Robert D. Macy

School-Based Mental Health Intervention for Children Affected by Political Violence in Indonesia: A Cluster Randomized Trial

CONTEXT Little is known about the efficacy of mental health interventions for children exposed to armed conflicts in low- and middle-income settings. Childhood mental health problems are difficult to address in situations of ongoing poverty and political instability. OBJECTIVE To assess the efficacy of a school-based intervention designed for conflict-exposed children, implemented in a low-income setting. DESIGN, SETTING, AND PARTICIPANTS A cluster randomized trial involving 495 children (81.4% inclusion rate) who were a mean (SD) age of 9.9 (1.3) years, were attending randomly selected schools in political violence-affected communities in Poso, Indonesia, and were screened for exposure (> or = 1 events), posttraumatic stress disorder, and anxiety symptoms compared with a wait-listed control group. Nonblinded assessment took place before, 1 week after, and 6 months after treatment between March and December 2006. INTERVENTION Fifteen sessions, over 5 weeks, of a manualized, school-based group intervention, including trauma-processing activities, cooperative play, and creative-expressive elements, implemented by locally trained paraprofessionals. MAIN OUTCOME MEASURES We assessed psychiatric symptoms using the Child Posttraumatic Stress Scale, Depression Self-Rating Scale, the Self-Report for Anxiety Related Disorders 5-item version, and the Childrens Hope Scale, and assessed function impairment as treatment outcomes using standardized symptom checklists and locally developed rating scales. RESULTS Correcting for clustering of participants within schools, we found significantly more improvement in posttraumatic stress disorder symptoms (mean change difference, 2.78; 95% confidence interval [CI], 1.02 to 4.53) and maintained hope (mean change difference, -2.21; 95% CI, -3.52 to -0.91) in the treatment group than in the wait-listed group. Changes in traumatic idioms (stress-related physical symptoms) (mean change difference, 0.50; 95% CI, -0.12 to 1.11), depressive symptoms (mean change difference, 0.70; 95% CI, -0.08 to 1.49), anxiety (mean change difference, 0.12; 95% CI, -0.31 to 0.56), and functioning (mean change difference, 0.52; 95% CI, -0.43 to 1.46) were not different between the treatment and wait-listed groups. CONCLUSIONS In this study of children in violence-affected communities, a school-based intervention reduced posttraumatic stress symptoms and helped maintain hope, but did not reduce traumatic-stress related symptoms, depressive symptoms, anxiety symptoms, or functional impairment. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN25172408.

Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled trial

BACKGROUND In situations of ongoing violence, childhood psychosocial and mental health problems require care. However, resources and evidence for adequate interventions are scarce for children in low- and middle-income countries. This study evaluated a school-based psychosocial intervention in conflict-affected, rural Nepal. METHODS A cluster randomized controlled trial was used to evaluate changes on a range of indicators, including psychiatric symptoms (depression, anxiety, posttraumatic stress disorder), psychological difficulties, resilience indicators (hope, prosocial behavior) and function impairment. Children (n = 325) (mean age = 12.7, SD = 1.04, range 11-14 years) with elevated psychosocial distress were allocated to a treatment or waitlist group. RESULTS Comparisons of crude change scores showed significant between-group differences on several outcome indicators, with moderate effect sizes (Cohen d = .41 to .58). After correcting for nested variance within schools, no evidence for treatment effects was found on any outcome variable. Additional analyses showed gender effects for treatment on prosocial behavior (mean change difference: 2.70; 95% CI, .97 to 4.44), psychological difficulties (-2.19; 95% CI, -3.82 to -.56), and aggression (-4.42; 95% CI, -6.16 to -2.67). An age effect for treatment was found for hope (.90; 95% CI, -1.54 to -.26). CONCLUSIONS A school-based psychosocial intervention demonstrated moderate short-term beneficial effects for improving social-behavioral and resilience indicators among subgroups of children exposed to armed conflict. The intervention reduced psychological difficulties and aggression among boys, increased prosocial behavior among girls, and increased hope for older children. The intervention did not result in reduction of psychiatric symptoms.

Brain mechanisms in human classical conditioning: a PET blood flow study.

