Evidence from LMIC studies

Fifteen unique studies (nine RCTs and six quasi-experimental (QEs)) examined effectiveness of interventions for internalizing symptoms. The studies varied in greatly in size and only two were conducted in conflict-affected settings (Jordan and Lebanon). The remaining 13 studies were conducted in LMICs, with 3 targeting children exposed to specific adversities: living in residential care institutions, child labor, exposed to child abuse. All studies required a diagnosis or a clinical score on a standardized measure, with many outreaching children in specialist services, and some doing broader screening including in schools. Five studies included children aged 6 and younger, one included children aged 7–9 years, and the remainder had age ranges between 8 and 14 years; one included only girls. Only 2 specified delivery by nonspecialists, and most used a group format with 6–16 sessions. Eight included children only (six group; two format not reported), three included parents and children (two group, one individual) and four worked with mothers only (two group, one combination and one format not reported).

Specific interventions included: variants of cognitive behavioral therapy (CBT) for children (n = 7): teaching mothers to implement CBT techniques or emotional coaching with their children (n = 2); social skills training (n = 1); parenting interventions (n = 1); quality of life therapy (n = 1); physical activity only (n = 1); and play therapy (n = 2).

Thirteen of these studies reported a significant improvement in the treatment group versus the control group on at least one child-focused outcome; however, for two studies, this was only for specific subscales of measures. Of the 15 interventions, 6 showed promising effects and further information was extracted and presented below.

Two studies examined the EASE intervention among Syrian refugee adolescents in Jordan (n = 471) (Bryant et al., Reference Bryant, Malik, Aqel, Ghatasheh, Habashneh, Dawson, Watts, Jordans, Brown, van Ommeren and Akhtar2022) and Lebanon (n = 198) (Jordans et al., Reference Jordans, Brown, Kane, Taha, Steen, Ali, Elias, Meksassi, Aoun and Greene2023). The intervention consisted of seven 90-min group sessions for adolescents and three sessions for caregivers, delivered by nonspecialist providers provided with brief training and regular supervision. Content for adolescents included identifying emotions, relaxation, behavioral activation and problem solving, while caregivers discussed how to support their adolescent, self-care and positive parenting strategies. In Jordan, the intervention improved internalizing symptoms for adolescents and reduced psychological distress and inconsistent parenting for caregivers at a 3-month follow-up. No significant effects were found on other measures. In Lebanon, the trial was ended prematurely due to ongoing adversity and the COVID-19 pandemic, but findings showed equivalent changes in treatment and control groups.

Two other studies evaluated group-based specialist-delivered CBT interventions. In Mauritius, Ramdhonee-Dowlot et al. (Reference Ramdhonee-Dowlot, Essau and Balloo2021) evaluated Super Skills for Life for 9- to 14-year-olds in residential care (n = 100), finding significant improvements in anxiety, depression, conduct problems, hyperactivity and inhibitory control and emotion regulation, at both post-intervention and a 3-month follow-up. In Nigeria (n = 178), a group-based CBT play therapy reduced social anxiety and general anxiety in children aged 6–12 years with stutters at post-intervention and 4 months later (Obiweluozo et al., Reference Obiweluozo, Ede, Onwurah, Uzodinma, Dike and Ejiofor2021).

Two studies targeted child outcomes via parents. In Turkey (n = 55), the group-based Triple P program significantly reduced psychological and anxiety symptoms and improved functioning for 8- to 12-year-olds with anxiety disorders at post-intervention and 4 months after the intervention (Özyurt et al., Reference Özyurt, Gencer, Öztürk and Özbek2019). Edrissi et al. (Reference Edrissi, Havighurst, Aghebati, Habibi and Arani2019) conducted an RCT of the six group-session Tuning into Kids intervention with 56 mothers of children aged 4–6 years in Iran, focused on teaching emotion coaching to mothers. Child anxiety significantly reduced in the intervention group compared to the control group and was maintained after 6 months.

Evidence from global reviews

Several reviews reported on the benefit of CBT for childhood anxiety, with small to moderate effect sizes. James et al. (Reference James, Reardon, Soler, James and Creswell2020) conducted a Cochrane review of 87 studies trialing CBT for anxiety disorders with 5,964 children. Findings showed that CBT had a higher remission rate for anxiety diagnoses compared to waitlist or no treatment controls. However, there was limited evidence when comparing CBT to active controls or other treatments. The review was not able to determine differences between CBT and medication or CBT combined with medication due to a lack of relevant studies, nor the long-term effects of CBT, due to insufficient studies. Outcomes did not vary based on duration of treatment. Group-based interventions had stronger symptom outcomes reported by parents and children, but potential confounding factors were noted. The review also highlighted age-related measurement issues as a source of variation in outcomes across different age groups.

