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Abstract Background Supportive social connections are a crucial determinant of the mental health and adjustment of youth in conflict-torn regions. Conflict-affected youth face particular risks to their well-being due to high levels of trauma exposure and perpetration of violent acts as members of armed groups and post-conflict discrimination. However, little is known about the possible protective role of close relationships with caregivers in the aftermath of trauma. This study examined whether a higher perceived quality of relationships with caregivers would attenuate the associations between exposure to traumatic experiences and four indicators of adjustment (posttraumatic stress symptoms [PTSS], emotional problems, behavioural problems, criminal behaviour) in a sample of 268 war-affected youth (61.2% male, Mage = 16.31 years) living in Bukavu, Democratic Republic of Congo. More than half of the present sample (56.7%) were former members of armed groups. Methods Data were collected using quantitative structured interviews and analyzed through regression models using the PROCESS macro. Results Higher cumulative trauma exposure was significantly related to higher levels of PTSS and emotional problems, while more frequent perpetration of war-related violence was significantly related to higher levels of PTSS, behavioural problems, and criminal behavior. The perceived quality of relationships with caregivers significantly moderated the associations between youth’s cumulative trauma exposure and all four outcomes. At higher perceived quality of relationships with caregivers, the associations between trauma exposure and emotional problems, behavioural problems, and criminal behaviour were no longer significant and the association with PTSS was significantly weakened. Higher perceived quality of relationships with caregivers was also directly significantly related to lower levels of mental health problems and criminal behaviour. Conclusions The findings suggest that interventions that focus on strengthening relationships with caregivers are crucial for supporting the mental health and functioning of youth who experienced and perpetrated war-related violence.

Abstract Background Violence against children at home and at school is particularly prevalent in Africa and is associated with adverse and persistent health effects on children. The violence prevention intervention Interaction Competencies with Children - for Teachers (ICC-T) is an effective tool to reduce violence against children by fostering teachers’ non-violent communication and interaction skills. To enhance these effects, in the present study, ICC-T will be extended to parents (ICC-P) aiming to increase children’s experience of consistent behavior and application of non-violent discipline strategies between teachers and parents. Methods To investigate the effectiveness of the school-based combined implementation of ICC-T and ICC-P, a cluster-randomized controlled trial with 16 primary schools in the urban district of Morogoro in Eastern Tanzania will be conducted. Both quantitative (structured interviews) and qualitative (focus group discussions, in-depth interviews, evaluation forms) methods will be used to investigate the effects on teachers’ and parents’ violence against children in home and school settings. The intervention implementation will be accompanied by a comprehensive process evaluation to assess the implementation quality of and participants’ engagement with ICC-T and ICC-P. Potential downstream effects of violence reduction will be investigated by assessing the children’s mental health and well-being. Discussion The present study aims to provide evidence for the feasibility, acceptability, and effectiveness of the school-based combined implementation of ICC-T and ICC-P to reduce teacher and parental violence against children and contribute to children’s well-being in home and school settings. Trail registration The clinical trial was registered at ClinicalTrials.gov (ClinicalTrials.gov, 2024) under the identifier NCT06369025 (Hecker, Preventing Physical and Emotional Violence by Parents and Teachers in Public Schools in Tanzania (ICC-T/ICC-P_Tanz) (PreVio), 2024) on April 17, 2024.

Background: When traumatic events and losses intersect in the form of traumatic loss, these events can trigger both posttraumatic stress disorder and pathological grief.Objective: This systematic review investigates which characteristics differentiate between the development of the respective disorders or are associated with comorbidity.Method: A systematic literature search using Medline, PubMed, APA PsycInfo and Web of Science yielded 46 studies which met the inclusion criteria. In these studies, PTSD was assessed using 17 and pathological grief using 16 different validated instruments. In the quality assessment, 12 studies were classified as average, 30 as above average, and 4 as excellent. The investigated risk factors were categorized into 19 superordinate clusters and processed using narrative synthesis.Results: The relationship to the deceased, mental health issues, and religious beliefs seem to be associated specifically with pathological grief symptoms compared to PTSD symptoms. Social support and social emotions emerged as significant correlates and potential risk factors for both PTSD and pathological grief. Included studies had mainly cross-sectional designs.Conclusions: Differentiating factors between pathological grief and PTSD appear to exist. The results should be considered within the limitations of the heterogeneity of the included studies and the research field. There is a lack of studies (1) using a longitudinal study design, (2) starting data collection early following the traumatic loss, (3) using standardized, up-to-date measurement instruments and (4) including comorbidity in their analyses. Further research is urgently needed for more accurate (acute) screenings, prognoses, and interventions following traumatic loss.