Five healthy male subjects participated in a classical conditioning experiment, and positron emission tomography (PET) was used to compare regional cerebral blood flow before and after conditioning. The subjects participated in three different experimental phases. In the first (habituation) phase they listened to 24 repetitions of a tone with random intervals. In the second (acquisition) phase, the tone was paired with a brief shock to the wrist. In the third (extinction) phase, the tone was presented alone again. 15OPET scans were taken during the habituation and extinction phases. Because the habituation and extinction phases were similar, any difference in blood flow to the tones presented during extinction probably reflected conditioning that occurred during the acquisition phase. Statistical parametric mapping (SPM) analysis of the PET data showed significantly increased activation in the right hemisphere in the orbito-frontal cortex, dorsolateral prefrontal cortex, inferior and superior frontal corticies, and inferior and middle temporal corticies. The only activated areas in the left hemisphere were area 19 and the superior frontal cortex. The results are interpreted as evidence for the involvement of cortical areas in human classical conditioning.

Mediators and moderators of a psychosocial intervention for children affected by political violence.

OBJECTIVE The authors examined moderators and mediators of a school-based psychosocial intervention for children affected by political violence, according to an ecological resilience theoretical framework. METHOD The authors examined data from a cluster randomized trial, involving children aged 8-13 in Central Sulawesi, Indonesia (treatment condition n = 182, waitlist control condition n = 221). Mediators (hope, coping, peer/emotional/play social support) and moderators (gender, age, family connectedness, household size, other forms of social support, exposure to political violence, and displacement) of treatment outcome on posttraumatic stress symptoms and function impairment were examined in parallel process latent growth curve models. RESULTS Compared with the waitlist group, those receiving treatment showed maintained hope, increased positive coping, maintained peer social support, and increased play social support. Of these putative mediators, only play social support was found to mediate treatment effects, such that increases in play social support were associated with smaller reductions in posttraumatic stress disorder (PTSD) symptoms. Furthermore, the authors identified a number of moderators: Girls showed larger treatment benefits on PTSD symptoms; girls, children in smaller households, and children receiving social support from adults outside the household showed larger treatment benefits on function impairment. CONCLUSIONS Findings provide limited evidence for an ecological resilience theoretical framework. On the basis of these findings, the authors recommend a stronger separation between universal prevention (e.g., resilience promotion through play) and selective/indicated prevention (e.g., interventions aimed at decreasing posttraumatic stress symptoms). Play-based interventions should be careful to exclude children with psychological distress. In addition, treatment effects may be augmented by selecting girls and socially vulnerable children.

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

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.

Community-Based, Acute Posttraumatic Stress Management: A Description and Evaluation of a Psychosocial-Intervention Continuum

&NA; Much of todays psychological trauma can be identified as resulting from sudden and seemingly random events, and particularly from events that involve the loss of human life. This article presents a perspective on how behavioral health providers may approach the design, development, and implementation of community‐based psychological trauma interventions. These interventions allow those community members most affected by the trauma to play a central role in the resolution of, and community adaptation to, traumatic losses. After a brief discussion of “critical incident stress debriefing”—a common form of psychological “first aid” that is sometimes used following traumatic events that affect a community—the article turns to the description of a community‐based trauma‐response program that provides a continuum‐of‐care model for the care and management of individual and group reactions to shared, traumatic events. A recent evaluation of that program, which was developed by the Community Services Program of the Trauma Center in Boston, is presented as an important first step toward determining the types of community‐based responses that show promise in our efforts to ameliorate the impact of traumatic events in communities nationwide and internationally.

Medical and Psychosocial Needs of Olympic and Pan American Athletes after the 2010 Earthquake in Haiti: An Opportunity to Promote Resilience Through Sports Medicine and Public Diplomacy

