Developing a function impairment measure for children affected by political violence: a mixed methods approach in Indonesia

Assessment Tools for Executive Function and Adaptive Function Following Brain Pathology Among Children in Developing Country Contexts: a Scoping Review of Current Tools

Several tools have been developed to assess executive function (EFs) and adaptive functioning, although in mainly Western populations. Information on tools for low-and-middle-income country children is scanty. A scoping review of such instruments was therefore undertaken.We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis- Scoping Review extension (PRISMA-ScR) checklist (Tricco et al., in Annals of Internal Medicine 169(7), 467-473, 2018). A search was made for primary research papers of all study designs that focused on development or adaptation of EF or adaptive function tools in low-and-middle-income countries, published between 1st January 1894 to 15th September 2020. 14 bibliographic databases were searched, including several non-English databases and the data were independently charted by at least 2 reviewers.The search strategy identified 5675 eligible abstracts, which was pruned down to 570 full text articles. These full-text articles were then manually screened for eligibility with 51 being eligible. 41 unique tools coming in 49 versions were reviewed. Of these, the Behaviour Rating Inventory of Executive Functioning (BRIEF- multiple versions), Wisconsin Card Sorting Test (WCST), Go/No-go and the Rey-Osterrieth complex figure (ROCF) had the most validations undertaken for EF tests. For adaptive functions, the tools with the most validation studies were the Vineland Adaptive Behaviour Scales (VABS- multiple versions) and the Child Function Impairment Rating Scale (CFIRS- first edition).There is a fair assortment of tests available that have either been developed or adapted for use among children in developing countries but with limited range of validation studies. However, their psychometric adequacy for this population was beyond the scope of this paper.

A Systematic Review of the Validity and Realiability of Assessment Tools for Executive Function and Adaptive Function Following Brain Pathology among Children and Adolescents in Low- and Middle-Income Countries

Minimal but increasing number of assessment instruments for Executive functions (EFs) and adaptive functioning (AF) have either been developed for or adapted and validated for use among children in low and middle income countries (LAMICs). However, the suitability of these tools for this context is unclear. A systematic review of such instruments was thus undertaken. The Systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist (Liberati et al., in BMJ (Clinical Research Ed.), 339, 2009). A search was made for primary research papers reporting psychometric properties for development or adaptation of either EF or AF tools among children in LAMICs, with no date or language restrictions. 14 bibliographic databases were searched, including grey literature. Risk of bias assessment was done following the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) guidelines (Mokkink et al., in Quality of Life Research,63, 32, 2014). For EF, the Behaviour Rating Inventory of Executive Functioning (BRIEF- multiple versions), Wisconsin Card Sorting Test (WCST), Go/No-go and the Rey-Osterrieth complex figure (ROCF) were the most rigorously validated. For AFs, the Vineland Adaptive Behaviour Scales (VABS- multiple versions) and the Child Function Impairment Rating Scale (CFIRS- first edition) were most validated. Most of these tools showed adequate internal consistency and structural validity. However, none of these tools showed acceptable quality of evidence for sufficient psychometric properties across all the measured domains, particularly so for content validity and cross-cultural validity in LAMICs. There is a great need for adequate adaptation of the most popular EF and AF instruments, or alternatively the development of purpose-made instruments for assessing children in LAMICs.

Systematic Review Registration numbers: CRD42020202190 (EF tools systematic review) and CRD42020203968 (AF tools systematic review) registered on PROSPERO website (https://www.crd.york.ac.uk/prospero/).

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.

Adaptive Functioning Behaviors for Trauma-Affected Children in the Cambodian Context

Across contexts, the roles and responsibilities for children are shaped by a range of sociocultural factors; thus, a contextually specific exploration of adaptive functioning norms is important in optimizing the acceptability, effectiveness, and sustainability of mental health intervention and community programming. The current study aimed to examine child adaptive functioning behaviors for children in Cambodia, a country faced with continuing recovery efforts from war and genocide, intergenerational trauma transmission, poverty, and minimal access to health and mental health services. Qualitative interviews were conducted with 30 children (ages 10–13, 16 girls) and 30 caregivers (ages 30–62, 24 females) in the Battambang province of Cambodia receiving mental health services related to caregiver intimate partner violence. Results reveal trauma-affected children in Cambodia engage in a range of familial, occupational, social, religious, and academic functioning domains. Children in this sample reported behaviors that reflect policy and community level priorities of development of children as a societal and economic resource, distress management strategies of self and others informed by mental health therapy and local healing strategies, and engagement in religio-cultural Khmer Buddhist practices and ceremonies. Findings highlight the importance of contextually specific conceptualizations of functional impairment in guiding assessment and community program design and identifying areas for monitoring intervention effectiveness.

