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Nature Reviews Psychoogy
nature reviews psychology https://doi.org/10.1038/s44159-025-00447-9
Review article Check for updates
Supporting the mental health
of forcibly displaced children
Michael Pluess 1,2 , Felicity L. Brown3 & Catherine Panter-Brick 4,5
Abstract
Close to 50 million children under 18 years of age are currently forcibly
displaced from their homes because of armed conict and other
emergencies. Displaced children and adolescents are at increased risk
of developing poor mental health. However, knowledge about how best
to support their mental health and well-being is limited. In this Review,
we consolidate knowledge on the prevalence of mental disorders
in settings of forced displacement, discuss individual dierences
in response to war and displacement, and review existing mental
health and psychosocial support approaches. Critical assessment of
this literature indicates a substantial mental health burden among
displaced children and supports a broad range of risk and resilience
mechanisms. Although some specic mental health and psychosocial
support interventions have positively inuenced forcibly displaced
children’s mental health, there is a need for more culturally and
contextually relevant, accessible and evidence-based services that also
address family and community factors during displacement. We discuss
recommendations to ensure that these services are linked to strategies
that target adverse conditions and structural barriers and strengthen
the socio-ecological resources that contribute to children’s positive
development and well-being.
Sections
Introduction
Prevalence of mental
health conditions
Pathways to resilience
Mental health and
psychosocial support
Summary and future
directions
1Department of Psychological Sciences, School of Psychology, University of Surrey, Guildford, UK. 2Department of
Biological and Experimental Psychology, School of Biological and Behavioural Sciences, Queen Mary University of
London, London, UK. 3Programme Division, UNICEF Headquarters, New York, NY, USA. 4Jackson School of Global
Affairs, Yale University, New Haven, CT, USA. 5Department of Anthropology, Yale University, New Haven, CT, USA.
e-mail: m.pluess@surrey.ac.uk
Nature Reviews Psychoogy
Review article
implementation of these interventions in relevant contexts. Finally,
we discuss lessons learnt with a focus on addressing needs, bolster-
ing resilience, designing effective interventions and strengthening
psychosocial support for war-affected and forcibly displaced children25.
Throughout the Review, we apply a socio-ecological systems
perspective
26
. Accordingly, we view mental health and well-being in
forcibly displaced children as involving psychosocial factors (such as
parenting, the experience of structural violence, discrimination and
poverty) and bioecological factors (such as the physical and built envi-
ronment) across nested system levels connected through mediating
pathways
23
. These levels include the individual (personality and genetic
factors), their immediate microsystems (such as family), more distant
exosystems (such as the community), higher-order macrosystems
(such as the socio-political context and cultural norms) and the chrono-
system (changes over the life-course). This model helps us toconsider
how individual, family and community-level factors interlink to influ-
encemental health and how to integrate intervention benefits into sus-
tainable and coordinated multisectoral systems of care that promote
culturally and contextually relevant programme implementation27.
Prevalence of mental health conditions
Scholarly literature has consolidated knowledge on the prevalence of
mental disorders among forcibly displaced children. Seven systematic
reviews of surveys and/or qualitative studies of mental illnesses in con-
flict and post-conflict contexts noted substantial heterogeneity across
studies and a broad range of prevalence rates across mental disorders.
For example, one initial review
9
reported a 47% pooled prevalence rate
of post-traumatic stress disorder (PTSD) among children exposed to
war, indicating that as many as one in two children might meet the
criteria for this condition in the wake of war. However, this pooled
estimate was based on studies reporting heterogeneous results, with
both low (4.5%) and high (89.3%) prevalence estimates. Another review
published 10 years later
10
indicated a 22.71% prevalence rate of PTSD
among refugees and asylum seekers, with one in five children meeting
the criteria for this condition and large confidence intervals (between
12.79% and 32.64% across studies). Systematic reviews have similarly
presented substantially heterogeneous findings for other mental dis-
orders; for example, the estimated prevalence of depression among
war-affected children displaced to HICs varied between 3% and 30%
in one review11 (Table1).
There are two main reasons for such heterogeneity in the estimates.
First, studies included populations that were very diverse in age, coun-
try of origin, experiences before, during and after migration, legal sta-
tus, resettlement conditions, and access to services and other forms
of support
28
. Forcibly displaced people are far from a homogeneous
group, and failure to account for these distinct differences prohibits
meaningful estimates. Risk factors and manifestations of poor mental
health differ according to developmental stage, gender, disabilities and
context-dependent variables28,29. However, studies generally do not
disaggregate data along these lines. Furthermore, little research has
been conducted with forcibly displaced children hosted in LMICs
9,10
,
who are often exposed to more adverse contexts than children in HICs
and therefore are at increased risk for mental health problems. Varying
living conditions within LMICs might also have different effects on mental
health. For example, in two separate studies, whereas more than 50% of
Syrian refugee children living in informal tented settlements in Lebanon
met the criteria for mental disorders
12
, the rate was 23.7% for Syrian refu-
gee children living in more stable urban settings in Turkey30. However, at
present the unique effects of contextual factors are not well understood.
Introduction
The term ‘forcibly displaced’ refers to populations who havehad to
leave their homes owing to armed conflict or other emergencies1, and
includes internally displaced persons who havehad to relocate within
their home country as well as refugees and asylum seekers who haveleft
for a host country. The number of forcibly displaced children (younger
than 18 years) reached a staggering 47.2 million in 2023 — the highest
number since World War II2 — coinciding with several emerging conflicts
and heightened volatility across the globe owing to political instability3
and climate change4.
The majority of forcibly displaced children are hosted in low- and
middle-income countries (LMICs)2; only about 25% of displaced chil-
dren resettle in well-resourced high-income countries (HICs)
5
(Box1).
Across LMICs and HICs, most displaced children experience substantial
post-resettlement challenges
6,7
in addition to the long-term effects of
exposure to conflict and displacement
8
. The experience of war or other
crises, the loss of home, family and friends, and the enduring challenges
of displacement and resettlement (such as socio-economic marginali-
zation and limited access to school) puts displaced children at high risk
for the development of mental health conditions
9–11
. It is estimated that
more than 50% of forcibly displaced children in highly adverse contexts
experience mental health problems
12
, a rate over four times higher than
the global estimate (13%) for non-displaced children13.
To address mental health and psychosocial support (referred to by
the acronym ‘MHPSS’ in expert contexts), a wide range of programmes
have been developed to protect or promote the psychosocial well-being
of displaced children and to prevent or treat mental disorders14. How-
ever, up to 90% of forcibly displaced children with mental health prob-
lems in LMICs never receive appropriate care
15,16
. Services in LMICs
and humanitarian settings are usually dependent on short-term fund-
ing and often hampered by various challenges that limit the avail-
ability and accessibility of appropriate support17. Challenges include
under-resourced local health and protection systems
18
, limited mental
health aid budgets
19,20
, a scarcity of trained mental health professionals
and poor coordination amongservices provided by non-governmental
organizations and local systems21,22. Following these (and other) chal-
lenges, research and intervention efforts have adjusted from a narrow
focus on identifying and treating mental disorders to encompass more
integrated, community-based approaches that also target prevention
and promotion. These efforts take a socio-ecological and systems
approach to understand why some children show persistent mental
health problems whereas others show remarkable resilience when cop-
ing with adverse experiences
23,24
. In addition, the focus of research has
shifted from the evaluation of single interventions to implementation
science to understand how systems can support successful and sustain-
able implementation of effective interventions that are culturally and
contextually relevant in each setting.
In this Review, we critically reflect on current approaches to mental
health and psychosocial support for forcibly displaced children. Our
Review is based on systematic literature reviews that were selected
for thematic relevance (not screened for robustness) and provides
examples of notable research and intervention work. First, we synthe-
size current knowledge on the prevalence of mental health problems
among forcibly displaced children and related risk factors. Next, we
discuss individual and community differences in response to war and
other adversities and the mechanisms that underlie resilience. We then
consider the evidence for the effectiveness of mental health promotion,
prevention and treatment interventions for forcibly displaced children
and focus on the components and mechanisms needed for successful
Nature Reviews Psychoogy
Review article
Second, studies have relied on very diverse research methodolo-
gies to establish the prevalence of mental disorders across populations.
