Hasanović, M., Srabović, S., Rašidović, M., Šehović, M., Hasanbašić, E., Husanović, J., & Hodžić, R. (2009). Psychosocial assistance to students with posttraumatic stress disorder in primary and secondary schools in post-war Bosnia Herzegovina. Psychiatria Danubina, 21(4), 463-473. https://hrcak.srce.hr/49575

PSYCHOSOCIAL ASSISTANCE TO STUDENTS WITH 
POSTTRAUMATIC STRESS DISORDER IN PRIMARY AND 
SECONDARY SCHOOLS IN POST-WAR BOSNIA HERZEGOVINA

Students who participated in this project experienced a reduction in symptom severity and cluster symptoms related to trauma.
Significant improvements were observed in reexperiencing and avoidance symptoms compared to the control group.
The study employed a cross-sectional follow-up design.

Michigan State University

Upstream intervention to address risk and protective factors prior to onset of problems

Prevention interventions for youth affected by war/conflict

Aimed at specific at-risk groups. Share similar goals with treatment interventions. 

Selective or indicated school-based programs

A type of intervention with an ecological focus on peers/school.

Peer/School level interventions for youth affected by war/conflict

Betancourt, T. S., Meyers-Ohki, S. E., Charrow, A. P., & Tol, W. A. (2013). Interventions for children affected by war: an ecological perspective on psychosocial support and mental health care. Harvard review of psychiatry, 21(2), 70–91. https://doi.org/10.1097/HRP.0b013e318283bf8f

Interventions for Children Affected by War: An Ecological Perspective on Psychosocial Support and Mental Health Care

an intervention that aims to improve mental health outcomes in the immediate aftermath of a disaster or conflict by providing practical support, connecting people with existing resources, and identifying those who need specialized services. However, there is no rigorous evidence available to support its effectiveness among children and adolescents affected by war.

Psychological first aid

A brief intervention aimed at preventing onset of mental health symptoms and facilitate active coping with stress & war experiences in war-affected children (ages ages 2-7). The intervention involves presenting children with a stuffed puppy doll and teaching them how to hug and take care of the doll, with a focus on being a responsible caretaker. In randomized trials in Israel, the huggy-puppy intervention had strong positive effects on symptoms of traumatic stress reactions in young children. Additionally, child adherence to the intervention and attachment to the doll correlated with improvements in well-being.

Huggy-puppy intervention

The act of tracing involves locating a child's primary legal or typical caregivers as well as other family members. Its primary objective is to identify a sustainable resolution that aligns with the child's best interests, often entailing reuniting the child with their parents or other immediate kin. While there is limited research on the effectiveness of child-tracing interventions in improving mental health outcomes, reuniting separated families is an important step towards promoting mental well-being in war zones. However, peer-reviewed studies demonstrating significant links between child tracing, family reunification, and psychosocial adjustment have not yet been published.

Child tracing

In Gaza, a psychosocial intervention focused on promoting positive well-being among children during an active conflict period.
The intervention emphasized aspects like good family and community relationships, trust, problem solving, and hope.
Cross-sectional analyses indicated significant positive effects of the intervention, which lasted for at least four years.
However, its effectiveness was lower in one subgroup assessed two years after the intervention.

School-Based Psychosocial Intervention for Palestinian Children

Schoolwide trauma-reduction project in Bosnia

A school-based intervention combining cognitive-behavioral treatment strategies with activities like drawing, creative play, and group discussion was implemented.
Delivered by teachers
However, no positive effects were observed among the children who received the intervention (n=101), when compared to matched controls (n=93).
Employed a cross-sectional follow-up design.

