On 6 January 1999, the Revolutionary United Front rebel group
attacked the capital city of Sierra Leone. During the invasion,
around 40000–50000 people were killed and 500000 civilians fled
the country.1Countless children saw family members being
burned alive, dismembered by machetes or tortured. Both the
nature and magnitude of warfare stressors vary from conflict to
conflict, as do the psychosocial effects produced by these events.
Research from war-torn countries indicates that higher levels of
exposure to traumatic events among children are associated with
higher levels of post-traumatic stress disorder.2–8In response to
the conflict, Plan International collaborated with the Ministry of
Youth, Education and Sports, and the United Nations Education,
Scientific and Cultural Organization (UNESCO), to implement a
psychosocial pilot project aimed at normalising displaced
children’s lives and alleviating psychological distress by participating
in nonformal education, trauma healing and recreation activities.
The major objectives of the pilot project were: (1) to assess the psy-
chosocial status of displaced children enrolled in the Rapid-Ed inter-
vention; and (2) to determine whether the Rapid-Ed intervention
reduced trauma symptoms that interfere with learning.9
The pre-test psychosocial assessment was administered at Trade
Center and Grafton camps for internally displaced persons
between 12 October and 2 November 1999, approximately 9–12
months after the rebel invasion. The post-test survey was adminis-
tered between 5 December 1999 and 10 January 2000, 4–6 weeks
after participants completed the nonformal education, trauma
healing and recreational activities at both camps.
Enrollment in the camp schools was mandatory for all school-age
children registered at Grafton and Trade Center camps. The
sampling approach was based on three strata:
(a) camp site;
(b) gender – a balance of about 50% for both male and female;
(c) class level at the camp schools.
A total of 315 displaced children aged 8–17 years were
randomly selected from the handwritten school registration lists
provided by the Ministry of Education, using rolled dice. All the
participants were interviewed in their mother tongue, Creole,
for the pre- and post-test surveys. A total of 97% of the pre-test
sample was re-interviewed for the post-test 4–6 weeks after com-
pleting the intervention. Nine children returned to their village
after completing the pre-test, resulting in a 3% reduction in the
post-test sample (n=306).
A detailed written and verbal explanation of the purpose of the
assessment, confidentiality issues and the voluntary nature of the
survey was provided to the supervisors at both camps prior to
administering the interviews. Written authorisation to participate
in the assessments and the intervention was obtained by Plan
staff from camp supervisors in the presence of the children.
Verbal permission was also obtained from each child before
conducting the interviews. Six camp teachers participated in
training to learn how to implement the Trauma Healing Module
of the intervention.
All 315 children who participated in the surveys were interviewed
individually by four locally trained female research assistants at
their respective camps. The semi-structured pre-test questionnaire
written in Creole contained four parts. Part I included basic
demographic items; Part II included a list of 34 ‘exposure to
war events’ items; and Part III contained a 15-item revised version
of the Impact of Events Scale (IES) developed by Horowitz et al.10
This scale focuses on intrusive images, avoidance of reminders,
arousal symptoms and associated post-traumatic stress reactions.
Respondents were asked how often they experienced symptoms
over the past 2 weeks, and the symptom frequency was assessed
Psychosocial intervention for war-affected
children in Sierra Leone
Leila Gupta and Catherine Zimmer
There are no psychosocial interventions to address both
educational needs and psychological distress among
displaced children in post-conflict settings.
To assess the psychosocial status of displaced children
enrolled in the Rapid-Ed intervention; and to determine
whether the Rapid-Ed intervention alleviated traumatic stress
symptoms that interfere with learning among war-affected
children in Sierra Leone.
A randomly selected sample of 315 children aged 8–18 years
who were displaced by war were interviewed about their
war experiences and reactions to the violence before and
after participating in the 4-week Rapid-Ed intervention
combining basic education with trauma healing activities.
High levels of intrusion, arousal and avoidance symptoms
were reported at the pre-test interviews conducted
9–12 months after the war. Post-test findings showed
statistically significant decreases in intrusion and arousal
symptoms (P<0.0001), a slight increase in avoidance
reactions (P<0.0001) and greater optimism about the
The findings suggest potential for combining basic education
with trauma healing activities for children in post-conflict
settings, but confirmatory studies using a control group are
needed. Conducting research in post-conflict settings
presents unique challenges.
Declaration of interest
None. Funding detailed in Acknowledgements.