Especially in low-resource settings, prevalence rates were established
from self-report symptom-rating measures and psychometric
questionnaires, which might overestimate symptomology
10
. Data on
mental disorders were rarely triangulated across multiple informants
(children, caregivers and teachers), and relatively few population-
level studies applied clinical interviews — often viewed as the gold
Box 1 | Origins and residence of forcibly displaced children by 2023
By the end of 2023, 47.2million children under the age of
18years were displaced as a result of conlict and violence166,167
(see the igure).
Some of these children were forced to lee their homes but
remained living in their country of origin (internally displaced).
By 2023, 3.1million children were internally displaced owing to
natural disasters and 28.1million children owing to conlict and
violence. Internally displaced children were mostly based in
Sudan (4.2million), Democratic Republic of Congo (3.6million),
Afghanistan (2.8million), Syrian Arab Republic (2.6million),
Somalia (2.1million), Yemen (2.1million), Ethiopia (1.7million),
Nigeria (1.7million), Colombia (1.3million) and Burkina Faso
(1.0million).
Externally displaced children are those who have been forced to
lee their country of origin and are now living in a dierent country
(country of residence). By the end of 2023, 15.3million child refugees
were externally displaced. This group included refugees and asylum
seekers. Refugees are individuals who have led their countries to
escape conlict, violence or persecution and have sought safety
in another country. There is usually a refugee status determination
process to establish whether an individual’s circumstances make
them a refugee. Sometimes people leeing from a particular situation
are granted refugee status ‘prima facie’.
Palestinian refugee children are those who have lost their home and
means of livelihood in Palestine since the 1948 Arab–Israeli conlict
and are registered with the United Nations Relief and Works Agency
for Palestine Refugees in the Near East (UNRWA). This group includes
Palestinian refugees and their descendants living in Gaza, West Bank,
Jordan, Lebanon and Syria who are younger than 18years. By the end of
2023, there were 1.7million Palestinian registered refugee children.
Asylum-seeking children are those who have left their country of
origin and formally applied for asylum in another country but whose
refugee status determination is still pending. There were 2million
asylum-seeking children by the end of 2023.
In 2023, about 50% of all refugee children registered with the
United Nations High Commissioner for Refugees (UNHCR) came from
just three countries: Afghanistan (3.1million), Syrian Arab Republic
(2.9million) and Ukraine (1.9million). The remaining displaced children
originate mostly from Venezuela, South Sudan, Sudan, Myanmar,
Democratic Republic of Congo, Somalia and Central African Republic.
About 69% of all externally displaced children settle in directly
bordering countries. In 2023, the most common countries of residence
were Iran (1.9million), Turkey (1.6million), Pakistan (1.0million), Uganda
(0.9million), Germany (0.8million), Colombia (0.8million), Ukraine
(0.7million), Chad (0.6million), Ethiopia (0.6million), Bangladesh
(0.5 million) and Russian Federation (0.5million).
>1 million
250,000–1 million
50,000–250,000
5,000–50,000
500–5,000
1–500
None
Nature Reviews Psychoogy
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Table 1 | Prevalence of mental disorders among forcibly displaced children across systematic reviews
Sample
characteristics (age
range)
Sample size Host country or
region Country or region of origin Prevalence (95% conidence interval) Ref.
PTSD Depression Anxiety Other disorders
Refugees, war
survivors, residents,
expatriates and IDPa
(5–17years)
Total n=7,920
across 17
studies;
range,22–2,976
per study
Israel, Bosnia and
Herzegovina,
Gaza, Greece, Iraqi
Kurdistan, Kuwait,
Palestine, Rwanda,
Sweden, UK, USA
Israel, Palestine, Gaza Strip,
Bosnia and Herzegovina,
Persian Gulf, Cambodia,
Rwanda, Central America
17 studies,47% pooled
estimate (35–60%);
range=4.5–89.3%
4 studies,43%
(31–55%)
3 studies,27%
(21–33%)
NA 9
Refugees and asylum
seekersb
(10–19years)
Total n=779
across 8 studies;
range,90–197
per study
Germany, Malaysia,
Norway, Sweden,
Turkey
Middle East, Africa,
South Asia, other regions 7 studies,22.71%
(12.79–32.64%)
5 studies,13.81%
(5.96–21.67%) 4 studies,15.77%
(8.04–23.50%)
ADHD, 4 studies,8.6%
(1.08–16.12%)
ODD, 4 studies,1.69%
(0.78–4.16%)
10
Refugees hosted in
Western countriesc
(<25years)
Total n=3,003
across 22
studies;
range,40–1,078
per study
Canada, Denmark,
Netherlands,
Sweden, UK, USA
Angola, Ethiopia, Iraq,
Somalia, Sudan, other 7 studies, range=19–54% 3 studies,
range=3–30% NA Internalizing and
externalizing
behavioural
problem, 7 studies;
no prevalence rate
available
11
Children and
adolescents living in
areas of armed conlict
in the Middle East
(1–19years)
Total n=52,977
across 71 studies;
range,29–4,054
per study
Israel, Palestine, Iraq,
Lebanon NA Israel, range=5–8%
Palestine, range=23–70%
Iraq, range=10–30%
Lebanon,insuficient
data
Israel, 2 studies,
3.3%
Palestine,11.3%
Israel, 3 studies,
1.4%
Palestine,
range=40–100%
ADHD, Israel,
2 studies,3%
ADHD, Palestine,10%
161
Forcibly displaced
children and
adolescents resettled
in HICsd
(2–19years)
Total n=5,776
across 44
studies;
range,39–920
per study
Australia, Belgium,
Canada, Croatia,
Denmark, Finland,
Netherlands,
Sweden, UK, USA
Bosnia and Herzegovina,
Cambodia, Central America,
Chile, Croatia, Cuba, Iraq,
Middle East, Somalia, Sudan,
Vietnam, former Yugoslavia
1 study,38% if severe
violence exposure; 11% if
some violence exposure
No pooled
prevalence
estimated
No pooled
prevalence
estimated
No pooled
prevalence
estimated
7
Forcibly displaced
children and
adolescents resettled
in LMICsd
(4–23years)
Total n=5,765
across 27
studies;
range,45–3,415
per study
Costa Rica,
Honduras, India,
Nepal, Nicaragua,
Pakistan, Thailand,
Turkey, Uganda
Afghanistan, Bhutan, Bosnia
and Herzegovina, Cambodia,
Democratic Republic of
Congo, Kosovo, El Salvador,
Eritrea, Guatemala,
Iraq, Namibia, occupied
Palestinian territory,
Sudan, Tibet
No pooled prevalence
estimated No pooled
prevalence
estimated
No pooled
prevalence
estimated
No pooled
prevalence
estimated
146
Children and
adolescents in
conlict-affected
LMICs (including
IDPs, refugees,
former child soldiers,
schoolchildren)d
(10–17years)
Total n=34,291
across 53
studies;
range,6–14,649
per study
Middle East, Central
Asia and Eastern
Europe, Eastern and
Southern Africa,
South Asia, other
regions
NA NA No pooled
prevalence
estimated
No pooled
prevalence
estimated
No pooled
prevalence
estimated
25
ADHD, attention deicit and hyperactivity disorder; HICs, high-income countries; IDP, internally displaced people; LMICs, low- and middle-income countries; NA, not available; ODD, oppositional deiance disorder; PTSD,
post-traumatic stress disorder. aMeta-regression analysis of studies among children exposed to war (four of them conducted in the midst of conlict). bMeta-analysis of studies using quantitative prevalence estimates of
DSM(Diagnostic and Statistical Manual of Mental Disorders)23 categories of mental illness identiied through clinical interviews. cIncluded non-clinical studies and used STROBE (Strengthening the Reporting of Observational
Studies in Epdemiology)reporting standards to determine prevalence rates. dDid not include meta-analysis because of clinical and/or methodological heterogeneity across studies, but analysed risk and/or protective factors across
quantitative and/or qualitative studies.