BackgroundTo bridge the gap in adolescent psychotherapy created by the increasing need for mental health interventions and the limited possibilities of in-person treatment during the pandemic, many health care providers opted to offer online mental health care programs. As a result, the number of mental health apps available in app stores experienced a sharp increase during the COVID-19 pandemic.ObjectiveThe aim of the current review is to provide an overview of feasibility and effectiveness studies testing mobile applications in adolescent psychotherapy during the peak phase of the COVID-19 pandemic.MethodsWe conducted a literature search in Pubmed, PsychInfo, Google Scholar, OpenSIGLE and OpenGREY for papers published from June 2020 to June 2023. Studies were included if they evaluated app-based interventions intended for psychotherapeutic treatment and targeted adolescents between 12 and 27 years of age with symptoms of psychological disorders. The quality of each study was assessed using the Systematic Assessment of Quality in Observational Research (SAQOR). Effectiveness outcomes were analyzed by vote counting and calculating a binomial probability test.ResultsThe search yielded 31 relevant studies that examined 27 different apps with a total of 1,578 adolescent participants. Nine articles were primary effectiveness studies and 22 focused on feasibility measures as primary outcome. There was evidence that mental health apps influenced adolescents' psychotherapy, with 83% of the studies with effectiveness outcomes favoring the intervention (p = 0.002). Sixty-one percent of the included studies were rated at low or very low quality.ConclusionsThe pandemic has given apps a firm and important role in healthcare that will probably continue to expand in the future. To ensure that mental health apps are truly effective and beneficial for adolescents' psychotherapy, we need a standardized measurement of quality features of mental health apps and higher quality app evaluation studies.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=406455, PROSPERO International Prospective Register of Systematic Reviews [CRD42023406455].

ABSTRACTBackground: Persons displaced by conflict often consider returning to their area of origin. Lack of reliable information about conditions in the area of origin makes this decision more difficult. Displaced persons address this by seeking information from other sources, but must then assess the credibility of these sources.Objective: This study examines the role of symptoms of posttraumatic stress as a moderator of how information from a trustworthy source influences return intentions among displaced persons.Method: We test our hypotheses with a factorial survey experiment, drawing participants (N = 822) from residents of internally displaced person (IDP) camps in northeastern Nigeria.Results: Information from a more trustworthy source led to increased return intentions. However, the more participants reported symptoms of posttraumatic stress, the smaller the effect source trustworthiness had on their return intentions.Conclusions: Findings highlight how traumatic experiences during wartime can undermine the effectiveness of the provision of information from a trustworthy source about good conditions in displaced persons’ areas of origin, and suggest that interventions addressing posttraumatic stress could have downstream effects on safe, durable, and dignified return.

ABSTRACTBackground: Sexual violence is a public health issue among adolescents globally but remains understudied in Sub-Saharan Africa.Objective: The present study focused on the association of cumulative exposure to different types of sexual violence with mental and physical health problems and prosocial behaviour.Method: We conducted a survey with a regionally representative sample of both in-school and out-of-school adolescents, aged 13–17 years, living in south-western Nigeria. Self-reported exposure to sexual violence, behavioural problems, physical complaints, and prosocial behaviour were assessed.Results: About three quarters of the participants reported the experience of sexual violence (74.6%). Multiple regression models revealed that the more types of sexual violence an individual reported, the more mental and physical health problems, and the fewer prosocial behaviours they reported when controlling for other forms of violence exposure. Latent class analysis revealed three severity classes of sexual violence. Symptoms of mental and physical health indicators were significantly higher as exposure increased by group whereas prosocial behaviours were non-significantly fewer in the opposite direction.Conclusion: This study revealed a consistent and unique relation between sexual violence exposure and negative health outcomes among adolescents. Further research on sexual violence in Sub-Saharan Africa and its associations is needed.

Background: War-related trauma is associated with varying posttraumatic stress disorder (PTSD) prevalence rates in refugees. In PTSD development, differential DNA methylation (DNAm) levels associated with trauma exposure might be involved in risk versus resilience processes. Studies investigating DNAm profiles related to trauma exposure and PTSD among refugees remain sparse. Objective: The present epigenome-wide association study investigated associations between war-related trauma, PTSD, and altered DNAm patterns in Burundian refugee families with 110 children and their 207 female and male caregivers. Method: War-related trauma load and PTSD symptom severity were assessed in structured clinical interviews with standardised instruments. Epigenome-wide DNAm levels were quantified from buccal epithelia using the Illumina EPIC beadchip. Results: Controlling for biological confounders, no significant epigenome-wide DNAm alterations associated with trauma exposure or PTSD were identified in children or caregivers (FDRs > .05). Co-methylated positions derived as modules from weighted gene correlation network analyses were not significantly associated with either war-related trauma experience in children or caregivers or with PTSD. Conclusions: These results do not provide evidence for altered DNAm patterns associated with exposure to war-related trauma or PTSD.

The coronavirus disease 2019 (COVID-19) pandemic has created opportunities to study resilience in multiple, interrelated societal systems while considering the institutional, community and individual level. We aim to discuss critical, yet underrepresented, issues in resilience discourses which are fundamental to advance theories, concepts and measurement of health system resilience. These relate to a better understanding of (i) how government’s handle and use uncertainties to facilitate or impede change, including the role of negotiation and conflicts, (ii) the intersections of health with multiple, co-occurring crises (systemic intersections), and (iii) cross-level interactions, ie, the interrelation between individual-level resilience, the collective resilience of groups and communities, and the resilience of a system as a whole (and vice versa). Analyses of these aspects can help to “contextualize” our understanding of resilience in complex adaptive systems. However, conceptual clarity is needed whether resilience is considered an underlying feature, outcome, or intermediate determinant of a (health) system’s performance.