The British Journal of Psychiatry (2008)
192, 212–216. doi: 10.1192/bjp.bp.107.038182
on a 4-point scale (‘Never’, ‘Rarely’, ‘Sometimes’ or ‘Often’). Part
IV included eight pilot items about children’s world view and
future perspectives. The pre-test interviews lasted 50–75 min.
The post-test questionnaire contained three parts. Part I
repeated the demographic questions; Part II included an 8-item
subjective assessment of children’s feelings11before and after
participating in the trauma healing activities; and Part III con-
tained the revised IES described above. The post-test interviews
lasted 20–30 min. After completing the interviews, the children
received two pieces of candy as a token of appreciation for parti-
cipating in the project. The subjective assessment questionnaire
asked children about the type of activities they engaged in during
the 4-week intervention (i.e. drawing pictures, story-telling,
writing essays, singing, dancing, role-playing and sports) and their
feelings ‘before’ and ‘after’ participating in the activities. The re-
maining four subjective assessment items addressed the prevalence
and intensity of selected post-traumatic stress symptoms (e.g.
‘How is your concentration now after sharing your experiences
from the war?’). The responses included ‘Much better’, ‘Better’,
‘Same’, ‘Worse’ or ‘Much worse’. The latter four items, which were
pilot-tested in Sierra Leone, may need to be revised to avoid
potential response bias in future studies.
The contextual meaning of each item from the pre-and post-test
instruments was carefully reviewed by the six-member Sierra
Leonean translation team to ensure cultural appropriateness and
linguistic accuracy. The final English–Creole version of both
questionnaires was verified by translating the Creole version back
into English, using a masked approach to ensure reliability and
face validity. The overall individual item correspondence between
the English–Creole translation and the Creole–English version was
96% for both questionnaires. The final Creole version of the pre-test
questionnaire was piloted on 25 children aged 8–18 years using a
convenience sampling technique. Three revisions were made based
on the pilot findings prior to administering the pre-test.
The information contained in the Rapid-Ed literacy and numeracy
modules was reviewed by a leading educational research specialist
in consultation with the Ministry of Education and the Plan
International staff to ensure that the content accurately reflected
the Sierra Leonean cultural context. The information on general
stress theory contained in the locally produced Rapid-Ed module
was modified by L.G. to integrate current theoretical information
on the neurophysiological aspects of traumatic stress reactions,
and to include detailed lesson plans for implementing the trauma
healing and recreation activities. The revised Trauma Healing
Module was then integrated into the existing Rapid-Ed literacy
lesson plans prior to implementing the pilot project in Sierra
Leone.12Before administering the Trauma Healing Module, the
camp teachers participated in a 6-h training session on basic child
development, current traumatic stress theory, loss and grief
reactions, and how to implement the structured trauma healing
and recreation activities. A total of eight 60-min structured
trauma healing activities were implemented in the camp classes
twice per week during the 4-week intervention. These activities
focused on reducing the children’s levels of emotional distress and
post-traumatic stress reactions that often interfere with learning
such as difficulty concentrating, nightmares, flashbacks and hyper-
(a) providing a safe environment to share their war experiences;
(b) providing accurate information about the war to clarify
misunderstandings and correct magical thinking;
(c) normalising children’s reactions to reassure them that they are
(d) rekindling a sense of optimism/hope about their future by
linking some of their positive memories before the war with
their present life and future aspirations.
The structured trauma healing activities included the following:
(a) sharing their war-related stories in pairs or small groups;
(b) drawing pictures about one of their worst memories (online
(c) sharing their drawings in small groups;
(d) writing essays about their experiences;
(e) taking part in role-plays;
(f) singing or performing traditional dances;
(g) playing musical instruments.
The children also participated in various recreational activities
for 20 min per session 4 days per week. These unstructured
activities (i.e. jump rope, volleyball, athletics, football, ball
tossing) enabled the children to engage in enjoyable physical
activities that helped release tension while providing respite from
their bad memories and/or painful feelings.
After all the interviews were completed, the data were coded, double
ate and multivariate analyses. Correlational analyses were conducted
assess the differences between groups for the pre- and post-test
samples, which varied across analyses because of missing data.
The demographic characteristics of the 315 children interviewed
in the pre-test survey are presented in Table 1. One-third of the
camp children lived with one parent, 20% lived with both parents
and the remaining children lived with a relative or guardian. A
total of 75% of children had been living at the camps for 4–7
months when the pre-test interviews were conducted and the
mean age was 10.7 years. The post-test interviews were conducted
on 306 children (n= 97%).
