Effectiveness of Trauma-Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: A Randomized Clinical Trial

Predicting fidelity and treatment outcomes in savoring interventions among mothers of young children

Savoring impacts parents' emotions and parent-child relationship quality. Using data from a randomized controlled trial (N = 164 mothers of 18-27-month-olds, 37 interveners) conducted with a community sample in the United States, this study examined predictors of fidelity and treatment outcomes across two savoring preventative interventions (relational savoring and personal savoring). Treatment outcome indicators were selected from a battery administered immediately post-intervention (maternal closeness to child) and at a 3-month follow-up (maternal sensitivity, reflective functioning). We examined whether intervener education level (bachelor's degree/no bachelor's degree) predicted fidelity (Research Question 1), whether intervener education level predicted treatment outcomes (Research Question 2), and whether fidelity predicted treatment outcomes (Research Question 3). In many cases, intervener education background was not related to fidelity or treatment outcome; however, interveners without bachelor's degrees showed greater adherence to the protocols on some scales (higher positivity, higher secure base, higher calm matching) and sessions with these interveners were associated with greater increases in maternal sensitivity. Regardless of the intervener education level, redirecting attention to the positive and calmly matching participants' tone were associated with higher maternal reflective functioning, and higher secure base scores were associated with greater closeness. Findings have implications for the training and implementation of prevention programs for parents.

Integrating Youth Readiness Intervention and Entrepreneurship in Sierra Leone: A Hybrid Type II Cluster Randomized Trial

OBJECTIVE

Conflict-affected youth are at risk for poor psychological and social outcomes, yet few receive mental health services. Strategies to expand access and sustain evidence-based interventions (EBIs) across novel delivery platforms must be tested. The present study was a hybrid type II implementation-effectiveness trial using a cluster randomized design. The primary goal was to evaluate feasibility and impact of using the collaborative team approach to deliver the Youth Readiness Intervention (YRI), an EBI, integrated into a youth entrepreneurship program (ENTR) with quality control in post-conflict Sierra Leone.

METHOD

Youth were screened and randomly assigned to control, ENTR, or combined YRI and ENTR (YRI+ENTR). Implementation outcomes were dissemination and implementation indicators, competence, and fidelity. Effectiveness outcomes were emotion regulation, psychological distress, and interpersonal functioning. Secondary outcomes were third-party reporter assessments of youth functioning and behavior.

RESULTS

Data were collected and analyzed from 1,151 youth participants and 528 third-party reporters. Scores on implementation constructs, competence, and fidelity demonstrated acceptable intervention response and quality. YRI+ENTR participants showed overall improvements in depression (β = -.081, 95% CI -0.124 to -0.038, d = -0.154) and anxiety (β = -.043, 95% CI -0.091 to -0.005, d = 0.082) symptoms compared with control participants. Community leaders indicated that YRI+ENTR participants demonstrated improvements in overall work or training performance compared with control participants (β = -.114, 95% CI 0.004 to 0.232, d = 0.374).

CONCLUSION

Integration of EBIs such as the YRI into youth employment programs has the potential to address limited reach of EBIs in conflict and post-conflict settings. A collaborative team implementation approach can facilitate integration and fidelity.

PLAIN LANGUAGE SUMMARY

In a Hybrid Type-II Implementation-Effectiveness trial conducted in Sierra Leone, researchers tested a Collaborative Team Approach (CTA) for delivering an evidence-based mental health intervention, the Youth Readiness Intervention (YRI), within a youth entrepreneurship program. A total of 1,151 youth participated in the study, with outcomes measured on youth mental health indicators of emotional regulation, psychological distress, and interpersonal functioning, as well as implementation indicators, competence, and fidelity. Results demonstrated that the integrated YRI and entrepreneurship program led to significant improvements in depression and anxiety symptoms compared to the control group. Community leaders also noted enhanced overall performance in YRI participants, suggesting that integrating evidence-based interventions into youth employment programs can effectively address mental health challenges in low-resource regions.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. One or more of the authors of this paper received support from a program designed to increase minority representation in science.

CLINICAL TRIAL REGISTRATION INFORMATION

Youth FORWARD Phase 2 YRI and EPP Study; https://clinicaltrials.gov/; NCT03542500.

STUDY PREREGISTRATION INFORMATION

Youth Functioning and Organizational Success for West African Regional Development (Youth FORWARD): Study Protocol; https://doi.org/10.1176/appi.ps.202000009.

Identifying effective moderators of cognitive behavioural trauma treatment with caregiver involvement for youth with PTSD: a meta-analysis

Children can develop post-traumatic stress disorder (PTSD) and mental health symptoms after traumatic events. This meta-analysis evaluated the influence of moderators of cognitive behavioural trauma treatment (CBTT) with caregiver involvement in traumatized children. A total of 28 studies were included, with 23 independent samples and 332 effect sizes, representing the data of 1931 children (M age = 11.10 years, SD = 2.36). Results showed a significant medium overall effect (d = 0.55, t = 2.478, p = 0.014), indicating CBTT with caregiver involvement was effective in treating PTSD (d = 0.70), with somewhat smaller effect sizes for internalizing, externalizing, social, cognitive and total problems (0.35 < d > 0.48). The positive treatment effect was robust; we found somewhat smaller effect sizes at follow-up (d = 0.49) compared to post-test (d = 0.57) assessments. Furthermore, several sample (i.e. child's age, gender, and trauma event), programme (i.e. the duration of treatment, number of sessions), study (i.e. control condition, type of instrument, informant, type of sample), and publication (i.e. publication year and impact factor) characteristics moderated the treatment outcomes of the child. In sum, the results of our meta-analysis might help to improve the effectiveness of cognitive behavioural trauma treatment for youth with PTSD, and guide the development of innovative trauma interventions that involve caregivers. Implications for theory and practice are discussed.

Psychological and social interventions for the promotion of mental health in people living in low- and middle-income countries affected by humanitarian crises

BACKGROUND

Because of wars, conflicts, persecutions, human rights violations, and humanitarian crises, about 84 million people are forcibly displaced around the world; the great majority of them live in low- and middle-income countries (LMICs). People living in humanitarian settings are affected by a constellation of stressors that threaten their mental health. Psychosocial interventions for people affected by humanitarian crises may be helpful to promote positive aspects of mental health, such as mental well-being, psychosocial functioning, coping, and quality of life. Previous reviews have focused on treatment and mixed promotion and prevention interventions. In this review, we focused on promotion of positive aspects of mental health.

OBJECTIVES

To assess the effects of psychosocial interventions aimed at promoting mental health versus control conditions (no intervention, intervention as usual, or waiting list) in people living in LMICs affected by humanitarian crises.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and seven other databases to January 2023. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies, and checked the reference lists of relevant studies and reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing psychosocial interventions versus control conditions (no intervention, intervention as usual, or waiting list) to promote positive aspects of mental health in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were mental well-being, functioning, quality of life, resilience, coping, hope, and prosocial behaviour. The secondary outcome was acceptability, defined as the number of participants who dropped out of the trial for any reason. We used GRADE to assess the certainty of evidence for the outcomes of mental well-being, functioning, and prosocial behaviour.

MAIN RESULTS

We included 13 RCTs with 7917 participants. Nine RCTs were conducted on children/adolescents, and four on adults. All included interventions were delivered to groups of participants, mainly by paraprofessionals. Paraprofessional is defined as an individual who is not a mental or behavioural health service professional, but works at the first stage of contact with people who are seeking mental health care. Four RCTs were carried out in Lebanon; two in India; and single RCTs in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The mean study duration was 18 weeks (minimum 10, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non-governmental organisations. For children and adolescents, there was no clear difference between psychosocial interventions and control conditions in improving mental well-being and prosocial behaviour at study endpoint (mental well-being: standardised mean difference (SMD) 0.06, 95% confidence interval (CI) -0.17 to 0.29; 3 RCTs, 3378 participants; very low-certainty evidence; prosocial behaviour: SMD -0.25, 95% CI -0.60 to 0.10; 5 RCTs, 1633 participants; low-certainty evidence), or at medium-term follow-up (mental well-being: mean difference (MD) -0.70, 95% CI -2.39 to 0.99; 1 RCT, 258 participants; prosocial behaviour: SMD -0.48, 95% CI -1.80 to 0.83; 2 RCT, 483 participants; both very low-certainty evidence). Interventions may improve functioning (MD -2.18, 95% CI -3.86 to -0.50; 1 RCT, 183 participants), with sustained effects at follow-up (MD -3.33, 95% CI -5.03 to -1.63; 1 RCT, 183 participants), but evidence is very uncertain as the data came from one RCT (both very low-certainty evidence). Psychosocial interventions may improve mental well-being slightly in adults at study endpoint (SMD -0.29, 95% CI -0.44 to -0.14; 3 RCTs, 674 participants; low-certainty evidence), but they may have little to no effect at follow-up, as the evidence is uncertain and future RCTs might either confirm or disprove this finding. No RCTs measured the outcomes of functioning and prosocial behaviour in adults.

AUTHORS' CONCLUSIONS

To date, there is scant and inconclusive randomised evidence on the potential benefits of psychological and social interventions to promote mental health in people living in LMICs affected by humanitarian crises. Confidence in the findings is hampered by the scarcity of studies included in the review, the small number of participants analysed, the risk of bias in the studies, and the substantial level of heterogeneity. Evidence on the efficacy of interventions on positive mental health outcomes is too scant to determine firm practice and policy implications. This review has identified a large gap between what is known and what still needs to be addressed in the research area of mental health promotion in humanitarian settings.

A qualitative study of mental health problems among children living in New Delhi slums

Children living in urban slums in India are exposed to chronic stressors that increase their risk of developing mental disorders, but they remain a neglected group. Effective mental health interventions are needed; however, it is necessary to understand how mental health symptoms and needs are perceived and prioritized locally to tailor interventions for this population. We used an existing rapid ethnographic assessment approach to identify mental health problems from the perspective of children living in Indian slums, including local descriptions, perceived causes, impact, and coping behavior. Local Hindi-speaking interviewers conducted 77 free-list interviews and 33 key informant interviews with children and adults (N = 107) from two slums in New Delhi. Results identified a range of internalizing and externalizing symptoms consistent with depression, anxiety, and conduct problems in children. Findings included both common cross-cultural experiences and symptoms as well as uniquely described symptoms (e.g., "madness or anger," "pain in the heart and mind") not typically included on western standardized measures of psychopathology. Mental health problems appeared to be highly interconnected, with experiences such as harassment and fighting often described as both causes and impacts of mental health symptoms in children. Community perspectives indicated that even in the face of several unmet basic needs, mental health problems were important to the community and counseling interventions were likely to be acceptable. We discuss implications for adapting mental health interventions and assessing their effectiveness to reduce the burden of mental illness among children living in urban slums in India.

