Follow-up and Mediation Outcomes of a Movement-Based Mental Health Promotion Intervention for Refugee Children in Uganda.

OBJECTIVE: There is limited evidence for the effectiveness of mental health promotion interventions in low- and middle-income settings, especially for longer-term benefits. This study evaluates the 5-month follow-up outcomes of a movement-based mental health promotion intervention (TeamUp) for refugee children in Northern Uganda (West Nile) and further investigates what explains longer-term benefits. METHODS: This quasi-experimental study was conducted in four primary schools, randomly allocated to an experimental or a control condition. Enrolled in the study were 549 children ages 10-15 years (n = 265 TeamUp; n = 284 control group). Primary outcomes were psychosocial well-being (Stirling Children's Wellbeing Scale), attitude toward school, and satisfaction with friendships (Multidimensional Students Life Satisfaction Scale [Friends and School subscales]). Mediators included social connectedness and sense of agency. RESULTS: At 5 months postintervention, 467 (85.1%) children were retained. Intent-to-treat analyses demonstrated sustained benefits for TeamUp for well-being (estimated mean difference -1.88, 95% CI -3.14 to -0.66, p = .003, effect size Cohen's d = 0.25) and friendships (-1.52, 95% CI -2.55 to -0.48, p = .005, d = 0.25). There were no significant between-group differences for attitude toward school. Secondary benefits were shown for traumatic stress (2.18, 95% CI 0.45 to 3.91, p = .014, d = 0.21), quality of life (-1.29, 95% CI -2.31 to -0.30, p = .014, d = 0.21), bullying (0.53, 95% CI 0.08 to 0.97, p = .020, d = 0.20), and depression symptoms (1.31, 95% CI 0.09 to 2.52, p = .035, d = 0.18). Increased sense of connectedness mediates the effect of TeamUp on improving well-being (indirect effect = 0.30, SE = 0.13, p = .001), explaining 15% of variance. CONCLUSION: This study shows sustained benefits of a mental health promotion intervention 5 months postintervention. Prolonged benefits are explained by an increase in social connectedness.

Evaluating a Movement-Based Mental Health Promotion Intervention for Refugee Children in Uganda: A Quasi-Experimental Study.

OBJECTIVE: Mental health promotion interventions are widely implemented in humanitarian settings and low- and middle-income contexts (LMICs), yet evidence on effectiveness is scarce and mixed. This study evaluated the movement-based mental health promotion intervention "TeamUp" in Bidibidi refugee settlement, in Northern Uganda. METHOD: A quasi-experimental study including four schools (two per arm) assessed the outcomes of 10- to 15-year-old South Sudanese and Ugandan children (n = 549). Randomly allocated, they either participated in up to 11 TeamUp sessions (n = 265) provided by trained facilitators; or belonged to a control group, which continued care as usual (n = 284). Primary outcomes measured psychosocial wellbeing, friendships and attitude to school; secondary outcomes included traumatic distress, depressive symptoms, quality of life, physical health, bullying, interoceptive awareness, and irritability. Data were collected at baseline and endline. RESULTS: Children joining TeamUp, showed significantly more improvements on primary outcomes: emotional and psychosocial wellbeing (Mdiff = -1.49, SE = 0.6, p = .01), satisfaction with and attitude toward school (-0.57, SE = 0.2, p = .004); and secondary outcomes: traumatic stress (2.64, SE = 0.8, p < .001), health-related quality of life (-1.56, SE = 0.4, p = .001), physical health (-0.78, SE = 0.3, p = .014) and the TeamUp mechanisms of action scale (-3.34, SE = 0.9, p < .001), specifically the subscales social connectedness (-0.74, SE = 0.3, p = .007) and sense of agency (-0.91, SE = 0.3, p = .005), compared to the control group. No significant differences were found on bullying, interoceptive awareness, irritability and depressive symptoms. CONCLUSION: The results are promising for TeamUp as a mental health promotion intervention for children affected by armed-conflict, displacement and on-going adversity. Further research will need to assess the intervention's effectiveness.

Supporting parenting among Syrian refugees in Lebanon: a randomized controlled trial of the caregiver support intervention.