Nature Reviews Psychoogy
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standard in assessing individual mental health based on standard
criteria31.
Furthermore, key debates remain regarding the cross-cultural
relevance of Western clinical models of mental health in humanitar-
ian and LMIC contexts. For example, research and evaluation studies
designed from a Western psychiatry standpoint often focus on PTSD,
depression and anxiety disorders, but overlook the importance of the
everyday burden of psychosocial and structural stressors — such as
those linked to restricted education and socio-economic exclusion.
These studies also lacked consideration of differences in symptom
expression across cultures and contexts
32
. Identifying and responding
to non-clinical psychological distress is crucial in contexts of chronic
adversity and protracted displacement33, with criticisms highlighting
the potential dangers of pathologizing typical reactions to traumatic
experiences. Culturally relevant and developmentally informed con-
ceptualizations of mental health needs still need to be developed10,19,34,35
to better understand what drives poor mental health and what can most
effectively accelerate mental health recovery for children experiencing
forced displacement.
Pathways to resilience
Various conceptual models of psychological resilience (broadly defined
as the process of positive adaptation in the context of adversity36,37)
have been developed over the past 50 years38–42 to describe individual
differences in response to childhood adversities, including war and
displacement23,35,43–45. At their core, resilience models suggest that
some children are less negatively affected by adversity than others
owing to co-occurring protective factors46,47 that buffer the impact of
negative experiences. Knowing what predicts individual differences in
response to war and displacement is crucial to identifying displaced
children who are vulnerable to the negative impacts of war and displace-
ment, and to guiding effective mental health and psychosocial support
services. In this section, we discuss published work on these mecha-
nisms in the context of war and displacement from the perspective of
a socio-ecological systems theory26.
Defining resilience in children
Frameworks of psychological resilience are increasingly popular.
However, the concept of resilience and its application are not with-
out criticism, because the varying conceptualizations of resilience
can be difficult to operationalize. For example, despite the often
extremely adverse circumstances to whichforcibly displaced children
are exposed, between 20% and 80% of displaced children — about 65%
on average — do not present mental health conditions9–11, pointing to
psychological resilience. However, traditional studies investigating
individual differences in response to war and displacement focused
on single mental disorders such as PTSD or depression (unidimen-
sional analyses of mental health)9–11. By contrast, the proportion of
resilience outcomes decreased to about 20% when multiple dimen-
sions and co-occurring mental disorders were considered simultane-
ously (multidimensional analyses of mental health)48. These findings
suggest that considering only one disorder — such as PTSD — as an
outcome is insufficient and likely to bemisleading, because different
children might develop different mental health problems in response
to exposure to the same adverse events (multi-finality)49. For example,
following war exposure, a child might not display PTSD symptoms but,
instead, might develop depression or aggressive behaviours; this child
cannot be labelled ‘resilient’ on the basis of onlythe absence of PTSD
symptomology12,48.
Moreover, to indicate psychological resilience, the absence of
mental disorders should also be accompanied by the presence of posi-
tive everyday functioning. Thus, resilience assessment should also
include measures of adjustment and positive psychosocial outcomes
50
,
such as daily functioning, adaptive coping, self-efficacy, self-esteem,
social and emotional competence, and well-being. This assessment
also requires a careful distinction between outcomes and mechanisms:
the positive outcomes of resilience are often measured in terms of
subjective well-being or social functioning, whereas the mechanisms of
resilience are those that facilitate the development of such outcomes,
including self-efficacy.
Risk and resilience factors across system levels
Through our review and synthesis of the relevant literature, we iden-
tified several factors that might increase risk or resilience in forcibly
displaced children (Table2). At the individual level, adaptive coping
strategies (such as cognitive restructuring and seeking social support)
were associated with good mental health in Syrian refugee children.
By contrast, avoidance strategies such as wishful thinking and social
withdrawal were associated with poor mental health51. Other relevant
individual factors included poor health leading to increased risk
23,48
and high cognitive abilities
45,52
leading to increased resilience. The
underlying mechanisms of these effectsmight include high-order pro-
cesses such as regulatory flexibility
53
, defined as dynamic behavioural
adjustment and change in the face of demanding situations.
Most research at the microsystem level has focused on family
factors, such as the importance of responsive parenting practices,
family dynamics and parental mental health. For example, supportive
parenting was associated with better academic achievement and fewer
internalizing and externalizing problems in Arab refugee adolescents54.
In Syrian refugees, how parents negotiate their parenting expectations
(and spousal interactions) was associated with child mental health
and learning competencies beyond parental engagement55. Similarly,
higher scores of parental PTSD, depression and anxiety symptoms
differentiated Syrian refugee children at risk for mental health condi-
tions from psychologically resilient children48. Furthermore, expo-
sure to armed conflict was associated with poorer parental mental
health, which had implications for family-level dynamics, caregiving
practices and child health, development and learning outcomes
56–61
,
whereas positive family functioning had a buffering effect on youth
outcomes62,63.
At the exosystem level, access to and a positive experience of
school emerged as central resilience factors among forcibly displaced
children. For example, a more positive experience of school was associ
-
ated with fewer PTSD symptoms in Iraqi refugee children64. Similarly,
higher social support from the community was associated with reduced
depression, PTSD and externalizing problems in Syrian refugees living
in Lebanon12.
Finally, at the macrosystem level, access to and availability of
basic public services was associated with reduced symptoms of PTSD
and externalizing problems in Syrian refugee children12. Importantly,
the macrosystem level was the least researched, which means that
resilience is more often understood in the context of psychosocial and
community rather than structural factors.
Multisystemic pathways
Resilience is shaped by multiple system levels which change over time
(chronosystem)23. Thus, resilience is likely to bedynamic in response
to changes across system levels, especially given the instability and
Nature Reviews Psychoogy
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complexity associated with forced displacement. For example, in a
study on resilience in Syrian refugee children, about 50% of the children
who were considered resilient at one point (defined as being below
clinical cut-offs for PTSD, depression and externalizing problems) no
longer met criteria for resilience a year later, whereas others improved
from being at risk to meeting the criteria for resilience65.
Resilience-building approaches usually focus on individual-level
outcomes but frequently neglect strengthening of resources at the
family, community and structural levels66. A multisystem perspective
cautions that efforts must be made at the structural level to change
the systemic factors that engender stress and adversity over time
66,67
and underscores the importance of refraining from reducing resil-
ience to personality traits or genes
48,68–71
. A viewpoint that attributes
the mental health consequences of the adverse and oppressive struc-
tures of forced displacement to children themselves is problematic
54
;
evidence suggests that resilience to adversity ismost likely toreflect
the combined protective function of multiple systems over time.
Indeed, even children who show resilience in the wake of displace-
ment require care and supportive systems around them throughout
development.
According to theories of environmental sensitivity
72–74
, includ-
ing the theory of differential susceptibility
75
, children differ in their
response to both negative and positive experiences as a result of
individual differences in their sensitivity to environmental influences
(for example, parenting quality). High environmental sensitivity
reflects a more sensitive central nervous system on which environ-
mental influences register more easily and more deeply, and has been
associated with genetic, physiological and psychological markers
of sensitivity75,76. More environmentally sensitive children are not
only more vulnerable to the adverse effects of exposure to war and
displacement48,77, but also benefit more from positive and support-
ive experiences (vantage sensitivity78), including psychological
interventions
79–82
. For example, only highly sensitive girls (assessed
with the 12-item Highly Sensitive Child scale
83
) showed reduced depres-
sion symptom scores81 after a school-based resilience-promoting
programme
84
in a controlled trial among girls aged 11–13 years in a
deprived inner-city context in the UK. Such findings show that highly
sensitive children are likely to bemore responsive to treatment, high-
lighting the need for alternative ways to support children who areless
sensitive to environmental influences (Fig.1).