Strawn et al. (Reference Strawn, Lu, Peris, Levine and Walkup2021) provide an overview of more than 20 RCTs showing the benefit of CBT and outline that the approach has limited negative side effects. Luo and McAloon (Reference Luo and McAloon2021) report similar findings, concluding that CBT moderately reduces anxiety symptoms. Wergeland et al. (Reference Wergeland, Riise and Ost2021) note that CBT is effective in reducing internalizing disorders and symptoms for children and adolescents, and the outcomes are comparable with older populations. Generally, children experiencing higher scores at baseline experienced higher rates of change (Wergeland et al., Reference Wergeland, Riise and Ost2021). Similar benefits were found for digitally delivered programs (Strawn et al., Reference Strawn, Lu, Peris, Levine and Walkup2021). One review found that school-based programs appear to reduce anxiety symptoms in this age group but evidence is weak (Caldwell et al., Reference Caldwell, Davies, Hetrick, Palmer, Caro, López-López, Gunnell, Kidger, Thomas, French, Stockings, Campbell and Welton2019). A further review found that very small benefits for anxiety symptoms were maintained until 12 months in school-based programs (Hugh-Jones et al., Reference Hugh-Jones, Beckett, Tumelty and Mallikarjun2021).

CBT-based interventions for childhood anxiety typically include psychoeducation, relaxation techniques, cognitive restructuring and exposure tasks (Strawn et al., Reference Strawn, Lu, Peris, Levine and Walkup2021). Specific therapeutic processes within CBT have been identified as driving program effectiveness. Individual-, group- and family-based CBT have shown more benefits compared to control conditions (Sigurvinsdottir et al., Reference Sigurvinsdottir, Jensinudottir, Baldvinsdottir, Smarason and Skarphedinsson2020). Brief interventions involving social skills training and parent training have been effective in reducing anxiety (Stoll et al., Reference Stoll, Pina and Schleider2020). In-session exposure tasks have been found to improve anxiety levels, while relaxation techniques have shown less impact (Whiteside et al., Reference Whiteside, Sim, Morrow, Farah, Hilliker, Murad and Wang2020). Group psychoeducation has also demonstrated reductions in anxiety symptoms, although interventions vary widely (Baourda et al., Reference Baourda, Brouzos, Mavridis, Vassilopoulos, Vatkali and Boumpouli2021). Mindfulness-based interventions have shown a small to moderate effect on anxiety but lack sustained outcomes (Odgers et al., Reference Odgers, Dargue, Creswell, Jones and Hudson2020).

Parent-only CBT was effective in reducing anxiety, comparable to programs involving both children and parents. Parent-directed CBT may be more suitable for younger children, but dropout rates tend to be higher in parent-only programs (Yin et al., Reference Yin, Teng, Tong, Li, Fan, Zhou and Xie2021). Other reviews have shown that parental involvement is not necessarily beneficial in the treatment of anxiety (Cordier et al., Reference Cordier, Speyer, Mahoney, Arnesen, Mjelve and Nyborg2021; Peris et al., Reference Peris, Thamrin and Rozenman2021; Wergeland et al., Reference Wergeland, Riise and Ost2021).

In contrast, there is limited evidence supporting the effectiveness of interventions for depression in young children (Cuijpers et al., Reference Cuijpers, Karyotaki, Ciharova, Miguel, Noma, Stikkelbroek, Weisz and Furukawa2021a,Reference Cuijpers, Pineda, Ng, Weisz, Munoz, Gentili, Quero and Karyotakib; Liang et al., Reference Liang, Li, Wu, Li, Qian, Jia, Wang, Qian and Xu2021). In a Cochrane review, the use of CBT, third-wave CBT and interpersonal therapy in preventing depression in children and adolescents was examined (Hetrick et al., Reference Hetrick, Cox, Witt, Bir and Merry2016). The review included 83 trials, with 53 involving targeted or indicated populations. Findings indicated a small positive effect on depression diagnosis, depression symptoms, general and social functioning, with evidence deemed of low to moderate quality.