Trajectories of psychological symptoms and resilience in conflict-affected children in low- and middle-income countries

Longitudinal studies on children's and adolescents' psychological reactions to conflict-related traumatic events in low- and middle-income countries are scarce. The present study aimed to analyze children's and adolescents' responses to conflict-related potentially traumatic events (PTEs) and the impact of the number of different types of PTEs on psychological symptoms and resilience over time. We investigated the presence of psychological symptoms and resilience, defined as low levels of symptoms and high levels of hope, in a sample of 597 conflict-affected children and adolescents allocated to a waiting list condition in four randomized trials conducted in Burundi, Indonesia, Nepal and Sri Lanka. A decrease in functional impairment (p < 0.001), symptoms of PTSD (p < 0.001), anxiety (p < 0.001), depression (p = 0.052), and an increase in social support (p < 0.001), was observed over a six-month follow-up. More than one third of children and adolescents (34.6%) exposed to conflict-related traumatic events improved at follow-up. Levels of hope did not significantly change. Improvement in psychological symptoms and resilience were significantly associated with the number of different types of PTEs experienced before study entry. This study showed that children and adolescents have the capacity to react to multiple traumatic events, and that the number of different types of traumatic events has an impact on resilience mechanisms. This will help differentiate the choice and focus of psychosocial interventions according to the amount of traumatic events experienced by children and adolescents, and will inform the development and testing of new psychosocial interventions.

Qualitative Methods Used to Generate Questionnaire Items: A Systematic Review

A systematic review of articles using qualitative methods to generate questionnaire items identified in MEDLINE and PsycINFO from 2000 to 2014 was carried out. Articles were analyzed for (a) year of publication and journal domain, (b) qualitative data collection methods, (c) method of data content analysis, (d) professional experts' input in item generation, and (e) debriefing of the newly developed items. In total, 371 articles were included and results showed (a) an acceleration of published articles, (b) individual interviews and focus groups were common ways of generating items and no emergent approach was identified, (c) the content analysis was usually not described (43% of articles), (d) experts were involved in eliciting concepts in less than a third of articles, (e) 61% of articles involved a step of further submission of newly developed items to the population of interest. This review showed an insufficient reporting of qualitative methods used to generate new questionnaires despite previous recommendations.

Validation of a cross-cultural instrument for child behavior problems: the Disruptive Behavior International Scale - Nepal version

BACKGROUND

Obtaining accurate and valid measurements of disruptive behavior disorders remains a challenge in non-Western settings due to variability in societal norms for child behavior and a lack of tools developed outside of Western contexts. This paper assesses the reliability and construct validity of the Disruptive Behavior International Scale - Nepal version (DBIS-N)-a scale developed using ethnographic research in Nepal-and compares it with a widely used Western-derived scale in assessing locally defined child behavior problems.

METHODS

We assessed a population-based sample of 268 children ages 5-15 years old in Nepal for behavior problems with a pool of candidate items developed from ethnographic research. We selected final items for the DBIS-N using exploratory factor analysis in a randomly selected half of the sample and then evaluated the model fit using confirmatory factor analysis in the remaining half. We compared the classification accuracy and incremental validity of the DBIS-N and Eyberg Child Behavior Inventory (ECBI) using local defined behavior problems as criteria. Local criteria were assessed via parent report using: 1) local behavior problem terms, and 2) a locally developed vignette-based assessment.

RESULTS

Ten items were selected for the final scale. The DBIS-N had good internal consistency (Cronbach's α: 0.84) and excellent test-retest reliability (intraclass correlation 0.93, r = .93). Classification accuracy and area under the curve (AUC) were similar and high for both the ECBI (AUC: 0.83 and 0.85) and DBIS-N (AUC: 0.83 and 0.85) on both local criteria. The DBIS-N added predictive value above the ECBI in logistic regression models, supporting its incremental validity.