In sum, individual differences in responses to armed conflict, other
crises and displacement reflect the combined influence of the levels of
adverse exposure and various risk and protective factors that threaten
or support mental health. According to cultural and socio-ecological
approaches to mental health theory and practice85, resilience should
be understood as fundamentally multisystemic23,40,86. However, more
Table 2 | Risk and resilience factors by system levels
System level Risk factors Resilience factors
Individual High exposure to war events (especially violence towards oneself
and close people)12,35,162
Exposure to war in past 1month–5years35
Older age at exposure12,45,52,163
Low general health23,48
High environmental sensitivity23,48
Avoidance coping strategies48,164
High cortisol levels70,148
Genetic predisposition for mental health problems70,148
Gender: girls more resilient for externalizing problems; boys more resilient for
depression and PTSD12,45,52
Younger age at exposure45,52,163
High levels of personality traits such as self-esteem23,48,52,163, optimism23,48,52,162,
self-control45 and self-eficacy45,52,162,163
High cognitive abilities45,52 and internal locus of control35
Religious beliefs and practices (meaning and hope)35,45,52,162 and maintenance
of cultural identity163
Acculturation (including language acquisition)45,52,163,164
Adaptive coping strategies (cognitive restructuring)52; altruism and prosocial
behaviour35
Future orientation and aspirations65
Microsystem Separation from and loss of caregivers (especially fathers)35,162
Caregiver’s poor mental health (PTSD, depression, anxiety)12,23,48,164
and poor general health23,48
Child–caregiver conlicts12
Maltreatment by parents12,23
High maternal psychological control23,48 and low maternal
acceptance65
Experience of bullying23,48,164
Basic and inancial needsmet162
Caregiver’s good mental health35
Low parent–child conlict23
Strong bond with primary caregiver (maternal acceptance)23,35,45,52
Supportive parenting45,52, family unity12,45,52,163
High parental education52 and access to school45,52,162,164
School connectedness and sense of belonging52,164
Feeling safe at school162,163
Exosystem Social isolation and loneliness48,164
High human insecurity23,162
Disruption of school or work162
Social support from community, teachers and peers23,35,45,48,52,162–164
Community acceptance12,45,52
Macrosystem No data available Socio-economic condition163
Availability and usage of health services12,163
Socially inclusive society162,163
Maintenance of cultural practices163
Availability of legal status for refugees162
Educational and employment opportunities52,162
Respect for diversity and equality52
We identiied risk and resilience factors based on systematic reviews35,45,52,162–164 and key publications12,48,165 on resilience among forcibly displaced children that included cross-sectional and
longitudinal studies of various sample sizes. PTSD, post-traumatic stress disorder.
Nature Reviews Psychoogy
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work is needed to better understand how multiple resilience factors
promote good mental health among forcibly displaced children.
Mental health and psychosocial support
There is increasing attention to the development and implementation
of interventions to prevent and respond to the mental health challenges
faced by forcibly displaced children. However, evidence gaps exist in
the available evidence for mental health and psychosocial support
interventions for displaced populations, and children specifically
87,88
,
and these hamper the wide-scale delivery of feasible, evidence-based
interventions. In this section, we highlight the pressing need for fur-
ther research in this area and outline key evidence-to-practice gaps on
the basis of evidence from ten systematic reviews on such interven-
tions for children who were exposed to humanitarian crises or forcibly
displaced (Table3).
Interventions across system levels
Overall, the ten reviews reported a growing number of evaluation stud-
ies of mental health and psychosocial support interventions at different
stages of forced displacement and resettlement, with original studies
indicating a range of potential benefits, such as decreases in symptoms
of anxiety, depression and traumatic stress89–91 and improvements
in daily functioning92,93. Yet the reviews consistently highlighted the
methodological weaknesses of studies, the broad range of interventions
studied and the scant research in children and adolescents compared
with adults.
The evidence of intervention effectiveness was less convincing
when looking at meta-analytical findings drawn only from randomized
controlled trials (RCTs). For example, a meta-analysis of RCTs of psy-
chosocial interventions for refugee and asylum seeker populations
found reductions in symptoms of PTSD, depression and anxiety when
combining adult and child populations, but did not find clear effects of
interventions in children specifically
94
. Another meta-analysis of indi-
vidual participant data reported an overall positive effect of focused
psychosocial interventions for children in humanitarian settings
on reductions in PTSD symptoms and functional impairment, with
increases in hope, coping and social support
95
. However, no effects
were found for depression and anxiety symptoms, and effects were
diminished among children who were younger and/or displaced.
Despite the theoretical support for a shift from focusing solely on
the individual child to taking a socio-ecological approach to child men
-
tal health and well-being and supporting the systems and environments
Risk factors Protective factors
High environmental sensitivity
Macrosystem
Exosystem
Microsystem
Low environmental sensitivity
Individual A
Individual B Low
sensitivity
High
sensitivity
Time
High
Low
Level of functioning
Negative
influence
Time
Individual A
Individual B
Positive
influence
Fig. 1 | Socio-ecological approach to mental health challenges and resilient
behaviour in forcibly displaced children. According to ecological systems
theory26, children’s mental health and behaviour are influenced by various
risk (red) and protective (yellow) factors associated with war, displacement
and support that can be categorized across systems levels into macrosystem
(the society), exosystem (the community), microsystem (the family or school) and
individual (the child’s constituent traits). Following theories of environmental
sensitivity72–75, individual differences in sensitivity to environmental influences
and exposure to risk and protective factors across systems interact across
settings and time. These interactions can manifest in children’s behaviours (blue).
Nature Reviews Psychoogy
Review article
Table 3 | Systematic reviews of intervention studies with children exposed to war or forced displacement
Target of
interventions Type and focus of
interventionsaPopulation Number and type of
studies included Review methods Key eectiveness indings on
children Ref.
Interventions across system levels
Prevention Psychological and
social interventions for
preventing mental health
disorders
Adults and
children living in
LMICs affected by
humanitarian crises
7 RCTs, 5 of which included
children and/or adolescents Cochrane review and
meta-analysis No data on effectiveness in
reducing incidence
No changes in symptoms of PTSD,
depression and anxiety
121
Prevention
and promotion Psychosocial support
interventions for
preventing mental health
disorders and promoting
well-being
Forcibly displaced
adults and children 162 studies (any type),
45 of which included
children and adolescents
Only 21% of interventions
focused on children;
7% on young children
Systematic review
and meta-analysis Moderately improved psychosocial
well-being (pooled adults and
children effect size=–0.534)
Small non-conclusive effects on
improved internalizing (pooled
adults and children effect
size=–0.152) and externalizing
problems (pooled adults and
children effect size=–0.249)
Worsened internalizing symptoms
in children (effect size=0.129)
108
Narrative synthesis
of qualitative and
quantitative data
Positive perceptions (98%) of
intervention effectiveness for most
studies
Mixed indings from quantitative
measurements: 44% showed
positive perceptions, but only
29% when considering RCT
designs alone
Transdiagnostic
psychosocial interventions
for preventing symptoms
and promoting well-being
Forcibly displaced
adults and children 36 RCTs identiied; 32 RCTs
included in meta-analysis,
10 of which included
children and/or adolescents
Systematic review
and meta-analysis No evidence of improvement;
44.4% of effect sizes indicated
non-signiicant negative effects
122
Treatment Psychosocial interventions
for mental health problems Adult and children
asylum seekers and
refugees
26 RCTs, of which
2 included children Systematic review
and meta-analysis No subgroup analyses conducted
speciically for children and
adolescents
94
Prevention,
promotion
and treatment
Focused psychosocial
support interventions
targeting individuals with
distress96
Children exposed to
humanitarian crises
in LMICs
11 RCTs including children Systematic review
and meta-analysis of
individual participant
data from 3,143
children
Improved PTSD symptoms
(SMD=–0.33) maintained at
follow-up 6weeks or later
(SMD=–0.21), particularly among
adolescents aged 15–18years
(SMD=–0.43), non-displaced
children (SMD=–0.40) and
children living in small
households (SMD=–0.27);
no gender differences
Improved functional impairment
(SMD=–0.29), coping
(SMD=–0.22), hope (SMD=–0.29)
and social support (SMD=–0.27)
95
Any psychological
intervention Youth up to age
24years impacted
by armed conlict in
LMICs
28 RCTs and controlled
trials Systematic review
with narrative
analysis
Improvements reported across
studies, although patterns were
inconsistent across outcomes and
interventions
99
Component analysis Interventions demonstrating
positive effects commonly included
access promotion, psychoeducation
for children and parents, insight
building, rapport-building
techniques, cognitive strategies, use
of narratives, exposure techniques
and relapse prevention
Mental health and
psychosocial support
interventions to promote
psychosocial well-being
and/or prevent or treat
mental health disorders
Children and
adolescents
affected by armed
conlict in LMICs
24 studies (any type) Systematic review
with narrative
synthesis
Improvements reported across
all interventions for at least some
outcomes
Only 43% of interventions
improved primary outcomes
22% of interventions worsened at
least one outcome
100
Nature Reviews Psychoogy
Review article
around children
96–98
, several reviews found that most interventions for
displaced young people focused on individual factors
94,99,100
. Whether
delivered to individual children or groups of children (including in a
school or community setting), most interventions targeted child-level
outcomes (such as depression, anxiety and traumatic stress symp-
toms) through building the child’s individual resources (such as
problem-solving strategies and stress management).
