This review of existing literature indicates that there are a number of significant implications of not addressing mental health and psychosocial (MHPSS) needs of children, youth, and adults in
conflict settings.
Mental health consequences of war are by now fairly well documented (see for example Murthy and Lakshminarayana, 2006; Werner, 2012; Betancourt et al., 2014; Jordans et al., 2016). Children are particularly vulnerable to the negative effects of conflict, and mental disorders resulting from war-related trauma can hamper development and lead to decreased functioning in adulthood (Werner, 2012). Launched in 2016, the new Sustainable Development Goals (SDGs), reflect recognition by the global development community of the significance of mental health problems, particularly in childhood or youth, as leading causes of problems throughout the life course (Brown et al., 2016). These new SDGs acknowledge mental health and well-being as key components of overall health and aim to reduce children’s exposure to violence and other adversities (Interagency Expert Group on SDG Indicators, 2016).
Historically, researchers in humanitarian settings have focused on the impact of armed conflict on mental health at the individual level (Rees et al., 2015), as well as on identifying rates of posttraumatic stress disorder (PTSD) and other mental health disorders (Tol et al., 2011; Jordans et al., 2018). War-related trauma has been a key outcome of interest; traumatisation was
understood to lead to depression, shame, withdrawal and aggression (Mattingly, 2017), sleep problems, disturbed plan and psychosomatic symptoms (Jordans et al., 2018). In these studies,
limited attention was paid to the psychological impact of “daily stressors” – that is, the persistently stressful conditions of daily life that are caused or exacerbated by armed conflict – for example, poverty, socioeconomic adversity, and social exclusion (Miller and Jordans, 2016).
More recently, research on MHPSS needs (particularly of children and young people in conflict-affected settings) has undergone a “paradigm shift”. Emerging consensus is that armed conflict
threatens children’s mental health and wellbeing both directly—through exposure to war-related violence and loss, which can also result in “toxic stress”1 —and indirectly—through diverse daily
stressors (Vostanis, 2014; Rees et al., 2015; Miller and Jordans, 2016; Eruyar et al., 2018; Jordans et al., 2018). Emphasis has moved towards a broader understanding of the diverse pathways through which organised violence impact on mental health and wellbeing, including risk factors during war, post-war daily stressors, and at all levels of the social ecology (individual, family, community, and societal) (Reed et al., 2012; Miller and Jordans, 2016; Eruyar et al., 2016; Hijazi et al., 2018). The focus of research has also shifted towards studying and evaluating MHPSS interventions (Miller and Jordans, 2016).
These trends have all shaped the findings of this review. MHPSS needs, particularly of children and adolescents, in areas of armed conflict and post-conflict societies have gained increased
attention over the last decades. There is a growing interest in the links between adverse mental health and physical health outcomes, with evidence that individuals exposed to major psychological stressors in early life have elevated rates of morbidity and mortality from chronic diseases in adulthood. A “two-way relationship” between mental disorders and unhealthy behaviours (e.g., diet and physical inactivity) has been highlighted, which, in turn, can contribute to increased rates of cancer, cardiovascular disease, obesity and diabetes and suicide (Mnookin, 2016). There is also an emerging body of work on the social (in particular intergenerational) and economic impacts of unmet MHPSS needs.
Nevertheless, there is still a lack of systematic empirical information about war-affected children and youth (Borba et al., 2016; Jordans et al., 2016).
This review examines the potential implications of not addressing MHPSS needs resulting from conflict throughout the life course, including on longer-term mental and physical health, communities and families (including intergenerational effects), and overall human development (including education and participation in the workforce).
A number of gaps in the evidence have been identified:
- Whilst negative consequences of adverse childhood experiences have been well researched, the evidence base on the longer-term consequences of unmet MHPSS needs, in the context of armed conflict and violence, is significantly weaker (Werner, 2012; Brown et al., 2016; Hijazi et al., 2018).
- There are key limitations of the evidence base on child mental health in humanitarian contexts. These include a dearth of longitudinal data, small and unrepresentative samples, and a narrow focus on an individual level rather than family- or community-level data (Panter-Brick et al., 2014).
- Additional research is needed to understand the importance of contextual factors (Mattingly, 2017) and ongoing stressors in the social ecology (Miller and Jordans, 2016) which can serve to promote or inhibit resilience.
- In conflict-affected settings where goals often include re-engagement of youth in educational or occupational activities, interventions must effect change in both symptoms and daily functioning. Yet, few studies provide data on functioning (Brown et al., 2016).
- There is a need for data that illuminate experiences of multiple adversities and intersectionality, and how these interact as risk factors for mental distress in emergencies, particularly for the most vulnerable (Hassan et al., 2016). More data is needed for people with mental and physical disabilities; male and female survivors of sexual violence or gender-based violence; elderly people, and LGBTQI individuals. (Hassan et al 2016; Hijazi et al 2018).
