Benefits and cultural adaptations of psychosocial interventions for parents and their children with intellectual disabilities in low-and middle-income countries: A systematic review.

BACKGROUND: Evidence and awareness of the importance of culturally adapting psychosocial interventions is growing. The aim of this paper is to systematically review studies on cultural adaptations of psychosocial interventions for parents and their children with intellectual disabilities, in low- and middle-income countries. METHODS: Studies were identified through electronic databases and searching bibliographies. The quality and cultural adaptations of thirteen studies focusing on parental trainings were analysed using standardised tools and frameworks. RESULTS: Findings suggest interventions reduce the risk of depression and stress and increase coping strategies and positive perceptions of family functioning. Parenting skills training may improve parent-child interactions and child development. However, these benefits should be interpreted cautiously due to methodological shortcomings. Most studies described efforts to make appropriate cultural adaptations to the interventions, but these adaptations were not comprehensive. CONCLUSION: High-quality cultural adaptations are crucial to providing meaningful interventions in different parts of the world.

Developing a function impairment measure for children affected by political violence: a mixed methods approach in Indonesia.

OBJECTIVE: Practitioners in political violence-affected settings would benefit from rating scales that assess child function impairment in a reliable and valid manner when designing and evaluating interventions. We developed a procedure to construct child function impairment rating scales using resources available in low- and middle-income countries. DESIGN: We applied a mixed methods approach. First, rapid ethnographic methods (brief participant observation, collection of diaries and a focus group with children) were used to select daily activities that best represented children's functioning. Second, rating scales based on these activities were examined for their psychometric properties. Construct validity was assessed through a confirmatory factor analysis procedure. SETTING: Central Sulawesi, Indonesia. PARTICIPANTS: Qualitative data were collected for 53 children and psychometric testing was done with 403 children [average age: 9.9 (SD = 1.21), 49% girls] and 385 parents. RESULTS: Using locally available resources, we developed separate child-rated and parent-rated scales, both containing 11 items. The child-rated scale evidenced good internal, test-retest and inter-rater reliability and acceptable convergent and discriminant validity. Construct validity was confirmed by fit of the theorized factor structure-a social-ecological clustering of daily activities. CONCLUSIONS: The procedure resulted in a reliable and valid rating scale to assess child function impairment in the context of political violence. Practitioners can apply this procedure to develop new locally adequate rating scales to strengthen epidemiological surveys, baseline assessments, monitoring and evaluation and eventually, interventions. Further research should address the importance of gender differences and criterion-related validity.

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.

Communal violence and child psychosocial well-being: qualitative findings from Poso, Indonesia.

This exploratory study examined the health care system in relation to communal violence-related psychosocial wellbeing in Poso, Indonesia, as preparation for conducting a cluster randomized trial of a psychosocial intervention. We employed focus groups with children (N = 9), parents (N = 11), and teachers (N = 8), as well as semi-structured interviews with families affected by communal violence (N = 42), and key informants (N = 33). An interrelated set of problems was found that included poverty, an indigenized trauma construct, morally inappropriate behavior, inter-religious tensions, and somatic problems. Participants emphasized social-ecological interactions between concerns at different systemic levels, although problems were mainly addressed through informal care by families. The programmatic and research implications of these findings are discussed.

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.

Development of a multi-layered psychosocial care system for children in areas of political violence.

Few psychosocial and mental health care systems have been reported for children affected by political violence in low- and middle income settings and there is a paucity of research-supported recommendations. This paper describes a field tested multi-layered psychosocial care system for children (focus age between 8-14 years), aiming to translate common principles and guidelines into a comprehensive support package. This community-based approach includes different overlapping levels of interventions to address varying needs for support. These levels provide assessment and management of problems that range from the social-pedagogic domain to the psychosocial, the psychological and the psychiatric domains. Specific intervention methodologies and their rationale are described within the context of a four-country program (Burundi, Sri Lanka, Indonesia and Sudan). The paper aims to contribute to bridge the divide in the literature between guidelines, consensus & research and clinical practice in the field of psychosocial and mental health care in low- and middle-income countries.