The two reviews that focused specifically on family interven-
tions101,102 found promising potential for such approaches to improve
child and caregiver mental health and family processes, yet high-
lighted limited research to date. Original intervention studies in
forced displacement contexts indicated promising effects on child
outcomes for behavioural parenting interventions103, combined
support for parenting and parent mental health104, preventive family
interventions105 and systemic family interventions106. However,
evidence was largely limited to skills-based promotion and prevention
interventions
102,107
rather than covering more focused interventions
for families experiencing substantial distress. Although the majority
of forcibly displaced families live in LMICs, 60% of intervention stud-
ies were conducted in HICs102 and very few studies were conducted in
humanitarian settings.
Interventions were commonly delivered in schools100,108 — a key
part of the child’s social ecology109,110. However, we identified only
one systematic review specifically focused on school-based interven-
tions in humanitarian emergencies or forced displacement
111
. This
work reported positive effects for interventions that included verbal
processing of past experiences and/or creative art techniques, with
the most support reported for interventions that included cognitive
behavioural techniques. Nonetheless, empirical evidence so far has
been limited and most interventions have been conducted in HICs111.
Similarly, systematic reviews of school-based interventions conducted
in LMICs more broadly have consistently highlightedthe limited num-
ber ofscientific studies to date, the methodological weaknesses of
existing studies andthe few examples of successfully scaled-up ser-
vices
109,112,113
. A cost–benefit analysis of school-based interventions for
children and adolescents facing humanitarian emergencies or forced
displacement forecast benefit–cost ratios of US $57 and US $225 in
benefits per US $1 invested, respectively, for school-based group cogni-
tive behavioural therapy (CBT) prevention programmes for children
displaying symptoms of depression and school-based social and emo-
tional learning promotion programmes
114
. This result highlights the
interventions’ potential and underscores the importance of further
research in this area.
Additionally, implementing a mental health and psychosocial
support intervention within a school is different from implementing
interventions that aim to address the school environment. A realist
review conducted in 2022 identified 19 studies of universal prevention
programmes in humanitarian education settings in LMICs and devel-
oped evidence-informed programme theories that identified factors
likely to lead to improved well-being and learning for children. Beyond
individual child factors, factors driving change included teacher cop-
ing skills and support for students, strengthening interpersonal bonds
between caregivers and children, and fostering feelings of security
at school115. These findings lend support to more comprehensive
programmes addressing teachers and the school environment.
Communities can and should play a lead role in their own care
after adverse experiences, and should be meaningfully engaged in
interventions’ programming
116,117
. Community-based approaches not
only place communities in the driver’s seat in designing and imple-
menting interventions but also leverage community strengths and
skills, attend to improving collective well-being, and strengthen collec-
tive structures and systemsthat are integral to well-being and quality
of life
118
. These approaches might also reduce stigma around mental
health services, which is a commonly reported barrier for accessing
support
119,120
(Box2). However, there is scarce evidence for interven-
tions that work with communities to support child and adolescent
Target of
interventions Type and focus of
interventionsaPopulation Number and type of
studies included Review methods Key eectiveness indings on
children Ref.
Interventions delivered with the family
Prevention,
promotion
and treatment
Family-based mental
health interventions Refugee families in
HICs and LMICs 10 studies (pre–post,
quasi-experimental
and RCTs)
Systematic review
and narrative
synthesis
Evidence base is still emerging,
but interventions showed
potential to improve child and
caregiver mental health, family
processes and functioning
102
Refugees and
immigrants
exposed to
traumatic events
6 studies (pre–post,
quasi-experimental and
RCTs) including 4 school-
based interventions and 2
multifamily support groups
Systematic review
and narrative
analysis
Limited research hindered
conclusions 101
Interventions delivered in schools and community
Treatment School and community-
based interventions for
reducing psychological
disorders
Refugee and
asylum-seeking
children
21 studies (pre–post,
quasi-experimental and
RCTs), including 14 in
HIC schools (n=11) or
community (n=3) settings
and 7 in LMIC refugee
camps
Systematic review
and narrative
analysis
Verbal processing of past
experiences (n=9), creative
art techniques (n=7) or a
combination of both (n=5)
improved outcomes (effect size
range=0.31–0.93)
Interventions using CBT had the
largest effect sizes
111
Only systematic reviews that reported interventions’ effectswere included. Reviews of interventions in low- and middle income countries not focused on humanitarian emergencies and
forced displacement were excluded. aDescriptions are provided according to terminology as described in the main text. CBT, cognitive behavioural therapy; HICs, high-income countries;
LMICs, low- and middle-income countries; PTSD, post-traumatic stress disorder; RCT, randomized controlled trial; SMD, standardized mean difference.
Table 3 (continued) | Systematic reviews of intervention studies with children exposed to war or forced displacement
Nature Reviews Psychoogy
Review article
mental health and well-being
100,111
. Only one review specifically focused
on community-based interventions for refugee and asylum-seeking
children, yet the included studies evaluated interventions delivered
in community settings that targeted individual-level processes, rather
than interventions targeting community environments and inter-
personal processes
101
. Another review, focused on children affected
by armed conflict in LMICs, highlighted the dearth of evidence on
interventions to strengthen communities87. The assumption that
mental health and psychosocial support programmes can improve
outcomes in refugee children in the absence of structural changes in
society and in the presence of meaningful ongoing adversity needs to be
rigorously tested.
Interventions from promotion to treatment
Experts frequently advocate for a stepped care approach via multi-
layered and multisectoral collaboration and coordination to deliver
services that progressively become more specialized. These layers
can be visualized as a pyramid in which mental health and psychoso-
cial considerations built into basic services and universal preventive
interventions for all members of the community sit at the bottom and
Box 2 | Mental healthcare gap
The ‘mental healthcare gap’ is the number of individuals requiring
mental healthcare but not receiving it. Estimates for depression
indicate gaps of up to 67% in high-income countries (HICs) and
greater than 90% in low- and middle-income countries (LMICs)168,
with only 1 in 5 people in HICs and 1 in 27 in LMICs receiving minimally
adequate care168,169. The proposed drivers of this gap include lack of
resources, limited access and low demand170,171.
Lack and ineicient use of resources
Despite mental health conditions being a leading contributor to
the global burden of disease and estimated to cost US$2.5trillion
annually172, countries spend, on average, 2% of their health budget
on mental health173, and this percentage is lowest in LMICs, where
the majority of forcibly displaced children live174. For comparison,
experts call for spending to increase to 5% in LMICs and 10% in HICs
at a minimum175. Spending on child and adolescent mental health
services (as opposed to adult services) is even more limited19,173.