BACKGROUND: Parenting interventions in humanitarian settings have prioritized the acquisition of parenting knowledge and skills, while overlooking the adverse effects of stress and distress on parenting-a key mediator of refugee children's mental health. We evaluated the effectiveness of the Caregiver Support Intervention (CSI), which emphasizes caregiver wellbeing together with training in positive parenting. METHODS: We conducted a two-arm randomized controlled trial of the CSI with Syrian refugees in Lebanon, with an intent-to-treat design, from September 2019-December 2020. A total of 480 caregivers from 240 families were randomized to the CSI or a waitlist control group (1:1). Retention from baseline to endline was 93%. Data on parenting and caregiver psychological wellbeing were collected at baseline, endline, and three-month follow-up. Prospective trial registration: ISRCTN22321773. RESULTS: We did not find a significant change on overall parenting skills at endline (primary outcome endpoint) (d = .11, p = .126) or at follow-up (Cohen's d = .15, p = .054). We did find a significant effect on overall parenting skills among participants receiving the full intervention-the sub-sample not interrupted by (COVID-19) (d = 0.25, p < .05). The CSI showed beneficial effects in the full sample at endline and follow-up on harsh parenting (d = -.17, p < .05; d = .19, p < .05), parenting knowledge (d = .63, p < .001; d = .50, p < .001), and caregiver distress (d = -.33, p < .001; d = .23, p < .01). We found no effects on parental warmth and responsiveness, psychosocial wellbeing, stress, or stress management. Changes in caregiver wellbeing partially mediated the impact of the CSI on harsh parenting, accounting for 37% of the reduction in harsh parenting. CONCLUSIONS: The CSI reduced harsh parenting and caregiver distress, and demonstrated the value of addressing caregiver wellbeing as a pathway to strengthening parenting in adversity. These effects were achieved despite a pandemic-related lockdown that impacted implementation, a severe economic crisis, and widespread social unrest. Replication under less extreme conditions may more accurately demonstrate the intervention's full potential.

A mathematical model for the simulation of the contraction of burns.

A continuum hypothesis-based model is developed for the simulation of the contraction of burns in order to gain new insights into which elements of the healing response might have a substantial influence on this process. Tissue is modeled as a neo-Hookean solid. Furthermore, (myo)fibroblasts, collagen molecules, and a generic signaling molecule are selected as model components. An overview of the custom-made numerical algorithm is presented. Subsequently, good agreement is demonstrated with respect to variability in the evolution of the surface area of burns over time between the outcomes of computer simulations and measurements obtained in an experimental study. In the model this variability is caused by varying the values for some of its parameters simultaneously. A factorial design combined with a regression analysis are used to quantify the individual contributions of these parameter value variations to the dispersion in the surface area of healing burns. The analysis shows that almost all variability in the surface area can be explained by variability in the value for the myofibroblast apoptosis rate and, to a lesser extent, the value for the collagen molecule secretion rate. This suggests that most of the variability in the evolution of the surface area of burns over time in the experimental study might be attributed to variability in these two rates. Finally, a probabilistic analysis is used in order to investigate in more detail the effect of variability in the values for the two rates on the healing process. Results of this analysis are presented and discussed.

Short-term memory development: differences in serial position curves between age groups and latent classes.

In studies on the development of cognitive processes, children are often grouped based on their ages before analyzing the data. After the analysis, the differences between age groups are interpreted as developmental differences. We argue that this approach is problematic because the variance in cognitive performance within an age group is considered to be measurement error. However, if a part of this variance is systematic, it can provide very useful information about the cognitive processes used by some children of a certain age but not others. In the current study, we presented 210 children aged 5 to 12 years with serial order short-term memory tasks. First we analyze our data according to the approach using age groups, and then we apply latent class analysis to form latent classes of children based on their performance instead of their ages. We display the results of the age groups and the latent classes in terms of serial position curves, and we discuss the differences in results. Our findings show that there are considerable differences in performance between the age groups and the latent classes. We interpret our findings as indicating that the latent class analysis yielded a much more meaningful way of grouping children in terms of cognitive processes than the a priori grouping of children based on their ages.

Validation of Arabic versions of the child psychosocial distress screener and pediatric symptom checklist for young adolescents living in vulnerable communities in Lebanon.

