School-based mental health intervention for children in war-affected Burundi: a cluster randomized trial.

BACKGROUND: Armed conflicts are associated with a wide range of impacts on the mental health of children and adolescents. We evaluated the effectiveness of a school-based intervention aimed at reducing symptoms of posttraumatic stress disorder, depression, and anxiety (treatment aim); and improving a sense of hope and functioning (preventive aim). METHODS: We conducted a cluster randomized trial with 329 children in war-affected Burundi (aged 8 to 17 (mean 12.29 years, standard deviation 1.61); 48% girls). One group of children (n = 153) participated in a 15-session school-based intervention implemented by para-professionals, and the remaining 176 children formed a waitlist control condition. Outcomes were measured before, one week after, and three months after the intervention. RESULTS: No main effects of the intervention were identified. However, longitudinal growth curve analyses showed six favorable and two unfavorable differences in trajectories between study conditions in interaction with several moderators. Children in the intervention condition living in larger households showed decreases on depressive symptoms and function impairment, and those living with both parents showed decreases on posttraumatic stress disorder and depressive symptoms. The groups of children in the waitlist condition showed increases in depressive symptoms. In addition, younger children and those with low levels of exposure to traumatic events in the intervention condition showed improvements on hope. Children in the waitlist condition who lived on their original or newly bought land showed improvements in hope and function impairment, whereas children in the intervention condition showed deterioration on these outcomes. CONCLUSIONS: Given inconsistent effects across studies, findings do not support this school-based intervention as a treatment for posttraumatic stress disorder and depressive symptoms in conflict-affected children. The intervention appears to have more consistent preventive benefits, but these effects are contingent upon individual (for example, age, gender) and contextual (for example, family functioning, state of conflict, displacement) variables. Results suggest the potential benefit of school-based preventive interventions particularly in post-conflict settings. TRIAL REGISTRATION: The study was registered as ISRCTN42284825.

Medical and psychosocial needs of Olympic and Pan American athletes after the 2010 earthquake in Haiti: an opportunity to promote resilience through sports medicine and public diplomacy.

INTRODUCTION: On January 12, 2010, a magnitude 7.0 earthquake devastated Haiti. Data regarding the prevalence of medical and psychosocial needs after the earthquake is scarce, complicating informed targeting of aid. The effects of the earthquake on athletes, as they differ from the general population, are especially unclear. The Center for Disaster Resilience (Boston, Massachusetts USA) and the Disaster Medicine Section at Harvard Medical School (Boston, Massachusetts USA) have partnered with Child in Hand to care for athletes training for the Pan American and Olympic games in Haiti, as well as for children from the general population. This report presents preliminary epidemiologic data illustrating the burden of medical and psychosocial needs of Haitian athletes and the general population after the earthquake of 2010. METHODS: The study was a cross-sectional, comparative study conducted a year after the earthquake. The study group comprised 104 athletes, aged 12-18 years, enrolled from the National Sports Center in Haiti. The control group (N = 104) from the general population was age- and gender-matched from orphanages and schools in and around Port-au-Prince, Haiti. Medical teams assessed illness based on history and physicals. Psychosocial teams utilized the Child Psychosocial Distress Screener (CPDS). Two-proportion z tests and two-sample t tests were used to compare the proportions of medical illnesses, mean CPDS scores, and proportion of CPDS scores indicating treatment. RESULTS: The most prevalent medical condition in athletes was musculoskeletal pain, which was more common than in controls (49% versus 2.9%). All other medical conditions were more common in the controls than athletes: abdominal pain (28.8% versus 4.8%); headache (22.1% versus 5.8%); fever (15.4% versus 1%); and malnutrition (18.3% versus 1.9%). In contrast, there was no significant difference in mean psychosocial scores and the proportion of scores indicating treatment between athletes and controls. CONCLUSION: Elite athletes in Haiti have a low prevalence of most medical conditions after the disaster, suggesting that they may be protected from risk factors affecting the general population. However, athletes have a higher prevalence of musculoskeletal ailments and were not protected from psychosocial distress. This presents an opportunity for sports medicine physicians and mental health providers to engage in efforts to rebuild Haiti on an individual level by providing targeted care to athletes, and on a larger scale, by supporting international sports competition, which enhances human capital and facilitates public diplomacy.

Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled trial.