CONCLUSIONS

While both the DBIS-N and the ECBI had high classification accuracy for local idioms for behavior problems, the DBIS-N had a more coherent factor structure and added predictive value above the ECBI. Items from the DBIS-N were more consistent with cultural themes identified in qualitative research, whereas multiple items in the ECBI that did not fit with these themes performed poorly in factor analysis. In conjunction with practical considerations such as price and scale length, our results lend support for the utility of the DBIS-N for the assessment of locally prioritized behavior problems in Nepal.

Psychological therapies for the treatment of mental disorders in low- and middle-income countries affected by humanitarian crises

BACKGROUND

People living in humanitarian settings in low- and middle-income countries (LMICs) are exposed to a constellation of stressors that make them vulnerable to developing mental disorders. Mental disorders with a higher prevalence in these settings include post-traumatic stress disorder (PTSD) and major depressive, anxiety, somatoform (e.g. medically unexplained physical symptoms (MUPS)), and related disorders. A range of psychological therapies are used to manage symptoms of mental disorders in this population.

OBJECTIVES

To compare the effectiveness and acceptability of psychological therapies versus control conditions (wait list, treatment as usual, attention placebo, psychological placebo, or no treatment) aimed at treating people with mental disorders (PTSD and major depressive, anxiety, somatoform, and related disorders) living in LMICs affected by humanitarian crises.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), the Cochrane Central Register of Controlled Trials (Wiley), MEDLINE (OVID), Embase (OVID), and PsycINFO (OVID), with results incorporated from searches to 3 February 2016. We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify any unpublished or ongoing studies. We checked the reference lists of relevant studies and reviews.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing psychological therapies versus control conditions (including no treatment, usual care, wait list, attention placebo, and psychological placebo) to treat adults and children with mental disorders living in LMICs affected by humanitarian crises.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane procedures for collecting data and evaluating risk of bias. We calculated standardised mean differences for continuous outcomes and risk ratios for dichotomous data, using a random-effects model. We analysed data at endpoint (zero to four weeks after therapy); at medium term (one to four months after therapy); and at long term (six months or longer). GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) was used to assess the quality of evidence for post-traumatic stress disorder (PTSD), depression, anxiety and withdrawal outcomes.

MAIN RESULTS

We included 36 studies (33 RCTs) with a total of 3523 participants. Included studies were conducted in sub-Saharan Africa, the Middle East and North Africa, and Asia. Studies were implemented in response to armed conflicts; disasters triggered by natural hazards; and other types of humanitarian crises. Together, the 33 RCTs compared eight psychological treatments against a control comparator.Four studies included children and adolescents between 5 and 18 years of age. Three studies included mixed populations (two studies included participants between 12 and 25 years of age, and one study included participants between 16 and 65 years of age). Remaining studies included adult populations (18 years of age or older).Included trials compared a psychological therapy versus a control intervention (wait list in most studies; no treatment; treatment as usual). Psychological therapies were categorised mainly as cognitive-behavioural therapy (CBT) in 23 comparisons (including seven comparisons focused on narrative exposure therapy (NET), two focused on common elements treatment approach (CETA), and one focused on brief behavioural activation treatment (BA)); eye movement desensitisation and reprocessing (EMDR) in two comparisons; interpersonal psychotherapy (IPT) in three comparisons; thought field therapy (TFT) in three comparisons; and trauma or general supportive counselling in two comparisons. Although interventions were described under these categories, several psychotherapeutic elements were common to a range of therapies (i.e. psychoeducation, coping skills).In adults, psychological therapies may substantially reduce endpoint PTSD symptoms compared to control conditions (standardised mean difference (SMD) -1.07, 95% confidence interval (CI) -1.34 to -0.79; 1272 participants; 16 studies; low-quality evidence). The effect is smaller at one to four months (SMD -0.49, 95% CI -0.68 to -0.31; 1660 participants; 18 studies) and at six months (SMD -0.37, 95% CI -0.61 to -0.14; 400 participants; five studies). Psychological therapies may also substantially reduce endpoint depression symptoms compared to control conditions (SMD -0.86, 95% CI -1.06 to -0.67; 1254 participants; 14 studies; low-quality evidence). Similar to PTSD symptoms, follow-up data at one to four months showed a smaller effect on depression (SMD -0.42, 95% CI -0.63 to -0.21; 1386 participants; 16 studies). Psychological therapies may moderately reduce anxiety at endpoint (SMD -0.74, 95% CI -0.98 to -0.49; 694 participants; five studies; low-quality evidence) and at one to four months' follow-up after treatment (SMD -0.53, 95% CI -0.66 to -0.39; 969 participants; seven studies). Dropout rates are probably similar between study conditions (19.5% with control versus 19.1% with psychological therapy (RR 0.98 95% CI 0.82 to 1.16; 2930 participants; 23 studies, moderate quality evidence)).In children and adolescents, we found very low quality evidence for lower endpoint PTSD symptoms scores in psychotherapy conditions (CBT) compared to control conditions, although the confidence interval is wide (SMD -1.56, 95% CI -3.13 to 0.01; 130 participants; three studies;). No RCTs provided data on major depression or anxiety in children. The effect on withdrawal was uncertain (RR 1.87 95% CI 0.47 to 7.47; 138 participants; 3 studies, low quality evidence).We did not identify any studies that evaluated psychological treatments on (symptoms of) somatoform disorders or MUPS in LMIC humanitarian settings.