Abstract Background It is unclear whether findings from previous network analyses of posttraumatic stress disorder (PTSD) symptoms among children and adolescents are generalizable to youth living in war‐torn settings and whether there are differences in the structure and connectivity of symptoms between children and adolescents. This study examined the network structure of PTSD symptoms in a sample of war‐affected youth and compared the symptom networks of children and adolescents. Methods The overall sample comprised 2007 youth (6–18 years old) living in Burundi, Democratic Republic of Congo, Iraq, Palestine, Tanzania, and Uganda amid or close to war and armed conflict. Youth reported their PTSD symptoms using a self‐report questionnaire in Palestine and structured clinical interviews in all other countries. We computed the networks of the overall sample and of two sub‐samples of 412 children (6–12 years) and 473 adolescents (13–18 years) and compared the structure and global connectivity of symptoms among children and adolescents. Results In both the overall sample and the sub‐samples, re‐experiencing and avoidance symptoms were most strongly connected. The adolescents' network had a higher global connectivity of symptoms than the children's network. Hyperarousal symptoms and intrusions were more strongly connected among adolescents compared to children. Conclusion The findings lend support to a universal concept of PTSD among youth characterized by core deficits in fear processing and emotion regulation. However, different symptoms may be particularly important in different developmental stages, with avoidance and dissociative symptoms dominating in childhood and intrusions and hypervigilance gaining importance in adolescence. Stronger symptom connections may render adolescents more vulnerable to the persistence of symptoms.

Abstract Background Violence has severe and long-lasting negative consequences for children’s and adolescents’ well-being and psychosocial functioning, thereby also hampering communities’ and societies’ economic growth. Positive attitudes towards violence and the lack of access to alternative non-violent strategies are likely to contribute to the high levels of teachers’ ongoing use of violence against children in sub-Saharan African countries. Notwithstanding, there are currently very few school-level interventions to reduce violence by teachers that a) have been scientifically evaluated and b) that focus both on changing attitudes towards violence and on equipping teachers with non-violent discipline strategies. Thus, the present study tests the effectiveness of the preventative intervention Interaction Competencies with Children – for Teachers (ICC-T) in primary and secondary schools in Tanzania, Uganda, and Ghana. Methods The study is a multi-site cluster randomized controlled trial with schools (clusters) as level of randomization and three data assessment points: baseline assessment prior to the intervention, the first follow-up assessment 6 months after the intervention and the second follow-up assessment 18 months after the intervention. Multi-stage random sampling will be applied to select a total number of 72 schools (24 per country). Schools will be randomly allocated to the intervention and the control condition after baseline. At each school, 40 students (stratified by gender) in the third year of primary school or in the first year of secondary/junior high school and all teachers (expected average number: 20) will be recruited. Thus, the final sample will comprise 2880 students and at least 1440 teachers. Data will be collected using structured clinical interviews. Primary outcome measures are student- and teacher-reported physical and emotional violence by teachers in the past week. Secondary outcome measures include children’s emotional and behavioral problems, quality of life, cognitive functioning, academic performance, school attendance and social competence. Data will be analyzed using multilevel analyses. Discussion This study aims to provide further evidence for the effectiveness of ICC-T to reduce teacher violence and to improve children’s functioning (i.e., mental health, well-being, academic performance) across educational settings, societies and cultures. Trial registration The trial was registered at clinicaltrials.org under the ClinicalTrials.gov identifier NCT04948580 on July 2, 2021.

Abstract Background Child maltreatment poses high risks to the mental health and cognitive functioning of children not only in childhood but also in later life. However, it remains unclear whether child maltreatment is directly associated with impaired cognitive functioning or whether this link is mediated by mental health problems. Our study aimed at examining this research question among children and adolescents in Uganda. Methods A sample of 232 school-going children and adolescents with a mean age of 14.03 (SD = 3.25) was assessed on multiple forms of maltreatment using the Maltreatment and Abuse Chronology Exposure—Pediatric Version (pediMACE). Executive functions were assessed by the Tower of London task and working memory by the Corsi Block Tapping task, while mental health problems were assessed using the Child PTSD Symptom Scale for PTSD and the Center for Epidemiological Studies Depression Scale for Children (CES-DC). Results In total, 232 (100%) of the participant reported to have experienced at least one type of maltreatment in their lifetime including emotional, physical, and sexual violence as well as neglect. We found a negative association between child maltreatment and executive functions (β = − 0.487, p

