Outcomes and moderators of a preventive school-based mental health intervention for children affected by war in Sri Lanka: A cluster randomized trial

Global Health Initiative, MacMillan Center, Yale University, New Haven, CT, USA.
World psychiatry: official journal of the World Psychiatric Association (WPA) (Impact Factor: 14.23). 06/2012; 11(2):114-22. DOI: 10.1016/j.wpsyc.2012.05.008
Source: PubMed


We aimed to examine outcomes, moderators and mediators of a preventive school-based mental health intervention implemented by paraprofessionals in a war-affected setting in northern Sri Lanka. A cluster randomized trial was employed. Subsequent to screening 1,370 children in randomly selected schools, 399 children were assigned to an intervention (n=199) or waitlist control condition (n=200). The intervention consisted of 15 manualized sessions over 5 weeks of cognitive behavioral techniques and creative expressive elements. Assessments took place before, 1 week after, and 3 months after the intervention. Primary outcomes included post-traumatic stress disorder (PTSD), depressive, and anxiety symptoms. No main effects on primary outcomes were identified. A main effect in favor of intervention for conduct problems was observed. This effect was stronger for younger children. Furthermore, we found intervention benefits for specific subgroups. Stronger effects were found for boys with regard to PTSD and anxiety symptoms, and for younger children on pro-social behavior. Moreover, we found stronger intervention effects on PTSD, anxiety, and function impairment for children experiencing lower levels of current war-related stressors. Girls in the intervention condition showed smaller reductions on PTSD symptoms than waitlisted girls. We conclude that preventive school-based psychosocial interventions in volatile areas characterized by ongoing war-related stressors may effectively improve indicators of psychological wellbeing and posttraumatic stress-related symptoms in some children. However, they may undermine natural recovery for others. Further research is necessary to examine how gender, age and current war-related experiences contribute to differential intervention effects.

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Available from: Wietse A Tol, Dec 13, 2013
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    • "The field of immigrant and refugee studies emphasises the role of schools to implement prevention programs based on ecological principles that enhance young people's ability to adapt to life circumstances [9]–[11]. Psychotherapy (mostly cognitive behavioural therapy), creative play, and mixed modalities have been shown to be effective to improve mental health for immigrant and refugee children [12] or for children which, like many of them, have experienced an armed conflict [13]–[15]. Building on the literature describing the usefulness of creative expression programs for immigrant and refugee children in clinical and community settings [16]–[20], a Montreal Team composed of schools, community organizations and health professionals developed a set of creative expression arts-based prevention programs for preschools, elementary schools and high schools. The aims of these programs are to help immigrant children and adolescents bridge the gap between home and school and past and present and to work through experiences of loss and trauma. "
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    ABSTRACT: The aim of this cluster randomized trial was to evaluate the effectiveness of a school-based theatre intervention program for immigrant and refugee youth in special classes for improving mental health and academic outcomes. The primary hypothesis was that students in the theatre intervention group would report a greater reduction in impairment from symptoms compared to students in the control and tutoring groups.
    Full-text · Article · Aug 2014 · PLoS ONE
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    • "All trials aimed to assess the efficacy of the prominent and widely disseminated school-based intervention CBI [8] in reducing psychiatric symptoms (depression, PTSD, anxiety) and improving sense of hope and functioning. CBI was applied to groups of war-affected children (between 7- and 17-years-old) by paraprofessionals in Indonesia, Nepal, Sri Lanka and Burundi between March 2006 and March 2008, with assessment periods ranging from post-treatment to a six months follow-up [4-7]. "
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    ABSTRACT: In recent years, different approaches to large-scale mental health service provision for children in war-affected, mainly low- and middle-income, countries have been developed. Some school-based programs aiming at both strengthening resilience and reducing symptoms of trauma-related distress have been evaluated. In an article published in BMC Medicine, Tol and colleagues integrate their findings of the efficacy of universal school-based intervention across four countries and do not recommend classroom-based intervention as a treatment of trauma-related symptoms, since no consistent positive effects were found. On the contrary, for some children this type of universal intervention may impair recovery. Since universal school-based programs similar to the one evaluated here are widely implemented, Tol et al.’s results are highly relevant to inform the field of mental health service provision in war-affected countries. Please see related article
    Full-text · Article · May 2014 · BMC Medicine
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    • "The results from these studies underscore the importance of understanding optimum programme components in terms of content, duration, and target age range in order to ensure the development of effective school-based interventions in conflict areas. This is in line with recommendations from previous reviews of school-based interventions implemented in war exposed countries [71,72] including those from secondary prevention interventions, not covered in this review, which also point to the need for more rigorous research on the differential intervention effects related to age, gender and war-related experiences [73,83]. The studies in this review support previous findings concerning the role of universal school programmes for children living in conflict areas as an effective, accessible and efficient means of enhancing and protecting good mental health alongside more targeted approaches for students at higher risk [84]. "
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    ABSTRACT: This systematic review provides a narrative synthesis of the evidence on the effectiveness of mental health promotion interventions for young people in low and middle-income countries (LMICs). Commissioned by the WHO, a review of the evidence for mental health promotion interventions across the lifespan from early years to adulthood was conducted. This paper reports on the findings for interventions promoting the positive mental health of young people (aged 6--18 years) in school and community-based settings. Searching a range of electronic databases, 22 studies employing RCTs (N = 11) and quasi-experimental designs conducted in LMICs since 2000 were identified. Fourteen studies of school-based interventions implemented in eight LMICs were reviewed; seven of which included interventions for children living in areas of armed conflict and six interventions of multicomponent lifeskills and resilience training. Eight studies evaluating out-of-school community interventions for adolescents were identified in five countries. Using the Effective Public Health Practice Project (EPHPP) criteria, two reviewers independently assessed the quality of the evidence. The findings from the majority of the school-based interventions are strong. Structured universal interventions for children living in conflict areas indicate generally significant positive effects on students' emotional and behavioural wellbeing, including improved self-esteem and coping skills. However, mixed results were also reported, including differential effects for gender and age groups, and two studies reported nonsignficant findings. The majority of the school-based lifeskills and resilience programmes received a moderate quality rating, with findings indicating positive effects on students' self-esteem, motivation and self-efficacy. The quality of evidence from the community-based interventions for adolescents was moderate to strong with promising findings concerning the potential of multicomponent interventions to impact on youth mental health and social wellbeing. The review findings indicate that interventions promoting the mental health of young people can be implemented effectively in LMIC school and community settings with moderate to strong evidence of their impact on both positive and negative mental health outcomes. There is a paucity of evidence relating to interventions for younger children in LMIC primary schools. Evidence for the scaling up and sustainability of mental health promotion interventions in LMICs needs to be strengthened.
    Full-text · Article · Sep 2013 · BMC Public Health
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