AUTHORS' CONCLUSIONS

There is low quality evidence that psychological therapies have large or moderate effects in reducing PTSD, depressive, and anxiety symptoms in adults living in humanitarian settings in LMICs. By one to four month and six month follow-up assessments treatment effects were smaller. Fewer trials were focused on children and adolescents and they provide very low quality evidence of a beneficial effect of psychological therapies in reducing PTSD symptoms at endpoint. Confidence in these findings is influenced by the risk of bias in the studies and by substantial levels of heterogeneity. More research evidence is needed, particularly for children and adolescents over longer periods of follow-up.

Psychological therapies for children and adolescents exposed to trauma

BACKGROUND

Children and adolescents who have experienced trauma are at high risk of developing post-traumatic stress disorder (PTSD) and other negative emotional, behavioural and mental health outcomes, all of which are associated with high personal and health costs. A wide range of psychological treatments are used to prevent negative outcomes associated with trauma in children and adolescents.

OBJECTIVES

To assess the effects of psychological therapies in preventing PTSD and associated negative emotional, behavioural and mental health outcomes in children and adolescents who have undergone a traumatic event.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Specialised Register to 29 May 2015. This register contains reports of relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We also checked reference lists of relevant studies and reviews. We did not restrict the searches by date, language or publication status.

SELECTION CRITERIA

All randomised controlled trials of psychological therapies compared with a control such as treatment as usual, waiting list or no treatment, pharmacological therapy or other treatments in children or adolescents who had undergone a traumatic event.

DATA COLLECTION AND ANALYSIS

Two members of the review group independently extracted data. We calculated odds ratios for binary outcomes and standardised mean differences for continuous outcomes using a random-effects model. We analysed data as short-term (up to and including one month after therapy), medium-term (one month to one year after therapy) and long-term (one year or longer).

