I NTERVENTIONS TO IMPROVE CHILDREN ’ S MENTAL HEALTH

As detailed above, children’s mental health is known to be adversely affected by experiences of family violence and organized violence. Often, violent experiences qualify as traumatic events and can lead to the development of PTSD. Children with trauma spectrum disorders show an impaired functionality, decreased physical health, and often develop comorbid disorders like depression or externalizing problems (Catani et al., 2008; Elbert et al., 2009;

Schauer & Elbert, 2010; Vinck et al., 2007). As a result, it is essential that an intervention addresses the traumatic stress endured by children in these contexts and helps them to integrate their traumatic experiences into their memory.

Narrative Exposure Therapy (NET), an evidence-based short-term intervention for PTSD, has proven to be successful in different settings (Ertl et al., 2011; Hoge, 2011; Schauer, Neuner, & Elbert, 2011). In brief, during NET the client, with the assistance of the therapist, constructs a chronological narrative of his or her whole life with the focus on exposure to traumatic stress. For traumatic experiences the therapist asks in detail for emotions, cognitions, sensory information and physiological reactions linking them to an autobiographical context, namely time and place. Several studies have shown that NET can be effective within four to six sessions (Hijazi et al., 2014; Neuner et al., 2008; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004; Schaal, Elbert, & Neuner, 2009). The effectiveness as a short-term intervention is essential for implementing NET in unstable and resource-poor environments like refugee camps or regions of on-going conflict (Neuner et al., 2008).

The child-friendly version KIDNET (Onyut et al., 2005; Ruf et al., 2007, 2010) fits exactly to the needs of traumatized OVC in institutional care. This adaption of NET uses symbols and techniques like drawing for a more child-appropriate trauma exposure. It can be successfully applied within a few sessions and with little resources by a trained therapist.

The treatment of trauma spectrum disorders is an important component to improve the mental health of children who suffer from the exposure to violence. However, even the most successful treatment will not protect the children from further violent experiences if the abusive environment does not change. Therefore, an intervention component is needed that reduces the exposure to further violence.

Studies from other countries have already shown that it is possible to improve the caregiving quality in institutional care (Levin & Haines, 2007; McCall, 2013; Muhamedrahimov, Palmov, Nikiforova, Groark, & McCall, 2004; St. Petersburg-USA Orphanage Research Team, 2008;

Taneja et al., 2002; Wolff & Fesseha, 1999). However, in countries in which corporal punishment is still common, programs improving caregiving in institutional care also need to address potential corporal punishment. It is mandatory to end all forms of corporal punishment, abuse, and neglect and to equip undereducated staff with non-abusive caregiving skills. Therefore, in the context of the present thesis we developed and tested a caregiver training that can be implemented despite a dearth of resources common to these institutions. This training program contains many practice units and role-plays that aim to be applicable in everyday contexts. The training concept focuses on theoretically and practically educating caregivers on topics like child development, attachment and bonding, communication with children, non-abusive caregiving strategies and supporting children suffering from mental health problems or HIV/AIDS. Culture undeniably influences the upbringing of children. However, the content of the training focuses on the universal needs of

children, e.g. safety from physical and emotional harm, that are independent of cultural specificities.

In regions of armed conflict it may be very difficult to curtail the exposure of children to violence. However, even in this context a two-component approach focusing on improving the children’s mental health as well as protecting them from further exposure to violence is applicable.

NET has proven to be successful with former child soldiers (Ertl et al., 2011). However, child soldiers were mostly treated as victims of violence, neglecting that they also reported positive feelings during the perpetration of violent acts (Elbert et al., 2010; Maclure & Denov, 2006).

As Medeiros (2007) stated, it is crucial to overcome the dichotomy of victim and perpetrator to address the complexity of the former combatants' feelings and experiences. Consistent with this line of thought, a study comparing non-responders and responders to NET treatment in a sample of refugees in Norway showed that especially male refugees who reported to have perpetrated violent acts were less likely to respond to NET treatment (Stenmark, Guzey, Elbert, & Holen, 2014). Correspondingly, in the course of this thesis an advanced version of NET was developed that takes both traumatic experiences and perpetrated violent acts into account. This adapted version of NET is called Narrative Exposure Therapy for Forensic Offender Rehabilitation (FORNET; Elbert, Hermenau, Hecker, Weierstall, & Schauer, 2012). FORNET helps the former combatant to anchor not only fearful and traumatic experiences but also positive feelings that might have been linked to various forms of aggressive behavior in the past. Thus it aims to reduce both PTSD symptomology and appetitive aggression through narrative exposure.

In order to reduce the exposure of former child soldiers to violence, it is necessary to prevent them from returning to armed conflict. This is best achieved by successful integration into civil society. In order to successfully integrate former child soldiers they need to find closure with their past as well as change their self-image from “combatant” to “civilian” (Boyden, 2003; Williamson, 2006). In order to help them to find closure with their past, FORNET includes a group component, in which the role change is addressed and reinforced and the group discusses perspectives for the future.

In addition to psychological support, former child soldiers need future economic prospects.

Without the opportunity for an improved living situation the risk remains high that some of them will choose to return to armed conflict, despite the suffering they bear from the consequences of violent experiences on their mental health (Annan et al., 2009; Betancourt et al., 2008; Boyden, 2003; Stott, 2009). The combination of reintegration components, such as social and economic support with psychological support might be most effective in targeting successful reintegration (Betancourt et al., 2008; Mogapi, 2004; Stott, 2009).

In summary, psychological interventions promise to be more effective if they not only include an individual component reducing trauma-related suffering, but also a component reducing risk of the children to be continuously exposed to violence. The present thesis describes the development and evaluation of two psychological interventions addressing the needs of children in institutional care and former child soldiers in Sub-Saharan Africa.