BACKGROUND: In situations of ongoing violence, childhood psychosocial and mental health problems require care. However, resources and evidence for adequate interventions are scarce for children in low- and middle-income countries. This study evaluated a school-based psychosocial intervention in conflict-affected, rural Nepal. METHODS: A cluster randomized controlled trial was used to evaluate changes on a range of indicators, including psychiatric symptoms (depression, anxiety, posttraumatic stress disorder), psychological difficulties, resilience indicators (hope, prosocial behavior) and function impairment. Children (n = 325) (mean age = 12.7, SD = 1.04, range 11-14 years) with elevated psychosocial distress were allocated to a treatment or waitlist group. RESULTS: Comparisons of crude change scores showed significant between-group differences on several outcome indicators, with moderate effect sizes (Cohen d = .41 to .58). After correcting for nested variance within schools, no evidence for treatment effects was found on any outcome variable. Additional analyses showed gender effects for treatment on prosocial behavior (mean change difference: 2.70; 95% CI, .97 to 4.44), psychological difficulties (-2.19; 95% CI, -3.82 to -.56), and aggression (-4.42; 95% CI, -6.16 to -2.67). An age effect for treatment was found for hope (.90; 95% CI, -1.54 to -.26). CONCLUSIONS: A school-based psychosocial intervention demonstrated moderate short-term beneficial effects for improving social-behavioral and resilience indicators among subgroups of children exposed to armed conflict. The intervention reduced psychological difficulties and aggression among boys, increased prosocial behavior among girls, and increased hope for older children. The intervention did not result in reduction of psychiatric symptoms.

School-based mental health intervention for children affected by political violence in Indonesia: a cluster randomized trial.

CONTEXT: Little is known about the efficacy of mental health interventions for children exposed to armed conflicts in low- and middle-income settings. Childhood mental health problems are difficult to address in situations of ongoing poverty and political instability. OBJECTIVE: To assess the efficacy of a school-based intervention designed for conflict-exposed children, implemented in a low-income setting. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized trial involving 495 children (81.4% inclusion rate) who were a mean (SD) age of 9.9 (1.3) years, were attending randomly selected schools in political violence-affected communities in Poso, Indonesia, and were screened for exposure (> or = 1 events), posttraumatic stress disorder, and anxiety symptoms compared with a wait-listed control group. Nonblinded assessment took place before, 1 week after, and 6 months after treatment between March and December 2006. INTERVENTION: Fifteen sessions, over 5 weeks, of a manualized, school-based group intervention, including trauma-processing activities, cooperative play, and creative-expressive elements, implemented by locally trained paraprofessionals. MAIN OUTCOME MEASURES: We assessed psychiatric symptoms using the Child Posttraumatic Stress Scale, Depression Self-Rating Scale, the Self-Report for Anxiety Related Disorders 5-item version, and the Children's Hope Scale, and assessed function impairment as treatment outcomes using standardized symptom checklists and locally developed rating scales. RESULTS: Correcting for clustering of participants within schools, we found significantly more improvement in posttraumatic stress disorder symptoms (mean change difference, 2.78; 95% confidence interval [CI], 1.02 to 4.53) and maintained hope (mean change difference, -2.21; 95% CI, -3.52 to -0.91) in the treatment group than in the wait-listed group. Changes in traumatic idioms (stress-related physical symptoms) (mean change difference, 0.50; 95% CI, -0.12 to 1.11), depressive symptoms (mean change difference, 0.70; 95% CI, -0.08 to 1.49), anxiety (mean change difference, 0.12; 95% CI, -0.31 to 0.56), and functioning (mean change difference, 0.52; 95% CI, -0.43 to 1.46) were not different between the treatment and wait-listed groups. CONCLUSIONS: In this study of children in violence-affected communities, a school-based intervention reduced posttraumatic stress symptoms and helped maintain hope, but did not reduce traumatic-stress related symptoms, depressive symptoms, anxiety symptoms, or functional impairment. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN25172408.

Community-based, acute posttraumatic stress management: a description and evaluation of a psychosocial-intervention continuum.