MAIN RESULTS

Investigators included 6201 participants in the 51 included trials. Twenty studies included only children, two included only preschool children and ten only adolescents; all others included both children and adolescents. Participants were exposed to sexual abuse in 12 trials, to war or community violence in ten, to physical trauma and natural disaster in six each and to interpersonal violence in three; participants had suffered a life-threatening illness and had been physically abused or maltreated in one trial each. Participants in remaining trials were exposed to a range of traumas.Most trials compared a psychological therapy with a control such as treatment as usual, wait list or no treatment. Seventeen trials used cognitive-behavioural therapy (CBT); four used family therapy; three required debriefing; two trials each used eye movement desensitisation and reprocessing (EMDR), narrative therapy, psychoeducation and supportive therapy; and one trial each provided exposure and CBT plus narrative therapy. Eight trials compared CBT with supportive therapy, two compared CBT with EMDR and one trial each compared CBT with psychodynamic therapy, exposure plus supportive therapy with supportive therapy alone and narrative therapy plus CBT versus CBT alone. Four trials compared individual delivery of psychological therapy to a group model of the same therapy, and one compared CBT for children versus CBT for both mothers and children.The likelihood of being diagnosed with PTSD in children and adolescents who received a psychological therapy was significantly reduced compared to those who received no treatment, treatment as usual or were on a waiting list for up to a month following treatment (odds ratio (OR) 0.51, 95% confidence interval (CI) 0.34 to 0.77; number needed to treat for an additional beneficial outcome (NNTB) 6.25, 95% CI 3.70 to 16.67; five studies; 874 participants). However the overall quality of evidence for the diagnosis of PTSD was rated as very low. PTSD symptoms were also significantly reduced for a month after therapy (standardised mean difference (SMD) -0.42, 95% CI -0.61 to -0.24; 15 studies; 2051 participants) and the quality of evidence was rated as low. These effects of psychological therapies were not apparent over the longer term.CBT was found to be no more or less effective than EMDR and supportive therapy in reducing diagnosis of PTSD in the short term (OR 0.74, 95% CI 0.29 to 1.91; 2 studies; 160 participants), however this was considered very low quality evidence. For reduction of PTSD symptoms in the short term, there was a small effect favouring CBT over EMDR, play therapy and supportive therapies (SMD -0.24, 95% CI -0.42 to -0.05; 7 studies; 466 participants). The quality of evidence for this outcome was rated as moderate.We did not identify any studies that compared pharmacological therapies with psychological therapies.

AUTHORS' CONCLUSIONS

The meta-analyses in this review provide some evidence for the effectiveness of psychological therapies in prevention of PTSD and reduction of symptoms in children and adolescents exposed to trauma for up to a month. However, our confidence in these findings is limited by the quality of the included studies and by substantial heterogeneity between studies. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies for children exposed to trauma, particularly over the longer term. High-quality studies should be conducted to compare these therapies.

Mental Suffering in Protracted Political Conflict: Feeling Broken or Destroyed

PURPOSE

This mixed-methods exploratory study identified and then developed and validated a quantitative measure of a new construct of mental suffering in the occupied Palestinian territory: feeling broken or destroyed.

METHODS

Group interviews were conducted in 2011 with 68 Palestinians, most aged 30-40, in the West Bank, East Jerusalem, and the Gaza Strip to discern local definitions of functioning. Interview participants articulated of a type of suffering not captured in existing mental health instruments used in regions of political conflict. In contrast to the specific difficulties measured by depression and PTSD (sleep, appetite, energy, flashbacks, avoidance, etc.), participants elaborated a more existential form of mental suffering: feeling that one's spirit, morale and/or future was broken or destroyed, and emotional and psychological exhaustion. Participants articulated these feelings when describing the rigors of the political and economic contexts in which they live. We wrote survey items to capture these sentiments and administered these items-along with standard survey measures of mental health-to a representative sample of 1,778 32-43 year olds in the occupied Palestinian territory. The same survey questions also were administered to a representative subsample (n = 508) six months earlier, providing repeated measures of the construct.

RESULTS

Across samples and time, the feeling broken or destroyed scale: 1) comprised a separate factor in exploratory factor analyses, 2) had high inter-item consistency, 3) was reported by both genders and in all regions, 4) showed discriminate validity via moderate correlations with measures of feelings of depression and trauma-related stress, and 5) was more commonly experienced than either feelings of depression or trauma-related stress.

CONCLUSIONS

Feeling broken or destroyed can be reliably measured and distinguished from conventional measures of mental health. Such locally grounded and contextualized measures should be identified and included in assessments of the full impact of protracted political conflict on functioning.

Psychosocial interventions for disruptive behavioural problems in children living in low- and middle-income countries: study protocol of a systematic review

INTRODUCTION

Disruptive behaviour disorders (DBDs) are among the most common forms of child psychopathology and have serious long-term academic, social, and mental health consequences worldwide. Psychosocial treatments are the first line of evidence-based treatments for DBDs, yet their effectiveness often varies according to patient sociodemographic characteristics, practice setting, and implementation procedures. While a large majority of the world's children live in low- and middle-income countries (LMIC), most studies have evaluated psychosocial treatments for DBDs in high-income Anglo countries.