Of the limited spending, two out of every three dollars fund psychiatric
hospitals, with little attention to more accessible community mental
health services and prevention and promotion activities173. Only 21%
of the World Health Organization (WHO) member states — and only
3% among low-income countries — have mental health policies and
plans implemented in full compliance with human rights, and even
fewer have speciic plans for child and adolescent mental health173.
Furthermore, there are fewer than 1 mental health professional per
100,000 people in low-income countries, compared with more than
60 in HICs18. Professionals trained to provide mental health support to
children and adolescents speciically are more scarce, with just
3 per 100,000 globally, and as few as 0.1 per 100,000 in low-income
countries173.
One approach to increasing resources is task-sharing, whereby
non-specialist providers are trained and supervised by mental health
specialists to deliver care176. Non-specialist interventions often
take a transdiagnostic approach and use core elements found to
be eective in psychotherapy (often with fewer sessions than the
original psychotherapy guidelines and often in group format170,177).
This approach has demonstrated safety and eicacy across contexts,
including with forcibly displaced children144, although implementation
science research is needed to improve delivery and scale27,144.
Limited and inequitable access
There are many barriers to accessing interventions, especially for
people with lower socio-economic status171. Services are commonly
delivered face to face in healthcare facilities in urban settings and at
times that are suitable for providers but not for users, which makes
access challenging, especially for disadvantaged groups119,170. Other
barriers include insurance and coverage for mental health services,
and discrimination171,178.
Potential solutions include a shift to community-based
interventions including integrating mental healthcare into primary
healthcare and education, delivering services at times and locations
that prioritize users (for example, evenings and weekends), provision
of transport or reimbursement of costs and use of digital technology
to facilitate remote service delivery170,178–180.
Limited help-seeking behaviour in mental healthcare
Although eorts to enhance the availability and quality of services
are critical in closing the gap, the use of available services is
contingent upon individuals’ recognition and prioritization of mental
health concerns and their willingness to seek help175,178. Factors
such as stigma, lack of awareness about mental health needs and
concerns around quality of care have been cited as barriers to
help-seeking157,171,178. These factors are typically addressed through
eorts to raise awareness, enhance quality of services and promote
human rights34, reduce stigma181and implement community-based
identiication tools182, and interventions to boost help-seeking178.
However, the most commonly reported barrier is a lack of
perceived need for treatment183. Although one interpretation is that
further awareness-raising is needed, an alternative is that current
services might lack contextual relevance, and failure to address
the complex needs of disadvantaged communities might inluence
acceptability157. Active involvement of the population in the co-design
of mental health services, avoiding biomedical labels, using relevant
explanatory models129,170 and leveraging individuals’ resources,
including family and community170, might ultimately increase
uptake157,170,176.
Moreover, service usage can be limited when populations
perceive their distress as inextricably linked to social and economic
circumstances rather than as clinical disorders157. Displaced
populations rarely receive adequate income, housing, employment
or education support173, yet these are known to improve mental health
and well-being, and interventions might have limited eectiveness
when social and economic conditions are not improved(F.L.B. et al.,
unpublished work)157,184. Social and structural determinants of mental
health should be fully recognized and addressed concurrently with
mental health and psychosocial support interventions170,185, with
cross-sectoral collaboration and partnership to deliver adequate and
meaningful services97,157.
Nature Reviews Psychoogy
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broadest level, and progressively fewer people need the services at
higher, more specialized service layers
14,97
. Universal services are fol-
lowed by selective prevention services targeting specific family and
community mental health needs, which in turn are followed by indi-
cated prevention services focused on identified mental health risks
and conditions, reaching highly specialized clinical management at
the top of the pyramid.
Prevention and promotion interventions at the population level
are consistently recommended in guidelines, widely implemented
and largely reported to have benefits in practice88,100,108. However, the
three systematic reviews thatfocused on prevention and promotion
interventions108,121,122 found relatively few studies with forcibly dis-
placed populations, especially for children. One of these systematic
reviews, which included a meta-analysis of prevention and promo-
tion interventions in forcibly displaced populations (children and
adults combined), found a moderately strong overall effect (effect
size = –0.534) on psychosocial well-being, and non-significant small
effects on internalizing (effect size = –0.152) and externalizing (effect
size = –0.249) problems
108
. However, only 21% of the included research
focused on children (and fewer on young children), and a subgroup
analysis indicated that children showed worse internalizing symptoms
after receiving these services. The other two reviews similarly found no
evidence of positive effects of prevention or promotion interventions
for children and adolescents
121,122
. Furthermore, most original stud-
ies lacked the long-term follow-up assessments that areessential to
evaluate the interventions’ potential to reduce the incidence of mental
disorders108,121,122. This finding reflects a persistent evidence–practice
gap whereby the most widely implemented interventions have the
least evidence123. Authors also highlight a lack of coherence between
intervention aims and measured outcomes, with a focus on clinical
symptoms and a failure to measure other potentially meaningful posi-
tive effects on mental health that might have occurred in response to
such interventions (such as effects on well-being or quality of life)
100,108
.
Interventions across cultures and contexts
The importance of adequate consideration of culture and context in
the delivery of mental health and psychosocial support interventions
with forcibly displaced communities has been repeatedly highlighted,
and cultural adaptations have been demonstrated to relevantly and
iteratively improve intervention effectiveness
124–127
. The vast majority of
current approaches are from HIC settings with non-displaced popula-
tions, yet substantial research indicates that conceptualizations and
expressions of psychological distress differ across settings and often
do not align with Western diagnostic models32,128. Thus, ‘off-the-shelf’
interventions are not necessarily directly applicable to all communities,
might not directly fit local understandings of intrapersonal and inter-
personal distress or treatment preferences, and risk doing harm117,129.
Despite this background, reviews found that few studies adapted inter-
ventions to the context and those that did seldom reported substantial
modifications99,100.
When conducted, cultural and contextual adaptation of evidence-
based interventions typically aims to strike a balance between ‘fidelity’
(retaining core intervention components; for example, psychoeduca-
tion or relaxation) and ‘fit’ (ensuring acceptability, comprehensibility,
relevance and completeness through changes such as the use of illustra-
tions and relevant local idioms)
130
. Such adaptations should address
changes needed to the cultural concepts of distress, the treatment
components and the treatment delivery129, and avoid the assumption
that refugees are a homogeneous group (even if they share the same
country of origin)28. An example of a rigorous contextualization process
was a psychological intervention with young adolescents displaced
from Syria to Lebanon
131
. This intervention was adapted through a
comprehensive process of desk research, qualitative interviews with
adolescents and other community members, iterative workshops with
local experts and potential end users, and gathering detailed feedback
during pilot testing.
Active ingredients and mechanisms of change
Beyond questions of ‘what works’, the thorough investigation of the
interventions’ effectiveness entails addressing questions of how, for
whom and under what circumstances mental health and psychoso-
cial support interventions work. Such research can help elucidate the
specific ‘active ingredients’ of these intervention packages to identify
critical programme components that drive change
27
. For example, one
systematic review
99
included an analysis of the treatment components
commonly present within manualized intervention packages that had
positive effects on young people in LMICs affected by armed conflict.
The identified intervention components included psychoeducation,
cognitive exposure, relaxation and expressive techniques such as art
and dance. The interventions also commonly included strategies to
promote accessibility (such as holding sessions in the community),
build rapport between providers and young people, encourage practice
at home between sessions and maintain treatment gains99.
Similar component analyses have been conducted for parenting
and family interventions102,107,132. Findings indicated that strategies used
in family interventions for refugee populations commonly included
psychoeducation, stress management techniques, positive parent-
ing, communication skills and connection to social supports102. These
methods provide important insights into the components included
in successful intervention packages, but thefindings are descrip-
tive only and cannot attribute the effectiveness of interventions to
particular components. Further experimental investigation of the
unique effectsof different components will allow more sophisticated
intervention design.