BACKGROUND: In humanitarian settings, brief screening instruments for child psychological distress have potential to assist in assessing prevalence, monitoring outcomes, and identifying children and adolescents in most need of scarce resources, given few mental health professionals for diagnostic services. Yet, there are few validated screening tools available, particularly in Arabic. METHODS: We translated and adapted the Child Psychosocial Distress Screener (CPDS) and the Pediatric Symptom Checklist (PSC) and conducted a validation study with 85 adolescents (aged 10-15) in Lebanon. We assessed internal consistency; test-retest reliability; convergent validity between adolescent- and caregiver-report and between the two measures; ability to distinguish between clinical and non-clinical samples; and concurrent validity against psychiatrist interview using the Kiddie Schedule for Affective Disorders and Schizophrenia. RESULTS: The translated and adapted child-reported PSC-17 and PSC-35, and caregiver-reported PSC-35 all showed adequate internal consistency and test-retest reliability and high concurrent validity with psychiatrist interview and were able to distinguish between clinical and non-clinical samples. However, the caregiver-reported PSC-17 did not demonstrate adequate performance in this setting. Child-reported versions of the PSC outperformed caregiver-reported versions and the 35-item PSC scales showed stronger performance than 17-item scales. The CPDS showed adequate convergent validity with the PSC, ability to distinguish between clinical and non-clinical samples, and concurrent validity with psychiatrist interview. Internal consistency was low for the CPDS, likely due to the nature of the brief risk-screening tool. There were discrepancies between caregiver and child-reports, worthy of future investigation. For indication of any diagnosis requiring treatment, we recommend cut-offs of 5 for CPDS, 12 for child-reported PSC-17, 21 for child-reported PSC-35, and 26 for caregiver-reported PSC-35. CONCLUSIONS: The Arabic PSC and CPDS are reliable and valid instruments for use as primary screening tools in Lebanon. Further research is needed to understand discrepancies between adolescent and caregiver reports, and optimal methods of using multiple informants.

The development of verbal and visual working memory processes: a latent variable approach.

Working memory (WM) processing in children has been studied with different approaches, focusing on either the organizational structure of WM processing during development (factor analytic) or the influence of different task conditions on WM processing (experimental). The current study combined both approaches, aiming to distinguish verbal and visual processing in order to investigate WM development. We investigated recall performance under different task conditions in a sample of 5- to 13-year-olds, applying latent class regression analysis. In this analysis, we examined latent classes (subgroups) within the sample that differed in terms of processing type. The interpretations of the latent classes were validated internally using characteristics of the latent classes and externally using recall performance of words and figures. The results showed that children of different developmental stages used the same type of processing under the same conditions. However, due to developmental differences, their overall performances differed, showing groups of children who were successful in verbal or visual processing and groups of children who were not. This study shows and discusses the importance of disentangling the influence of task conditions from the influence of WM development when interpreting recall performance in children.

Assessing stigma in low- and middle-income countries: A systematic review of scales used with children and adolescents.

INTRODUCTION: Stigmatization contributes to health inequalities, impacting the wellbeing of children and adolescents negatively. Addressing stigmatization requires adequate measurement. Our systematic review synthesizes the content of scales used with children and adolescents in low- and middle-income countries (LMICs) across stigmas, and examines their comparability and level of cultural adaptation. METHODS: Ten databases were systematically searched combining three sets of search terms: (i) stigma, (ii) scales, and (iii) LMICs. Studies conducted in LMICs, with a sample with mean age below 18 and reporting a minimum of one stigma scale, were eligible. We allocated scale items to four frameworks: (i) dimensions, or drivers of stigmatization; (ii) target variants, or types of stigmatization; (iii) socio-ecological levels, and (iv) cross-cultural equivalence, or scale adaptation to context/population. Based on percentages, we compared scale content per age cohort, stigma status, region, and stigma category. RESULTS: Out of 14,348 records, we included 93 articles (112 scales). Most studies focused on adolescents (12-18 years). Twelve scales were used more than once, seven were used across regions, and four were employed for multiple stigmas. Physical health stigma, and HIV/AIDS-related stigma in particular, was measured most; mental health and multiple/generic stigmas least. Physical and mental health scales were generally more comprehensive, i.e., measuring more stigma facets. In general, scales consistently measured two of the 21 included stigma facets, namely the disruptiveness dimension and the community level. Cross-cultural equivalence was moderate; conceptual and measurement equivalence were high. DISCUSSION: Although scales were largely comparable in how they measure stigma, they failed to reflect the complexity of the stigmatization process and fell short of existing stigma frameworks and qualitative research. Stigma research with children should work towards cross-culturally validated stigma scale sets which incorporate more facets of existing stigma frameworks, thus facilitating comparability across cultural contexts and informing intervention development and evaluation.