Classroom-based psychosocial intervention after war in Lebanon

Researchers conducted a nonrandomized trial over one year in the Palestinian Territories to evaluate the impact of structured activities at nongovernmental organization sites on child mental health (internalizing and externalizing), child hopefulness, and parental support (40). The structured activities included traditional dance, art, sports, drama, and puppetry, with the hypothesis that they would (1) aid emotional adjustment in hostile environments by providing routine constructive engagement and opportunities for attachment and expression, (2) have a positive impact on parent-child relationships by providing safe outdoor activities to be shared, and (3) increase children's orientation towards the future. The study ensured a culturally appropriate community focus by translating all materials to the local language, employing local volunteers as providers, implementing cultural activities, and using the community center as the primary location for all activities. The child participants demonstrated improved internalizing/externalizing outcomes compared to a small control group, but no improvements in hopefulness were observed, and parental support improvements were reported at only one of the involved sites.

Structured activities at NGO sites

A type of psychosocial intervention for young refugees that includes a variety of participant-driven activities like communal games and group debates. In Serbia, researchers examined the impact of youth clubs on the psychological well-being of 128  participants, comparing them to 978 non-participate. The findings revealed significant improvements in self-respect. Boys experienced reductions in withdrawal and anxiety, while girls showed decreases in withdrawal and social problems. However, no reductions in traumatic stress were observed specifically for refugees.

Youth Clubs

In Uganda, a 15-session school-based intervention was tested, incorporating play therapy, drama, art, movement, and community service opportunities to improve emotional outcomes. A follow-up study found that the intervention improved child well-being, especially in girls. In Israel, a universal intervention called Overshadowing the Threat of Terrorism was implemented to reduce PTSD, somatic complaints, and anxiety. The intervention involved cognitive-behavioral techniques, art therapy, body-oriented strategies, and narrative approaches. Positive treatment effects were observed. Two preventive interventions were also identified in Israel. ERASE-Stress used psychoeducation and skill training to reprocess traumatic experiences and boost self-esteem and social supports, while the other intervention focused on social support, self-efficacy, and meaning attribution to moderate psychological distress. Both interventions were effective in moderating psychological distress compared to control groups.

Universal school-based interventions for war-affected children

In a randomized controlled trial (RCT) aimed at reducing depression symptoms among youth affected by war in northern Uganda, adolescents were divided into three groups: (1) those receiving an adapted group interpersonal psychotherapy, (2) a creative play intervention, and (3) a wait-list control group. The findings revealed that the adapted group interpersonal psychotherapy had positive effects on mood disorders that were locally relevant, particularly among young women. However, the creative play intervention did not lead to improvements in mental health or functioning.

Group interpersonal psychotherapy & creative play

Interventions with the aim to reduce the chance of relapse.

Maintenance interventions for youth affected by war/conflict



Interventions to reduce either distress and symptoms.

Treatment interventions for youth affected by war/conflict

The programs typically utilize a combination of Cognitive Behavioral Therapy (CBT), cooperative playgroup activities, and creative-expressive exercises (drama, art, dance, and music). These programs are implemented in structured sessions/phases and are usually led by teachers or volunteers with humanitarian experience instead of trained mental health professionals. While the effectiveness of these programs varies, they have shown moderate to significant short-term improvements in PTSD, behavioral, and emotional symptoms. However, no robust evidence yet for the long-term sustaining of these results post-intervention.

School-based programs for war-affected children exhibiting distress 

This study examined a school-based group intervention using cognitive-behavioral therapy (CBT) techniques for 26 children (11-15 years) who had experienced war-related trauma. The intervention consisted of six sessions of group CBT over a 6-week period. The treatment group showed statistically significant improvements in post-traumatic stress symptoms, behavioral difficulties, and emotional symptoms compared to the control group, which was on a waiting list. However, follow-up data for a small subset of eight children indicated that the gains were not maintained at a 2-month follow-up.