Interventions for subthreshold depression have shown little effectiveness (Cuijpers et al., Reference Cuijpers, Pineda, Ng, Weisz, Munoz, Gentili, Quero and Karyotaki2021b). Only a small proportion of young people respond to current depression therapy models (Cuijpers et al., Reference Cuijpers, Karyotaki, Ciharova, Miguel, Noma, Stikkelbroek, Weisz and Furukawa2021a). School-based programs have not demonstrated evidence for reducing depression symptoms (Caldwell et al., Reference Caldwell, Davies, Hetrick, Palmer, Caro, López-López, Gunnell, Kidger, Thomas, French, Stockings, Campbell and Welton2019). Network meta-analyses have shown that interpersonal psychotherapy and in-person CBT have better effects than control conditions, but the age range covered extends into adolescence (Liang et al., Reference Liang, Li, Wu, Li, Qian, Jia, Wang, Qian and Xu2021). Resilience-oriented programs focusing on cognitive, problem-solving and social skills resulted in improvements in depression symptoms in both targeted and universally delivered programs, which were maintained in the medium term (Ma et al., Reference Ma, Zhang, Huang and Cui2020).

Technical guidelines

Technical guidelines reviewed generally underscored the lack of quality evidence for this age group, yet largely recommended group- or individual-based CBT for anxiety and depression with recommendations of family-therapy components to provide adjunctive benefits, in particular for more severe presentations (National Institute for Health Care and Clinical Excellence, 2019; Walter et al., Reference Walter, Bukstein, Abright, Keable, Ramtekkar, Ripperger-Suhler and Rockhill2020, Reference Walter, Abright, Bukstein, Diamond, Keable, Ripperger-Suhler and Rockhill2023).

Evidence from LMIC studies

Seventeen studies, including sixteen RCTs and one QE study with varying sample sizes, examined interventions for externalizing problems such as attention–deficit hyperactivity disorder (ADHD) symptoms, aggression, oppositional defiant behavior, conduct problems and antisocial behavior. All studies required children to have a diagnosis, or score above a cut-off on a structured screening tool and most studies included children referred to specialist clinics. Two studies were conducted in Romania in 2019 when it was classified as a middle-income country, while the rest were in LMICs, with only one working with conflict-affected orphans with behavioral difficulties in Uganda. Seven studies included children with behavioral difficulties broadly, while 10 studies specifically focused on children with an ADHD diagnosis or clinical level of symptoms. Six studies included young children 6 years and younger, seven included children between 7 and 14 years and two included only 10- to 12-year-olds (two did not report age). Four studies only included boys. Eight interventions were conducted in schools, while seven were conducted in clinics (two did not report location).

Therapeutic approaches varied, including mindfulness/meditation (n = 2), parent skills training (n = 8), teacher training (n = 1), touch therapy (n = 1), play (n = 1), cognitive exercises (n = 2), problem solving (n = 2) and cognitive behavioral (n = 4). The length of each intervention varied greatly and ranged from a single session with two follow-up calls, to weekly sessions for 1 year. Within this range, most interventions were run between 3 and 10 weeks. Interventions involved children only (n = 5), child-caregiver dyads (n = 5) and caregivers only (n = 7). The majority (n = 12) delivered content in group or a combination of group and individual sessions. None reported delivery by nonspecialists.

Thirteen studies reported on a significant improvement in the treatment group on at least one outcome; five of these had sufficient detail and sample size to explore further. Only one study evaluated a child-focused program. Ojiambo (Reference Ojiambo2013) observed significant improvements in externalizing problems for displaced orphans aged 10–12 years living in Uganda and participating in group activity play therapy compared to a control group, with positive effects also seen for internalizing symptoms.

Two studies tested parenting interventions for parents of children with ADHD. Behbahani et al. (Reference Behbahani, Zargar, Assarian and Akbari2018) evaluated a mindful parenting group intervention with a sample of 56 parents of children aged 7–12 years in Iran. They found significant improvements in child symptoms, as well as parent distress and parent–child interactions. Malik et al. (Reference Malik, Rooney, Chronis-Tuscano and Tariq2017) trialed an adapted version of the Defiant Child intervention with 85 parents of children aged 4–12 years in Pakistan, consisting of both group and individual sessions. They found significant treatment effects for several indicators of disruptive behavior in the home, but not school.