Process evaluation of TeamUp: a movement-based psychosocial intervention for refugee children in the Netherlands.

BACKGROUND: Nearly 60,000 people applied for asylum in the Netherland in 2015, confronting the governmental structures and services with great administrative, logistical and service provision challenges. Refugee children's psychosocial needs and wellbeing are often overlooked, and post-migration support is of pivotal importance. METHODS: An easy accessible movement-based psychosocial intervention, called TeamUp, was developed for children aged 6-17 living in refugee reception centres. A mixed-method process evaluation was conducted of (1) implementation process, assessing attendance (n = 2183 children, and n = 209 children); (2) implementation quality, using structured observations at two time points to evaluate facilitator's (2a) individual-level fidelity (n = 81 facilitators); (2b) team-level fidelity (n = 22 teams); (2c) facilitators' competencies (n = 81); (2d) trainee perceived self-efficacy pre-post training (n = 73); and (3) perceptions on implementation and outcomes, employing a survey (n = 99), focus group discussions and key informant interviews with children (n = 94), facilitators (n = 24) and reception centre staff (n = 10). RESULTS: Attendance lists showed a mean of 8.5 children per session, and children attending 31.3% of sessions. Structured observations demonstrated 49.2% and 58.2% individual-level fidelity, 72.5% and 73.0% team-level fidelity, and 82.9% and 88.4% adequacy in competencies, each at T1 and T2 respectively. The main reported challenges included managing children's energy regulation (e.g. offering settling moments) and challenging behaviour. Training participation significantly improved perceived self-efficacy for trainees. The facilitator survey demonstrated on average, high satisfaction and self-efficacy, low experienced burden, and high perceived capacity-building support. Qualitatively, TeamUp was positively perceived by all stakeholders and was regarded as contributing to children's psychosocial outcomes. CONCLUSION: (1) Attendance and group size were lower than expected. (2) The intervention's facilitator fidelity ranged from moderate to adequate-exhibiting a need for specific fidelity and capacity strengthening-while facilitator competencies were high. Trainee's perceived self-efficacy improved significantly following a 2-day training. (3) Facilitators expressed high levels of satisfaction, self-efficacy and support, and low burden. The intervention was positively perceived by all stakeholders and to have a positive impact on children's psychosocial learning and wellbeing.

Proactive detection of people in need of mental healthcare: accuracy of the community case detection tool among children, adolescents and families in Sri Lanka.

BACKGROUND: Most children and adolescents in need of mental healthcare remain untreated even when services are available. This study evaluates the accuracy of a new tool, the Community Case Detection Tool (CCDT). The CCDT uses illustrated vignettes, two questions and a simple decision algorithm to support proactive community-level detection of children, adolescents and families in need of mental healthcare to improve help-seeking. METHODS: Trusted and respected community members in the Eastern Province of Sri Lanka used the CCDT in their daily routine. Children and families detected as potentially in need of mental healthcare based on utilizing the CCDT (N = 157, aged 6-18 years) were invited for a clinical interview by a mental health counsellor using the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). The CCDT results were compared against the results of the clinical interview. The concurrent validity and performance of the CCDT were also evaluated by comparing the CCDT outcomes against the Strengths and Difficulties Questionnaire (SDQ). RESULTS: 7 out of 10 children and families detected by community members using the CCDT were confirmed to be in need for treatment (positive predictive value [PPV] = 0.69; 0.75 when compared to the SDQ). Detections based on the family problem vignette were most accurate (PPV = 0.76), followed by the internalising problem vignette (PPV = 0.71) and the externalising problem vignette (PPV = 0.62). CONCLUSIONS: The CCDT is a promising low-cost solution to overcome under-detection of children and families in need of mental healthcare. Future research should focus on evaluating the effectiveness, as well as additional strategies to improve help-seeking.