Application of trauma-focused cognitive behavioral therapy among children and adolescents with childhood household dysfunction

Childhood household dysfunction (CHD) is a common adverse childhood experience, which brings the heavy physical and mental afflictions to children and adolescents. Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy that helps children and adolescents who have experienced childhood trauma with traumatic memories. It aims to enhance the coping abilities of CHD children and adolescents, thereby improving the negative effects caused by trauma and effectively reducing psychological burden. TF-CBT can effectively improve post-traumatic stress disorder, emotional and behavioral problems, and family function in children and adolescents with CHD. It is recommended to conduct high-quality original research in the future, develop targeted TF-CBT intervention plans based on potential predictive factors, adopt a combination of online and offline methods, and construct TF-CBT interventions suitable for the Chinese CHD population to meet the mental health service needs of CHD children and adolescents.

Development and Usability Testing of an mHealth Tool for Trauma-Informed Prevention of Substance Use, HIV Acquisition, and Risky Sexual Behaviors Among Adolescents: Mixed Methods Study

BACKGROUND

Youth who experience traumatic events are at a substantially higher risk of engaging in substance use and sexual risk behaviors and problems (eg, HIV acquisition) than their non-trauma-exposed counterparts. Evidence-based substance use and risky sexual behavior prevention may reduce the risk of these outcomes. Trauma-focused mental health treatment provides a window of opportunity for the implementation of such preventive work with these youth. However, overburdened clinicians face challenges in adding prevention content while implementing evidence-based treatments. Mobile health (mHealth) tools can help reduce this burden in delivering prevention curricula. Trauma-Informed Prevention for Substance Use and Risky Sexual Behavior (TIPS) is an mHealth app that was developed to aid trauma-focused cognitive behavioral therapy (TF-CBT) clinicians in the implementation of an evidence-based risk behavior prevention curriculum.

OBJECTIVE

The goal of this paper is to describe the rationale for and development of the TIPS app and present the results of a mixed methods approach for the initial evaluation of its usability.

METHODS

Participants included clinicians (n=11), adolescents (n=11), and caregivers (n=10) who completed qualitative interviews and an adapted version of the Website Analysis and Measurement Inventory.

RESULTS

In total, 4 overarching themes emerged from the participants' answers to the qualitative interview questions, demonstrating a generally positive response to the app. The themes were (1) strength of app content, (2) suggestions about app content, (3) esthetics and usability, and (4) benefits to the patient and session implementation. Clinicians, adolescents, and caregivers all agreed that the content was very relevant to adolescents and used examples and language that adolescents could relate to. All 3 groups also discussed that the content was comprehensive and addressed issues often faced by adolescents. All 3 groups of users made suggestions about the esthetics, which mostly comprised suggestions to change the font, color, or pictures within the app. Of all the groups, adolescents were most positive about the esthetics and usability of the app. Results from the Website Analysis and Measurement Inventory further illustrated the users' favorable reaction to the TIPS app, with 100% (11/11) of clinicians, 100% (10/10) of caregivers, and most adolescents (7/11, 64%) selecting strongly agree or somewhat agree to the following statement: "This app has much that is of interest to me." Adolescents generally found the app easier to use than did caregivers and clinicians.

CONCLUSIONS

The TIPS app shows promise as an mHealth tool for TF-CBT clinicians to integrate evidence-based substance use, risky sexual behavior, and HIV prevention during treatment. Future research, including a randomized controlled trial comparing TF-CBT implementation with and without the inclusion of the app, is necessary to evaluate the feasibility and efficacy of the app in reducing the risk of substance use and risky sexual behavior among trauma-exposed adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03710720; https://clinicaltrials.gov/study/NCT03710720.

Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials

BACKGROUND

Existing clinical trials of cognitive behavioural therapies with a trauma focus (CBTs-TF) are underpowered to examine key variables that might moderate treatment effects. We aimed to determine the efficacy of CBTs-TF for young people, relative to passive and active control conditions, and elucidate putative individual-level and treatment-level moderators.

METHODS

This was an individual participant data meta-analysis of published and unpublished randomised studies in young people aged 6-18 years exposed to trauma. We included studies identified by the latest UK National Institute of Health and Care Excellence guidelines (completed on Jan 29, 2018) and updated their search. The search strategy included database searches restricted to publications between Jan 1, 2018, and Nov 12, 2019; grey literature search of trial registries ClinicalTrials.gov and ISRCTN; preprint archives PsyArXiv and bioRxiv; and use of social media and emails to key authors to identify any unpublished datasets. The primary outcome was post-traumatic stress symptoms after treatment (<1 month after the final session). Predominantly, one-stage random-effects models were fitted. This study is registered with PROSPERO, CRD42019151954.

FINDINGS

We identified 38 studies; 25 studies provided individual participant data, comprising 1686 young people (mean age 13·65 years [SD 3·01]), with 802 receiving CBTs-TF and 884 a control condition. The risk-of-bias assessment indicated five studies as low risk and 20 studies with some concerns. Participants who received CBTs-TF had lower mean post-traumatic stress symptoms after treatment than those who received the control conditions, after adjusting for post-traumatic stress symptoms before treatment (b=-13·17, 95% CI -17·84 to -8·50, p<0·001, τ2=103·72). Moderation analysis indicated that this effect of CBTs-TF on post-traumatic stress symptoms post-treatment increased by 0·15 units (b=-0·15, 95% CI -0·29 to -0·01, p=0·041, τ2=0·03) for each unit increase in pre-treatment post-traumatic stress symptoms.

INTERPRETATION

This is the first individual participant data meta-analysis of young people exposed to trauma. Our findings support CBTs-TF as the first-line treatment, irrespective of age, gender, trauma characteristics, or carer involvement in treatment, with particular benefits for those with higher initial distress.

FUNDING

Swiss National Science Foundation.

Effectiveness of trauma-focused cognitive behavioral therapy compared to psychosocial counseling in reducing HIV risk behaviors, substance use, and mental health problems among orphans and vulnerable children in Zambia: a community-based randomized controlled trial

Orphans and vulnerable children (OVC) in sub-Saharan Africa are at high risk for HIV infection and transmission. HIV prevention and treatment efforts with OVC are hindered by mental health and substance use problems. This randomized controlled trial compared a mental health intervention, Trauma Focused Cognitive Behavioral Therapy (TF-CBT), to an enhanced version of an existing HIV Psychosocial Counseling (PC+) program among 610 adolescents who met PEPFAR criteria for OVC and had HIV risk behaviors in Lusaka, Zambia. Outcomes included HIV risk behaviors (e.g., risky sexual behaviors), mental health (internalizing symptoms, externalizing behaviors, PTSD) and substance use. At 12-month follow-up, there were significant within group reductions in both groups for all outcomes, with the only significant between group difference being for substance use, in which OVC who received TF-CBT had significantly greater reductions than OVC who received PC+. In a subgroup analysis of OVC with high levels of PTSD symptoms, TF-CBT was superior to PC + in reducing internalizing symptoms, functional impairment, and substance use. Findings support TF-CBT for reducing substance use among OVC. Subgroup analysis results suggest that a robust intervention such as TF-CBT is warranted for OVC with significant mental and behavioral health comorbidities. The similar performance of TF-CBT and PC + in the overall sample for risky sexual behavior and mild mental health problems indicates that enhancing existing psychosocial programs, such as PC, with standard implementation factors like having a defined training and supervision schedule (as was done to create PC+) may improve the efficacy of HIV risk reduction efforts.Clinical Trials Number: NCT02054780.

Research Review: Psychological and psychosocial interventions for children and adolescents with depression, anxiety, and post-traumatic stress disorder in low- and middle-income countries - a systematic review and meta-analysis

BACKGROUND

The incidence of depression, anxiety, and post-traumatic stress disorder (PTSD) among children and adolescents residing in low- and middle-income countries (LMICs) poses a significant public health concern. However, there is variation in the evidence of effective psychological interventions. This meta-analysis aims to provide a complete overview of the current body of evidence in this rapidly evolving field.

METHODS

We conducted searches on PubMed, Embase.com, and EBSCO/APA PsycInfo databases up to June 23, 2022, identify randomized controlled trials (RCTs) investigating the effectiveness of psychological interventions in LMICs that targeted children and adolescents with elevated symptoms above a cut-off score for depression, anxiety, and PTSD, comparing a psychological or psychosocial intervention with other control conditions. We conducted random effects meta-analyses for depression, anxiety, and PTSD symptoms. Sensitivity analysis for outliers and high-risk studies, and analyses for the publication bias were carried out. Subgroup analyses investigated how the intervention type, intervention format, the facilitator, study design, and age group of the participant predicted effect sizes.

RESULTS

Thirty-one RCTs (6,123 participants) were included. We found a moderate effect of interventions on depression outcomes compared to the control conditions (g = 0.53; 95% CI: 0.06-0.99; NNT = 6.09) with a broad prediction interval (PI) (-1.8 to 2.86). We found a moderate to large effect for interventions on anxiety outcomes (g = 0.88; 95% CI: -0.03 to 1.79; NNT = 3.32) with a broad PI (-3.14 to 4.9). Additionally, a moderate effect was observed on PTSD outcomes (g = 0.54; 95% CI: 0.19-0.9; NNT = 5.86) with a broad PI (-0.64 to 1.72).

CONCLUSIONS

Psychological and psychosocial interventions aimed at addressing depression, anxiety, and PTSD among children and adolescents in LMICs have demonstrated promising results. However, future studies should consider the variation in evidence and incorporate long-term outcomes to better understand the effectiveness of these interventions.