Two studies tested parent skills training for parents of children with externalizing behavioral difficulties. David et al. (Reference David, David and Dobrean2014) conducted a trial of a 10-session enhanced Rational Positive Parenting intervention (delivered by specialist school counselors) including behavioral parenting strategies plus caregiver emotion regulation strategies with 106 caregivers in Romania. They found significantly reduced child externalizing behavior problems in both the standard behavioral parenting program and the enhanced program, compared to waitlist. In a sample of 106 parents in Panama, Mejia et al. (Reference Mejia, Calam and Sanders2015) found that a single session Triple P discussion group on the topic of disobedience led to significant improvements in problematic behaviors in children, sustained through 6-month follow-up.

Evidence from global reviews

Several reviews find that parenting support programs effectively reduce child behavior problems (O’Connor and Hayes, Reference O’Connor and Hayes2018; Leijten et al., Reference Leijten, Gardner, Melendez-Torres, Van Aar, Hutchings, Schulz, Knerr and Overbeek2019a; Retuerto et al., Reference Retuerto, Ros Martinez de Lahidalga and Ibanez Lasurtegui2020; Thongseiratch et al., Reference Thongseiratch, Leijten and Melendez-Torres2020; McAloon and de la Poer Beresford, Reference McAloon and de la Poer Beresford2021; Parker et al., Reference Parker, Hunnicutt Hollenbaugh and Kelly2021; Riise et al., Reference Riise, Wergeland, Njardvik and Ost2021; Valero Aguayo et al., Reference Valero Aguayo, Rodríguez Bocanegra, Ferro García and Ascanio Velasco2021). These programs are often based on behavior management skills rooted in Operant Learning Theory and Social Learning Theory (Patterson, Reference Patterson1982; Leijten et al., Reference Leijten, Gardner, Melendez-Torres, Van Aar, Hutchings, Schulz, Knerr and Overbeek2019a). Some effective programs primarily focus on teaching techniques to promote positive reinforcement (e.g., reward or praise), whereas others programs include techniques on nonviolent discipline (Leijten et al., Reference Leijten, Gardner, Melendez-Torres, Van Aar, Hutchings, Schulz, Knerr and Overbeek2019a). A meta-analysis was conducted on 156 studies to test whether parenting programmes consisting of the “golden couple” (relationship enhancement and behavior management) were more effective in reducing disruptive child behavior than programs that included only one component (Leijten et al., Reference Leijten, Gardner, Melendez-Torres, Van Aar, Hutchings, Schulz, Knerr and Overbeek2019a). Authors found that the “golden couple” was more beneficial for use in treatment programs but not preventive programs.

A network meta-analysis identified four active parenting program types (behavior management, behavior management with parental self-management, behavior management with psychoeducation and relationship enhancement), with focused interventions on behavior management alone showing the highest effectiveness (Leijten et al., Reference Leijten, Melendez‐Torres and Gardner2022). They conclude that there is a need for more targeted or tailored programs, or programs whose components are flexible and adaptable to the target population (Leijten et al., Reference Leijten, Melendez‐Torres, Gardner, Van Aar, Schulz and Overbeek2018b). The “Incredible Years” parenting program (Leijten et al., Reference Leijten, Gardner, Landau, Harris, Mann, Hutchings, Beecham, Bonin and Scott2018a; Reference Leijten, Gardner, Melendez-Torres, Weeland, Hutchings, Landau, McGilloway, Overbeek, van Aar and Menting2019b Gardner et al., Reference Gardner, Leijten, Harris, Mann, Hutchings, Beecham, Bonin, Berry, McGilloway and Gaspar2019) is an example of an effective manualized intervention that incorporates multiple strategies. It follows a collaborative group-based model that enables parents to identify their own skills and enables them to identify effective strategies to achieve their goals in their own family context. Overall, there is a strong rationale for including more than just behavior management techniques in parent and family support programs as it can effectively target multiple family characteristics that can contribute to the prevention of disruptive child behavior (Leijten et al., Reference Leijten, Gardner, Melendez-Torres, Van Aar, Hutchings, Schulz, Knerr and Overbeek2019a). However, there is also evidence that suggests “less is more” in parenting programs, as it provides parents with the opportunity to focus and master one technique (Leijten et al., Reference Leijten, Gardner, Melendez-Torres, Van Aar, Hutchings, Schulz, Knerr and Overbeek2019a).