Abstract Background Despite the existing national and international plans of action to end violent discipline strategies used by teachers in schools, they still prevail in Tanzanian schools. This underlines the need to implement school-based interventions that aim at reducing violent discipline by teachers. In this study, we will evaluate the feasibility and effectiveness of the preventative intervention Interaction Competencies with Children – for Teachers (ICC-T) in Tanzanian primary schools. Following its success in secondary schools, we hypothesize that the intervention will reduce teachers’ positive attitudes towards and their use of violent discipline at school. Methods/design The study will be conducted in six randomly selected regions in Tanzania. We have already randomly selected two schools in each region (12 in total) that fulfill our inclusion criteria. From each region, one school will be randomly assigned to the intervention and the other to the monitoring group (no intervention). Eighty students between the ages of 9 to 12 years (N = 960) and 20 teachers from each school (N = 240) will be included in the trial. We will collect data directly before the intervention (t1) and 6 months after the intervention (t2) both at intervention and monitoring schools. Using guided questionnaire assessments, we will measure violence by teachers using students’ reports on their exposure to and teachers’ reports on their use of violence using the Conflict Tactics Scale. Furthermore, we will assess teachers’ positive attitudes towards violent discipline using a modified version of the Conflict Tactic Scale. The feasibility of the intervention will be evaluated using purpose-built measures assessing the demand, applicability, acceptability, and integration of core elements into daily work in the participating schools. Discussion The proposed study will allow us to test the feasibility and effectiveness of an intervention aiming to reduce positive attitudes towards and the use of violent discipline by teachers in school settings. With the reduction of violent discipline by teachers, this study contributes to national and international efforts towards ending violence against children as well as the attainment of the United Nations’ Sustainable Development Goals that also aim to prevent all types of maltreatment of children. Trial registration ClinicalTrials.gov, NCT03893851. Registered on 28 March 2019.

Abstract Background The wars in the Democratic Republic of Congo have left indelible marks on the mental health and functioning of the Congolese civilians that sought refuge in Uganda. Even though it is clear that civilians who are exposed to potentially traumatizing events in war and conflict areas develop trauma-related mental health problems, scholarly information on gender differences on exposure to different war-related traumatic events, their conditional risks to developing PTSD and whether the cumulative exposure to traumatic events affects men and women differently is still scanty. Methods In total, 325 (n = 143 males, n = 182 females) Congolese refugees who lived in Nakivale, a refugee settlement in the Southwestern part of Uganda were interviewed within a year after their arrival. Assessment included exposure to war-related traumatic events, and DSM-IV PTSD symptom severity. Results Our main findings were that refugees were highly exposed to war-related traumatic events with experiencing dangerous flight as the most common event for both men (97%) and women (97%). The overall high prevalence of PTSD differed among women (94%) and men (84%). The highest conditional prevalence of PTSD in women was associated with experiencing rape. The dose-response effect differed significantly between men and women with women showing higher PTSD symptom severity when experiencing low and moderate levels of potentially traumatizing event types. Conclusion In conflict areas, civilians are highly exposed to different types of war-related traumatic events that expose them to high levels of PTSD symptoms, particularly women. Interventions focused at reducing mental health problems resulting from war should take the context of gender into consideration.

ContextAlthough teacher violence at schools is a serious problem in Haiti, there is a lack of systematic evidence on the effectiveness of school-based interventions in reducing teacher violence in this low-income country.ObjectiveTo test the effectiveness of the preventative intervention Interaction Competencies with Children for Teachers (ICC-T) aiming to reduce teachers' use of violent disciplinary strategies and to improve their interaction competences with children in the Haitian context.Design, Setting, ParticipantsThe study is designed as a two-arm matched cluster randomized controlled trial. The sample consists of 468 teachers and 1,008 children from 36 (community and public) primary schools around Cap-Haïtien (Département du Nord) in Haiti. Data will be collected in three phases, before the intervention, and 6 and 18 months after.InterventionIn the group of intervention schools, ICC-T will be delivered as a 5-day training workshop. Workshop sessions are divided into five modules: 1) improving teacher-student interactions, 2) maltreatment prevention, 3) effective discipline strategies, 4) identifying and supporting burdened students, and 5) implementation in everyday school life.Main Outcome MeasureThe main outcome measure is teacher violence assessed in two ways: (i) teachers' self-reported use of violence, and (ii) children's self-reported experiences of violence by teachers.ConclusionsPrior evaluations of ICC-T had been conducted in sub-Saharan Africa with promising results. This study will test for the first time the effectiveness of this intervention outside the context of sub-Saharan Africa.