Prevalence of mental distress in adults with and without a history of tuberculosis in an urban Zambian community

People with tuberculosis (TB) are susceptible to mental distress. Mental distress can be driven by biological and socio-economic factors including poverty. These factors can persist beyond TB treatment completion yet there is minimal evidence about the mental health of TB survivors. A cross-sectional TB prevalence survey of adults was conducted in an urban community in Zambia. Survey participants were administered the five-item Self Reporting Questionnaire (SRQ-5) mental health screening tool to measure mental distress. Associations between primary exposure (history of TB) and other co-variates with mental distress were investigated using logistic regression. Of 3,393 study participants, 120 were TB survivors (3.5%). The overall prevalence of mental distress (SRQ-5 ≥ 4) in the whole study population was 16.9% (95% CI 15.6%-18.1%). Previous TB history was not associated with mental distress (OR 1.20, 95% CI 0.75-1.92, p-value 1.66). Mental distress was associated with being female (OR 1.23 95% CI 1.00-1.51), older age (OR 1.71 95% CI 1.09-2.68) and alcohol abuse (OR 1.81 95% CI 1.19-2.76). Our findings show no association between a previous TB history and mental distress. However, approximately one in six people in the study population screened positive for mental distress.

"Building that strong energy": An exploration of stigma coping strategies among sexual and gender minorities in Nigeria

Sexual and gender minority stigma (SGM stigma) affecting Nigerian sexual and gender minorities (SGM) is associated with suboptimal HIV outcomes, and one mechanism found to explain the relationship is suicidal ideation. A better understanding of coping strategies may help mitigate the harmful impacts of SGM stigma. Interviews of 25 SGM from Abuja, Nigeria participating in the [Blinded for Review] study were thematically analyzed in regards to how they coped with SGM stigma. Four coping themes emerged: avoidant behaviors, self-monitoring so as to not attract stigma, seeking support and safe spaces to be themselves, and empowerment and self-acceptance through a process of cognitive change. They utilized multiple coping strategies, often believing that stigma could be avoided through the right actions and a masculine appearance. Multi-level and person-centered interventions that increase safety and support, facilitate resiliency, and improve mental health and engagement in HIV programming could mitigate the effects of SGM stigma and coping responses of isolation, blame, and mental health stressors among Nigerian SGM.

Effectiveness of a school-based, lay counselor-delivered cognitive behavioral therapy for Chinese children with posttraumatic stress symptoms: a randomized controlled trial

Background

Improving children's access to mental health services need more innovative solutions, especially in low- and middle-income countries. School-based psychosocial interventions delivered by lay counselors may be an efficient way to improve children's access to mental health services. But few studies were conducted to examine the effectiveness of these interventions. Therefore, this study is to evaluate the effectiveness of trauma-focused cognitive behavioral therapy (TF-CBT) in a group format delivered by lay counselors to children with trauma-related symptoms in China.

Methods

A total of 234 children (aged 9-12 years) with full or subthreshold posttraumatic stress disorder (PTSD) were randomly assigned to group-based TF-CBT or treatment as usual (TAU). In the intervention group, 118 children received 10-12 sessions of group-based TF-CBT delivered by lay counselors for 9 consecutive weeks. In the TAU group, 116 children received the usual school services provided by psychology teachers. The primary outcome was the reduction in PTSD severity, which was assessed with the UCLA PTSD reaction index for DSM-5 (PTSD-RI-5). The secondary outcomes included the reduction in PTSD severity and the remission of PTSD, both of which were measured with the PTSD checklist-5 (PCL-5). Secondary outcomes also included the reduction in depression severity and the reduction in generalized anxiety severity. Blinded assessments were collected at baseline, posttreatment (primary endpoint), and 3-month follow-up. This trial is registered with Chinese Clinical Trial Registry, ChiCTR1900027131.

Findings

At posttreatment, the intervention group scored significantly lower than the TAU group on PTSD-RI-5 PTSD (30.98 vs. 39.22; adjusted mean difference [AMD], -7.35; 95% CI, -11.66 to -3.04), PCL-5 PTSD (28.78 vs. 38.04; AMD, -8.49; 95% CI, -13.23 to -3.75), depression (5.52 vs. 7.96; AMD, -1.63; 95% CI, -2.50 to -0.76), and generalized anxiety (7.23 vs. 8.64; AMD, -1.21; 95% CI, -2.20 to -0.23). The remission of PCL-5 PTSD was also significantly higher in the intervention group (42.86% vs. 13.54%, χ ²  = 13.10, P < 0.001). These two groups showed a similar level of symptoms at the 3-month follow-up.

Interpretation

The group-based TF-CBT can significantly alleviate PTSD, depression, and generalized anxiety right after treatment in Chinese children who suffer from different types of trauma. But the long-term effects of this intervention need to be further tested. This intervention can be delivered by trained lay counselors in low- and middle-income countries.

Funding

None.

Stepping Together in Stepped Care Trauma-Focused Cognitive Behavioral Therapy: Case Report of Core Components

New service delivery systems are needed to expand the reach of evidence-based practices for childhood trauma. Cognitive behavioral therapy is an effective approach for treating -childhood trauma, yet treatment barriers remain. Stepped care models that incorporate parent-led -treatment with therapist assistance may be one approach to improve access. This case study highlights the core components of a parent-led therapist-assisted treatment called Stepping Together that serves as a Step 1 treatment within a stepped care model. The components and structure of Stepping Together are described, along with excerpts from therapy sessions to illustrate the therapist's implementation of the model. Results of the case, in which improvements occurred, are presented. Stepping Together, a parent-led therapist-assisted first-line treatment within stepped care trauma-focused cognitive behavioral therapy, may be an effective treatment for some children after trauma and their caregivers, although more research is needed.

Effectiveness of abbreviated trauma-focused cognitive behavioural therapy for South African adolescents: a randomized controlled trial

Background: In low- and middle- income countries (LMICs) trauma exposure among youth is high, but mental health services are critically under-resourced. In such contexts, abbreviated trauma treatments are needed.Objective: To evaluate the efficacy of an abbreviated eight-session version of Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) for improving posttraumatic stress disorder (PTSD) and depression symptoms in a sample of South African adolescents.Method: 75 trauma-exposed adolescents (21 males, 54 females; mean age = 14.92, range = 11-19) with posttraumatic stress disorder (PTSD) symptoms were randomly assigned to eight sessions of TF-CBT or to usual services. At baseline, post-treatment and three-month follow-up, participants completed the Child PTSD Symptom Scale for DSM 5 (CPSS-5) and the Beck Depression Inventory II (BDI-II). The trial is registered on the Pan African Trial Registry (PACTR202011506380839).6.Results: 95% of TF-CBT participants completed treatment while only 47% of TAU participants accessed treatment. Intention-to-treat analyses found that the TF-CBT group had a significantly greater reduction in CPSS-5 PTSD symptom severity at post-treatment (Cohen's d = 0. 60, p < .01) and three-month follow-up (Cohen's d = 0.62, p < . 01), and a greater reduction in the proportion of participants meeting the CPSS-5 clinical cut-off for PTSD at both time points (p = .02 and p = .03, respectively). There was also a significantly greater reduction in depression symptom severity in the TF-CBT group at post-treatment (Cohen's d = 0.51, p = .03) and three-month follow-up (Cohen's d = 0.41, p = .05), and a greater reduction in the proportion of TF-CBT participants meeting the BDI clinical cut-off for depression at both time points (p = .02 and p = .03, respectively).Conclusion: The findings provide preliminary evidence of the efficacy of an abbreviated eight-session version of TF-CBT for reducing PTSD and depression symptoms in a LMIC sample of adolescents with multiple trauma exposure.

Meta-analysis: The Effectiveness of Youth Psychotherapy Interventions in Low- and Middle-Income Countries

OBJECTIVE

Because most youth psychotherapies are developed and tested in high-income countries, relatively little is known about their effectiveness or moderators in low- and middle-income countries (LMICs). To address this gap, we conducted a meta-analysis of randomized controlled trials (RCTs) testing psychotherapies for youth with multiple psychiatric conditions in LMICs, and we tested candidate moderators.

METHOD

We searched 9 international databases for RCTs of youth psychotherapies in LMICs published through January 2021. The RCTs targeted elevated symptoms of youth anxiety (including post-traumatic stress disorder [PTSD] and obsessive-compulsive disorder), depression, conduct problems, and attention problems. Using robust variance estimation, we estimated the pooled effect sizes (Hedges g) at post treatment and follow-up for intervention vs control conditions.

RESULTS

Of 5,145 articles identified, 34 articles (with 43 treatment-control comparisons and 4,176 participants) met methodological standards and were included. The overall pooled g with winsorized outliers was 1.01 (95% CI = 0.72-1.29, p < .001) at post treatment and 0.68 (95% CI = 0.29-1.07, p = .003) at follow-up. Interventions delivered by professional clinicians significantly outperformed those delivered by lay providers (g = 1.59 vs 0.53), but all interventions for conduct problems were delivered by professionals, and the difference for interventions targeting internalizing problems (g = 1.33 vs .53) was not significant. Interventions developed non-locally were more effective if they were not adapted to local contexts than if they were adapted locally (g = 2.31 vs 0.66), highlighting a need for further research on effective adaptations. Significant risk of bias was identified.

CONCLUSION

Overall, pooled effects of youth psychotherapies in LMICs were markedly larger than those in recent comparable non-LMIC meta-analyses, which have shown small-to-medium effects for youth psychotherapies. Findings highlight the potential benefits of youth psychotherapies in LMICs, as well as a need for more RCTs and improved study quality.

A systematic review and meta-analysis of trauma-focused cognitive behavioral therapy for children and adolescents

BACKGROUND

Among minors, posttraumatic stress symptoms (PTSS) are a common consequence of traumatic events requiring trauma-focused treatment.

OBJECTIVE

This meta-analysis quantified treatment effects of trauma-focused cognitive behavioral therapy (TF-CBT) with PTSS as primary outcome and symptoms of depression, anxiety, and grief as secondary outcomes.

PARTICIPANTS AND SETTING

Inclusion criteria for individual settings: (1) patients aged between 3 and 21, (2) at least one traumatic event, (3) minimum 8 sessions of (4) TF-CBT according to Cohen, Mannarino and Deblinger (2006, 2017), (5) a quantitative PTSS measure at pre- and post-treatment, (6) original research only. Inclusion criteria for group settings: had to involve (1) psychoeducation, (2) coping strategies, (3) exposure, (4) cognitive processing/restructuring, (5) contain some reference to the manual and no minimum session number was required.