Beyond parenting intervention, two reviews examined moderators of effectiveness in psychosocial programs for children and adolescents with conduct problems. McMahon et al. (Reference McMahon, Goulter and Frick2021) found that higher baseline symptoms, maternal depression, father engagement and individual program delivery (compared to group) were associated with larger positive effects. On the other hand, they found no evidence of moderation in either direction for child diagnosis, family risk level and intervention setting. Baumel et al. (Reference Baumel, Mathur, Pawar and Muench2021) similarly found that interventions for children with behavior problems within the clinical range had small to moderate effects (with no significant effect for interventions for children with symptoms below clinical levels) and individually delivered programs involving both the parent and child were most effective. Two school-based reviews did not report on factors that might have contributed to the effectiveness of these programs so little is known about what works in the school setting specifically (O’Connor and Hayes, Reference O’Connor and Hayes2018; Retuerto et al., Reference Retuerto, Ros Martinez de Lahidalga and Ibanez Lasurtegui2020).

Technical guidelines

The Helping Adolescents Thrive (HAT) guidelines conditionally recommend (based on very low certainty of evidence) that interventions be provided to adolescents with disruptive behavior, and could include training for parents based on social learning approaches, social-cognitive problem solving and interpersonal skills training for adolescents and joint caregiver-adolescent session based on social learning model (WHO, 2020). WHO’s mhGAP Intervention Guide (WHO, 2016) recommends providing psychoeducation, parent skills training, caregiver support, engagement with school, strengthening of social supports and behavioral interventions when available. The National Institute for Health Care and Clinical Excellence guidelines for antisocial and conduct problems in young people recommend group cognitive-behavioral and social problem solving interventions only for children aged 9 and above (National Institute for Health Care and Clinical Excellence, 2023). This guidance recommends parent-only or child-and-parent interventions based on social learning models for children aged 3–11 years and encourages involvement of both caregivers where possible.

Evidence from LMIC studies

Nine unique studies, including seven RCTs and two QE studies of varying sample sizes, examined interventions for traumatic stress outcomes for populations affected by natural disasters (n = 4), armed conflict and displacement (n = 3), a bombing (n = 1) and exposure to other traumatic events (n = 1). Four studies required a PTSD diagnosis as determined by clinical interview, while five utilized standardized self-report measures. The interventions tested were primarily CBT-based (n = 6), with other content including critical incident stress management, spiritual hypnosis and psychodrama. Interventions had varying session lengths and formats (n = 6 group, n = 3 individual) and five were conducted in school settings. Screening methods relied on standardized tools, and all but one study included both boys and girls. Interventions focused on children aged 5–18 years with two studies including children 6 years and younger. Only three interventions also included caregivers for at least one session.

Six out of the nine studies reported significant improvements in the treatment group compared to the control group for at least one outcome, including reductions in PTS symptoms. Two studies showed significant within-group improvements, but no difference between two active treatment conditions: trauma-focused CBT (TF-CBT) versus problem solving (Dawson et al., Reference Dawson, Joscelyne, Meijer, Steel, Silove and Bryant2018), and narrative exposure therapy versus meditation-relaxation (Catani et al., Reference Catani, Kohiladevy, Ruf, Schauer, Elbert and Neuner2009). The three promising studies all evaluated interventions based on TF-CBT and found significant improvements in PTS and other outcomes: group-based intervention delivered by specialists in schools for children aged 7–13 years following floods in Pakistan (Amin et al., Reference Amin, Nadeem, Iqbal, Asadullah and Hussain2020); group-based Teaching Recovery Techniques intervention plus behavioral parenting sessions, delivered by teachers in schools for Syrian refugee children aged 9–12 years and their caregivers in Lebanon (El-Khani et al., Reference El-Khani, Cartwright, Maalouf, Haar, Zehra, Çokamay-Yılmaz and Calam2021); and individual nonspecialist delivered TF-CBT for trauma-affected children aged 5–18 years in Zambia, and their caregivers (Kane et al., Reference Kane, Murray, Cohen, Dorsey, Skavenski van Wyk, Galloway Henderson, Imasiku, Mayeya and Bolton2016; Murray et al. Reference Murray, Hall, Dorsey, Ugueto, Puffer, Sim, Ismael, Bass, Akiba, Lucid, Harrison, Erikson and Bolton2018). Both nonspecialist interventions relied on brief trainings and regular supervision.