School-based Cognitive-Behavioural Therapy
Group Intervention for War-affected Refugee Children in the United Kingdom

In Indonesia: CBI reduced post-traumatic stress disorder (PTSD) symptoms and helped maintain hope, but did not reduce traumatic-stress related symptoms, depressive symptoms, anxiety symptoms, or functional impairment.
In Nepal: CBI did not lead to a reduction in psychiatric symptoms. Rather, it had moderate short-term beneficial effects, such as reduced psychological difficulties and aggression among boys, increased prosocial behavior among girls, and increased hope among older children. 
Similalrly, in Sri Lanka: no main effects were observed on PTSD, depressive, and anxiety symptoms.

Effectiveness of Classroom-Based Intervention (CBI) for war-affected children in Indonesia, Nepal, and Sri Lanka (cluster randomized trials)

This type of intervention aims to build self-confidence, improve emotional regulation, and foster resilience and recovery by using culturally relevant designs. Although there is no published data on the long-term sustaining of the effects of DMT on outcomes such as aggressive behavior, depression, anxiety, intrusive recollections, and elevated arousal. There are qualitative reports indicating that DMT is highly feasible in a postwar context in terms of emphasizing group cohesion and preventive and reparative capacities.

Dance and movement therapy (DMT) for war-affected children in Sierra Leone and South Sudanese refugee in the US

An intervention that aims to reduce PTSD symptoms. Usually administered in schools by trained teachers (non-specialists). It incorporates a range of techniques including meditation, biofeedback, art therapy, autogenic training (a self-relaxation technique to produce a psychophysiologically determined relaxation response), guided imagery, genograms, physical movement, and specialized breathing exercises. The effectiveness of this intervention was examined through a randomized control trial involving high school students in Kosovo after the war (with a wait-list control group), as well as Kosovar refugees in Gaza (without a control group). The studies revealed significant reductions in PTSD symptoms among participants postintervention, and these improvements were sustained during the follow-up period.

Mind-body techniques for youth affected by war

A three-tiered intervention for youth affected by war in Bosnia post-war.
Tier 1: classroom-based psychoeducation and skills intervention.
Tier 2: school-based trauma- and grief-focused group treatment.
Tier 3: community-based mental health services for students at acute risk for harm.
Tier 1 and 2 interventions were implemented by local school counselors. A randomized control trial revealed significant reductions in PTSD and depressive symptoms, as well as improvements in maladaptive grief, among participants compared to controls. Effective for war-affected youths in low-resource settings.

Skills, psychoeducation, and trauma/grief-focused group treatment  intervention for war-affected youths

An intervention that aims to provide vocational training and offer psychosocial assistance to youth who exhibit significant distress. The psychosocial support encompassed counseling on coping strategies, cognitive and behavioral techniques, and facilitating referrals for those requiring further assistance. It addresses sleep problems, psychosomatic symptoms, and concerns about family, future, and income. The intervention is implemented by counselors with a wide range of training backgrounds. A study in Uganda evaluated the intervention using qualitative research methods and found that the majority of participants' psychological distress was alleviated.

Vocational training and psychosocial support intervention for war-affected youths

An intervention that aimed to reduce psychosocial trauma and promote social healing in war-affected youths From Croatia through a school-based curriculum. Trained teachers implemented trauma/grief-focused psychotherapy. Post-intervention and follow-up after a year revealed small but significant positive outcomes in terms of stress reduction and ethnic bias in participants compared to the 2 control groups. A few confounding variables pose limitations to the study and can be controlled for by future research. 

Teacher-led trauma/grief psychotherapy intervention for war-affected youths

An intervention that addresses both educational needs and psychological distress among displaced youths in post-conflict settings by combining basic non-formal education (e.g., literacy and numeracy) with trauma healing activities (e.g., group sharing about past war experiences). Trauma healing activities focused on reducing levels of emotional distress and post-traumatic stress reactions that often interfere with learning. A noncontrolled pilot study in Sierra Leone examined the effectiveness of the intervention and found that participants had decreased intrusion and arousal symptoms and greater optimism about the future, but increased avoidance symptoms. However, future studies with control groups are still needed. 

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