Protocol for a randomized control trial of the caregiver support intervention with Syrian refugees in Lebanon.

BACKGROUND: There is evidence that chronic stress negatively impacts parenting among refugees and other war-affected communities. Persistent parental stress and distress may lead to unresponsive, anxious, or overly harsh parenting and a corresponding increase in emotional and behavior problems among children. Most parenting interventions emphasize the acquisition of knowledge and skills; however, this overlooks the deleterious effects of chronic stress on parenting. The Caregiver Support Intervention (CSI) aims to strengthen quality of parenting skills by lowering stress and improving psychosocial wellbeing among refugee caregivers of children aged 3-12 years, while also increasing knowledge and skills related to positive parenting. The CSI is a nine-session psychosocial group intervention delivered by non-specialist providers. It is intended for all adult primary caregivers of children in high-adversity communities, rather than specifically targeting caregivers already showing signs of elevated distress. METHODS/DESIGN: The primary objective of this study is to assess the effectiveness of the CSI through a parallel group randomized controlled study with Syrian refugee families in North Lebanon. Participants will be primary caregivers of children aged 3-12 years, with one index child per family. Families will be randomized to the CSI or a waitlist control group. A total of 240 families (480 caregivers) will be recruited into the study. Randomization will be at the family level, and CSI groups will be held separately for women and men. The study will be implemented in two waves. Outcomes for both arms will be assessed at baseline, post-intervention, and at a 3-month follow-up. The primary outcome is quality of parenting skills. Secondary outcomes include parental warmth and sensitivity, harsh parenting, parenting knowledge, and child psychosocial wellbeing. Putative mediators of the CSI on parenting are caregiver stress, distress, psychosocial wellbeing, and stress management. DISCUSSION: This trial may establish the CSI as an effective intervention for strengthening parenting in families living in settings of high adversity, particularly refugee communities. TRIAL REGISTRATION: International Society for the Registration of Clinical Trials, ISRCTN22321773. Registered on 5 August 2019.

Supporting Syrian families displaced by armed conflict: A pilot randomized controlled trial of the Caregiver Support Intervention.

BACKGROUND: The impact of armed conflict and displacement on children's mental health is strongly mediated by compromised parenting stemming from persistently high caregiver stress. Parenting interventions for refugees emphasize the acquisition of parenting knowledge and skills, while overlooking the deleterious effects of chronic stress on parenting. War Child Holland's Caregiver Support Intervention (CSI) aims to strengthen parenting by lowering stress and improving psychosocial wellbeing among refugee parents, while also increasing knowledge and skill related to positive parenting. The CSI is a nine-session group intervention delivered by non-specialist providers. OBJECTIVE: We describe the findings of a two-arm pilot randomized controlled trial of the CSI with Syrian refugees in Lebanon. The primary aim was to test the feasibility of our study methodology prior to conducting a definitive RCT. METHODS: We recruited 78 families (151 parents), who were randomized to the CSI or a waitlist control group. Data were collected at baseline and post-intervention. RESULTS: Randomization was successful, retention was high (99 %), as was intervention completion (95 % among women, 86 % among men). Implementation fidelity was excellent. Blinding was largely, though not completely effective. The CSI group showed significantly increased parental warmth and responsiveness, decreased harsh parenting, lowered stress and distress, improved psychosocial wellbeing, and improved stress management. CSI parents reported increased child psychosocial wellbeing. Control families showed no significant change on any variable. CONCLUSIONS: Findings demonstrate the feasibility of our methodology for a definitive RCT, and suggest that the CSI shows promise as a scalable approach to strengthening parenting in refugee communities. Trial registration # ISRCTN33665023.

Strengthening parenting in conflict-affected communities: development of the Caregiver Support Intervention.

