Efficacy of Child Psychosocial Interventions: Synthesis of Cluster Randomized Trials in Burundi, Indonesia, Nepal, and Sri Lanka
Wietse A. Tol - HealthNet TPO, Amsterdam, the Netherlands
Mark J.D. Jordans - HealthNet TPO, Amsterdam, the Netherlands
Ivan H. Komproe - HealthNet TPO & Utrecht University, the Netherlands
Joop T.V.M. de Jong - VU University, Amsterdam, the Netherlands & Boston University School of Medicine
Introduction
• In 2007, 34 armed conflicts• 191 million lives lost in 25 largest wars in 20th
century• 60% not engaged in fighting• 67 million displaced, out of whom 26 million
conflict-related Internally Displaced Persons
Introduction
• Psychiatric epidemiology with conflict-affected populations (Steel et al, JAMA 2009)
• 161 articles, 81,866 individuals, 40 countries• Weighted percentages: PTSD 30.6%,
depression 30.8%• Torture, potentially traumatic events, level of
political terror in country are risk factors; time since conflict associated with decrease in symptoms
Introduction
• Despite the mental health burden of political violence, and evidence for mental health treatments in developing countries, there is a lack of evidence for treatments in war-affected settings
• E.g. among children, only 4 rigorous studies have been published– 2 Bosnia (Layne et al, 2009)– 1 Uganda (Bolton et al, – 1 Indonesia (Tol et al, 2008)
Methods: Intervention• A secondary preventive
intervention; aimed at children with psychosocial problems, at risk of developing disorders
• Combining:– Symptom reduction (e.g.
PTSD, depression, anxiety)– Strengthening resilience
(e.g. hope, coping, social support)
Methods: Intervention• Structured intervention: 15
sessions over 5 weeks (specific themes)
• In classrooms with groups of around 15 children
• Combining cognitive-behavioral techniques (psycho-education, safety building, relaxation, exposure-based techniques) with creative-expressive therapy techniques
Methods
• As part of a larger public health project for children in war-affected settings www.psychosocialcarechildren.org
• School-aged children in Burundi, Indonesia, Nepal, and Sri Lanka
Methods: Cluster Randomized TrialsBaseline assessment
Treatment Follow-up #1
Follow-up #2
Treatment
Burundi (n=329)
0 weeks CBI for treatment cond.
6 weeks (88%)
5 Months (84%)
CBI for waitlist cond.
Indonesia (N=403)
0 weeks CBI for treatment cond.
6 weeks (98%)
6 Months (94%)
CBI for waitlist cond.
Nepal (N=325)
0 weeks CBI For treatment cond.
6 weeks (99%)
CBI for waitlist cond.
Sri Lanka (N=399)
0 weeks CBI for treatment cond.
6 weeks (100%)
4 Months (99%)
CBI for waitlist cond.
Methods: InstrumentsBurundi Indonesia Nepal Sri Lanka
PTSD symptoms - CPSS* - CPSS* - CPSS* -CPSS
Depressive symptoms
- DSRS* - DSRS* - DSRS* -DSRS
Anxiety - SCARED-5 - SCARED-5 - SCARED-5 - SCARED-5
Locally relevant constructs
- Supernatural-Grief
-Somatic - Supernatural-Moral
Other - Aggression-SDQ
- SDQ*
Function Impairment
- Locally constructed
- Locally constructed
- Locally constructed*
- Locally constructed
Strengths - Hope- Coping- Social Support- Family Connectedness- Social Capital
- Hope- Coping- Social Support- Family Connectedness
- Hope- Pro-social behavior
- Coping
* Locally validated instruments
Results: BurundiMean change difference
Mean change difference 95% CI
Child-rated % change Mean SEPTSD symptoms -36.7 .85 1.30 -1.70 – 3.41Anxiety symptoms -23.6 .13 .28 -.42 – .68Depressive symptoms -17.1 -.69 .75 -2.16 – .79Supernatural complaints -56.0 -.16 .31 -.77 – .46Grief complaints -36.7 .49 .44 -.37 – 1.36Function impairment -10.0 .45 .76 -1.04 – 1.93Hope 11.8 -.71 .95 -2.58 – 1.16Coping repertoire -5.8 -.10 .40 -.89 – .69Coping satisfaction -8.4 .67 1.07 -1.43 – 2.77Social support -.8 .88 .70 -.49 – 2.26Social capital 1.1 .18 .51 -.82 – 1.18Parent-rated % change Mean SEAggression -6.1 1.89 1.89 -1.83 – 5.61Function impairment -8.7 1.34 .67 .04 – 2.66Family connectedness .5 -.23 .79 -1.79 – 1.33
