About the A&R Programme

Anxiety disorders are the most common mental health problem in children. In areas affected by war and conflict, at least 32% of young people at any time will have an anxiety disorder; many more may feel very anxious a lot of the time (WHO:2019). Anxiety makes it difficult to concentrate and learn, and can badly affect all areas of life.   The Anxiety and Resilience programme provides materials for teachers, nurses, youth workers etc who work with children and teens (including displaced children and refugees) in conflict and disaster-affected areas, to reduce their anxiety and build hope and resilience.

The A&R Programme can be used with individuals and with small groups or school classes. The manual contains step-by-step directions to safely help children and their families understand and manage anxiety and also sadness and grief, low mood, and anger. It presents ways to help children deal with difficult memories, and to develop resilience and mental health skills for the future. The programme consists of five sessions, with a sixth follow-up session a few weeks after session five, and two group sessions for parents or carers. All teaching and activities needed to run the sessions are provided in the manual, with optional scripts for practitioners to follow.

The anxiety management techniques or tools in the programme are based on well-tested CBT and Mindfulness strategies and are illustrated by stories designed to help children affected by conflict or disaster. The stories can be adapted for different ages, cultural backgrounds and situations. Each session also includes games and activities which help children practice the tools and build their confidence and resilience.

About the A&R Pilot

In late 2020 Dr Ghalia Al Asha, child psychologist and principal trainer for ACT International, ran an online course in Arabic on how to treat anxiety in children and build hope and resilience, using the A&R Programme, for 21 mental health workers and teachers working with internally displaced children in Northern Syria.for UOSSM (Union of Medical Care and Relief Organizations).

In early 2021 the trained facilitators ran their first 12 groups comprising 110 children as a pilot to look at the suitability and effectiveness of the A&R programme in this context. All the children have experienced conflict and related hardships and losses. Groups comprised different ages, in various geographic locations. There was a range of additional needs among the children, but all were included in the groups because they have signs and symptoms of anxiety.

A short form of the Spence Children’s Anxiety Scale (Arabic version) was used to measure each child’s anxiety level before and after the A&R programme, with an assessment held before starting the sessions, and again at a follow-up meeting three to six weeks after session five. 

Statistical analysis

Every child scored higher on the anxiety scale before the programme, compared to after the programme, indicating that the children's anxiety had diminished after the course. This decrease in anxiety scores was statistically significant:

Mean score before the programme: 11.10, SD = 3.84.

Mean score after  the programme: 4.85, SD = 2.14.

This decrease in anxiety scores, M = 6.25, 95%CI [5.61, 6.88], was statistically significant, t(109)= 19.386, p < 0.001. 

With thanks to Lily Holland MSc for statistical analysis.

About the audit report

Facilitators completed feedback forms on which they noted their views about the  strengths and weaknesses of the programme, including comments from children and parents, and suggestions for improvement. This audit is based on information from these forms, translated from Arabic by the author               .

Programme strengths and positive impacts:

Reduction in stress and anxiety

Facilitators and parents noticed a significant reduction in anxiety and improvement in the mental health of the participating children. According to the feedback, children gained a wide variety of effective anxiety- reducing methods and techniques, which resulted in them having a better understanding of their body’s reactions to stress and anxiety, overcoming many of their fears, feeling more able to discuss their problems and showing fewer outward signs of fear and anxiety, including less shyness, social withdrawal, crying and neediness.

Children learned about goal setting and felt more able to deal with different life situations, and parents and facilitators commented that these impacts are very important to help the children have a better future.

Some specific observations from caregivers and facilitators included:

• “It teaches children effective methods and ways to take control of their fears and anxiety.”

• “Most of the parents noticed their children’s psychological situation improved. They were more capable of facing problems they were exposed to and didn’t run away from them.”

• “The children have become aware of how their bodies behave in stressful situations.”