Exposure to war violence
The total number of war experiences to which the respondents an-
swered ‘Yes’ were added up to achieve an overall summary score
(alpha=0.80). Data analyses revealed that participants (n=311)
were exposed to an average of 25 war-related exposures, with a
range between 8 and 34 experiences (online Table DS1). Overall,
the percentages shown in Table DS1 reflect high levels of violence
where the majority of children witnessed someone being injured/
killed by guns, saw dead bodies/body parts, and houses being
burned. Altogether, 80% of the children experienced a death in
their immediate family, and more than half of them witnessed
the killing of their parent(s), sibling(s) or relatives. No significant
differences were found between males and females in terms of
number of exposures to war experiences (t=0.64, P=0.5214). How-
ever, a very small difference was found to be significant between
the two camps (t=3.83, P=0.0002) with children at Grafton
(mean=25.7) being exposed to 2.3 more violent events than those
at Trade Center (mean=23.4). A similarly small significant differ-
ence in number of exposures (mean difference=2.2, F=7.30,
P=0.0008) was evident between children aged 8–10 years and
Psychosocial intervention for war-affected children
Gupta & Zimmer
11–13 years. Figure DS1 provides an example of a trauma healing
activity completed by a 13-year-old boy, whose drawing shows a
rebel amputating a man’s hand using a machete.
The IES pre-test data in Table 2 show that the majority of
participants experienced intrusive recollections and intense
arousal symptoms. A total of 95% reported that they thought
about the event sometimes or often when they did not want to,
and 71% experienced recurrent pictures in their minds about
the worst event. Most of the children also reported increased arou-
sal symptoms such as irritability, hypervigilence, sleep distur-
bances and difficulty concentrating at school. Bad dreams or
nightmares associated with the violence they witnessed were
reported by 72%, and 76% were worried that they might not live
to be an adult. In terms of avoidance symptoms, almost all the
children said they sometimes or often tried to avoid reminders of
the violence. The correlation analyses conducted on the exposure
to violence and psychological reactions data revealed a positive
dose–response relationship, whereby greater exposure to war events
produced higher total IES scores (r=0.54, P50.0001). The positive
dose–response effect observed in this study is consistent with other
research findings in children affected by war from the former
Yugoslavia, the Middle East, Rwanda, and Afghanistan.5–8,13–15
The IES post-test data (alpha=0.73), also shown in Table 2,
revealed a significant decline in reported occurrence of intrusion
(alpha=0.57) and arousal symptoms (alpha=0.61), and a slight
increase in avoidance symptoms (alpha=0.74) following the inter-
vention. One possible explanation for the reported increase in
post-test avoidance reactions may be that the structured drawing
and writing activities were more effective at reducing the levels
activities targeted the arousal symptoms. Additional explanations
for this finding are provided in the discussion section below.
The difference in the total intrusion mean sub-scale scores at
the pre-test (mean=13.0) and post-test (mean=10.2) interviews
was statistically significant (t=14.5, P50.0001); and the difference
whereas the recreational
in the total arousal mean sub-scale scores at the pre-test
(mean=17.0) and the post-test (mean=8.7) was also statistically
significant (t=29.3, P50.0001) (Table 3). For the avoidance sub-
scale scores, the pre-test mean was 12.5 and the post-test mean
was slightly higher (mean=14.5, t=–6.8, P50.0001). One of the
most striking changes between the pre- and post-test study findings
was a 63% reduction in the frequency of intrusive images reported
by the participants. The most notable reduction in the frequency of
arousal symptoms reported between the pre-test (80%) and post-
test (9.9%) occurred among the children who had difficulty concen-
trating at school. The mean total IES score at the post-test was sig-
nificantly lower than the mean total pre-test IES score (32.9 and 42.5
respectively; t= 18.82, P50 .0001). The mean total IES scores were
also significantly lower at the post-test for both boys and girls within
every age group, irrespective of the time spent in camp and their
living situation. Baseline exposure to violence was strongly posi-
tively correlated with the total IES at pre-test. However, there is
no significant relationship between the exposures from the pre-
test on the total IES as measured after the intervention (r=0.12,
P=0.0526). These findings suggest that participation in the trauma
healing and nonformal education intervention may have reduced
the levels of the children’s psychological distress associated with
their exposure to the violence they witnessed during the war.