Evidence from global reviews

Recently published reviews emphasize the effectiveness of TF-CBT as the recommended treatment for PTSD in children and adolescents (Chipalo, Reference Chipalo2021; Xiang et al., Reference Xiang, Cipriani, Teng, Del Giovane, Zhang, Weisz, Li, Cuijpers, Liu and Barth2021; Yohannan et al., Reference Yohannan, Carlson and Volker2022). Cognitive processing therapy, behavioral therapy, individual TF-CBT and group TF-CBT were found to be effective compared to controls; however, there is a limited evidence base and need for further research with different populations. McWey (Reference McWey2022) reviewed interventions for traumatic stress (in children and adolescents) that focused on couple of family- and partner- based relational processes. The author found that so-called systemic interventions reduced post-traumatic stress symptoms in young people. A further review on art therapy for children and adolescents with mental health disorders found two relevant RCTs and authors suggest that this approach may be beneficial for young people with PTSD (Braito et al., Reference Braito, Rudd, Buyuktaskin, Ahmed, Glancy and Mulligan2022).

When examining moderators of treatment effectiveness, Yohannan et al. (Reference Yohannan, Carlson and Volker2022) found that moderators of the effect of CBT treatment included trauma type (children who had experienced physical abuse, single incident or traumatic grief had better outcomes) and gender (males benefitted more). Danzi and La Greca (Reference Danzi and La Greca2021) identified age (younger children), maternal depression and unhelpful beliefs as moderators leading to poorer treatment response. Group-based interventions were less effective than individual ones, and no differences were found based on provider or trauma type. Powell et al. (Reference Powell, Patel, Haley, Haines, Knocke, Chandler, Katz, Seifert, Ake, Amaya-Jackson and Aarons2020) highlighted issues with parenting engagement, including logistical challenges and past experiences with accessing care.

Technical guidelines

The American Academy of Child and Adolescent Psychiatry Clinical Practice Parameter (Cohen et al., Reference Cohen2010) recommends that treatment of children with PTS symptoms should include education of the child and parents about PTSD, consultation with school personnel and TF psychotherapy including cognitive-behavioral therapy, psychodynamic psychotherapy and/or family therapy. Parents should be included in treatment where possible. The HAT guidelines similarly recommend individual TF-CBT for higher trauma exposure (WHO, 2020). International Society for Traumatic Stress Studies guidelines (Bisson et al., Reference Bisson, Berliner, Cloitre, Forbes, Jensen, Lewis, Monson, Olff, Pilling, Riggs, Roberts and Shapiro2019) recommend TF-CBT (both for caregiver/child dyads and child alone) and Eye Movement Desensitization and Reprocessing for the treatment of children and adolescents with clinically relevant post-traumatic stress symptoms.

Evidence from LMIC studies

Eight studies, consisting of seven randomized controlled trials (RCTs) and one QE study, examined interventions targeting multiple symptom presentations in conflict-affected settings (n = 5) and LMICs (n = 3). Interventions typically targeted broad age ranges, but only one worked with children 6 years and younger, and one worked only with boys. All studies utilized standardized screening measures to identify children; often screening took place in schools. The interventions, mostly based on CBT (n = 6), included group (n = 6), individual sessions (n = 1) and combination group/individual (n = 1), ranging from 2 to 20 sessions, with five conducted via schools. One intervention targeted parents only, and one targeted parent–child dyads, while the remainder focused on children only. Six interventions were delivered by nonspecialists. All eight studies reported significant improvements in the treatment group compared to the control group, but in some cases, these effects were specific to subgroups or study sites. All nonspecialist interventions utilized brief classroom-based trainings followed by practice and regular supervision.

Of the five studies showing promise, four were RCTs of the 15-group-session nonspecialist delivered classroom-based intervention in different conflict-affected contexts, with mixed results regarding reductions in emotional or behavioral problems. The intervention showed reductions in psychological difficulties and aggression for boys in Nepal but had no effects on PTSD, depression, anxiety or functioning (Jordans et al., Reference Jordans, Komproe, Tol, Kohrt, Luitel, Macy and De Jong2010). In Indonesia, there was a reduction in PTSD symptoms for girls (Tol et al., Reference Tol, Komproe, Susanty, Jordans, Macy and De Jong2008), while in Sri Lanka, the intervention had an effect on conduct problems and PTSD and anxiety symptoms in boys (Tol et al., Reference Tol, Komproe, Jordans, Vallipuram, Sipsma, Sivayokan, Macy and de Jong2012). In Burundi, no overall effects were found, but there were effects on depression symptoms and functional impairment for children in larger households (Tol et al., Reference Tol, Komproe, Jordans, Ndayisaba, Ntamutumba, Sipsma, Smallegange, Macy and de Jong2014).

