ISTSS 24 th Annual Meeting

1. ISTSS 24th 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 T1: 0 weeks CBI T2: 6 weeks T3: 4 months Treatment Condition (n=210) R T1: 0 weeks T2: 6 weeks T3: 4 months CBI Waitlist Condition (n=210)

13. Outcome Instruments

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

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. Consequences war Poso, Indonesia Christian n.hoods Christian peers child family Muslim peers Muslim n.hoods

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

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