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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 - PowerPoint PPT Presentation
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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
Presentation Contents• Introduction
– Rationale– The intervention
• Qualitative Study• Cluster Randomized Trial• Discussion
– Clinical implications
Acknowledgement
• This project and research was conduct with financial assistance from PLAN Netherlands
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
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
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
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
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
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
Cluster Randomized Trial: Selection• Random
selection of schools in Valikamam education zone; Tellipalai and Uduvil districts
• Screening in schools using a 7-item screener
Cluster Randomized Trial: Design
R
T1: 0 weeks
T2: 6 weeks
T3: 4 months
T2: 6 weeks
T1: 0 weeks
T3: 4 months
CBI
CBI
Treatment Condition (n=210)
Waitlist Condition (n=210)
Outcome InstrumentsConstruct Measure
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
Resilience Coping
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
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
Mixed Methods Regression AnalysesVariable 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 - - -
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
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:
child
family
Christian peers
Muslim n.hoods
Muslim peers
Consequences war Poso, IndonesiaConsequences war Poso, Indonesia
Christian n.hoods
Comm-unity
Peer/ school
familychild
Consequences war Burundi/ Sri Consequences war Burundi/ Sri LankaLanka
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)
THANK YOU