BACKGROUND: There is robust evidence that compromised parenting, stemming from persistently high stress, mediates the impact of war and displacement on children's mental health and psychosocial wellbeing. Parenting interventions generally prioritize the acquisition of parenting knowledge and skills, while under-attending to parental stress and distress. This paper describes the development of the Caregiver Support Intervention (CSI), a nine-session group intervention for conflict-affected parents of children aged 3-13, that aims to strengthen parenting both indirectly, by lowering stress and improving psychosocial wellbeing among parents, and directly, by increasing knowledge and skill related to positive parenting. METHODS: We describe the multi-phase, iterative process by which we developed the CSI, and illustrate the essential role of community input in shaping the intervention and strengthening its cultural fit and perceived usefulness. We used focus group data from participants in successive cycles of implementation, feedback, and revision, as well as quantitative data and expert consultation to develop a culturally and empirically grounded intervention. RESULTS: This mixed-method, iterative approach to intervention development enabled us to develop a psychosocial intervention for conflict-affected caregivers that is feasible, acceptable, and perceived by participants as useful in addressing their own wellbeing and their parenting. Focus group data support the underlying model in which caregiver wellbeing powerfully influences parenting. CONCLUSIONS: Programs aimed at strengthening parenting in conflict-affected communities should substantively address caregiver wellbeing. An iterative approach incorporating community feedback can help ensure intervention acceptability and feasibility. We also illustrate the feasibility of involving men in parenting interventions.

Short term memory for serial order: unraveling individual differences in the use of processes and changes across tasks.

In this study we investigated whether we could distinguish the use of specific verbal and visual short term memory (STM) processes in children, or whether the differences in memory performance could be interpreted only in terms of quantitative differences. First, the number of processes involved in the responses on six STM tasks (serial order reconstruction) of 210 primary school children aged 5-12 years was examined by means of latent states. The number of items to reconstruct was manipulated to unravel quantitative differences in responses (high or low performance), and the similarity of the items was manipulated to distinguish qualitative differences in responses (verbal or visual processing). Furthermore, we examined how children changed from one type of process to another on tasks with list lengths of 3, 5, and 7 items by means of the dynamics between the latent states using a latent Markov model. The results showed that two latent states representing the use of specific verbal and visual STM processes could be distinguished on all the tasks. Moreover, two latent states showing merely differences in performance were also found. These findings underline the value of latent variable models to unravel differences between as well as within individuals in the use of cognitive processes.

Psychiatrists' view on the risk factors for aggressive behavior in psychotic patients.

In meta-analytic studies it was found that patients diagnosed with a psychotic disorder are at increased risk for displaying violent behavior. However, it remains largely unclear which specific factors contribute to the heightened risk for aggression in this patient group, nor what the views of psychiatrists are on this issue. A cross-sectional survey study was carried out and a survey questionnaire was developed to investigate the view of 652 psychiatrists on the relative contributions of various factors (e.g., illness related, personality, social influences) that might explain aggression in psychosis. It was found that psychiatrists generally view illness-related features as the most important determinant of aggression in these patients, followed by impulsivity/lack of insight and social influences, whereas personality characteristics are considered as least relevant. Latent class cluster analysis revealed that there are several subgroups of psychiatrists who attach different levels of importance to various types of risk factors. In these subgroups, two cluster contrasts were found: one representing differences in response style, and one representing differences in the evaluation of personality characteristics. Overall, psychiatrists seem to adopt a medical model when interpreting aggression in psychotic patients, although several subgroups of psychiatrists can be identified who have different opinions of such behavior.

Understanding planning ability measured by the Tower of London: an evaluation of its internal structure by latent variable modeling.

The Tower of London (TOL) is a widely used instrument for assessing planning ability. Inhibition and (spatial) working memory are assumed to contribute to performance on the TOL, but findings about the relationship between these cognitive processes are often inconsistent. Moreover, the influence of specific properties of TOL problems on cognitive processes and difficulty level is often not taken into account. Furthermore, it may be expected that several planning strategies can be distinguished that cannot be extracted from the total score. In this study, a factor analysis and a latent class regression analysis were performed to address these issues. The results showed that 4 strategy groups that differed with respect to preplanning time could be distinguished. The effect of problem properties also differed for the 4 groups. Additional analyses showed that the groups differed on average planning performance but that there were no significant differences between inhibition and spatial working memory performance. Finally, it seemed that multiple factors influence performance on the TOL, the most important ones being the score measurements, the problem properties, and strategy use.