METHODS

Searched databases were PsychInfo, MEDLINE, Cochrane Library, PTSDPubs, PubMed, Web of Science, and OpenGrey.

RESULTS

4523 participants from 28 RCTs and 33 uncontrolled studies were included. TF-CBT showed large improvements across all outcomes from pre- to post-treatment (PTSS: g = 1.14, CI 0.97-1.30) and favorable results compared to any control condition including wait-list, treatment as usual, and active treatment at post-treatment (PTSS: g = 0.52, CI 0.31-0.73). Effects were more pronounced for group settings. We give pooled estimates adjusted for risk of bias and publication bias, which initially limited the quality of the analyzed data.

CONCLUSIONS

TF-CBT is an effective treatment for pediatric PTSS as well as for depressive, anxiety, and grief symptoms. It is superior to control conditions, supporting international guidelines recommending it as a first-line treatment.

Adaptations of evidence-based trauma-focused interventions for children and adolescents: a systematic review

BACKGROUND

Rates of potentially traumatic events (PTEs) and other forms of adversity among children are high globally, resulting in the development of a number of evidence-based interventions (EBIs) to address the adverse outcomes stemming from these experiences. Though EBIs are intended to be delivered according to set parameters, these EBIs are frequently adapted. However, little is known about existing adaptations of EBIs for children who experienced PTEs or other adversities. As such, this review aimed to determine: (1) why existing EBIs designed to address PTEs and other adversities experienced by children are adapted, (2) what processes are used to determine what elements should be adapted, and (3) what components of the intervention are adapted.

METHODS

Nine academic databases and publicly available search engines were used to identify academic and grey literature. Initial screening, full-text review, data extraction, and quality determinations were completed by two members of the research team. Data were synthesized narratively for each adapted EBI by research question.

RESULTS

Forty-two studies examining the adaptations of nine different EBIs were located, with Trauma-Focused Cognitive Behavioral Therapy and Cognitive Behavioral Intervention for Trauma in Schools being the most commonly adapted EBIs. Most frequently, EBIs were adapted to improve fit with a new population and to address cultural factors. Most commonly, researchers in combination with others made decisions about adapting interventions, though frequently who was involved in these decisions was not described. Common content adaptations included the addition of intervention elements and the tailoring/tweaking/refining of intervention materials. Common contextual adaptations included changes to the intended population, changes to the channel of treatment delivery, and changes to who administered the intervention.

CONCLUSIONS

Most published studies of EBI adaptions have been developed to improve fit and address cultural factors, but little research is available about adaptations made by clinicians in day-to-day practice. Efforts should be made to evaluate the various types of adaptations and especially whether adaptations improve access to services or improve child outcomes in order to ensure that all children exposed to trauma can access effective treatment.

TRIAL REGISTRATION

The protocol for this systematic review was published with PROSPERO (CRD42020149536).

Associations Among Age of First Experience of Violence, Type of Victimization, Polyvictimization, and Mental Distress in Nigerian Females

This study explored associations of age of first victimization, sexual violence (SV), physical violence (PV), polyvictimization, and mental distress among females in Nigeria (n = 1,766, 13-24 years old) using the nationally representative 2014 Nigeria Violence Against Children Survey. Multinomial logistic regressions were performed. Nigerian females reporting SV victimization and polyvictimization were more likely to experience higher mental distress. The older the female was at the time of PV victimization, the greater the risk for mental distress. Violence is prevalent in Nigeria and its impact on youth's health is severe. However, evidence-based and data-driven policies and programs can reduce and prevent violence.

Predictors of nonresponse and drop-out among children and adolescents receiving TF-CBT: investigation of client-, therapist-, and implementation factors

Background

There is a paucity of evidence about effective implementation strategies to increase treatment response and prevent drop-out among children receiving evidence-based treatment. This study examines patient, therapist, and implementation factors and their association to nonresponse and drop-out among youth receiving Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).

Methods

Youth (n = 1240) aged 6–18 (M = 14.6) received TF-CBT delivered by 382 TF-CBT therapists at 66 clinics. Odds ratio analyses were used to investigate whether pretreatment child (age, gender, number of trauma experiences, post-traumatic stress symptoms (PTSS), therapist (education), and implementation strategy factors (high-low, low-low, low–high intensity therapist and leadership training respectively) or tele-mental health training during the Covid-19 pandemic are associated with nonresponse (above clinical PTSS level post-treatment) and drop-out (therapist-defined early termination). Fidelity checks were conducted to ensure that TF-CBT was used consistently.

Results

One fourth of the children (24.4%) were nonresponders and 13.3 percent dropped out. Exposure to three or more traumatic experiences were related to nonresponse and drop-out. Higher baseline PTSS was related to a higher probability of nonresponse. There was no effect of therapist education or child gender on nonresponse and drop-out, whereas children over 15 years had a higher likelihood of both. After controlling for baseline PTSS, the effect of age on nonresponse was no longer significant. Drop-out was related to fewer sessions, and most dropped out during the first two phases of TF-CBT. Fidelity was high throughout the different implementation phases. High-intensity therapist training was related to a lower probability of both nonresponse and drop-out, whereas low therapist and leadership training were related to a higher likelihood of both. Multivariate analysis revealed higher child age and higher PTSS baseline scores as significant predictors of nonresponse, and number of trauma experiences (> = 3) at baseline as the only predictor of drop-out.

Conclusions

High-intensity therapist training seem key to prevent patient nonresponse and drop-out. Leadership training might positively affect both, although not enough to compensate for less intensive therapist training. More complex cases (higher PTSS and exposure to more traumas) predict nonresponse and drop-out respectively, which underscores the importance of symptom assessment to tailor the treatment. The lack of predictive effect of therapist education increases the utilization of TF-CBT.

Trial registration

Retrospectively registered in ClinicalTrials, ref. nr. NCT05248971.

Effectiveness of Cognitive Behavior Therapy Combined with Eye Movement Desensitization and Reprocessing on Psychological Problems and Life Quality in Patients' Postfacial Trauma

Objective

To investigate the effectiveness of cognitive behavior therapy (CBT) combined with eye movement desensitization and reprocessing (EMDR) on the esteem, anxiety, depression, posttrauma stress disorder (PTSD), and posttraumatic growth in patients with facial trauma.

Methods

A total of 92 facial trauma patients in Wenzhou People's Hospital from January 2017 to December 2019 were enrolled in this study. The patients were randomly divided into control group (n = 46) and intervention group (n = 46). Both of the control group and the intervention group received routine treatment, while the intervention group further received CBT combined with EMDR. Questionnaires were used to explore and record the general patient information. The Self-Esteem Scale (SES), Self-Anxiety Scale (SAS), Self-Depression Scale (SDS), Posttraumatic Stress Disorder Checklist Civilian Version (PCL-C), Posttraumatic Growth Inventory (PTGI), and World Health Organization Quality of Life-brief (WHOQOL-BREF) scores between the two groups were compared.

Results

After CBT combined with EMDR intervention, the SDS and SAS scores in the intervention group were significantly decreased compared with the scores before intervention with statistically significance (P < 0.001). Furthermore, the PCL-C score in the intervention group showed significant decrease in comparison with the control group (P < 0.001), while the PTGI score in the intervention group was significantly higher than the control group (P < 0.001). The WHOQOL-BREF scores were increased after treatment in the two groups compared with the scores before treatment, and the scores in the intervention group were higher than those in the control group after treatment (P < 0.01).

Conclusion

Psychological intervention therapy can effectively alleviate the anxiety, depression, and PTSD and improve the life quality and the recovery of facial trauma patients.

Conceptualization, detection, and management of psychological distress and mental health conditions among people with tuberculosis in Zambia: a qualitative study with stakeholders' and TB health workers

BACKGROUND

In recent years, there has been increased recognition of the need to integrate mental health services into routine tuberculosis (TB) care. For successful integration, policymakers need to first understand the practices of TB health workers in the management of mental health conditions, including depression, anxiety, and psychological distress, and use this to decide how best mental health services could be delivered in tandem with TB services. In this qualitative study we aimed to understand how TB health workers and other stakeholders viewed mental health conditions linked to TB and how they screened and treated these in their patients.

METHODS

The study draws on qualitative data collected in 2018 as part of the Tuberculosis Reduction through Expanded Antiretroviral Treatment and Screening for active TB trial (TREATS), conducted in eight urban communities in Zambia. Data were collected through 17 focus group discussions with local health committee members (n = 96) and TB stakeholders (n = 57) present in the communities. Further in-depth interviews were held with key TB health workers (n = 9). Thematic analysis was conducted.

RESULTS

TB stakeholders and health workers had an inadequate understanding of mental health and commonly described mental health conditions among TB patients by using stigmatizing terminology and overtones, for example "madness", which often implied a characterological flaw rather an actual illness. Psychological distress was also described as "overthinking", which participants attributed to psychosocial stressors, and was not perceived as a condition that would benefit from mental health intervention. There were no standard screening and treatment options for mental health conditions in TB patients and most TB health workers had no mental health training. TB Stakeholders and health workers understood the negative implications of mental health conditions on TB treatment adherence and overall wellbeing for TB patients.

CONCLUSIONS

TB stakeholders and health workers in Zambia have a complex conceptualisation of mental health and illness, that does not support the mental health needs of TB patients. The integration of mental health training in TB services could be beneficial and shift negative attitudes about mental health. Further, TB patients should be screened for mental health conditions and offered treatment. Trial registration number NCT03739736-Registered on the 14th of November 2018- Retrospectively registered- https://clinicaltrials.gov/ct2/results?cond=&term=NCT03739736&cntry=&state=&city=&dist.

Violence Exposure, Self-Reported Mental Health Concerns and Use of Alcohol and Drugs for Coping among Youth in the Slums of Kampala, Uganda

This study aimed to a) compute the prevalence of violence exposure types, polyvictimization, and self-reported depression, anxiety, and using substances to cope among youth ages 12 to 18 years living on the streets or in the slums of Kampala, Uganda, (b) examine the independent associations among orphan status, violence exposure types, and self-reported mental health concerns, and c) explore the association between polyvictimization and mental health concerns. Data are from a 2014 cross-sectional survey of service-seeking youth ages 12 to 18 years (N = 1134) in Kampala, Uganda. Violence exposure types explored in this study were: witnessing family physical violence, direct physical abuse by a parent, any rape history, and physical dating violence. We used descriptive statistics and multivariable logistic regression to test study objectives. Over half of the sample (60.5%) reported experiencing at least one type of violence exposure; many youth endorsed self-reported depression (57.8%), anxiety (76.8%), and substance use to cope (37.0%). Exposure to violence was associated with higher odds for self-reported depression, anxiety, and using substances to cope. These findings underscore the urgent need to implement evidence-based interventions among this young, underserved population and their families to prevent violence, improve mental health outcomes, and promote resilience.

