school-based psychosocial intervention for children affected by violence: cluster randomized trials...
TRANSCRIPT
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School-based Psychosocial Intervention for Children Affected by Violence: Cluster
Randomized Trials in Burundi and Indonesia
Wietse A. Tol - HealthNet TPO/ VU University Amsterdam
Ivan H. Komproe - HealthNet TPO, Amsterdam
Mark J.D. Jordans - HealthNet TPO / VU University Amsterdam
Dessy Susanty - CWS Indonesia
Aline Ndayisaba - HealthNet TPO Burundi
Robert D. Macy - Center for Trauma Psychology, Boston
Joop T.V.M. de Jong - VU University Amsterdam/ Boston University School of Medicine
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Rationale
• Increased implementation of psychosocial programs for children affected by war in Low- and Middle Income Countries
• But very little evidence base (3 randomized trials: 1 Uganda, 2 Bosnia)
• Especially school-based programs are popular
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Introduction: the Class-room Based Intervention (CBI)
• 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)
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Introduction: the Class-room Based Intervention (CBI)
• 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
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Methods
• Qualitative pre-study to select, adapt and construct outcome instruments
– Key Informant Interviews
– Focus Groups with children, parents, teachers
– Semi-structured interviews
• Random selection of schools in most affected areas (Northern Burundi & Poso district in Central Sulawesi, Indonesia); children aged 8 – 12
• Screening in schools on a) exposure to political violence, b) PTSD symptoms, c) anxiety symptoms, d) (Burundi) depressive symptoms
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Methods
• Assignment to either treatment (Burundi n=153, Indonesia n=182) or waitlist groups (Burundi n=176, Indonesia n=221). Total Burundi n=329, Indonesia n=403
• Measurements at 1) baseline, 2) directly after intervention, and 3) 6 months after intervention
• Intent-to-treat analyses based on a) mean changes and b) longitudinal growth modeling
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Outcome InstrumentsBurundi Indonesia
Exposure Locally constructed Locally constructed
Symptoms (standardized) PTSD, anxiety, depressive, aggression*
PTSD, anxiety, depressive, aggression*
Symptoms (locally constructed)
Supernatural complaints, grief
Somatic “trauma” idioms
Functioning Locally constructed** Locally constructed**
Resilience Hope, coping, social support, family connectedness*, social capital
Hope, coping, social support, family connectedness*, peer relations
* parent-rated, ** both child- and parent-rated
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Burundi results
• No lasting (6-month) changes seen except for functioning according to parents (d=.35)
• Temporary negative effect on depressive and supernatural complaints (immediately after)
• Longitudinal growth modeling shows:– Higher exposure inhibits growth on functioning– Older children show less growth on social support– Displacement inhibits growth on social capital and
grief symptoms– Girls show more growth of hope
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Indonesia results• Immediately after intervention, significant changes seen
on PTSD (d=.55), trauma idiom (d=.21), depressive symptoms (d=.31), functioning (d=.42), and hope (d=.29)
• At 6-month follow-up these changes remain; PTSD (d=.44), trauma idiom (d=.21), depressive symptoms (d=.24), functioning (d=.26), and hope (d=.38)
• Longitudinal growth modeling confirms an effect of treatment for:
– Girls: PTSD symptoms, function impairment and hope
– Boys: Hope
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Indonesia Treatment Mechanisms1. Identification of
moderators/ mediators of treatment (univariate): social support, coping, family connectedness
2. All identified moderators and mediators in one model (SEM; next slide)
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Indonesia Treatment MechanismsTreatm
ent status
Δ SS mat T1-2
SS mat T1
# house-hold
Δ Hope T1-3
Δ Hope T1-2
Δ PTSD T1-3
Δ PTSD T1-2
Coping sat T1
SS play T1
SS total T1
SS guid T1
Gender
Coping # T1
Δfunct.T1-2
Δ funct. T1-3
-.18
-.16 .14
-.09
-.20
.13 .12
-.18
-.65 -.08 -.53
-.63
.11
10
.11
.08
-.12
-.12-.11
-.14
-.91
.07
.09
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Discussion: Burundi
• CBI not effective
• Exposure/ displacement/ age/ gender are important factors to consider when designing alternatives
• Qualitative research has shown severe damage of civil war and poverty on all socio-ecological levels (members of families, schools, and communities) all mention specific problems in taking care of children. These need to be addressed first?
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Discussion: Indonesia (see Tol et al, JAMA 08)
• CBI moderately effective in targeting PTSD symptoms, comparable to cognitive-behavioral techniques (CBT) techniques in Western settings (d=.43 for PTSD symptoms [Silverman et al, 2008])
• Stronger effect for girls• Some changes at 6-month are not sustained; booster
sessions needed?• Changes to CBI could include:
– Working with the specific trauma idioms in more detail
– Integration with other interventions addressing major risk factors (poverty reduction, peace-building)
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Future Focus
• Examine treatment mechanisms;– Role of child characteristics (e.g. violence exposure, gender,
age, coping styles)
– Role of social-ecological environment (e.g. social support, family variables, social capital)
• Based on this, adapt intervention
• More focused trials
• Cost-effectiveness
• Interaction with poverty?
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THANK YOU