Subjective assessment of trauma healing intervention
The data below reflect the children’s subjective responses to five
questions about their feelings 4–6 weeks after participating in
the intervention. All 306 children who completed the question-
naire had participated in story-telling, small group discussions,
singing, dancing and jump rope, and 98% of the sample drew pic-
tures, participated in role-play, and engaged in volleyball, football
and catch. Overall, 75% of the respondents from the upper class
levels (classes 5 and 6) completed the writing activities. The
majority of children who participated in the trauma healing activ-
ities said they felt much better (22.3%) or better (73.4%) after
sharing their bad memories of the war. A total of 95% reported
that their concentration problems at school were also better or much
better, and 96% said their bad dreams and/or nightmares dimin-
ished. More than half of the children said they felt relief while
participating in the structured activities and 36% experienced sad-
ness. About 5% of the children reported mixed feelings or fear
while participating in the trauma healing intervention.
The magnitude of violent events witnessed by the children in this
study, coupled with the elevated levels of emotional distress and
traumatic stress symptoms reported, is sobering. Given the
sudden, cruel and interpersonal nature of the violence inflicted
at close range during the rebel invasion in Sierra Leone, it is no
wonder that these survivors experienced intrusive images, bad
dreams, nightmares and intense arousal symptoms. Not sur-
prisingly, the levels of exposure to violence as well as the intrusive
recollections, bodily arousal and avoidance reactions observed in
this sample are consistent with the findings from other studies
conducted in war-affected countries.7,8,14–17The data from this
pilot study integrating trauma healing activities with basic edu-
cation indicate that providing an opportunity for children
affected by war to share their bad memories/painful feelings in a
safe setting may significantly reduce the prevalence of intrusion
and arousal symptoms that interfere with learning, while restoring
a sense of optimism about the future. Overall, 96% reported a sig-
nificant reduction in concentration problems, sleep disturbances,
bad dreams and intrusive images after participating in the trauma
healing and recreation activities.
have been displaced by war in Sierra Leone (n=315)
Demographic characteristics of children who
Class at school
Mother or father
Duration spent in camp, months
Psychosocial intervention for war-affected children
However, the modest increase observed in the post-test avoid-
ance scores must be examined. Perhaps this finding may be par-
tially due to the unique nature of acute post-conflict situations,
since previous studies on the Rwandan genocide8as well as the
Taliban takeover in Kabul, Afghanistan,15reported similarly elev-
ated cognitive and behavioural avoidance reactions among chil-
dren. One might postulate that increased avoidance reactions
may serve as adaptive defense mechanisms in the short term,
which enable survivors to cope with the daily post-conflict realities
without being overwhelmed. However, prolonged denial and
avoidance of traumatic memories is considered maladaptive and
can result in future development of post-traumatic stress disorder.
Although these findings appear promising, it is important to note
the following limitations. The results of this pilot study would be
more conclusive if the researchers had included a matched control
group of children who did not receive the intervention. However,
given the horrific nature of the atrocities committed during the re-
bel invasion, it seemed unethical to deny a certain group of survi-
vors an opportunity to potentially alleviate some of their distress
by participating in the intervention. Future researchers may
choose to withhold the structured trauma healing activities from
a group of similarly exposed children; or alternatively, a staggered
approach could be used where one group of children receives the
structured trauma healing activities, while another group receives
the recreation activities, and a third group receives the nonformal
education only. A phased approach would enable researchers to
determine the relative contribution of each module, and to iden-
tify the most effective component in the Rapid-Ed intervention.
Conducting rigorous research and evidence-based interven-
tions in the aftermath of conflict poses several unique challenges.
First, there are always security risks to staff members due to the
participants occurred within the past 2 weeks for each item. Post-test responses (n=306)
Pre-test–post-test psychological reactions using the revised Impact of Events Scale (n=315). Responses reported by
Item NeverRarelySometimes Often
Do you think about the worst event when you don’t want to?
Do you try to remove the worst event from your mind?
Do you worry that you may not live to be an adult?
Do you have difficulty concentrating at school?
Do you have strong feelings about the worst event?
Do you startle more easily because of loud noises?
Do you avoid things that remind you of the worst event?
Do you try not to talk about the worst event?
Do pictures of the worst event suddenly come into your mind?
Do other things make you think about the worst event?
Do you feel upset in your body when reminded of the worst event?
Do you try not to think about the worst event?
Do you have difficulty falling/staying asleep at night?
Do you get irritable easily?
Do you try to stay alert to avoid bad things?