Respiratory Sinus Arrhythmia Change during Trauma-Focused Cognitive-Behavioral Therapy: Results from a Randomized Controlled Feasibility Trial

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a well-established treatment for pediatric posttraumatic stress disorder (PTSD). Animal-assisted therapy (AAT) has been proposed as an adjunct to TF-CBT that may improve treatment effects through enhanced targeting of affect regulation, as indexed by specific changes in the respiratory sinus arrhythmia (RSA). The current study reports results from a randomized controlled feasibility trial (N = 33; M_age = 11.79 [SD = 3.08]; 64% White; 67% female) that measured RSA during Sessions 1, 4, 8, and 12 of a twelve-session TF-CBT protocol and tested whether: 1) TF-CBT + AAT achieved higher average RSA amplitudes relative to TF-CBT alone, and 2) RSA regulation, defined as less variability around person-specific RSA slopes during treatment, explained variation in post-treatment PTSD symptoms. Multilevel modeling failed to support an effect for TF-CBT + AAT on RSA amplitudes (δ₀₀₁ = 0.08, p = 0.844). However, regardless of treatment condition, greater RSA withdrawal was observed within Sessions 4 (γ₁₁ = -.01, p < .001) and 12 (γ₁₃ = -.01, p = .015) relative to the Session 1 baseline. The average level of RSA amplitude in Session 8 was also significantly lower compared to Session 1 (γ₀₂ = -0.70, p = .046). Intraindividual regression models demonstrated that greater RSA regulation predicted improved PTSD symptoms at post-treatment after adjusting for pre-treatment levels (b₃ = 20.00, p = .012). These preliminary results offer support for future confirmatory trials testing whether affect regulation, as indexed by changes in RSA, is a mechanism of action for TF-CBT in the treatment of pediatric PTSD.

Community-Based Interventions for the Treatment and Management of Conflict-Related Trauma in Low-Middle Income, Conflict-Affected Countries: a Realist Review

Where low- and middle-income countries have limited economic resources to provide individualized mental health services to people exposed to conflict, community-based interventions may be more appropriate. We aimed to evaluate community level interventions for improving mental health outcomes in Low- and Middle-income countries (LMIC). A realist review of community-based interventions (CBIs) to improve mental health for people in LMIC following conflict. Five databases (Cochrane, PubMed, PsychINFO, Medline, and CINAHL) and a manual search of individual papers. We found 1318 articles, of which 29 were selected. Out of the 29 primary articles, 19 showed successful results, 4 showed mixed results, 1 showed inconclusive results, and 1 showed unsuccessful results. After analyzing the results, we found 3 mechanisms that may influence the effectiveness of these CBIs: the use of lay community members as intervention deliverers, the application of transdiagnostic approaches, and customized outcome assessment tools. Community-based approaches to improve mental health in LMICs are rare and evidence for their effectiveness is limited. Interventions that have a wide scope, train lay mental health workers, and use contextually adapted outcome assessment tools show promise.

Psychometric performance of the Mental Health Implementation Science Tools (mhIST) across six low- and middle-income countries

BACKGROUND

Existing implementation measures developed in high-income countries may have limited appropriateness for use within low- and middle-income countries (LMIC). In response, researchers at Johns Hopkins University began developing the Mental Health Implementation Science Tools (mhIST) in 2013 to assess priority implementation determinants and outcomes across four key stakeholder groups-consumers, providers, organization leaders, and policy makers-with dedicated versions of scales for each group. These were field tested and refined in several contexts, and criterion validity was established in Ukraine. The Consumer and Provider mhIST have since grown in popularity in mental health research, outpacing psychometric evaluation. Our objective was to establish the cross-context psychometric properties of these versions and inform future revisions.

METHODS

We compiled secondary data from seven studies across six LMIC-Colombia, Myanmar, Pakistan, Thailand, Ukraine, and Zambia-to evaluate the psychometric performance of the Consumer and Provider mhIST. We used exploratory factor analysis to identify dimensionality, factor structure, and item loadings for each scale within each stakeholder version. We also used alignment analysis (i.e., multi-group confirmatory factor analysis) to estimate measurement invariance and differential item functioning of the Consumer scales across the six countries.

RESULTS

All but one scale within the Provider and Consumer versions had Cronbach's alpha greater than 0.8. Exploratory factor analysis indicated most scales were multidimensional, with factors generally aligning with a priori subscales for the Provider version; the Consumer version has no predefined subscales. Alignment analysis of the Consumer mhIST indicated a range of measurement invariance for scales across settings (R2 0.46 to 0.77). Several items were identified for potential revision due to participant nonresponse or low or cross- factor loadings. We found only one item, which asked consumers whether their intervention provider was available when needed, to have differential item functioning in both intercept and loading.

CONCLUSION

We provide evidence that the Consumer and Provider versions of the mhIST are internally valid and reliable across diverse contexts and stakeholder groups for mental health research in LMIC. We recommend the instrument be revised based on these analyses and future research examine instrument utility by linking measurement to other outcomes of interest.

Comparative effectiveness of in-person vs. remote delivery of the Common Elements Treatment Approach for addressing mental and behavioral health problems among adolescents and young adults in Zambia: protocol of a three-arm randomized controlled trial

BACKGROUND

In low- and middle-income countries (LMIC), there is a substantial gap in the treatment of mental and behavioral health problems, which is particularly detrimental to adolescents and young adults (AYA). The Common Elements Treatment Approach (CETA) is an evidence-based, flexible, transdiagnostic intervention delivered by lay counselors to address comorbid mental and behavioral health conditions, though its effectiveness has not yet been tested among AYA. This paper describes the protocol for a randomized controlled trial that will test the effectiveness of traditional in-person delivered CETA and a telehealth-adapted version of CETA (T-CETA) in reducing mental and behavioral health problems among AYA in Zambia. Non-inferiority of T-CETA will also be assessed.

METHODS

This study is a hybrid type 1 three-arm randomized trial to be conducted in Lusaka, Zambia. Following an apprenticeship model, experienced non-professional counselors in Zambia will be trained as CETA trainers using a remote, technology-delivered training method. The new CETA trainers will subsequently facilitate technology-delivered trainings for a new cohort of counselors recruited from community-based partner organizations throughout Lusaka. AYA with mental and behavioral health problems seeking services at these same organizations will then be identified and randomized to (1) in-person CETA delivery, (2) telehealth-delivered CETA (T-CETA), or (3) treatment as usual (TAU). In the superiority design, CETA and T-CETA will be compared to TAU, and using a non-inferiority design, T-CETA will be compared to CETA, which is already evidence-based in other populations. At baseline, post-treatment (approximately 3-4 months post-baseline), and 6 months post-treatment (approximately 9 months post-baseline), we will assess the primary outcomes such as client trauma symptoms, internalizing symptoms, and externalizing behaviors and secondary outcomes such as client substance use, aggression, violence, and health utility. CETA trainer and counselor competency and cost-effectiveness will also be measured as secondary outcomes. Mixed methods interviews will be conducted with trainers, counselors, and AYA participants to explore the feasibility, acceptability, and sustainability of technology-delivered training and T-CETA provision in the Zambian context.

DISCUSSION

Adolescents and young adults in LMIC are a priority population for the treatment of mental and behavioral health problems. Technology-delivered approaches to training and intervention delivery can expand the reach of evidence-based interventions. If found effective, CETA and T-CETA would help address a major barrier to the scale-up and sustainability of mental and behavioral treatments among AYA in LMIC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03458039 . Prospectively registered on May 10, 2021.

Trauma-focused cognitive behavioral therapy for children and youth in low and middle-income countries: A systematic review

BACKGROUND

Trauma-focused cognitive behavioral therapy (TF-CBT) has been identified as a gold standard treatment for childhood posttraumatic stress disorder (PTSD) in Western countries. More recently, TF-CBT has emerged in the literature as an area of interest for children and youth affected by conflict and war in low- and middle-income countries (LMIC).

METHODS

The present systematic review assesses the current evidence base of TF-CBT for children and youth in LMIC, with a focus on conflict-affected countries. A total of 143 articles were identified, of which 11 articles, representing 1,354 participants, met the proposed inclusion criteria.

RESULTS

Results showed that the majority of the studies identified were conducted in low-resource community settings in East or Central Africa (n = 8). It was also found that cultural considerations were taken into account in TF-CBT delivery to meet the needs of local populations. Additionally, measures were translated and validated for local use.

CONCLUSIONS

Findings of outcome data indicated that TF-CBT was effective in treating trauma-related symptoms and improving psychosocial functioning in children and adolescents in LMICs. Given the limited number of published literature available in this area, further studies are needed to conclude when and for whom trauma-focused interventions are most relevant.

Results of the Kigali Imbereheza Project: A 2-Arm Individually Randomized Trial of TI-CBT Enhanced to Address ART Adherence and Mental Health for Rwandan Youth Living With HIV

BACKGROUND

Adolescents living with HIV have elevated mental distress and suboptimal antiretroviral therapy (ART) adherence.

SETTING

Two urban clinics in Kigali, Rwanda.

METHODS

A 2-arm individual randomized controlled trial compared Trauma-Informed Cognitive Behavioral Therapy enhanced to address HIV (TI-CBTe) with usual care (time-matched, long-standing, unstructured support groups) with 356 12- to 21-year-old (M = 16.78) Rwandans living with HIV. TI-CBTe included 6 group-based 2-hour sessions led by trained and supervised 21- to 25-year-old Rwandans living with HIV. Participants reported their ART adherence, depression/anxiety, and Post-Traumatic Stress Disorder symptoms at baseline, 6, 12, and 18 months.

RESULTS

ART adherence was relatively high at baseline, and youth reported elevated rates of depression/anxiety and trauma symptoms. There were no differential treatment effects on adherence, but depression/anxiety improved over time. Youth with lower depression/anxiety at baseline seemed to benefit more from TI-CBTe than usual care, whereas women with high baseline distress seemed to benefit more from usual care. Youth were less likely to score in high Post-Traumatic Stress Disorder symptom categories at the follow-up, with no differential treatment effects.