Results: Burundi (age and gender)
• Treatment effects for girls on anxiety• Treatment effects for boys on family
connectedness• Negative effects on social support for boys
• Statistically significant, but marginal differences
Results: IndonesiaMean change difference
Mean change difference 95% CI
Child-rated % change Mean SE
PTSD symptoms -43.2 -2.78 .89 -1.02 – 4.52Trauma idiom -30.0 -.50 .31 -.12 – 1.11Depressive symptoms -5.48 -.70 .40 -.08 – 1.49Anxiety symptoms -21.1 -.12 .22 -.31 - .56Function impairment -13.8 -.52 .48 -.43 – 1.46Hope 2.7 2.21 .66 -3.52 - -.91Coping repertoire .1 -.07 .24 .55 - .40Coping satisfaction -.2 -1.35 .69 -2.69 - -.00Social support 3.5 -.05 .47 -.97 - .86Parent-ratedAggression -8.4 -.80 1.28 -3.32 – 1.72Function impairment -11.8 .63 .53 -.41 – 1.67Family connectedness 1.6 .22 .31 -.39 - .83
Results: Indonesia (age and gender)
• Treatment effects for girls on PTSD symptoms and function impairment
Results: NepalMean change difference
Mean change difference 95% CI
Child-rated % change Mean SE
PTSD symptoms -12.07 -.13 .85 (-2.40 to 2.66)
Depression symptom -15.91 1.84 1.00 (-.62 to 4.29)
Anxiety symptoms -15.83 .46 .40 (-.51 to 1.43)
Aggression -.12 .55 .74 (-1.27 to 2.38)
Psychological difficulties -15.61 1.77 1.14 (-1.03 to 4.56)
Function impairment -29.21 3.10 1.72 (-1.12 to 7.31)
Hope 9.71 .62 .70 (-2.34 to 1.10)
Pro-social behaviour 11.12 -2.35 1.55 (-6.15 to 1.45)
Results: Nepal (age and gender)
• Treatment effects for girls on pro-social behavior
• Treatment effects for boys on psychological difficulties and aggression
• Treatment effects for older children on hope
Results: Sri Lanka
Mean change difference
Mean change difference 95% CI
Child-rated % change Mean SE
PTSD symptoms -38.0 -.37 .45 -1.26 - .52Anxiety symptoms -43.3 .08 .10 -.12 - .28Depressive symptoms -19.7 -.07 .24 -.55 - .39Supernatural complaints -43.1 .15 .10 -.05 - .34Moral complaints -31.7 .15 .12 -.08 - .38Psychological difficulties -27.6 .31 .28 -.25 - .87Function impairment -47.8 .17 .20 -.21 - .56Coping repertoire -6.3 -.07 .17 -.40 - .27
Coping satisfaction -4.7 -.13 .44 -.99 - .73
Pro-social behavior .1 -.04 .09 -.22 - .14
Results: Sri Lanka (age and gender)
• Treatment effects for boys on anxiety and depressive complaints
• Treatment effects for girls on social-moral complaints
• Borderline significance for function impairment (boys)
Overview of resultsBurundi Indonesia Nepal Sri Lanka
PTSD symptoms - CPSS* - CPSS* - CPSS* -CPSS
Depressive symptoms
- DSRS* - DSRS* - DSRS* -DSRS
Anxiety - SCARED-5 - SCARED-5 - SCARED-5 - SCARED-5
Locally relevant constructs
- Supernatural-Grief
-Somatic - Supernatural-Moral
Other - Aggression-SDQ
- SDQ*
Function Impairment
- Locally constructed
- Locally constructed
- Locally constructed*
- Locally constructed
Strengths - Hope- Coping- Social Support- Family Connectedness- Social Capital
- Hope- Coping- Social Support- Family Connectedness
- Hope- Pro-social behavior
- Coping
* Locally validated instruments
Discussion
• Appropriateness of (resilience) measures, in comparison with community feedback
• Influence of context on efficacy of treatment• Gender differences• Further work on treatment mechanisms• Debate on universal/selective vs. indicated
interventions, must be informed by yet to be proven protective & risk indicators
Acknowledgement
• This project and research was conducted with financial assistance from PLAN Netherlands
• Collaborators• TPO Burundi (Aline Ndayisaba, Seraphine
Hakizimana)• Church World Service Indonesia (Dessy
Susanty)• TPO Nepal (Nagendra Luitel)• Shanthiham (Anavarathan Vallipuram,
Sambasivamoorthy Sivayokan)