BackgroundMany orphans in East Africa are living in institutional care facilities where they experience poor quality of care and ongoing maltreatment. We report on the extension of a cluster-randomized controlled trial aiming to replicate and show sustainability of previous found effects and to discover long-term effects of the intervention Interaction Competencies with Children-for Caregivers (ICC-C) 12-months after the intervention's conclusion.MethodsConducting a robust 2x3 analysis of variance, we investigated the changes over time in the waitlist orphanages (n = 75, 62.7% female, Mage = 37.63 years, SDage = 11.81), which participated in the intervention after first follow-up and in the initial intervention orphanages (n = 81, 61.7% female, Mage = 38.73 years, SDage = 11.94).ResultsThe caregivers in the waitlist orphanages reported less reported levels of maltreatment (d = -0.09), fewer positive attitudes towards violent discipline (d = -0.44) and increased childcare knowledge (d = 1.26) three months after intervention, replicating our findings of the initial intervention condition. In addition, these effects were maintained in the intervention orphanages 12 months post intervention. Furthermore, we found long-term improvements in negative caregiver-child relationship (d = -0.83), caregivers' stress level (d = -0.98) and their mental health problems (d = -0.61).ConclusionsThe replication and maintenance of the intervention effects and first hints to additional long-term effects substantiates the effectiveness of ICC-C. As long as alternative care cannot be provided for all children in need, brief caregiver trainings can make an important contribution to enlarge the opportunities for many children.Trial registrationClinicalTrials.gov, NCT03594617. Registered on 20 July 2018.

Background Many orphans in East Africa are living in institutional care facilities where they experience poor quality of care and ongoing maltreatment. We report on the extension of a cluster-randomized controlled trial aiming to replicate and show sustainability of previous found effects and to discover long-term effects of the intervention Interaction Competencies with Children–for Caregivers (ICC-C) 12-months after the intervention’s conclusion. Methods Conducting a robust 2x3 analysis of variance, we investigated the changes over time in the waitlist orphanages (n = 75, 62.7% female, Mage = 37.63 years, SDage = 11.81), which participated in the intervention after first follow-up and in the initial intervention orphanages (n = 81, 61.7% female, Mage = 38.73 years, SDage = 11.94). Results The caregivers in the waitlist orphanages reported less reported levels of maltreatment (d = −0.09), fewer positive attitudes towards violent discipline (d = −0.44) and increased childcare knowledge (d = 1.26) three months after intervention, replicating our findings of the initial intervention condition. In addition, these effects were maintained in the intervention orphanages 12 months post intervention. Furthermore, we found long-term improvements in negative caregiver-child relationship (d = –0.83), caregivers’ stress level (d = −0.98) and their mental health problems (d = −0.61). Conclusions The replication and maintenance of the intervention effects and first hints to additional long-term effects substantiates the effectiveness of ICC-C. As long as alternative care cannot be provided for all children in need, brief caregiver trainings can make an important contribution to enlarge the opportunities for many children. Trial registration ClinicalTrials.gov, NCT03594617. Registered on 20 July 2018.

Populations in war-torn regions are exposed to a wide array of traumatic events that can cause an enormous psychological burden. Individual characteristics influence the likelihood of being exposed to certain events, pointing to systematic interindividual differences in trauma exposure. However, there is a dearth of studies examining potential patterns of trauma exposure in war regions. In this cross-sectional epidemiological study, we applied a person-centered approach to identify patterns in the exposure to conflict-related traumatic events and determine their impact on commonly reported mental health problems in a population-based sample (N ​= ​1000) from the eastern Democratic Republic of Congo. We implemented multi-stage random cluster sampling to randomly select adults from 100 villages. Of 1000 adults (Mage ​= ​43.19 years) included in the study, 50% were female. Results showed high prevalence of PTSD (17.0%), depression (27.8%), anxiety (25.4%) and suicidality (15.1%) following exposure to conflict-related traumatic events since 2002. Latent Class Analysis identified three distinct classes of trauma exposure: Class 1 “low-trauma-exposure” (51.4%, n ​= ​514) was characterized by the lowest probabilities of trauma exposure. Class 2 “non-physical-trauma” (39.1%, n ​= ​391) consisted of individuals with a high probability for exposure to non-physical trauma types only. Class 3 “interpersonal-trauma” (9.5%, n ​= ​95) had the overall highest probability of exposure to traumatic events and was the only class affected by interpersonal-trauma types. Class membership was related to gender, age and place of living. Vulnerability to mental health problems increased from low-trauma-exposure to non-physical-trauma to interpersonal-trauma class. Our findings indicate that the exposure to traumatic events in conflict-affected populations underlies distinct patterns, with interpersonal trauma as a distinguishing marker. Vulnerability to psychopathology varies with trauma patterns, revealing patterns that include both non-physical and interpersonal traumata as most detrimental for mental health. Identification of underlying trauma patterns and their effects may improve mental health care in war-affected populations.

An increasing number of orphans in low- and middle-income countries are living in institutional care facilities where they experience poor quality of care and ongoing maltreatment. To prevent maltreatment, we tested the effectiveness and feasibility of the intervention Interaction Competencies with Children – for Caregivers (ICC-C). In a two-arm cluster-randomized controlled trial, 203 caregivers (65.5% female, Mage = 36.63 years, SDage = 12.26) and 356 children (46.1% female, Mage = 9.43 years, SDage = 1.93) from 24 orphanages in Dar es salaam (Tanzania) participated from August to October 2018 (Baseline) and March to April 2019 (Follow-Up). Orphanages were assigned to the intervention or waitlist-group. Caregivers in the intervention group received the ICC-C intervention to prevent maltreatment through focusing on non-violent caregiving strategies. The primary outcome was the change in self-reported maltreatment by caregivers (Conflict Tactics Scale). Trial registration: ClinicalTrials.gov, NCT03594617, 20 July 2018. Participation in the intervention resulted in a significant reduction in reported maltreatment (f2 = 0.153), a decrease of positive attitudes toward violent discipline (f2 = 0.248), and an increased level of childcare knowledge (f2 = 0.220) in the caregiver sample, each indicating a moderate effect. Caregivers’ training participation did not predict reduced maltreatment reported by children. Aspects of feasibility, including motivation to participate, acceptability, and integration of the new strategies were evaluated positively. The study promises initial effectiveness and feasibility of efforts to improve the situation of children in institutional care settings in resource-poor countries by offering training to care providers.