Consideration of the mechanisms of change that explain the path-
way between the delivery of the intervention to the observed therapeu-
tic outcomes is also needed to understand ‘how’ interventions achieve
their intended effects. One systematic review of reviews analysed
mechanisms of change in 13 reviews of interventions for children and
adolescents affected by war and armed conflict (covering 30 coun-
tries). Only four mechanisms were supported through high-quality
evidence (quantitative data specifically testing the mechanism, such as
through mediational analysis). The findings suggested that the effects
of interventions on young people’s mental health and well-being might
be achieved via increased caregiver capacity to support their children,
strengthened family relationships, enhanced problem-solving skills
and enhanced therapeutic rapport with a counsellor. These findings
highlight the importance of interventions addressing family envi-
ronments to effectively change child outcomes. However, further
systematic measurement and delineation of the dynamic and complex
mechanisms that lead to optimal intervention outcomes for children
is still needed. Developing theories of change that link intervention
components with intended intermediate and long-term outcomes can
help tohypothesize and test these pathways (Box3).
Among displaced children, different risk and protective factors
and intervention needs are at play depending on developmental stage,
gender and disability (among other factors), and therefore it is essen-
tial to consider which interventions work for which subpopulations
Nature Reviews Psychoogy
Review article
Box 3 | Theory of change
A theory of change is a detailed description of how and why
a desired change is expected to take place in a particular
context186. A well-designed theory of change can help researchers
tounderstand the mechanisms by which the speciic components
of an intervention lead to desired outcomes. Furthermore, it can
improve programme evaluations by identifying what outcomes
should be measured, including hypothesized mediators.
Designing a theory of change entails mapping out the
‘missing middle’ or ‘black box’ that links intervention activities
to the desired long-term outcomes. The process typically starts
by identifying the challenges to be addressed, specifying the
desired long-term outcomes of a given intervention, and then
working backwards to identify the intermediate outcomes and
the conditions that must be achieved to reach the long-term
aims. The process of developing a theory of change also
brings stakeholders together, which promotes discussion and
collaboration when developing intervention activities, selecting
outcome measures, and ensuring that priorities and expectations
are aligned.
An example of a theory of change is provided in the igure.
The goal in this example was to develop a mental health and
psychosocial support intervention targeting the family system
in Iraqi and Syrian refugee families and host Jordanian families.
Several collaborative workshops were held with researchers,
practitioners from an international non-governmental organization,
a community-based organization, community advisory boards,
and global and regional experts. The description of the status
quo (see the igure, pink) included the most pressing current
psychosocial challenges facing families identiied through the
qualitative work and local consultation. Next, the long-term
outcomes to be achieved were identiied, as were the relationships
among them (see the igure, orange). This step also included the
speciication of a ‘line of accountability’ with the potential impacts
that could occur after the long-term outcomes were achieved
(see the igure, blue). Stakeholders then identiied the intermediate
outcomes (see the igure, purple) that wereessential to move
towards these outcomes. This step enabled speciic intervention
components to be identiied and developed into what was called
the ‘Nurturing Families Intervention’.
In this example, having a clear theory of change ensured
that the intervention components perceived to be the most
important drivers of change could be prioritized and measured
during implementation. A pilot evaluation of the intervention
found support for potential beneits of the ‘Nurturing Families
Intervention’ and helpedto identify potential mediating factors for
achieving long-term outcomes29.
Psychosocial challenges at
individual and family levels
Intermediate aims Long-term outcomes to be
achieved by intervention
Potential impacts
Line of
accountability
Caregivers have increased
parenting conidence
and skills
Ability to access social
support or formal support
Manage disagreements
and conlicts
Members manage
problems together
Members have strong
communication skills
Members manage emotions
and support each other
through diicult emotions
Joint understanding of
problems, goals and values
Identify roles and strengths
Strained family
functioning
Challenges
with parenting
capacity
Poor caregiver
mental health
Poor child
mental health
Improved use of
parenting skills
and reduced
harsh punishment
Improved family
functioning
Improved caregiver
mental health and
well-being
Improved
engagement
in community
Improved child
mental health
and well-being
Nature Reviews Psychoogy
Review article
(‘for whom’). Stratified analyses or calculations of moderation effects
are increasingly conducted in RCTs to assess participant character-
istics that might predict better or worse responses to treatment.
However, findings remain mixed across population characteristics
and outcomes of interest and do not enable strong conclusions to
be drawn. For example, four RCTs have been conducted using the
same classroom-based intervention for children in various settings.
This classroom-based intervention integrates CBT techniques with
cooperative play and creative-expressive exercises (drama, dance and
music) in a structured curriculum consisting of 15 sessions to be deliv-
ered over 5 weeks by trained non-specialists. The intervention was
associated with reductions in psychological problems and aggression
among boys only in Nepal
133
, reductions in PTSD symptoms among girls
only in Indonesia
134
, and reductions in conduct problems and PTSD and
anxiety symptoms among boys only in Sri Lanka
135
. In Burundi, there
were effects on depression symptoms and functional impairment only
among children in larger households
136
. Meta-analyses that combine
individual participant data across studies are needed to better under-
stand specific subgroup effects
95
and reach clear recommendations for
policy and practice. In addition, evaluation studies often exclude chil-
dren with pre-existing health conditions, developmental delays or dis-
abilities, or unaccompanied minors
28
, and therefore concerted efforts
must be made to determine intervention options for these subgroups.
Finally, implementation research efforts have focused on under-
standing how to ensure programme gains in real-life contexts outside
tightly controlled research trials. Three indicators of quality implemen-
tation have been proposed as essential to achieve impact137: provider
adherence (to what extent providers retain fidelity to intervention
manuals), provider competence (to what extent providers demon-
strate core skills in intervention delivery) and participant attendance
at sessions. However, to date these indicators are not systematically
measured or reported in published studies or practice, particularly
provider competence because measuring this indicator requires more
nuanced measurement strategies. In an effort to support organiza-
tions in assessing and strengthening competency of non-specialists
working with children and adolescents, the World Health Organization
(WHO)–UNICEF Ensuring Quality in Psychological Care platform has
been developed. Tools to assess core provider competencies have been
validated in several sites
138,139
, and a proof-of-concept study has demon-
strated superior outcomes of competency-based training compared
with training as usual140. Beyond the quality of implementation, there
are some indications that the intervention format, such as the inclusion
of booster sessions
29,141,142
(additional sessions delivered several months
after main content) and whether delivered individually or in a group119,
might affect feasibility and impact. However, further implementation
research, including high-quality process evaluations that can tease
apart the complex role of contextual factors on intervention delivery
and outcomes, is still needed143,144.
In sum, although promising progress has been made on expanding
the evidence base for mental health and psychosocial support interven-
tions for forcibly displaced children, the gap between the empirical
evidence and existing guidelines and practice is particularly stark. The
evidence quality was limited by small sample sizes, inadequate consid-
eration of the impact of the control condition in individual trials and
meta-analyses, self-report measures rather than clinical assessments
or observational tools, and the use of measurement tools based on
Western constructs of mental health and validated in non-displaced
samples in HICs. Although the current evidence base does not enable
clear conclusions about which types of interventions work, for which
outcomes and for which children, the findings indicate that attention
must be paid to broader family, community, school and systemic fac-
tors to improve mental health outcomes for forcibly displaced children
and adolescents. Sophisticated methods that identify theactive ingre-
dients of interventions, how interventions exert their effects, for which
populations and under what conditions will be essential to effectively
tailor efforts, improve quality and ensure equity.
Summary and future directions
Our Review synthesizes evidence towards the effective support of
children’s mental health in contexts of forced displacement. The
literature suggests heterogeneous trajectories leading to mental
health risk and resilience, over time and across diverse settings and
individuals. A multisectoral and multilayered model of develop-
mentally relevant mental health and psychosocial support services,
grounded in a socio-ecological approach and tailored to address both
risk and resilience factors, is recommended in global guidelines and
frameworks96,98,145. However, there has been only limited implementa-
tion of this principle in practice, and research in this area has substantial
shortcomings that hinder effective policy formulation and programme
delivery. We highlight key recommendations to guide future empirical
research, effective interventions and theoretical framing.