METHODS AND ANALYSIS

The primary objective of this systematic review is to assess the effects of psychosocial treatments for DBDs in children and adolescents (under age 18) diagnosed with oppositional defiant disorder, conduct disorder, or other disruptive behavioural problems living in LMIC. The secondary objectives are to: (1) describe the range and types of psychosocial treatments used to address DBDs in LMIC and (2) identify key dissemination and implementation factors (adaptation processes, training/supervision processes, and financial costs). All controlled trials comparing psychosocial treatments versus waiting list, no treatment, or treatment as usual in children living in LMIC will be included. Studies will be identified using the methods outlined in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines without restrictions on language, publication type, status, or date of publication. The primary outcome measures will be disruptive behavioural problems (eg, oppositionality, defiance, aggression or deceit). Secondary outcomes will be positive mental health outcomes (eg, prosocial behaviour), function impairment, institutionalisation (or hospitalisation), academic outcomes and caregiver outcomes.

ETHICS AND DISSEMINATION

This study uses data from published studies; therefore ethical review is not required. Findings will be presented in a published manuscript.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42014015334.

Challenges of creating synergy between global mental health and cultural psychiatry

This article addresses four major challenges for efforts to create synergy between the global mental health movement and cultural psychiatry. First, although they appear to share domains of mutual interest, the worlds of global mental health and cultural psychiatry have distinct lineages. Expanding their horizons by learning from adjacent disciplines would be mutually beneficial. A second challenge concerns the conceptualization of a new classification system for mental health problems. Adopting a classification system that integrates new insights from socio-neurobiology and from a networks perspective could bring cultural psychiatry and global mental health closer and change the way each field addresses the mental health gap, which constitutes the third challenge. I summarize attempts to achieve comprehensive mental health coverage around the globe and question whether the strategies employed to achieve these goals have been successful, both in high- (HIC) and low- and middle-income countries (LMIC). In LMIC, the dominant strategy needs to be complemented by mobilization of other community resources including local practitioners. A fourth challenge is the lack of mathematical models to guide action and research and solve major preoccupations such as access to care or multi-level analyses in complex ecological or health systems.

Understanding resilience in armed conflict: social resources and mental health of children in Burundi

Little is known about the role of cognitive social capital among war-affected youth in low- and middle-income countries. We examined the longitudinal association between cognitive social capital and mental health (depression and posttraumatic stress disorder (PTSD) symptoms), functioning, and received social support of children in Burundi. Data were obtained from face-to-face interviews with 176 children over three measurement occasions over the span of 4-months. Cognitive social capital measured the degree to which children believed their community was trustworthy and cohesive. Mental health measures included the Depression Self-Rating Scale (DSRS) (Birleson, 1981), the Child Posttraumatic Symptom Scale (Foa et al., 2001), and a locally constructed scale of functional impairment. Children reported received social support by listing whether they received different types of social support from self-selected key individuals. Cross-lagged path analytic modeling evaluated relationships between cognitive social capital, symptoms and received support separately over baseline (T1), 6-week follow-up (T2), and 4-month follow-up (T3). Each concept was treated and analyzed as a continuous score using manifest indicators. Significant associations between study variables were unidirectional. Cognitive social capital was associated with decreased depression between T1 and T2 (B = -.22, p < .001) and T2 and T3 (β = -.25, p < .001), and with functional impairment between T1 and T2 (β = -.15, p = .005) and T2 and T3 (β = -.14, p = .005); no association was found for PTSD symptoms at either time point. Cognitive social capital was associated with increased social support between T1 and T2 (β = .16, p = .002) and T2 and T3 (β = .16, p = .002). In this longitudinal study, cognitive social capital was related to a declining trajectory of children's mental health problems and increases in social support. Interventions that improve community relations in war-affected communities may alter the trajectories of resource loss and gain with conflict-affected children.

