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School-Based Mental Health Intervention for Children Affected by Political Violence in IndonesiaA Cluster Randomized Trial
Wietse A. Tol, MA;
Ivan H. Komproe, PhD;
Dessy Susanty, MPsych;
Mark J. D. Jordans, MA;
Robert D. Macy, PhD;
Joop T. V. M. De Jong, MD, PhD
JAMA. 2008;300(6):655-662.
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 ( 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 Children's 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
Author Affiliations: HealthNet TPO, Department of Public Health and Research (Messrs Tol and Jordans and Dr Komproe), Section Culture and Health (Messrs Tol and Jordans) and Department of Psychiatry (Dr De Jong), Vrije Universiteit Medical Center, Amsterdam, the Netherlands; Church World Service Indonesia, Sulawesi, Indonesia (Ms Susanty); Center for Trauma Psychology, Harvard University, School of Medicine (Dr Macy) and Boston University Medical Center, Department of Psychiatry (Dr De Jong), Boston, Massachusetts
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