e. both parents` psychopathology and maltreatment by parents, as promising targets for interventions. In view of these findings, we emphasize the need for both trauma-focused and family-level interventions taking into account parents` well-being and aiming at reducing child maltreatment. Interventions that can be provided by non-specialist facilitators without cost- and time-intensive training may be most suitable. Most importantly, only evidence-based interventions should be included in the model, which need to be constantly evaluated (Fazel, 2018; Wessells, 2009).
With regard to trauma-focused interventions, narrative exposure therapy (NET) and its adaptation for children (KidNET) have been shown to be effective in reducing PTSD symptoms among refugee and war-affected children and adults in low- and middle-income settings (Neuner et al., 2004; Robjant & Fazel, 2010). It is a short and pragmatic treatment that can be provided by trained lay counsellors even without a mental health background and can be easily disseminated in low-resource settings through a “train-the-trainer” approach (Jacob et al., 2014; Neuner et al., 2008). Trauma-focused cognitive behavioral therapy (TF-CBT; Cohen et al., 2016) may be another promising intervention in this setting. This treatment model has the advantage that it also includes parents and caregivers through individual and joint parent-child sessions and addresses several risk factors identified by our studies, for example supporting children and parents in processing their own and joint traumatic experiences, improving the parent-child relationship and teaching parenting skills that may prevent child maltreatment (Cohen et al., 2016). TF-CBT has been evaluated as a group-based and culturally modified intervention provided by local facilitators in randomized controlled trials with war-affected adolescents in DR Congo showing reductions in PTSD symptoms, internalizing and externalizing problems compared to wait-list controls (McMullen et al., 2013; O’Callaghan et al., 2013). Although a group format implies an efficient use of resources and may be beneficial through normalizing problems and providing peer support, the creation of trauma narratives should be done in individual sessions to avoid vicarious traumatization within the group (McMullen et al., 2013).
Based on a more detailed diagnostic assessment of children following identification, it is possible to tailor the intervention to the individual child`s specific problem areas. A common elements approach allows to combine different treatment elements in a flexible manner depending on the child`s needs and addresses not only PTSD symptoms stemming from prior trauma, but also emotional and behavioral problems related to daily stressors (Murray et al., 2018). Caregivers can be taught parenting skills in individual sessions. However, compared to the trauma-focused interventions described above, the evidence for such a common elements approach for refugee youth is much more preliminary. It has only been evaluated in a non-controlled study with refugee youth living in Somali refugee camps indicating decreases in PTSD symptoms, internalizing and externalizing problems as reported by youth and caregivers and improvements in youth-reported well-being (Murray et al., 2018).
Involvement of parents is only limited in the interventions described so far and a stronger focus on parenting may be warranted in order to effectively counter child maltreatment in the camps. In particular, our findings suggest that the mother-child relationship may be an important target for the prevention of child maltreatment in the participating families. Therefore, the contextual adaptation and evaluation of existing relational interventions that have demonstrated effectiveness in reducing child maltreatment in Western samples may be promising (Toth et al., 2013; Valentino, 2017). For the camp context, these should be brief, independent of technical equipment and ideally be delivered by non-professionals without costly and time-consuming training. While available parenting interventions in low-resource settings (Puffer et al., 2015, 2017) focus on teaching parenting knowledge and skills, interventions additionally addressing parents` well-being may be fruitful in the refugee camps as parents` own mental health problems can continuously undermine their interactional and parenting skills. A recent RCT with Syrian refugee parents living in Lebanon tested the effectiveness of a group-based parenting support intervention containing four sessions each to reduce parents` distress and improve their well-being on the one hand and teach parenting knowledge and skills on the other hand (Miller et al., 2020). The intervention group demonstrated increased parental warmth and well-being, decreased harsh parenting and distress as well as improved parent-reported child well-being compared to a wait list control group, but the stability of these effects remains to be shown (Miller et al., 2020). Problem Management Plus (PM+) developed by the WHO may be another promising intervention for parents` distress as it can be delivered by non-specialists in a group format and is currently being evaluated in resource-poor refugee camp settings (Akhtar et al., 2020; Sijbrandij et al., 2017).
Community-based prevention and resilience building
The layer at the top of the inverted pyramid comprises large-scale community-level psychosocial activities that promote children`s well-being and strengthen their resilience. Importantly, these should focus on prevention and not contain elements aiming at reducing mental health problems, for example through creating trauma narratives, given the potential for harmful intervention effects (Jordans et al., 2016). Such interventions may still have a secondary effect also on mental health problems (Panter-Brick et al., 2018). It is recommended to work with existing sources of children`s and adolescents` resilience in their social ecology at this stage (de Jong et al., 2015; Jordans et al., 2010), for example through sports contests, drumming and dancing sessions or praying groups (see Table 1). An overall positive effect of such joint activities is to strengthen peer relationships, which were related to better mental health in our study. A suitable setting may be child-friendly spaces, which are already implemented in the camps and provide a safe environment for children. A meta-analysis on the impact of child-friendly spaces in humanitarian settings in Ethiopia, Uganda, Iraq, Jordan, and Nepal observed an overall positive effect of these facilities on younger children`s (6 to 11 years) psychological well-being (Hermosilla et al., 2019). However, child-friendly spaces did not have an impact on adolescents` well-being and appeared to be ineffective in connecting younger and older children to wider community resources. Here schools may provide more appropriate settings to also engage families and communities as structured psychosocial activities can be combined with activities focusing on psychoeducation and community sensitization. For instance, Jordans et al. (2013) conducted a 2-session psychoeducation intervention delivered by lay community counsellors for groups of parents of children who had screened positive for emotional and behavioral problems at school in Burundi. The intervention group showed a short-term effect in reducing child-reported externalizing problems among boys compared to the control group.
In order to achieve sustainable and comprehensive reductions of risks for and improvements of Burundian refugee children`s well-being, contextual factors related to living in the camps need to be addressed as well (Miller & Rasmussen, 2017). Our study findings support the need for prevention of structural risk factors for children`s ongoing exposure to violence within the family and community, which constitute a source of continuous trauma and thus a significant mental health risk. Another study connected to this research project found that families` lower household income was related to higher levels of mothers` self-reported violence against children (Hecker et al., 2020). This suggests that policies allowing refugees to work inside and outside the camps as well as livelihood programs teaching vocational skills may be fruitful to reduce economic and psychological strain on families and parents (Bermudez et al., 2018; Miller & Rasmussen, 2017). In a similar vein, a higher educational level of fathers was related to a lower child-reported use of paternal violence against children (Hecker et al., 2020). This implies that programs which support parents in pursuing further education in the camps may also benefit families and children.