Psychosocial interventions for children exposed to traumatic events in low- and middle-income countries: study protocol of an individual patient data meta-analysis

BACKGROUND

The burden of mental health and psychosocial problems in children exposed to traumatic events in humanitarian settings in low- and middle-income countries is substantial. An increasing number of randomized studies has shown promising effects of psychosocial interventions, but this evidence has shown complexity with regard to setting, conflict-phase, gender, and age. These complex findings raise the need of a detailed evaluation of the specific factors which influence size and direction of intervention effects.Individual patient data meta-analysis is a specific type of meta-analysis that allows the collection of exact information at an individual patient level, and to examine whether intervention and socio-demographic characteristics, trauma-related variables, environmental conditions, and social support may act as moderators and mediators of intervention effect.The aim of the present study is to carry out an individual patient data meta-analysis using data from all available randomized controlled trials (either published or unpublished) comparing psychosocial intervention with waiting list or no intervention arms in children exposed to traumatic events living in low- and middle-income countries.

METHODS/DESIGN

All randomized trials comparing selective preventive psychosocial intervention versus waiting list or no treatment conditions in children (0-18 years) living in low- and middle-income countries will be included. Studies will be identified in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. There will be no restrictions on publication type, status, language, or date of publication. The primary outcome measures will be psychological symptoms (post-traumatic stress disorder, anxiety, depression). Secondary outcomes will be positive mental health outcomes (coping methods, social support, self-esteem), and function impairment.

DISCUSSION

We are expecting that some variables, like socio-demographic characteristics, trauma-related variables, environmental conditions, and social support will act as moderators/mediators of intervention effect. The investigation of the role of these factors on the intervention effects will help in the appropriate selection, development, implementation, and dissemination of evidence-based programs in low- and middle-income countries.

TRIAL REGISTRATION

This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42013006960).

School-based mental health intervention for children in war-affected Burundi: a cluster randomized trial

BACKGROUND

Armed conflicts are associated with a wide range of impacts on the mental health of children and adolescents. We evaluated the effectiveness of a school-based intervention aimed at reducing symptoms of posttraumatic stress disorder, depression, and anxiety (treatment aim); and improving a sense of hope and functioning (preventive aim).

METHODS

We conducted a cluster randomized trial with 329 children in war-affected Burundi (aged 8 to 17 (mean 12.29 years, standard deviation 1.61); 48% girls). One group of children (n = 153) participated in a 15-session school-based intervention implemented by para-professionals, and the remaining 176 children formed a waitlist control condition. Outcomes were measured before, one week after, and three months after the intervention.

RESULTS

No main effects of the intervention were identified. However, longitudinal growth curve analyses showed six favorable and two unfavorable differences in trajectories between study conditions in interaction with several moderators. Children in the intervention condition living in larger households showed decreases on depressive symptoms and function impairment, and those living with both parents showed decreases on posttraumatic stress disorder and depressive symptoms. The groups of children in the waitlist condition showed increases in depressive symptoms. In addition, younger children and those with low levels of exposure to traumatic events in the intervention condition showed improvements on hope. Children in the waitlist condition who lived on their original or newly bought land showed improvements in hope and function impairment, whereas children in the intervention condition showed deterioration on these outcomes.

CONCLUSIONS

Given inconsistent effects across studies, findings do not support this school-based intervention as a treatment for posttraumatic stress disorder and depressive symptoms in conflict-affected children. The intervention appears to have more consistent preventive benefits, but these effects are contingent upon individual (for example, age, gender) and contextual (for example, family functioning, state of conflict, displacement) variables. Results suggest the potential benefit of school-based preventive interventions particularly in post-conflict settings.

TRIAL REGISTRATION

The study was registered as ISRCTN42284825.

Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries

BACKGROUND

Many people with mental, neurological and substance-use disorders (MNS) do not receive health care. Non-specialist health workers (NSHWs) and other professionals with health roles (OPHRs) are a key strategy for closing the treatment gap.

OBJECTIVES

To assess the effect of NSHWs and OPHRs delivering MNS interventions in primary and community health care in low- and middle-income countries.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 21 June 2012); MEDLINE, OvidSP; MEDLINE In Process & Other Non-Indexed Citations, OvidSP; EMBASE, OvidSP (searched 15 June 2012); CINAHL, EBSCOhost; PsycINFO, OvidSP (searched 18 and 19 June 2012); World Health Organization (WHO) Global Health Library (searched 29 June 2012); LILACS; the International Clinical Trials Registry Platform (WHO); OpenGrey; the metaRegister of Controlled Trials (searched 8 and 9 August 2012); Science Citation Index and Social Sciences Citation Index (ISI Web of Knowledge) (searched 2 October 2012) and reference lists, without language or date restrictions. We contacted authors for additional studies.