CONCLUSIONS

TI-CBTe did not outperform usual care on ART adherence, possibly reflecting relatively high adherence at baseline, simplified medication regimens over time, a strong comparison condition, or because youth assigned to TI-CBTe returned to their support groups after the intervention. TI-CBTe was more effective for youth with lower depression/anxiety symptoms, whereas youth with high distress benefitted more from the support groups. TI-CBTe was feasible and acceptable, and young adults living with HIV were able to deliver a mental health intervention with fidelity. The powerful nature of the comparison group, ongoing support groups, points to the potential value of locally crafted interventions in low-resource settings.

A Community-Embedded Implementation Model for Mental-Health Interventions: Reaching the Hardest to Reach

The mental-health-care treatment gap remains very large in low-resource communities, both within high-income countries and globally in low- and middle-income countries. Existing approaches for disseminating psychological interventions within health systems are not working well enough, and hard-to-reach, high-risk populations are often going unreached. Alternative implementation models are needed to expand access and to address the burden of mental-health disorders and risk factors at the family and community levels. In this article, we present empirically supported implementation strategies and propose an implementation model-the community-embedded model (CEM)-that integrates these approaches and situates them within social settings. Key elements of the model include (a) embedding in an existing, community-based social setting; (b) delivering prevention and treatment in tandem; (c) using multiproblem interventions; (d) delivering through lay providers within the social setting; and (e) facilitating relationships between community settings and external systems of care. We propose integrating these elements to maximize the benefits of each to improve clinical outcomes and sustainment of interventions. A case study illustrates the application of the CEM to the delivery of a family-based prevention and treatment intervention within the social setting of religious congregations in Kenya. The discussion highlights challenges and opportunities for applying the CEM across contexts and interventions.

Trauma-focused treatments for refugee children: study protocol for a randomized controlled trial of the effectiveness of KIDNET versus EMDR therapy versus a waitlist control group (KIEM)

BACKGROUND

Prevalence of posttraumatic stress disorder (PTSD) in refugees is reportedly higher in comparison to the general population. Refugee children specifically are often coping with trauma and loss and are at risk for mental health difficulties. With staggering numbers of people seeking refuge around the world and 50% being 18 years or younger, research examining the effects of trauma-focused therapies for refugee children with PTSD is highly needed. Both Eye Movement Desensitization and Reprocessing (EMDR) therapy and the child version of Narrative Exposure Therapy (KIDNET) have been used for refugees, although these treatment methods have not been systematically compared. The aim of the current study is to investigate the effectiveness of EMDR and KIDNET, compared to a waitlist control group and with each other, offered to refugee children.

METHODS

A randomized controlled three-arm trial has been designed. The primary outcome is PTSD diagnosis and symptom severity assessed with the Clinician-Administered PTSD Scale for Children DSM5 (CAPS-CA-5) at baseline (T1), 1 month post-treatment, or after 8 weeks of waiting (T2) and 3 months follow-up (T3). Additionally, instruments to assess posttraumatic stress symptoms, behavioral and emotional problems, and quality of life perception in children aged 8-18 are conducted at T1, T2, and T3.

DISCUSSION

This is the first RCT that examines the effectiveness of EMDR and KIDNET in refugee children aged 8-18 years specifically, compared to a waitlist control group intended to reduce PTSD diagnosis and severity of posttraumatic stress symptoms and comorbid complaints in a growing and challenging population.

TRIAL REGISTRATION

Dutch Trial Register NL40769 . Retrospectively registered on June 16, 2021.

Post-traumatic stress disorder psychological interventions in sub-Saharan Africa: protocol for a systematic review of the literature

INTRODUCTION

Untreated post-traumatic stress disorder (PTSD) results in considerable morbidity and higher risk of mortality. However, little is being done to treat PTSD in sub-Saharan Africa (SSA) settings where rates of PTSD are likely to be elevated due to mass exposure of the population to traumatic events. This systematic review aims to summarise available evidence on the efficacy of psychological therapies for PTSD in SSA.

METHODS AND ANALYSIS

A systematic search of the literature will be conducted in four electronic databases: PubMed, PsychInfo, EMBASE and Cochrane Register of Controlled Trials using keywords and synonyms related to 'PTSD', 'psychological therapies' and 'SSA'. Studies will be included if they were conducted in SSA and used a randomised controlled trial design. Two researchers will screen the studies for eligibility to be included, and data on intervention types, population, comorbidities, comparison group intervention and PTSD outcomes will be extracted from those included. Risk of bias will be assessed using Cochrane risk-of-bias tool for randomised trials (version 2). Narrative synthesis of data will be conducted and pooled effect estimates calculated.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is a protocol of a systematic review of available data. Findings will be disseminated to the scientific community through peer-reviewed publications and presentation at conferences.

PROSPERO REGISTRATION

CRD42020181638.

Client and counsellor experiences of abbreviated trauma-focused cognitive behavioural therapy for South African adolescents

Although South Africa has high rates of child and adolescent trauma exposure and associated mental health difficulties, there is a poor evidence base for trauma interventions with youth in this setting. In a resource-constrained context, there is a need for brief evidence-based trauma treatments. However, abbreviated interventions may reduce the acceptability and tolerability of treatment for clients and impact treatment delivery by providers. We developed an abbreviated eight-session version of trauma-focused cognitive behavioural therapy. Using a sequential mixed-methods design, we piloted this intervention with 10 adolescents and their caregivers to assess the acceptability and tolerability of the abbreviated trauma-focused cognitive behavioural therapy model for participants, the degree of counsellor fidelity to the abbreviated treatment manual and counsellor experiences of implementation. The treatment completion rate was 90% and post-traumatic stress disorder symptoms reduced over the course of treatment for all treatment completers. Although there was flexibility in timing and dosing of delivery, counsellor fidelity to treatment components and treatment length was high. Thematic analysis of interviews with participants and counsellors indicated that, within this abbreviated trauma treatment, the therapeutic alliance was able to provide a solid foundation for trauma processing, there was adequate time to practice coping skills and the compressed trauma processing component was difficult but tolerable. Counsellors indicated that a degree of flexibility within fidelity to the abbreviated treatment model enhanced their implementation of the treatment. The findings provide evidence to support a formal evaluation of the abbreviated trauma-focused cognitive behavioural therapy treatment protocol.

Gender-Oriented Mental Health Prevention: A Reappraisal

Many studies have investigated the impact of gender on mental health, but only a few have addressed gender differences in mental health risk and prevention. We conducted a narrative review to assess the current state of knowledge on gender-specific mental health preventive interventions, along with an analysis of gender-based risk factors and available screening strategies. Out of 1598 articles screened using a comprehensive electronic search of the PubMed, Web-of-Science, Scopus, and Cochrane databases, 53 were included for review. Among risk factors for mental health problems, there are individual, familiar, social, and healthcare factors. Individual factors include childhood adversities, which show gender differences in distribution rates. However, current childhood abuse prevention programs are not gender-specific. Familiar factors for mental health problems include maternity issues and intimate partner violence, and for both, some gender-specific preventive interventions are available. Social risk factors for mental health problems are related to education, employment, discrimination, and relationships. They all display gender differences, but these differences are rarely taken into account in mental health prevention programs. Lastly, despite gender differences in mental health service use being widely known, mental health services appear to be slow in developing strategies that guarantee equal access to care for all individuals.

Mental health interventions for adolescents in sub-Saharan Africa: A scoping review

BACKGROUND

Globally, adolescents are vulnerable to mental health problems, particularly those from sub-Saharan Africa (SSA) due to impoverished living conditions and a higher prevalence of chronic conditions such as HIV/AIDS in the region. The COVID-19 pandemic has further exacerbated this risk. This calls for an urgent need for evidence-based adolescent mental health interventions to reduce the risk and burden of mental health problems in SSA. The review aims to identify and characterize existing adolescent mental health interventions in SSA, as well as to evaluate their implementation strategies and effectiveness.

METHODS

We systematically searched PubMed, African Index Medicus, PsycINFO, Web of Science, and CINAHL databases for relevant articles. Furthermore, we searched gray literature databases, including Think Tank search, open gray, NGO search engine, and IGO search engine for additional relevant articles. The scoping review was conducted to identify original research articles on mental health interventions among adolescents in sub-Saharan Africa published from database inception to 31 December 2021. We carried out a narrative synthesis to report our findings.

RESULTS

Our literature search generated 4,750 studies, of which 1,141 were duplicates, 3,545 were excluded after screening, and 64 articles met the inclusion criteria. The 64 studies describe a total of 57 unique mental health interventions comprising 40,072 adolescents. The nature of these interventions was diverse, encompassing various implementation strategies such as economic-based, family strengthening, psychoeducation, interpersonal psychotherapy, Cognitive Behavioral Therapy, and resilience training, among others. Most of the interventions were selective interventions that targeted adolescents at high risk of developing mental health problems including adolescents living with HIV, war-affected adolescents, orphans, adolescents from poorer backgrounds, and survivors of sexual violence. Half of the interventions were delivered by lay persons. Sixty-two of the eligible studies examined the effectiveness of the mental health interventions, of which 55 of them reported a positive significant impact on various mental health outcomes.

CONCLUSIONS

The review findings show that there exist several diverse interventions that promote mental health among adolescents in sub-Saharan Africa. These interventions can be implemented in diverse settings including schools, communities, health facilities, and camps, and can be delivered by lay persons.

Consumer perspectives on acceptability of trauma-focused cognitive behavioral therapy in Tanzania and Kenya: A mixed methods study

Background

There is a substantial mental health treatment gap globally. Increasingly, mental health treatments with evidence of effectiveness in western countries have been adapted and tested in culturally and contextually distinct countries. Findings from these studies have been promising, but to better understand treatment outcome results and consider broader scale up, treatment acceptability needs to be assessed and better understood. This mixed methods study aimed to examine child and guardian acceptability of trauma-focused cognitive behavioral therapy (TF-CBT) in two regions in Tanzania and Kenya and to better understand how TF-CBT was perceived as helpful for children and guardians.