Clinical practice guidelines, such as those focusing on traumatic stress treatment, can play an important role in promoting inclusion and equity. Based on a review of 14 international trauma treatment guidance documents that explicitly mentioned children, we reflect on two areas in which these guidelines can become more inclusive and equitable; a) representation of children’s cultural background and b) children’s opportunity to have their voice heard. While a few guidelines mentioned that treatment should be tailored to children’s cultural needs, there was little guidance on how this could be done. Moreover, there still appears to be a strong white Western lens across all stages of producing and evaluating the international evidence base. The available documentation also suggested that no young people under the age of 18 had been consulted in the guideline development processes. To contribute to inclusion and equity, we suggest five elements for future national guideline development endeavours. Promoting research and guideline development with, by, and for currently under-represented communities should be a high priority for our field. Our national, regional and global professional associations are in an excellent position to (continue to) stimulate conversation and action in this domain.

Background: Although the family constitutes the prime source of risk and resilience for the well-being of children growing up in adverse conditions, the mental health of children living in refugee camps has rarely been investigated in conjunction with their parents’ mental health. Objectives: To examine the prevalence of posttraumatic stress disorder (PTSD) and other mental health problems among Burundian refugee children and their parents living in Tanzanian refugee camps and to identify patterns of comorbidity among children and their parents based on PTSD symptom levels and functional impairment. Methods: We recruited a representative sample of 230 children aged 7–15 years and both of their parents (n = 690) and conducted separate structured clinical interviews. Latent Class Analysis was applied to identify patterns of comorbidity. Results: Children and parents were exposed to multiple traumatic event types. In total, 5.7% of children fulfilled DSM-5 criteria for PTSD in the past month and 10.9% reported enhanced levels of other mental health problems. 42.6% indicated clinically significant functional impairment due to PTSD symptoms. PTSD prevalence was higher among mothers (32.6%) and fathers (29.1%). Latent Class Analysis (LCA) revealed a familial accumulation of PTSD symptoms as children with high symptom levels and impairment were likely to live in families with two traumatized parents. Conclusions: Although the number of children who need support for trauma-related mental health problems was relatively low, taking into account parental trauma could aid to identify at-risk children with elevated PTSD symptom levels and impairment even in the face of existing barriers to mental health care access for children in refugee camp settings (e.g. lack of targeted services, prioritization of managing daily stressors).

Abstract Background An adolescent's school is often the second most important place for his development and education after the home. However, reports highlight the recurrence of the use of violent discipline in schools. There are few school-based interventions that aim at reducing violence at school that have been implemented and evaluated in sub-Saharan Africa. To reduce violent disciplinary measures used at school, we aim to implement and evaluate the feasibility and efficacy of the preventative intervention Interaction Competencies with Children for Teachers (ICC-T). Methods/design The study will be conducted in six randomly selected districts of the Ankole region in southwestern Uganda. We shall randomly select two mixed-day secondary schools from each district that fulfill our inclusion criteria. Schools will be randomly assigned to the intervention condition, where ICC-T will be implemented, and control schools (no intervention). Sixty students between the ages of 12 and 17 years and at least 15 teachers per school will be included in the trial. We aim to collect pre-assessment data directly before the intervention (t1) and 3 months after the intervention (t2) in both intervention and control schools. Using self-administered questionnaires, we will measure students’ exposure to violence using the Conflict Tactics Scale (CTS), their psychological well-being using the Strengths and Difficulties Questionnaire (SDQ), and teachers’ positive attitudes towards violent disciplining and teachers’ use of violent disciplinary methods (CTS). The implementation feasibility of ICC-T in the cultural context of southwestern Uganda will be assessed with purpose-built measures that follow the guidelines for feasibility studies assessing the demand, applicability, acceptability, and integration of core elements in the daily work. Discussion The proposed study will allow us to test the feasibility and efficacy of a preventative intervention seeking to reduce violent disciplinary measures in school settings using a scientifically rigorous design. The proposed study provides the opportunity to contribute to the attainment of goal number 16.2 of the United Nations’ Sustainable Development Agenda 2015–2030, which aspires to end all forms of violence against children. Trial registration ClinicalTrials.gov, NCT03051854. Registered on 14 February 2017.

