1. Efficacy of Child Psychosocial Interventions: Synthesis of Cluster Randomized Trials in Burundi, Indonesia, Nepal, and Sri Lanka Wietse A. Tol-HealthNet TPO, Amsterdam, the Netherlands Mark J.D. Jordans-HealthNet TPO, Amsterdam, the Netherlands Ivan H. Komproe-HealthNet TPO & Utrecht University, the Netherlands Joop T.V.M. de Jong-VU University, Amsterdam, the Netherlands & Boston University School of Medicine

2. Introduction In 2007, 34 armed conflicts 191 million lives lost in 25 largest wars in 20 th century 60% not engaged in fighting 67 million displaced, out of whom 26 million conflict-related Internally Displaced Persons

3. Introduction Psychiatric epidemiology with conflict- affected populations (Steel et al, JAMA 2009) 161 articles, 81,866 individuals, 40 countries Weighted percentages: PTSD 30.6%, depression 30.8% Torture, potentially traumatic events, level of political terror in country are risk factors; time since conflict associated with decrease in symptoms

4. Introduction Despite the mental health burden of political violence, and evidence for mental health treatments in developing countries, there is a lack of evidence for treatments in war- affected settings E.g. among children, only 4 rigorous studies have been published – 2 Bosnia (Layne et al, 2009) – 1 Uganda (Bolton et al, – 1 Indonesia (Tol et al, 2008)

5. Methods: Intervention 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)

6. Methods: Intervention 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

7. Methods As part of a larger public health project for children in war-affected settings www.psychosocialcarechildren.org www.psychosocialcarechildren.org School-aged children in Burundi, Indonesia, Nepal, and Sri Lanka

8. Methods: Cluster Randomized Trials Baseline assessment TreatmentFollow-up #1 Follow-up #2 Treatment Burundi (n=329) 0 weeksCBI for treatment cond. 6 weeks (88%) 5 Months (84%) CBI for waitlist cond. Indonesia (N=403) 0 weeksCBI for treatment cond. 6 weeks (98%) 6 Months (94%) CBI for waitlist cond. Nepal (N=325) 0 weeksCBI For treatment cond. 6 weeks (99%) CBI for waitlist cond. Sri Lanka (N=399) 0 weeksCBI for treatment cond. 6 weeks (100%) 4 Months (99%) CBI for waitlist cond.

9. Methods: Instruments BurundiIndonesiaNepalSri Lanka PTSD symptoms- CPSS* -CPSS Depressive symptoms - DSRS* -DSRS Anxiety- SCARED-5 Locally relevant constructs - Supernatural -Grief -Somatic- Supernatural -Moral Other- Aggression -SDQ - SDQ* Function Impairment - Locally constructed - Locally constructed* - Locally constructed Strengths- Hope - Coping - Social Support - Family Connectedness - Social Capital - Hope - Coping - Social Support - Family Connectedness - Hope - Pro-social behavior - Coping * Locally validated instruments

10. Results: Burundi Mean change difference Mean change difference 95% CI Child-rated% changeMeanSE PTSD symptoms-36.7.851.30-1.70 – 3.41 Anxiety symptoms-23.6.13.28-.42 –.68 Depressive symptoms-17.1-.69.75-2.16 –.79 Supernatural complaints-56.0-.16.31-.77 –.46 Grief complaints-36.7.49.44-.37 – 1.36 Function impairment-10.0.45.76-1.04 – 1.93 Hope11.8-.71.95-2.58 – 1.16 Coping repertoire-5.8-.10.40-.89 –.69 Coping satisfaction-8.4.671.07-1.43 – 2.77 Social support-.8.88.70-.49 – 2.26 Social capital1.1.18.51-.82 – 1.18 Parent-rated% changeMeanSE Aggression-6.11.89 -1.83 – 5.61 Function impairment-8.71.34.67.04 – 2.66 Family connectedness.5-.23.79-1.79 – 1.33

