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

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

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)

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

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

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

Outcome Instruments BurundiIndonesia ExposureLocally constructed Symptoms (standardized)PTSD, anxiety, depressive, aggression* Symptoms (locally constructed) Supernatural complaints, grief Somatic “trauma” idioms FunctioningLocally constructed** ResilienceHope, coping, social support, family connectedness*, social capital Hope, coping, social support, family connectedness*, peer relations * parent-rated, ** both child- and parent-rated

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

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

Indonesia Treatment Mechanisms 1.Identification of moderators/ mediators of treatment (univariate): social support, coping, family connectedness 2.All identified moderators and mediators in one model (SEM; next slide)

Indonesia Treatment Mechanisms Treatm 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. T

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?

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)

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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