Dorsey et al. (Reference Dorsey, Lucid, Martin, King, O’Donnell, Murray, Wasonga, Itemba, Cohen and Manongi2020) tested a 12-week culturally adapted group-based TF-CBT focusing on parental death with 634 orphaned children aged 7–13 years in Kenya and Tanzania. The intervention consisted of 12 group sessions, plus 3–4 individual sessions, delivered by a lay counselor trained over 4.5 days and provided with weekly supervision by local supervisors who in turn received weekly master supervision from international study leads. Counselors showed high levels of competence and fidelity. Children were included if they screened positive on a measure of post-traumatic stress, or a measure of prolonged grief. TF-CBT was effective in reducing PTS symptoms in three of four sites, and this was retained at the 12-month follow-up in two sites, with similar patterns for outcomes of prolonged grief, and internalizing symptoms.

Evidence from global reviews

Some reviews examined interventions for cross-diagnostic benefits. In the parenting-directed programs, we found four reviews focused on establishing the impact of programs for parents of children with disruptive behaviors on internalizing problems. Phillips and Mychailyszyn (Reference Phillips and Mychailyszyn2021) found that PCIT reduced anxiety compared to control condition. A review of the effect of parenting interventions for child disruptive behavior on internalizing symptoms identified 12 studies of the Incredible Years, Triple-P and Tuning into Kids reporting on both outcomes. All but one study reported positive impact on externalizing behaviors and over half also reported significant improvement in internalizing symptoms (Zarakoviti et al., Reference Zarakoviti, Shafran, Papadimitriou and Bennett2021). Similarly, one review looked at parenting programs for conduct disorder and found small post-intervention effects on parent-reported emotional problems, but that these were not sustained. There were no specific individual program elements that predicted larger improvements, but behavior management and relationship enhancement together predicted larger effects (Kjøbli et al., Reference Kjøbli, Melendez‐Torres, Gardner, Backhaus, Linnerud and Leijten2022). Another review found that Triple P had a positive impact on social competence, emotional and behavioral problems, as well as a range of parenting-related outcomes (Li et al., Reference Li, Peng and Li2021).

Many of the other reviews on interventions that might reduce both internalizing and externalizing interventions did not identify sufficient studies or were inconclusive. One review looked to describe the evidence for the use of modular school-based mental health interventions based on a common-elements approach and was only able to identify programs for internalizing problems, but not externalizing (Kininger et al., Reference Kininger, O’Dell and Schultz2018). A review of school-based interventions showed that there was some evidence to suggest that selective prevention for either anxiety or depression was more effective than working across diagnostic categories, but authors were not able to draw firm conclusions (Caldwell et al., Reference Caldwell, Davies, Hetrick, Palmer, Caro, López-López, Gunnell, Kidger, Thomas, French, Stockings, Campbell and Welton2019). A review of an attachment-based intervention for children with existing symptoms or diagnoses was not able to establish the effectiveness of the program; however, the authors concluded that it may be effective for children with more than one condition (Money et al., Reference Money, Wilde and Dawson2021). One review that specifically looked at the effects of CBT on PTSD, depression and anxiety in child refugees found that most studies (including but not isolated to RCTs) reported positive results (Lawton and Spencer, Reference Lawton and Spencer2021). However, another review of interventions for refugees to target depression and PTSD was not able to draw conclusions on the effectiveness of interventions for refugees under 18 years due to the lack of evidence (Kip et al., Reference Kip, Priebe, Holling and Morina2020).

Technical guidelines

No guidelines were identified specifically for transdiagnostic interventions designed to address a range of symptoms. However, UNICEF’s review of evidence and practice (UNICEF, 2020) identifies several promising approaches to reduce general emotional distress and highlights the promise of Common Elements Treatment Approach and the Youth Readiness Intervention – both of which are transdiagnostic, components/common-elements approaches with adaptation of treatment strategies to fit new contexts and problems.