1. ISTSS 24 th Annual Meeting School-Based Intervention for Children Affected by War: Cluster Randomized Trial in Northern Sri Lanka Wietse A. Tol-HealthNet TPO/ VU University Amsterdam Ivan H. Komproe-HealthNet TPO, Amsterdam Mark J.D. Jordans-HealthNet TPO / VU University Amsterdam A. Vallipuram-Shanthiham S. Sivayokan-Shanthiham Robert D. Macy-Center for Trauma Psychology, Boston Joop T.V.M. de Jong-VU University Amsterdam/ Boston University School of Medicine

2. Presentation Contents Introduction –Rationale –The intervention Qualitative Study Cluster Randomized Trial Discussion –Clinical implications

3. Acknowledgement This project and research was conduct with financial assistance from PLAN Netherlands

4. Rationale Increased popularity of psychosocial programs for children affected by war in LAMIC Evidence base remains weak (3 randomized trials: 1 Uganda, 2 Bosnia) Debates in field regarding appropriateness of psychiatric classification and treatment from high-income settings in other socio-cultural settings

5. Sri Lanka: Conflict Background 1983; ‘First Eelam War’ sparked by LTTE killings of 13 policemen 1987-1990 Indian Peacekeeping Forces; start of ‘Second Eelam War’ 1995 ‘Third Eelam War’ after peace talks break down 2002 ceasefire agreement Renewed large-scale violence from August 2006 70,000 killed since 1983 Currently 500,000 displaced

6. 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)

7. 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

8. Qualitative Pre-Study: Objectives Explore public health context before the start of the trial: (a) participants’ perspectives regarding the psychosocial consequences of armed conflict, and (b) current methods through which community members deal with these consequences Prepare culturally valid instruments to assess efficacy of intervention

9. Qualitative Pre-Study: Methods Rapid Ethnography –Key Informant Interviews (religious healers [Hindu, Christian], Ayurvedic practitioners, principals) –Semi-structured Interviews –Focus Group Discussions (children, parents, teachers) Construction of Child Function Impairment Scale –Brief participant observation –Diaries –Focus Groups

10. Qualitative Pre-Study: Results Selection, adaptation and systematic translation of contextually relevant standardized outcome measures (e.g. PTSD symptoms, depressive symptoms, coping) Construction of rating scales for local idioms of distress (e.g. exposure events, supernatural complaints) Construction of Child Function Impairment Scale

11. Cluster Randomized Trial: Selection Random selection of schools in Valikamam education zone; Tellipalai and Uduvil districts Screening in schools using a 7-item screener

12. Cluster Randomized Trial: Design R T1: 0 weeks T2: 6 weeks T3: 4 months T2: 6 weeks T1: 0 weeks T3: 4 months CBI Treatment Condition (n=210) Waitlist Condition (n=210)

13. Outcome Instruments ConstructMeasure Exposure (locally constructed)Past political violence and current war-related stressors Symptoms (standardized): PTSD, depressive, anxiety symptoms, general difficulties Child PTSD Symptom Scale (CPSS; Foa et al, 2001) Depression Self-Rating Scale (DSRS; Birleson et al, 1981) Self-report for Childhood Anxiety-Related Disorders - 5 item version (SCARED; Birmaher et al, 1997) Strengths & Difficulties Questionnaire (SDQ; Goodman, 2001) Symptoms (locally constructed)Supernatural complaints (e.g. evil spirits, witchcraft) “Morally inappropriate” behaviour (imitating violence, increased use of violence, ‘love’ relations) Functioning (locally constructed)Functioning in individual, family, peer, school and community domains ResilienceCoping

14. Cluster Randomized Trial: Procedures & Analysis Informed consent/ ethical approval from VU University and local education authorities Non-blinded assessments by locally trained assessors Mixed method regression analyses to take into account cluster effects due to randomization of schools

15. Cluster Randomized Trial: Results No statistically significant differences between study conditions at baseline Exposure to political violence increased significantly between baseline and first follow-up (both past violence and current difficulties), and 4-month follow-up (past violence) Exploratory analyses (based on mean scores) show intervention effects: –From baseline to 1-week follow-up: total difficulties (SDQ) (t=2.193, p=.029) and function impairment (t=3.928, p=.000) –No changes from baseline to 4-month follow-up

16. Mixed Methods Regression Analyses Variable Effective for group as a whole? Effective with gender effect? Effective with age effect? PTSD symptoms--- (.079) Depressive symptoms --- Anxiety symptoms-+ (.020)- Supernatural problems --- (.095) Social consequences--- Pro-social behavior--- (.056) Total difficulties SDQ--- Function impairment-- (.059)- Coping repertoire--- Coping satisfaction---

17. Discussion CBI moderately effective in short term on total difficulties and functioning Not effective on the long-term, although some borderline significant effects In comparison with previous cluster randomized trials: –Indonesia: CBI moderate effects on PTSD, hope, function impairment for girls –Burundi: CBI no longer-term effects –Palestine: CBI effective for younger boys and girls –Uganda: IPT effective for depression symptoms with girls, but no effects for creative play

18. Discussion Results may show that currently popular psychosocial interventions, which combine some form of creative- expressive/ play techniques and trauma-focused elements in groups at schools, are not sufficient when political violence affects wider social-ecological context Hypothesis based on qualitative data:

19. childfamily Christian peers Muslim n.hoods Muslim peers Consequences war Poso, Indonesia Christian n.hoods

20. Comm -unity Peer/ school familychild Consequences war Burundi/ Sri Lanka

21. Discussion Comprehensive programs are necessary that combine: –Primary prevention; targeting effects of political violence on context (e.g. poverty alleviation, damage to moral and social fabric) –Secondary prevention (e.g. assisting families at risk, substance abuse, domestic violence) –Tertiary prevention (e.g. targeting common mental disorders: depressive complaints most strongly with depressive complaints)

22. THANK YOU wtol@healthnettpo.org