Much of today's psychological trauma can be identified as resulting from sudden and seemingly random events, and particularly from events that involve the loss of human life. This article presents a perspective on how behavioral health providers may approach the design, development, and implementation of community-based psychological trauma interventions. These interventions allow those community members most affected by the trauma to play a central role in the resolution of, and community adaptation to, traumatic losses. After a brief discussion of "critical incident stress debriefing"--a common form of psychological "first aid" that is sometimes used following traumatic events that affect a community--the article turns to the description of a community-based trauma-response program that provides a continuum-of-care model for the care and management of individual and group reactions to shared, traumatic events. A recent evaluation of that program, which was developed by the Community Services Program of the Trauma Center in Boston, is presented as an important first step toward determining the types of community-based responses that show promise in our efforts to ameliorate the impact of traumatic events in communities nationwide and internationally.

Outcomes and moderators of a preventive school-based mental health intervention for children affected by war in Sri Lanka: a cluster randomized trial.

We aimed to examine outcomes, moderators and mediators of a preventive school-based mental health intervention implemented by paraprofessionals in a war-affected setting in northern Sri Lanka. A cluster randomized trial was employed. Subsequent to screening 1,370 children in randomly selected schools, 399 children were assigned to an intervention (n=199) or waitlist control condition (n=200). The intervention consisted of 15 manualized sessions over 5 weeks of cognitive behavioral techniques and creative expressive elements. Assessments took place before, 1 week after, and 3 months after the intervention. Primary outcomes included post-traumatic stress disorder (PTSD), depressive, and anxiety symptoms. No main effects on primary outcomes were identified. A main effect in favor of intervention for conduct problems was observed. This effect was stronger for younger children. Furthermore, we found intervention benefits for specific subgroups. Stronger effects were found for boys with regard to PTSD and anxiety symptoms, and for younger children on pro-social behavior. Moreover, we found stronger intervention effects on PTSD, anxiety, and function impairment for children experiencing lower levels of current war-related stressors. Girls in the intervention condition showed smaller reductions on PTSD symptoms than waitlisted girls. We conclude that preventive school-based psychosocial interventions in volatile areas characterized by ongoing war-related stressors may effectively improve indicators of psychological wellbeing and posttraumatic stress-related symptoms in some children. However, they may undermine natural recovery for others. Further research is necessary to examine how gender, age and current war-related experiences contribute to differential intervention effects.

Mediators and moderators of a psychosocial intervention for children affected by political violence.

OBJECTIVE: The authors examined moderators and mediators of a school-based psychosocial intervention for children affected by political violence, according to an ecological resilience theoretical framework. METHOD: The authors examined data from a cluster randomized trial, involving children aged 8-13 in Central Sulawesi, Indonesia (treatment condition n = 182, waitlist control condition n = 221). Mediators (hope, coping, peer/emotional/play social support) and moderators (gender, age, family connectedness, household size, other forms of social support, exposure to political violence, and displacement) of treatment outcome on posttraumatic stress symptoms and function impairment were examined in parallel process latent growth curve models. RESULTS: Compared with the waitlist group, those receiving treatment showed maintained hope, increased positive coping, maintained peer social support, and increased play social support. Of these putative mediators, only play social support was found to mediate treatment effects, such that increases in play social support were associated with smaller reductions in posttraumatic stress disorder (PTSD) symptoms. Furthermore, the authors identified a number of moderators: Girls showed larger treatment benefits on PTSD symptoms; girls, children in smaller households, and children receiving social support from adults outside the household showed larger treatment benefits on function impairment. CONCLUSIONS: Findings provide limited evidence for an ecological resilience theoretical framework. On the basis of these findings, the authors recommend a stronger separation between universal prevention (e.g., resilience promotion through play) and selective/indicated prevention (e.g., interventions aimed at decreasing posttraumatic stress symptoms). Play-based interventions should be careful to exclude children with psychological distress. In addition, treatment effects may be augmented by selecting girls and socially vulnerable children.

Community-based trauma response for youth.

The "golden rule" of youth trauma response is that those most affected by the trauma or threat event must be afforded an ongoing opportunity to play a central role in the resolution of and recovery from the trauma and its aftermath.

Threat and trauma: an overview.

Common responses after exposure to threat include reexperiencing the event, intrusive thoughts and images, hyperarousal, avoidance and numbing, a sense of a foreshortened future, and shattered assumptions about control and safety.

Healing in familiar settings: support for children and youth in the classroom and community.

The Classroom-Based Intervention emphasizes a specific theme each week to allow children to construct safe places to express their stories and develop coping strategies in a group environment.