Methods

Participants were 315 children (7–13), who experienced the death of one or both parents and 315 guardians, both of whom participated in TF-CBT as part of a randomized controlled trial conducted in Tanzania and Kenya. The study used mixed methods, with quantitative evaluation from guardian perspective ( N=315) using the Treatment Acceptability Questionnaire (TAQ) and the Client Satisfaction Questionnaire-8 (CSQ-8). Acceptability was assessed qualitatively from both guardian and child perspectives. Qualitative evaluation involved analysis using stratified selection to identify 160 child and 160 guardian interviews, to allow exploration of potential differences in acceptability by country, setting (urban/rural), and youth age (younger/older).

Results

Guardians reported high acceptability on the TAQ and, using an interpretation guide from U.S.-based work, medium acceptability on the CSQ-8. Guardians and children noted high acceptability in the qualitative analysis, noting benefits that correspond to TF-CBT’s therapeutic goals. Analyses exploring differences in acceptability yielded few differences by setting or child age but suggested some potential differences by country.

Conclusion

Quantitative and qualitative data converged to suggest high acceptability of TF-CBT from guardian and child perspectives in Tanzania and Kenya. Findings add to accumulating evidence of high TF-CBT acceptability from Zambia and other countries (United States, Norway, Australia). Plain Language Summary: Evidence-based treatments have been shown to be effective in countries and regions that are contextually and culturally distinct from where they were developed. But, perspectives of consumers on these treatments have not been assessed regularly or thoroughly. We used open-ended questions and rating scales to assess guardian and youth perspectives on a group-based, cognitive behavioral treatment for children impacted by parental death, in regions within Tanzania and Kenya. Our findings indicate that both guardians and youth found the treatment to be very acceptable. Nearly all guardians talked about specific benefits for the child, followed by benefits for the family and themselves. Eighty percent of youth mentioned benefits for themselves and all youth said they would recommend the program to others. Benefits mentioned by guardians and youth corresponded to treatment goals (improved mood/feelings or behavior, less distress when thinking about the parent/s’ death). Both guardians and children named specific aspects of the treatment that they liked and found useful. Dislikes and challenges of the treatment were less frequently mentioned, but point to areas where acceptability could be further improved. Recommendations from participants also offer areas where acceptability could be improved, namely guardians’ recommendation that the treatment also address non-mental health needs and offer some follow-up or opportunity to participate in the program again. Our study provides an example of how to assess acceptability and identify places to further enhance acceptability.

Behavioral and pharmacological interventions for the prevention and treatment of psychiatric disorders with children exposed to maltreatment

There is a well-established relation between exposure to child maltreatment and the onset and course of multiple, comorbid psychiatric disorders. Given the heterogeneous clinical presentations at the time services are initiated, interventions for children exposed to maltreatment need to be highly effective to curtail the lifelong burden and public health costs attributable to psychiatric disorders. The current review describes the most effective, well-researched, and widely-used behavioral and pharmacological interventions for preventing and treating a range of psychiatric disorders common in children exposed to maltreatment. Detailed descriptions of each intervention, including their target population, indicated age range, hypothesized mechanisms of action, and effectiveness demonstrated through randomized controlled trials research, are presented. Current limitations of these interventions are noted to guide specific directions for future research aiming to optimize both treatment effectiveness and efficiency with children and families exposed to maltreatment. Strategic and programmatic future research can continue the substantial progress that has been made in the prevention and treatment of psychiatric disorders for children exposed to maltreatment.

Is Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) Effective in Reducing Trauma Symptoms among Traumatized Refugee Children? A Systematic Review

In 2019, more than 25.9 million children under 18 were displaced due to unending political conflicts. Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) has a high level of empirical evidence to support its efficacy in processing trauma and behavioral problems in non-refugee children. Yet, little is known about its long-term effectiveness in refugee children. This study conducted a systematic review that assessed the evidence of the effectiveness of TF-CBT in reducing trauma symptoms among refugee children under 18 years of age. A systematic review was conducted from peer-reviewed literature databases (12 databases): PsycINFO, PubMed, Scopus, Google Scholar, ProQuest Dissertations and Theses (PQDT), Cochrane Library, MEDLINE, PROSPERO, EBSCOHost, Campbell Collaboration Library of Systematic Reviews, Social Sciences Index, and grey literature sources published from 1990 to 2019. The search yielded 1650 articles, and 4 peer reviewed studies were identified that met inclusion criteria and yielded a sample size of 64 refugee children from 21 different countries. All 4 studies provided evidence that supported TF-CBT's effectiveness in decreasing trauma symptoms and sustainment during the follow-up assessment among refugee children participants. Despite TF-CBT effectiveness for trauma symptoms treatment, there is still limited evidence to suggest that TF-CBT is effective for all refugee children due to the pilot nature of the studies, and its underutilization in traumatized refugee children from different cultural backgrounds. Future studies should conduct more TF-CBT interventions with diverse refugee children to provide more empirical support for its effectiveness with that population.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40653-021-00370-0.

Intergenerational maltreatment in parent-child dyads from Burundi, Africa: Associations among parental depression and connectedness, posttraumatic stress symptoms, and aggression in children

Studies investigating the associations between histories of childhood maltreatment (CM) in parent-child dyads have primarily involved samples from high-income countries; however, CM rates are higher in low- and middle-income countries. The present study aimed to examine the (a) association between maltreatment in parents and maltreatment of their children through risk (i.e., parent depression) and protective (i.e., parent-child connectedness) factors and (b) associations between CM in children with aggression through posttraumatic stress symptoms (PTSS) and peer/sibling victimization. Participants were 227 parent-child dyads from Burundi, Africa, a low-income country. Parents were 18 years of age or older, and children were 12-18 years (M = 14.76, SD = 1.88, 57.7% female). Among parents, 20.7%-69.5% of participants reported a history of physical and emotional abuse and neglect; among children, the rates of sexual, physical, and emotional abuse ranged from 14.5% to 89.4%. A history of CM in parents was associated with CM in children, B = 0.19, p < .01, and CM in parents was indirectly associated with CM in children through parent-child connectedness, β = .04, 95% CI [.01, .10], and parental depression, β = .08, 95% CI [.03, .15]. In children, maltreatment was positively associated with peer/sibling victimization, and CM was associated with aggression, β = .07, 95% CI [.04, 0.11], through PTSS but not via peer/sibling victimization. Continued efforts to improve CM-related preventive strategies and the accessibility of prevention services are needed to reduce CM in low-income countries such as Burundi.

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS

PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

Lost in Transition? Evidence-Based Treatments for Adolescents and Young Adults with Posttraumatic Stress Disorder and Results of an Uncontrolled Feasibility Trial Evaluating Cognitive Processing Therapy

Posttraumatic stress disorder (PTSD) is not uncommon among adolescents and young adults (AYAs). Left untreated, transition to adulthood might be especially challenging and/or prolonged for AYAs. However, it is unclear whether AYAs are adequately represented in current PTSD treatment research and whether they benefit to the same degree as younger or older individuals. In the first part of the paper, we reflect on developmental considerations in the treatment of AYAs and give an overview of current age-specific results in PTSD treatment research. Furthermore, we review individual trauma-focused evidence-based treatments that were examined in AYAs over the last 10 years. In the second part, we present data from an uncontrolled feasibility trial evaluating cognitive processing therapy (CPT) with some age-adapted modifications and an exposure component (written accounts). We treated 17 AYAs (aged 14 to 21) suffering from posttraumatic stress symptoms (PTSS). At posttreatment, participants had improved significantly with respect to clinician-rated PTSS severity (d = 1.32). Treatment gains were maintained throughout the 6-week and 6-month follow-ups. Results indicated that CPT, with only minor adaptations, was feasible and safe in AYAs. The recommendations for future research focus on the inclusion of young adults in trials with adolescents, more refined age reporting in clinical trials, and the encouragement of dismantling studies in youth. To conclude, clinical recommendations for caregiver involvement and the addressing of developmental tasks, motivational issues and emotion regulation problems are discussed.

Mental health interventions by lay counsellors: a systematic review and meta-analysis

Objective

To investigate the effectiveness of community-based mental health interventions by professionally trained, lay counsellors in low- and middle-income countries.

Methods

We searched PubMed®, Cochrane Central Register of Controlled Trials, PROSPERO and EBSCO databases and professional section publications of the United States National Center for PTSD for randomized controlled trials of mental health interventions by professionally trained, lay counsellors in low- and middle-income countries published between 2000 and 2019. Studies of interventions by professional mental health workers, medical professionals or community health workers were excluded because there are shortages of these personnel in the study countries. Additional data were obtained from study authors. The primary outcomes were measures of post-traumatic stress disorder, depression, anxiety and alcohol use. To estimate effect size, we used a random-effects meta-analysis model.

Findings

We identified 1072 studies, of which 19 (involving 20 trials and 5612 participants in total) met the inclusion criteria. Hedges' g for the aggregate effect size of the interventions by professionally trained, lay counsellors compared with mostly either no intervention or usual care was -0.616 (95% confidence interval: -0.866 to -0.366). This result indicates a significant, medium-sized effect. There was no evidence of publication bias or any other form of bias across the studies and there were no extreme outliers among the study results.

Conclusion

The use of professionally trained, lay counsellors to provide mental health interventions in low- and middle-income countries was associated with significant improvements in mental health symptoms across a range of settings.

Interventions that address institutional child maltreatment: An evidence and gap map

Background

Child maltreatment has serious short and long-term negative impacts for those experiencing it. Child maltreatment occurring in institutional settings has recently received substantial attention. However, evidence about the effectiveness of interventions that prevent, disclose, respond to, or treat maltreatment that has occurred in these environments is fragmented and can be difficult to access. This evidence and gap map (EGM) collates this research evidence. It was developed as a resource for stakeholders operating in the child health, welfare and protection sectors, including practitioners, organisational leaders, policy developers and researchers, wanting to access high quality evidence on interventions addressing institutional child maltreatment.

Objectives

The objectives of this EGM were twofold: (a) To provide a structured and accessible collection of existing evidence from finalised and ongoing overviews of systematic reviews, systematic reviews and effectiveness studies of interventions addressing institutional child maltreatment-for those who work to fund, develop, implement and evaluate interventions aimed at ensuring children's safety in institutional settings; (b) to identify gaps in the available evidence on interventions addressing institutional child maltreatment-thereby helping to inform the research agendas of funders and other organisations.