INTRODUCTION On January 12, 2010, a magnitude 7.0 earthquake devastated Haiti. Data regarding the prevalence of medical and psychosocial needs after the earthquake is scarce, complicating informed targeting of aid. The effects of the earthquake on athletes, as they differ from the general population, are especially unclear. The Center for Disaster Resilience (Boston, Massachusetts USA) and the Disaster Medicine Section at Harvard Medical School (Boston, Massachusetts USA) have partnered with Child in Hand to care for athletes training for the Pan American and Olympic games in Haiti, as well as for children from the general population. This report presents preliminary epidemiologic data illustrating the burden of medical and psychosocial needs of Haitian athletes and the general population after the earthquake of 2010. METHODS The study was a cross-sectional, comparative study conducted a year after the earthquake. The study group comprised 104 athletes, aged 12-18 years, enrolled from the National Sports Center in Haiti. The control group (N = 104) from the general population was age- and gender-matched from orphanages and schools in and around Port-au-Prince, Haiti. Medical teams assessed illness based on history and physicals. Psychosocial teams utilized the Child Psychosocial Distress Screener (CPDS). Two-proportion z tests and two-sample t tests were used to compare the proportions of medical illnesses, mean CPDS scores, and proportion of CPDS scores indicating treatment. RESULTS The most prevalent medical condition in athletes was musculoskeletal pain, which was more common than in controls (49% versus 2.9%). All other medical conditions were more common in the controls than athletes: abdominal pain (28.8% versus 4.8%); headache (22.1% versus 5.8%); fever (15.4% versus 1%); and malnutrition (18.3% versus 1.9%). In contrast, there was no significant difference in mean psychosocial scores and the proportion of scores indicating treatment between athletes and controls. CONCLUSION Elite athletes in Haiti have a low prevalence of most medical conditions after the disaster, suggesting that they may be protected from risk factors affecting the general population. However, athletes have a higher prevalence of musculoskeletal ailments and were not protected from psychosocial distress. This presents an opportunity for sports medicine physicians and mental health providers to engage in efforts to rebuild Haiti on an individual level by providing targeted care to athletes, and on a larger scale, by supporting international sports competition, which enhances human capital and facilitates public diplomacy.

Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal

BACKGROUND In situations of ongoing violence, childhood psychosocial and mental health problems require care. However, resources and evidence for adequate interventions are scarce for children in low- and middle-income countries. This study evaluated a school-based psychosocial intervention in conflict-affected, rural Nepal. METHODS A cluster randomized controlled trial was used to evaluate changes on a range of indicators, including psychiatric symptoms (depression, anxiety, posttraumatic stress disorder), psychological difficulties, resilience indicators (hope, prosocial behavior) and function impairment. Children (n = 325) (mean age = 12.7, SD = 1.04, range 11-14 years) with elevated psychosocial distress were allocated to a treatment or waitlist group. RESULTS Comparisons of crude change scores showed significant between-group differences on several outcome indicators, with moderate effect sizes (Cohen d = .41 to .58). After correcting for nested variance within schools, no evidence for treatment effects was found on any outcome variable. Additional analyses showed gender effects for treatment on prosocial behavior (mean change difference: 2.70; 95% CI, .97 to 4.44), psychological difficulties (-2.19; 95% CI, -3.82 to -.56), and aggression (-4.42; 95% CI, -6.16 to -2.67). An age effect for treatment was found for hope (.90; 95% CI, -1.54 to -.26). CONCLUSIONS A school-based psychosocial intervention demonstrated moderate short-term beneficial effects for improving social-behavioral and resilience indicators among subgroups of children exposed to armed conflict. The intervention reduced psychological difficulties and aggression among boys, increased prosocial behavior among girls, and increased hope for older children. The intervention did not result in reduction of psychiatric symptoms.

Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled trial: Evaluation of a psychosocial intervention in Nepal

BACKGROUND In situations of ongoing violence, childhood psychosocial and mental health problems require care. However, resources and evidence for adequate interventions are scarce for children in low- and middle-income countries. This study evaluated a school-based psychosocial intervention in conflict-affected, rural Nepal. METHODS A cluster randomized controlled trial was used to evaluate changes on a range of indicators, including psychiatric symptoms (depression, anxiety, posttraumatic stress disorder), psychological difficulties, resilience indicators (hope, prosocial behavior) and function impairment. Children (n = 325) (mean age = 12.7, SD = 1.04, range 11-14 years) with elevated psychosocial distress were allocated to a treatment or waitlist group. RESULTS Comparisons of crude change scores showed significant between-group differences on several outcome indicators, with moderate effect sizes (Cohen d = .41 to .58). After correcting for nested variance within schools, no evidence for treatment effects was found on any outcome variable. Additional analyses showed gender effects for treatment on prosocial behavior (mean change difference: 2.70; 95% CI, .97 to 4.44), psychological difficulties (-2.19; 95% CI, -3.82 to -.56), and aggression (-4.42; 95% CI, -6.16 to -2.67). An age effect for treatment was found for hope (.90; 95% CI, -1.54 to -.26). CONCLUSIONS A school-based psychosocial intervention demonstrated moderate short-term beneficial effects for improving social-behavioral and resilience indicators among subgroups of children exposed to armed conflict. The intervention reduced psychological difficulties and aggression among boys, increased prosocial behavior among girls, and increased hope for older children. The intervention did not result in reduction of psychiatric symptoms.