School-based Psychosocial Intervention for Children Affected by Violence: Cluster Randomized Trials in Burundi and Indon

1. 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

2. 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

3. 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)

4. 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

5. 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

6. 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

7. Outcome Instruments * parent-rated, ** both child- and parent-rated

8. 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

9. 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

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

11. Treatment status # house-hold Gender .11 .09 .07 10 SS mat T1 -.20 SS guid T1 .11 Δ funct. T1-3 Δfunct.T1-2 -.63 -.91 SS total T1 Δ SS mat T1-2 SS play T1 -.18 -.09 .13 .12 -.14 .14 -.16 -.18 Coping # T1 Coping sat T1 -.12 .08 -.11 -.12 -.53 Δ PTSD T1-2 -.65 Δ PTSD T1-3 -.08 Δ Hope T1-2 Δ Hope T1-3 Indonesia Treatment Mechanisms

12. 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?

13. 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)

14. 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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