High-quality studies must be designed to enable a deeper under-
standing of bio-developmental and socio-ecological pathways that
promote mental health and togenerate actionable insights for con
-
crete strategies. Prospective, longitudinal studies are essential:
cross-sectional research cannot clarify how poor mental health can
be improved over the life-course
19,34
, and cannot accurately identify the
mechanisms that shape positive and negative outcomes
7,11
. A shift from
cross-sectional to longitudinal, mixed-methods studies will enable a
more precise understanding of risk and protective factors at differ-
ent stages of displacement146 and help toidentify causal mechanisms
linked to prevention, promotion and care
25
. Relatedly, prospective
examination of relationships between caregiver and child mental
health can shed light on the intergenerational aspects of mental health
and resilience (as shown by studies in Jordan
55,60
) and help the develop
-
ment of evidence-informed family-system interventions (as done in
Lebanon106). Future studies should also expand beyond unidimensional
examinations of mental disorders such as anxiety, depression and
PTSD to encompass a broader spectrum of psychosocial outcomes,
including social and emotional learning, emotion regulation, social
cohesion, protection and well-being
147
. Furthermore, advancing inter-
disciplinary research that bridges psychosocial and socio-ecological
perspectives with physiological and genomic approaches is critical in
order to understand the biological pathways that underlie the impact
of forced displacement70,148–150.
Our Review describes several compelling examples of effective
interventions that support displaced children and their families.
Indeed, mental health and psychosocial support initiatives have been
increasingly recognized as integral components of national devel-
opment strategies in some governments, including in war-affected
contexts
151
. They are also a fundamental priority for achieving the sus-
tainable development goals. In May 2024, the World Health Assembly
adopted a resolution calling on all member states to integrate mental
health and psychosocial support into emergency preparedness and
response frameworks
152
. However, the evidence base on effective inter-
ventions for forcibly displaced young people remains limited. There is a
particular gap in research examining interventions that extend beyond
individual-level approaches to address the broader socio-ecological
Nature Reviews Psychoogy
Review article
context in which refugee children are embedded. This gap is even more
pronounced in acute humanitarian settings, where the evidence base
pertaining to child mental health and psychosocial support interven-
tions is even more limited than in non-humanitarian settings in LMICs
88
and HICs
108,153
, despite the increased rates of psychological distress
in these contexts. More efforts are required to understand how to
effectively promote positive mental health and prevent mental health
conditions
108,115
, including studies assessing non-clinical outcomes, and
longer-term intervention effectiveness.
There is a need to further integrate systems thinking into mental
health and psychosocial support, moving beyond reactive, deficit-based
models to proactive, well-being-centred approaches
66,85
. Specifically,
comprehensive strategies that support children and their families, engage
state organizations and mobilize community networks are essential for
enhancing access to education, legal protection and socio-economic
opportunities — all of which support long-term gains in child and ado-
lescent mental health and well-being
154
. These resource-focused and
strengths-based intervention models envisage mental healthcare as part
of an interconnected system rather than a stand-alone service
55
, extend-
ing socio-ecological models to focus attention on the drivers of change,
or determinants of mental health, in complex ecosystems.
Achieving systemic, real-world impact raises several questions,
including how to ensure equitable access to mental health services, how
to promote sustained uptake and long-term care, and how to scale inter-
ventions effectively while maintaining quality and cultural relevance.
Given the high burden of mental health conditions, particularly among
forcibly displaced populations, sustainable funding mechanisms are
imperative. With limited numbers of mental health professionals in
many settings, researchers must consider how best to train and equip
non-specialist workforces to safely and effectively deliver services.
Similarly, rigorous implementation research is needed to evaluate
multisectoral, multilayered delivery models, including stepped care
models. Mental health prevention and promotion approaches (rather
than treatment), despite being widely implemented, have historically
been under-researched, and therefore more research is needed to
understand their impact.
A sophisticated and nuanced approach to community-level
adaptation requires active engagement with local partners
30,155–157
.
Effective adaptation relies on strong, reciprocal partnerships that
facilitate knowledge translation130 and leverage existing strengths and
resources
128,130,131
. In settings characterized by population mobility and
socio-cultural diversity, adaptation of interventions requires specific
Box 4 | Recommendations for mental health research on forcibly displaced children drawn
from existing systematic reviews
Available guidelines state that mental health and psychosocial
support interventions should be made routinely available in all
settings14. However, there is a need for more rigorous research
designs that provide evidence for interventions working with parents,
families and communities.
Target population
•Strengthen the evidence base on interventions for displaced and
refugee children and adolescents, especially younger children.
•Further studies are needed in low- and middle-income countries
(LMICs) and humanitarian settings.
Measures and assessment
•Include indicators of non-clinical outcomes along with indicators
of distress and clinical outcomes, in particular when assessing the
eectiveness of prevention and promotion interventions.
•Match the stated aim of the intervention (for example, reduce
symptoms) and measured outcomes (for example, clinical
outcomes).
•Include longer-term follow-ups to assess outcomes trajectories.
•Develop larger controlled trials to provide more conclusive
evidence of eectiveness.
•Measure family-level processes such as parenting, and
parent–child relationships.
•Measure school-related variables such as educational attendance
and attainment, future aspirations of individuals and the overall
school climate to determine the impact of school-based services.
Scaling up interventions
•Enhance processes and reporting of cultural adaptations of
interventions.
•Tailor interventions to speciic populations.
•Develop clear theories of change to guide intervention
development and evaluation.
•Develop further studies of prevention interventions with long-term
follow-up.
•Develop further studies of interventions delivered in schools and
communities.
•Develop further studies on family-based interventions for forcibly
displaced children, including and family-based mental health
treatment (versus prevention) and whole-family (versus parent-only)
approaches.
•Develop strategies to engage fathers, retain whole families in
services.
•Conduct further studies into eective methods to build
workforces.
Research analysis
•Individual participant meta-analyses are needed to clarify
dierences across subgroups (more eective than under-powered
post-hoc analysis of randomized controlled trials (RCTs)).
•Identify speciic intervention components that lead to impact,
and specify which components are universally eective versus
context-dependent.
•Increase attention to mechanisms of change, and moderators of
eectiveness.
Unexpected challenges
•Be aware of potential negative eects of mental health and
psychosocial support interventions. Interventions might
undermine the natural recovery of some children.
•There are ethical and pragmatic obstacles to conducting RCTs in
small communities with limited access to mental healthcare.
Nature Reviews Psychoogy
Review article
guidance for care providers based on reliable evidence about which
‘active ingredients’ of a care package must be retained. Collaborative
partnerships also require ensuring ownership for the next generation
of clinicians, community-based workers and policymakers to lead and
sustain mental health and psychosocial support efforts158. All acting
parts should ensure that services fit the lived realities of displaced
populations, featuring systems that help children flourish over the
long term66,159.
Funding agencies have encouraged scholars to report the evidence
for effective interventions in humanitarian crises in clear language, and
to provide concrete examples of good practice, ethical engagement and
commitments to local partnerships155,156. For their part, scholars have
highlighted their profound responsibility to address ethical challenges,
share relevant study protocols, and partner with local institutions and
communities
27,70,155
when working with forcibly displaced communities.
To enhance accountability, funders and researchers should prioritize
intervention models that ensure equitable access, uptake and sustained
feasibility
160
. Relevant examples of mental health and psychosocial sup-
port initiatives championed by governmental, international and local
institutions that are culturally relevant and operationally embedded
in local systems can be found in the Inter-Agency Standing Committee
coordination handbook21 or the WHO’s Building Back Better22.
The number of forcibly displaced children is growing, yet access
to essential mental health services remains critically inadequate.
A stronger, science-driven vision for mental health and psychosocial
support — one that prioritizes child and adolescent mental health within
the broader humanitarian response — is needed to bolster resources for
children, families and communities and support pathways to positive
mental health and well-being129,157 (Box4).
Published online: xx xx xxxx
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Acknowledgements
The authors thank S. Palmas (UNICEF) for providing the data for the world map, and Z. Hijazi
and T. Gill (both UNICEF) for their comments on the manuscript.
Author contributions
The authors contributed equally to all aspects of the article.
Competing interests
The authors declare no competing interests.
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