Stress during pregnancy widely associates with epigenetic changes and psychiatric problems during childhood. Animal studies, however, show that under specific postnatal conditions prenatal stress may have other, less detrimental consequences for the offspring. Here, we studied mental health and epigenome-wide DNA methylation in saliva following intimate partner violence (IPV) during pregnancy in São Gonçalo, a Brazilian city with high levels of violence. Not surprisingly, mothers exposed to pregnancy IPV expressed elevated depression, PTSD and anxiety symptoms. Children had similar psychiatric problems when they experienced maternal IPV after being born. More surprisingly, when maternal IPV occurred both during (prenatal) and after pregnancy these problems were absent. Following prenatal IPV, genomic sites in genes encoding the glucocorticoid receptor (NR3C1) and its repressor FKBP51 (FKBP5) were among the most differentially methylated and indicated an enhanced ability to terminate hormonal stress responses in prenatally stressed children. These children also showed more DNA methylation in heterochromatin-like regions, which previously has been associated with stress/disease resilience. A similar relationship was seen in prenatally stressed middle-eastern refugees of the same age as the São Gonçalo children but exposed to postnatal war-related violence. While our study is limited in location and sample size, it provides novel insights on how prenatal stress may epigenetically shape resilience in humans, possibly through interactions with the postnatal environment. This translates animal findings and emphasizes the importance to account for population differences when studying how early life gene–environment interactions affects mental health.

Posttraumatic stress disorder (PTSD) is one of the very few mental disorders that requires by definition an environmental context—a traumatic event or events—as a precondition for diagnosis. Both trauma sequelae and recovery always occur in the context of social–interpersonal contexts, for example, in interaction with a partner, family, the community, and the society. The present paper elaborates and extends the social–interpersonal framework model of PTSD. This was developed to complement other intrapersonally focused models of PTSD, which emphasize alterations in an individual's memory, cognitions, or neurobiology. Four primary reasons for broadening the perspective from the individual to the interpersonal–societal contexts are discussed. The three layers of the model (social affects, close relationships, and culture and society) are outlined. We further discuss additional insights and benefits of the social–interpersonal perspective for the growing field of research regarding resilience after traumatic experiences. The paper closes with an outlook on therapy approaches and interventions considering this broader social–interpersonal perspective on PTSD.

The high global prevalence of school violence underlines the need for prevention. However, there are few scientifically evaluated intervention approaches that aim at preventing violence by teachers. We evaluated the feasibility and efficacy of the preventative intervention Interaction Competencies with Children for Teachers (ICC-T). In a cluster randomized controlled trial we assessed attitudes towards and use of violence by teachers (self-reported and reported by students) at eight schools in four regions in Tanzania. Two regions were randomly assigned as intervention regions. Data were assessed in the months before and three months after intervention. In total, 158 teachers (58% females; age: 32.08 years, SD = 5.65) and 486 students (54% females; age: 15.61 years, SD = 0.89) participated in this study. The feasibility was very good: Participants' acceptance was high and they reported a good integration of the core elements in their working routine. The significantly stronger decrease in the use of emotional and physical violence reported both by teachers and students as well as the stronger decrease in positive attitudes of teachers towards physical and emotional violence in the intervention schools at follow-up provide initial evidence of the efficacy. However, further evidence for the sustainability of its effect is needed.

Background: We present a literature review on trauma exposure and spirit possession in low- and middle-income countries (LMICs). Despite the World Health Organization's objective of culturally appropriate mental health care in the Mental Health Action Plan 2013–2020, and the recommendations of the Inter-Agency Standing Committee to consider local idioms of distress and to collaborate with local resources, this topic still receives very little attention. Pathological spirit possession is commonly defined as involuntary, uncontrollable, and occurring outside of ritual settings. It is often associated with stigmatization, suffering, and dysfunctional behavior. While spirit possession has been discussed as an idiom of distress in anthropological literature, recent quantitative studies have presented support for a strong relationship between traumatic experiences and pathological possession states. Objective: The aim of this review was to investigate this relationship systematically in LMICs, in view of the debate on how to address the mental health gap in LMICs. Methods: Twenty-one articles, published in peer-reviewed English-language journals between 1994 and 2013, were identified and analyzed with regard to prevalence of possessive trance disorders, patients’ sociodemographic characteristics, and its relation to traumatic experiences. Results: The review and analysis of 917 patients with symptoms of possessive trance disorders from 14 LMICs indicated that it is a phenomenon occurring worldwide and with global relevance. This literature review suggests a strong relationship between trauma exposure and spirit possession with high prevalence rates found especially in postwar areas in African countries. Conclusions: More attention for possessive trance disorders in mental health and psychosocial intervention programs in humanitarian emergency settings as well as in societies in transition in LMICs is needed and justified by the results of this systematic literature review.

