Young people exposed to trauma and loss can develop lasting problems with mental health and day-to-day functioning. This column outlines the challenges – and the potential solutions in evidence-based mental health interventions – linked to new delivery platforms for extending the reach of services, including education and youth entrepreneurship programs. When integrated into other programs to promote life opportunities, evidence-based mental health interventions can promote mental health and young people’s interpersonal functioning while simultaneously developing their academic or career skills – a powerful combination for a healthy and productive life.
Today, the world faces the largest humanitarian crisis since the Second World War. Globally, one in six children live in countries affected by conflict, exposing them to a range of adversities and limited opportunities to advance themselves. Exposures include both direct experiences of violence, such as witnessing and participating in violence; and indirect effects, such as poor health and weakened economic, social, community, and family structures.
War-related exposures to violence and loss have grave consequences for young people, including high rates of depression, anxiety, and post-traumatic stress disorder (PTSD). In addition, psychological distress due to exposure to trauma is often expressed in problems with emotion regulation and daily functioning, which can contribute to poor school and work performance, and social isolation.
If not effectively addressed, such mental health problems can have lasting effects on human capital across the life course. These difficulties are exacerbated in post-conflict settings where direct exposures to war-related traumas are compounded by multiple adversities, such as poverty, natural disasters, and displacement.
Challenges to effective solutions
The need to address the effects of trauma on the mental health and daily functioning of young people exposed to violence and adversity is at the heart of development assistance in war-affected settings. Nevertheless, efforts to find effective solutions face many challenges.
For one, the extent of untreated mental disorders is especially high in low- and middle-income countries (LMICs), where war, violence, and poverty are common. Globally, more than 70% of individuals with mental disorders do not receive treatment, and for children and adolescents, the mental health treatment gap in many war-affected settings is much higher.
Conflict is a double-edged sword: one that deepens the need for healthcare services while simultaneously wreaking havoc on healthcare infrastructures, which often already face shortages in facilities and personnel.
This lack of access to adequate mental health treatment also tends to persist in youth development programs. Even when development assistance efforts do incorporate mental health, they often fail to use evidence-based models and may focus narrowly on single disorder categories, such as PTSD, without attention to cross-cutting issues such as emotion dysregulation and functional impairments, which may manifest across a range of disorder categories from traumatic stress reactions to depression and conduct problems. Left unaddressed, these mental health problems can get in the way of young people’s ability to participate in development opportunities, such as the chance to return to school or engage in entrepreneurship.
Alternative delivery platforms
Education and employment training programs are seldom considered as potential delivery platforms for mental health services. Nevertheless, if they are properly leveraged, such programs can both help young people make a healthy transition back to normalcy through school or work, and serve as an innovative delivery platform to reach vulnerable youth with evidence-based mental health interventions, which may also bolster their participation in life development activities.
Our research in Sierra Leone provides an illustration of such opportunities. In 2002, immediately after the end of civil war, we launched the Longitudinal Survey of War-Affected Youth (LSWAY). Among former child soldiers, we found high levels of mental health difficulties linked to past exposure to violence, manifested in poor emotional regulation, anger, depression, and feelings of hopelessness. Evidence from the LSWAY also revealed key protective factors to leverage in intervention models, such as education, social support, as well as community and family relationships, which are critical to shaping better outcomes for war-affected youth.
Harnessing these findings, we developed the Youth Readiness Intervention (YRI), a transdiagnostic common-elements-based intervention drawing on cognitive behavioral therapy and interpersonal therapy components. Interventions like the YRI can address common mental health issues facing young people in LMICs, especially when developed with attention to context and the realities of a post-conflict setting with limited human resources for mental health.
While entrepreneurship programs respond to market demands by ensuring that young people obtain qualifications for employment, the YRI helps to bolster their daily functioning, emotion regulation, and interpersonal skills. The YRI demonstrated effectiveness in a trial integrating it into a school setting. In this manner, it holds great potential as an integrated component of youth entrepreneurship programs, as it was designed to be delivered by lay counsellors who receive excellent training and supervision.
Considerations for the development community
Our current project – Youth FORWARD – delivers the YRI within the alternative platform of a youth entrepreneurship program. Linking evidence-based mental health interventions to livelihood programs in this way highlights core considerations for the development community.
First, there is an urgent need to make mental health a priority within youth development programs. This requires transdiagnostic approaches that address key areas of difficulty, such as emotion dysregulation and interpersonal functioning that present across a range of mental disorders affecting adolescents and young adults, including depression, conduct problems, and traumatic stress reactions.
Second, research and interventions must be contextualised with careful consideration of the setting. Considerations should draw on knowledge about risk and protective factors at the individual, family, peer, community, and social and cultural levels. In fragile and conflict-affected settings, the development agenda must attend to the mental health consequences of violence and insecurity because it is precisely in these settings where addressing the consequences of trauma and cultivating human capital is a priority.
Finally, the development community should consider alternative platforms for the safe and cost-effective delivery of mental health services to make them both high-quality but also sustainable. With careful planning, interventions can be delivered by community health workers and other paraprofessionals if structures are tested to ensure high-quality training but also supervision that attends to quality and fidelity to the evidence-based intervention. It is essential to address the limited human resources and capacity challenges in post-conflict settings while at the same time investigating how to develop sustainable systems for mental health and social services.
The integration of evidence-based mental health interventions into innovative delivery platforms such as youth educational, employment and entrepreneurship programs may be key to supporting young people’s daily functioning and interpersonal relationships while simultaneously developing academic or career skills – a powerful combination for a healthy and productive life.
Theresa S. Betancourt is the inaugural Salem Professor in Global Practice at the Boston College School of Social Work and Director of the Research Program on Children and Adversity (RPCA).