Search Methods

A comprehensive search strategy identified relevant studies from published and grey literature, comprising: (1) 10 electronic academic databases; (2) five trial and systematic review registries; (3) nine organisational websites; (4) websites and reference lists of inquiry reports associated with seven international inquiries into child abuse and (4) the lists of included studies within systematic reviews identified by the search strategy. Members of this EGM's Subject Matter Experts group were also invited to forward relevant unpublished studies or grey literature.

Selection Criteria

The selection criteria were developed to identify finalised and ongoing overviews of reviews, systematic reviews and primary studies that reported on the effectiveness of interventions addressing child maltreatment (including sexual abuse, physical abuse, neglect and emotional abuse) within institutional settings. Eligible effectiveness study designs included: randomised controlled trials (RCTs), nonrandomised trials, controlled before-and-after studies and quasi-experimental studies. Reviews were eligible if they reported a systematic literature search strategy.

Data Collection and Analysis

All screening, data extraction, coding and critical appraisals were undertaken by two or more reviewers working independently, with discrepancies resolved via consensus or by a third reviewer. The titles and abstracts of studies identified by the search strategy were screened, and each full text of potentially relevant studies was further assessed for inclusion. Key data were extracted from all included studies and reviews. This included information about: publication details (e.g., year, author, country), inclusion/exclusion criteria (for reviews), study design, institutional setting, target population, type of maltreatment, intervention type and outcomes. Critical appraisal of included systematic reviews was achieved using the AMSTAR 2 tool, and completed RCTs were assessed using the updated Cochrane Risk of Bias 2.0 tool.

Main Results

Number of studies The electronic database search yielded 6318 citations, and a further 2375 records were identified from additional sources. Following deduplication and title/abstract screening, 256 studies remained for full text review. A total of 73 eligible studies (reported across 84 publications) met the inclusion criteria, including: 11 systematic reviews (plus, one update); 62 primary studies (including, three protocols for primary studies). Study characteristics The studies were conducted across 18 countries, however more than half (52%) were undertaken in the United States. Overall, most studies evaluated curriculum-based interventions delivered in educational settings, primarily aimed at the prevention of sexual abuse. Institutional setting: Most studies evaluated interventions in school or early learning environments (n = 8 systematic reviews; n = 58 primary studies). Far fewer studies examined other organisational settings. Out of home care (including foster care, residential care and orphanages), and social service organisations servicing children were minimally represented. No studies were identified where the primary setting was sports clubs, churches/religious organisations, summer/vacation camps, detention centres/juvenile justice settings, or primary/secondary health care facilities. Target population: Most interventions targeted children rather than adults (n = 7 systematic reviews; n = 47 primary studies) from the general population. Fewer studies included populations known to be at an increased risk, or those already exposed to maltreatment. Just over a third of the primary studies conducted an analysis to ascertain differences in the effect of an intervention between the genders. Intervention type: Prevention interventions were the most studied (n = 5 systematic reviews; n = 57 primary studies), with additional studies including prevention approaches alongside other intervention types. Fewer studies evaluated interventions targeting disclosure, institutional responses, or treatment interventions. Type of maltreatment: The vast majority of the studies assessed interventions solely addressing the sexual abuse of children (n = 8 systematic reviews; n = 45 primary studies). The remaining studies addressed other forms of maltreatment, including physical and emotional abuse, or neglect, either in combination or as a sole focus. Outcomes: Primary reported outcomes reflected the bias toward child targeted interventions. Outcome measures captured child wellbeing and knowledge outcomes, including measures of mental health, children's knowledge retention and/or self-protective skills. Measures of maltreatment disclosure or maltreatment occurrence/reoccurrence were less common, and all other outcome categories included in the EGM were minimally or not reported. A third of studies reported on some measure of implementation. Study quality The overall quality of the studies was low to moderate. Most systematic reviews were low-quality (n = 10), with only one high quality review (and update) identified. Most completed RCTs had some concerns relating to the risk of bias (n = 30), and the remainder were considered to be at a high risk of bias (n = 19).

Authors' Conclusions

This EGM has highlighted a substantial need for more high quality studies that evaluate interventions across a broader range of institutional contexts and maltreatment types. The current evidence base does not represent countries with large populations and the greatest incidence of child maltreatment. Few studies focussed on perpetrators or the organisational environment. Further evidence gaps were identified for interventions relating to disclosure, organisational responses and treatment, and few studies assessed interventions targeting perpetrators' maltreatment behaviours, recidivism or desistence. Future studies should also include measure of programme implementation.

Islamic Trauma Healing: Integrating Faith and Empirically Supported Principles in a Community-Based Program

Access to adequate, much less state-of-the-art, mental health care is a global problem. Natural disasters, civil war, and terrorist conflict have forcibly displaced millions of Muslims and have resulted in a remarkable level of individual and communitywide trauma exposure. As a result, many are at risk for posttraumatic stress and other trauma-related disorders. Many religiously oriented Muslims traditionally rely on Islamic principles and teachings, as well as their community, to cope with and address trauma-related distress. Islamic Trauma Healing is a six-session, lay-led group intervention developed within a Somali Muslim community that integrates evidence-based trauma-focused cognitive-behavioral therapy principles with cultural and religious practices aimed to enhance uptake and create an easily up-scalable intervention for a wide range of trauma. In sessions, narratives of prophets who have undergone trauma (e.g., Prophet Ayyub, faith during hard times) present Islamic principles and facilitate cognitive shifts. Group members spend individual time turning to Allah in dua (i.e., informal prayer), focused on exposure to trauma memories. Program themes arc across suffering to healing to growth following trauma. This paper describes the core theoretical principles and methods in the Islamic Trauma Healing program. We also describe leader perspectives and the program's train-the-trainer model, in which lay leaders are trained to further disseminate the program and allow Islamic Trauma Healing to be owned and sustained by the Muslim community.

Systematic Review on the Application of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Preschool-Aged Children

Trauma-focused cognitive behavioral therapy (TF-CBT) is one of the most widely studied and disseminated treatments for posttraumatic stress disorder (PTSD) and other comorbid conditions, and has been identified as a "level one" or "well-established" intervention for school-aged children and adolescents. The present systematic review examined the literature on the application of TF-CBT within a preschool-aged population (i.e., children ages three to six), as well as the developmental literature that could increase the efficacy of TF-CBT for preschool-aged children. Information on the use of TF-CBT with preschool-aged children was extracted from randomized controlled trials, case studies, meta-analyses, and other forms of empirical evidence, as part of the evidence-based practice in psychology framework. In comparison to research with school-aged children and adolescents, fewer studies have directly assessed the efficacy of TF-CBT for preschool-aged children who have been exposed to trauma. Given the few studies published to date and difference in treatment protocols for TF-CBT used with preschool-age children, TF-CBT appears to meet criteria as a "level two" or "probably efficacious" intervention for preschool-aged children specifically. According to the available literature, language and cognitive abilities, family context, culture, and clinician expertise are considered as potential variables to address when contemplating the use of TF-CBT for preschool-aged children with symptoms of post-traumatic stress.

A meta-analysis of dropout from evidence-based psychological treatment for post-traumatic stress disorder (PTSD) in children and young people

BACKGROUND

Despite the established evidence base of psychological interventions in treating PTSD in children and young people, concern that these trauma-focused treatments may 'retraumatise' patients or exacerbate symptoms and cause dropout has been identified as a barrier to their implementation. Dropout from treatment is indicative of its relative acceptability in this population.

OBJECTIVE

Estimate the prevalence of dropout in children and young people receiving a psychological therapy for PTSD as part of a randomized controlled trial (RCT).

METHODS

A systematic search of the literature was conducted to identify RCTs of evidence-based treatment of PTSD in children and young people. Proportion meta-analyses estimated the prevalence of dropout. Odds ratios compared the relative likelihood of dropout between different treatments and controls. Subgroup analysis assessed the impact of potential moderating variables.

RESULTS

Forty RCTs were identified. Dropout from all treatment or active control arms was estimated to be 11.7%, 95% CI [9.0, 14.6]. Dropout from evidence-based treatment (TFCBTs and EMDR) was 11.2%, 95% CI [8.2, 14.6]. Dropout from non-trauma focused treatments or controls was 12.8%, 95% CI [7.6, 19.1]. There was no significant difference in the odds of dropout when comparing different modalities. Group rather than individual delivery, and lay versus professional delivery, were associated with less dropout.

CONCLUSIONS

Evidence-based treatments for children and young people with PTSD do not result in higher prevalence of dropout than non-trauma focused treatment or waiting list conditions. Trauma-focused therapies appear to be well tolerated in children and young people.

Psychological Distress Among Orphaned Youth and Youth Reporting Sexual Exploitation in Kampala, Uganda

Psychological distress is a priority health issue in low- and middle-income countries; however, it is inadequately addressed among vulnerable youth living in extremely underserved communities (i.e., on the streets and in the slums) who are at a high risk of experiencing adversity. The purpose of this study was to compute the prevalence of self-reported psychological distress among youth living in the slums of Kampala, Uganda, and examine how orphan status and commercial sexual exploitation (CSE) are related to youth psychological distress. Analyses are based on a 2014 cross-sectional survey of service-seeking youth (N = 1134) in Kampala, Uganda. Bivariate and multivariable multinomial regression analyses were used to determine associations between orphan status, sexual exploitation, and psychological distress (defined as experiencing the following proxy variables for more complex psychopathology: hopelessness and/or worry). Among all youth participants, 83.2% (n = 937) reported at least one type of psychological distress; 51.3% (n = 578) reported experiencing both types. The reported prevalence of any type of psychological distress was highest among youth who reported experiencing sexual exploitation (91.2%), double orphans (90.0%), and single orphans (83.8%); however, a high prevalence (76.7%) of any type of distress was also found among youth who reported both parents alive. Experiencing both types of distress was associated with being a double orphan (adjusted odds ratio [AOR] = 2.92, 95% confidence interval [CI] = [1.77, 4.81]), reporting CSE (AOR = 2.71, 95% CI = [1.67, 4.41]), and increased age (AOR = 1.31, 95% CI = [1.20, 1.44]). Psychological distress is prevalent among all youth living in the slums of Kampala and is independently associated with being a double orphan and experiencing CSE. These findings underscore the urgent need to intervene with all youth who reside in this particular underserved community, especially those who have lost both parents, and to prevent CSE among this vulnerable, underserved population.