11. Results: Burundi (age and gender) Treatment effects for girls on anxiety Treatment effects for boys on family connectedness Negative effects on social support for boys Statistically significant, but marginal differences

12. Results: Indonesia Mean change difference Mean change difference 95% CI Child-rated% changeMeanSE PTSD symptoms-43.2-2.78.89-1.02 – 4.52 Trauma idiom-30.0-.50.31-.12 – 1.11 Depressive symptoms-5.48-.70.40-.08 – 1.49 Anxiety symptoms-21.1-.12.22-.31 -.56 Function impairment-13.8-.52.48-.43 – 1.46 Hope2.72.21.66-3.52 - -.91 Coping repertoire.1-.07.24.55 -.40 Coping satisfaction-.2-1.35.69-2.69 - -.00 Social support3.5-.05.47-.97 -.86 Parent-rated Aggression-8.4-.801.28-3.32 – 1.72 Function impairment-11.8.63.53-.41 – 1.67 Family connectedness1.6.22.31-.39 -.83

13. Results: Indonesia (age and gender) Treatment effects for girls on PTSD symptoms and function impairment

14. Results: Nepal Mean change difference Mean change difference 95% CI Child-rated% changeMeanSE PTSD symptoms-12.07-.13.85(-2.40 to 2.66) Depression symptom-15.911.841.00(-.62 to 4.29) Anxiety symptoms-15.83.46.40(-.51 to 1.43) Aggression-.12.55.74(-1.27 to 2.38) Psychological difficulties-15.611.771.14(-1.03 to 4.56) Function impairment-29.213.101.72(-1.12 to 7.31) Hope9.71.62.70(-2.34 to 1.10) Pro-social behaviour11.12-2.351.55(-6.15 to 1.45)

15. Results: Nepal (age and gender) Treatment effects for girls on pro-social behavior Treatment effects for boys on psychological difficulties and aggression Treatment effects for older children on hope

16. Results: Sri Lanka Mean change difference Mean change difference 95% CI Child-rated% changeMeanSE PTSD symptoms-38.0-.37.45-1.26 -.52 Anxiety symptoms-43.3.08.10-.12 -.28 Depressive symptoms-19.7-.07.24-.55 -.39 Supernatural complaints-43.1.15.10-.05 -.34 Moral complaints-31.7.15.12-.08 -.38 Psychological difficulties-27.6.31.28-.25 -.87 Function impairment-47.8.17.20-.21 -.56 Coping repertoire-6.3-.07.17-.40 -.27 Coping satisfaction-4.7-.13.44-.99 -.73 Pro-social behavior.1-.04.09-.22 -.14

17. Results: Sri Lanka (age and gender) Treatment effects for boys on anxiety and depressive complaints Treatment effects for girls on social-moral complaints Borderline significance for function impairment (boys)

18. Overview of results BurundiIndonesiaNepalSri Lanka PTSD symptoms- CPSS* -CPSS Depressive symptoms - DSRS* -DSRS Anxiety- SCARED-5 Locally relevant constructs - Supernatural -Grief -Somatic- Supernatural -Moral Other- Aggression -SDQ - SDQ* Function Impairment - Locally constructed - Locally constructed* - Locally constructed Strengths- Hope - Coping - Social Support - Family Connectedness - Social Capital - Hope - Coping - Social Support - Family Connectedness - Hope - Pro-social behavior - Coping * Locally validated instruments

19. Discussion Appropriateness of (resilience) measures, in comparison with community feedback Influence of context on efficacy of treatment Gender differences Further work on treatment mechanisms Debate on universal/selective vs. indicated interventions, must be informed by yet to be proven protective & risk indicators

20. Acknowledgement This project and research was conducted with financial assistance from PLAN Netherlands Collaborators TPO Burundi (Aline Ndayisaba, Seraphine Hakizimana) Church World Service Indonesia (Dessy Susanty) TPO Nepal (Nagendra Luitel) Shanthiham (Anavarathan Vallipuram, Sambasivamoorthy Sivayokan)