• “The parents noticed notable improvements in their children; some of them were shy and fearful but they became brave and able to discuss and ask for their needs. Most of the parents noticed a markable recovery in their children’s situation and mental state.”

• “Many of the children have clearly overcome their fears.”

• “Many of the children now feel brave enough to talk about their fears and discuss them with their parents.”

• “The children expressed their enjoyment and the benefits of the programme and that their view of past experiences had changed. They can now control many of their thoughts and feelings and their happiness by relaxing and going to their safe place.”

In addition, the programme helped children learn more about themselves and their own emotions, and understand how their emotions relate to their behaviour:

• “It helps the child learn more about themselves by being able to name the emotions that they experience.”

• “The programme helped the children to understand both their positive and negative feelings as a first and necessary step towards being able to deal with them.”

• “The children know that dealing with their emotions can reduce their behavioural problems.”

Better understanding and improved family relationships

The parents were overwhelmingly positive and encouraging about the programme, including the tools and methods used to deliver information to the children. They were grateful for their children’s participation, and for how much their children and they themselves had benefited.

One facilitator relayed a parent’s comment that:

One of the most frequent comments was that the programme helps to improve relationships between children and their families. The programme built parents’ understanding of the sources and symptoms of their children’s anxiety, stress and fears, and increased parents’ ability to help their children reduce their anxiety and overcome their fears. Some comments included:

• “The programme is good at teaching us how we can help our children when we notice they are stressed or anxious and now we can understand that is what they are feeling.”

• “The programme helped involve the parents in understanding their children’s fears and their feelings about stressful situations. The parents’ involvement in itself helps the children to deal with anxiety and manage their problems.”

• “The sessions helped the parents themselves to understand their own feelings and stresses and how they affect their children.”

• “The programme is useful because it helps parents to take on the burden of good parental care, and helps them to understand what is behind their children’s behaviour.”

• “The programme helped the parents to understand the relationship between many of their children’s behavioural problems (nail biting, bed wetting etc) and their fears and anxieties.”

• “The programme helped the parents to avoid some of the issues that were helping to stoke their children’s fears without them realising.”

• “The programme changed some of the incorrect ideas and misunderstandings related to anxiety, fear and psychological stress.”

Other benefits for children

The facilitators found the programme had many other related benefits for the children, including:

It helps the children to build positive social relationships with their peers and increases their feelings of belonging:

• “It helps children by bringing them together with other children who are experiencing the same hardships.”

• “It facilitated connection, communication, participation and interaction and created a familiar and friendly atmosphere among the group, which was helped by the variety of techniques used.”

The programme increases children’s self-confidence and helps them to express themselves:

• “The programme helped the fifth year students to express themselves without fear or hesitation and to talk about their past experiences and life situations.”

• “The chosen activities were appropriate for the age group, the programme increased their feelings of social belonging and helped to reinforce their self-confidence.”

It can also be used as a preventative tool to help children to protect themselves and take precautionary measures when dealing with stress that could lead to anxiety or mental health issues. 

A&R manual strengths

The facilitators were positive about the programme materials and activities provided, noting in particular:

• The stories are effective as they mimic the young people’s circumstances.

• The illustrations and tools help to apply the programme.

• The programme uses effective techniques, like the safe space and relaxation tool.

• The programme is clear and easy to follow for the facilitators.

• The programme is flexible and can be applied to different cultural backgrounds.

• The activities help establish a trusting and friendly relationship between the children and facilitators.

• The activities are age-appropriate.

Programme issues:  

Logistical issues

It should be noted that the facilitators of the pilot faced many challenges due to working in a war-affected region. Many facilitators commented that ‘lack of logistics’ was an issue, although did not elaborate or provide recommendations. However, some specific logistical issues mentioned include:

• The time was too tight – most facilitators implemented the programme during school lessons, which are too short, and the schools are not able to give more time for the programme.

• Corona related issues (Note: The pilot groups met during the Covid-19 pandemic) – including some children or parents being scared about corona spreading through the activities and the difficulty of implementing social distancing.