Background: Research has shown that orphans in sub-Saharan Africa are at increased risk for mental health problems. Exposure to maltreatment and HIV/AIDS-related stigmatization are related to orphans’ psychological distress. Yet, researchers stress the need for more research in low-income countries to identify which factors of being an orphan may lead to psychological distress. Objectives: The present study aims to systematically investigate orphans’ experiences of maltreatment and stigmatization to identify factors that relate to their psychological distress. Methods: In total, 89 Tanzanian children who had lost at least one parent were compared to 89 matched non-orphans (mean age: 11 years; 51% boys). We measured exposure to maltreatment and perceived stigmatization as an orphan. Mental health was assessed using the Strengths and Difficulties Questionnaire, the Children's Depression Inventory, the UCLA PTSD Index for Children, and the Reactive–Proactive Questionnaire. Results: Orphans reported significantly more experiences of neglect, but not of abuse. A group comparison revealed more depressive symptoms, posttraumatic stress symptoms, and aggressive behavior among orphans. Neglect, abuse, and stigmatization correlated with orphans’ internalizing and externalizing problems, yet only neglect and stigmatization were related to orphans’ depression severity. Perceived stigmatization moderated the relationship between neglect and depression. Conclusions: Our findings suggest that orphans in Tanzania are at increased risk of experiencing neglect. Maltreatment and perceived stigmatization may play a role in orphans’ psychological distress. Culturally appropriate and evidence-based interventions may help to prevent maltreatment and stigmatization of orphans.

Background: In the ongoing conflict in the Democratic Republic of the Congo (DRC), civilians have been heavily exposed to traumatic stressors. Traumatizing experiences cumulatively heighten the risk for trauma-related disorders, and with it affect cognitive and psycho-social functioning. Objectives: We aimed at investigating the association between trauma-related disorders and cognitive and psycho-social functioning and hypothesized that PTSD symptom severity would negatively correlate with executive functioning, working memory and psycho-social functioning in everyday life. Method: In total, 323 Congolese refugees (mean age: 31.3 years) who arrived in the Ugandan Nakivale refugee settlement after January 2012 were assessed regarding their exposure to traumatic events, PTSD symptom severity (posttraumatic symptom scale interview), executive functioning (Tower of London), working memory performance (Corsi block tapping task) and psycho-social dysfunctioning (Luo functioning scale). Results: Hierarchical regression analyses indicated a significant negative association between PTSD symptom severity and working memory (β = –0.32, p 0.05). Conclusion: Trauma survivors not only suffer from the core PTSD symptoms but also from impaired cognitive functioning. PTSD symptom severity seems furthermore to be related to impaired psycho-social functioning. Our findings suggest that trauma-related mental health problems may heighten the risk for poverty and lack of prospect and further aggravate the consequences of war and conflict.

Background: Child soldiers are often both victims and perpetrators of horrendous acts of violence. Research with former child soldiers has consistently shown that exposure to violence is linked to trauma-related disorders and that living in a violent environment is correlated with enhanced levels of aggression. Objective: To gain more insight into the experiences and the mental health status of former child soldiers, we conducted a survey with N=200 former child soldiers and adult combatants in the DR Congo. Methods: We conducted semi-structured interviews concerning military experiences, experienced and perpetrated violence, and mental health. Results: Former child soldiers reported more experienced and perpetrated violence, a greater severity of trauma-related suffering, as well as higher appetitive aggression than adult ex-combatants. Appetitive aggression was related to more perpetrated violence, higher military ranks, voluntary recruitment and higher rates of reenlistments in former child soldiers. Conclusions: Our results indicate that growing up in an armed group is related to higher levels of trauma-related disorders and aggressive behavior. This may explain the challenge of reintegrating former child soldiers. It is thus important to consider mental health problems, particularly trauma-related disorders and aggressive behavior, of former child soldiers for designing adequate reintegration programs.

Background: In the ongoing conflict in the Democratic Republic of the Congo (DRC), combatants are exposed to massive forms of violence and other traumatic stressors. Nevertheless, many combatants do not suffer from trauma-related disorders, although they have experienced numerous traumatizing events. Perceiving aggressive behavior as fascinating and arousing might be a defense against trauma-related disorders in the violent environment of war and conflict. Objective: Thus, in this study we investigated the relationship between the exposure to traumatic stressors, appetitive aggression, and posttraumatic stress disorder (PTSD) symptom severity. We hypothesized that cumulative traumatic experiences correlated positively and appetitive aggression negatively with PTSD symptom severity. Method: In total, 105 voluntary male combatants from different armed groups in the eastern DRC took part in this study. In a semistructured interview, respondents were questioned about their exposure to traumatic stressors, the extent of appetitive aggression (Appetitive Aggression Scale) and their PTSD symptom severity (PTSD Symptom Scale - Interview). Results: A multiple sequential regression analysis showed that traumatic events were positively related to PTSD symptom severity. For participants with low to medium PTSD symptom severity, appetitive aggression correlated negatively with PTSD symptom severity. Conclusions: The results of this study provide further support for earlier findings that repeated exposure to traumatic stressors cumulatively heightens the risk of PTSD and revealed that appetitive aggression buffers the risk of developing PTSD symptoms under certain circumstances. Thus, the perception of aggressive behavior as fascinating and arousing seem to help combatants to adapt to violent environments but may also be one reason for recurrent failure of reintegration programs for excombatants.