• Difficulties of implementing the programme in the camps after the school year finishes.

• Difficulties in bringing children together with others.

• Lack of an appropriate space to hold the programme and issues with the distance and lack of transport (not mentioned if this affected the children or the facilitators).

Parental issues

Many of the facilitators mentioned issues with parents that affected programme implementation, these included:

• The difficulty of convincing some of the caregivers of the importance of reducing anxiety as some don’t think it’s worth the time.

• Some parents insisted on being present in every session.

• Some parents weren’t committed to bringing their children to in-person sessions, or to bringing them on time, so some sessions were held remotely.

• Some parents and caregivers struggled to grasp the devices and tools used in the programme and to understand their effectiveness.

Programmatic issues

Although feedback was generally very positive, facilitators also noted some issues in the programme and materials, including:

• The difficulty of teaching children the meanings of concepts unfamiliar in their community (like anxiety).

• The programme is relatively long, which makes it difficult for parents to commit to sending their children.

• In one case, some of the stories upset the children who had lived experiences of that story.

• There is a lack of guidance for the children at the end of the programme for their long-term commitment to the tools and techniques.

Other issues

Some other issues mentioned include:

• The children not included in the programme felt excluded and worried.

• The suitability of children for the programme  - some children had issues other than anxiety that require separate treatment, while some children had very serious cases of anxiety or fears and symptoms that require the use of TRT (a group programme for children with traumatic memories).

Recommendations:

Key recommendations from facilitators

There were many suggestions for how the programme could be further developed. The most commonly mentioned recommendations from facilitators were:

• Create video clips and photos to narrate the stories in the guide – some mentioned videos from the children’s reality – which could be cartoons or children acting out the stories.

• Add theatre or role plays using real-life scenarios from the children’s environment.

• Make the programme accessible to all the protection and mental health sectors to increase its impact.

• Create a complementary parenting skills programme – this would help parents gain skills for themselves as well as to help their children continue to reduce their anxiety and implement the tools and techniques learned.

Other recommendations from facilitators

• Other recommendations included:

• Some parents wanted more sessions, while some facilitators asked for fewer sessions to make it easier for parents to commit to sending their children.

• Provide students with a weekly calendar to help them apply the anxiety reduction tools and keep developing awareness of their emotions as they face new life situations.

• Create more stories.

• Create a video explaining the programme to share with the parents on social media.

• Establish a clear pre and post-assessment scale based on scientific research.

• Involve the children’s teachers in the sessions to educate them about the programme. (This is already recommended in the A&R manual.)

• Run more trainings to help with the children’s many ongoing problems.

Conclusions:

Overall, the programme was highly rated and facilitators, parents and children all gave positive feedback.

The programme met its aims of reducing children’s stress, anxiety and fears, and providing them with helpful tools they can use in their daily lives for stress management, to relax and cope better with their emotions as they come across stressful situations, and to feel more positive about the future. Improvements in family relationships were also noted. Facilitators commented that the stories are generally age and context-appropriate, the tools are practical, effective and easily implementable for the children, while the programme itself is easy for them to follow.

The feedback forms highlighted some issues affecting the success of the programme. This includes the lack of skills and understanding among parents, leading to issues with commitment as well as their ability to support their children’s recovery and mental wellbeing. To overcome this, more sessions and information on the importance of anxiety management for parents are recommended, although it should be noted that bringing parents together can also be challenging.

Although not an issue, nearly all facilitators asked for either videos or drama and role plays based on the stories and activities to be included to help bring the programme to life for the children. The manual should also be more explicit about the importance of including the children’s teachers in the programme.

Finally, the feedback forms highlighted the need for more training or ongoing support for facilitators – this was shown by the use of overly realistic stories in one context (resulting in children becoming upset), the difficulty of teaching certain concepts and tools to the children, and the request from some facilitators for more support for them to deal with the different issues and levels of anxiety the children experience.