SELECTION CRITERIA

Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted-time-series studies of NSHWs/OPHR-delivered interventions in primary/community health care in low- and middle-income countries, and intended to improve outcomes in people with MNS disorders and in their carers. We defined an NSHW as any professional health worker (e.g. doctors, nurses and social workers) or lay health worker without specialised training in MNS disorders. OPHRs included people outside the health sector (only teachers in this review).

DATA COLLECTION AND ANALYSIS

Review authors double screened, double data-extracted and assessed risk of bias using standard formats. We grouped studies with similar interventions together. Where feasible, we combined data to obtain an overall estimate of effect.

MAIN RESULTS

The 38 included studies were from seven low- and 15 middle-income countries. Twenty-two studies used lay health workers, and most addressed depression or post-traumatic stress disorder (PTSD). The review shows that the use of NSHWs, compared with usual healthcare services: 1. may increase the number of adults who recover from depression or anxiety, or both, two to six months after treatment (prevalence of depression: risk ratio (RR) 0.30, 95% confidence interval (CI) 0.14 to 0.64; low-quality evidence); 2. may slightly reduce symptoms for mothers with perinatal depression (severity of depressive symptoms: standardised mean difference (SMD) -0.42, 95% CI -0.58 to -0.26; low-quality evidence); 3. may slightly reduce the symptoms of adults with PTSD (severity of PTSD symptoms: SMD -0.36, 95% CI -0.67 to -0.05; low-quality evidence); 4. probably slightly improves the symptoms of people with dementia (severity of behavioural symptoms: SMD -0.26, 95% CI -0.60 to 0.08; moderate-quality evidence); 5. probably improves/slightly improves the mental well-being, burden and distress of carers of people with dementia (carer burden: SMD -0.50, 95% CI -0.84 to -0.15; moderate-quality evidence); 6. may decrease the amount of alcohol consumed by people with alcohol-use disorders (drinks/drinking day in last 7 to 30 days: mean difference -1.68, 95% CI -2.79 to -0.57); low-quality evidence).It is uncertain whether lay health workers or teachers reduce PTSD symptoms among children. There were insufficient data to draw conclusions about the cost-effectiveness of using NSHWs or teachers, or about their impact on people with other MNS conditions. In addition, very few studies measured adverse effects of NSHW-led care - such effects could impact on the appropriateness and quality of care.

AUTHORS' CONCLUSIONS

Overall, NSHWs and teachers have some promising benefits in improving people's outcomes for general and perinatal depression, PTSD and alcohol-use disorders, and patient- and carer-outcomes for dementia. However, this evidence is mostly low or very low quality, and for some issues no evidence is available. Therefore, we cannot make conclusions about which specific NSHW-led interventions are more effective.

Broadening the scope of epidemiology in conflict-affected settings: opportunities for mental health prevention and promotion

This editorial proposes a shift in emphasis in the field of mental health epidemiology in conflict-affected settings. After a brief summary of the nature of contemporary armed conflicts, we consider the current and potential roles that epidemiology can play with regard to: (1) establishing the burden of mental disorders; (2) identifying risk and protective factors; and (3) intervention research. We advocate for improved methodological rigor; more attention to mixed methods approaches and multi-level longitudinal research; inclusion of the determinants of mental health beyond conflict-related violence; and consideration of a wider array of mental health outcomes. We particularly highlight the importance of expanding interest to epidemiological research that advances prevention and promotion interventions (e.g., in the early childhood period), in order to fill the gap between epidemiology and mental health practice in conflict-affected settings.

Implementation of a mental health care package for children in areas of armed conflict: a case study from Burundi, Indonesia, Nepal, Sri Lanka, and Sudan

As one article in an ongoing series on Global Mental Health Practice, Mark Jordans and colleagues describe their work developing and evaluating a community-based psychosocial and mental health care package for children in five conflict affected countries: Burundi, Indonesia, Nepal, Sri Lanka, and Sudan.

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

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

Mental health and psychosocial support in humanitarian settings: linking practice and research

This review links practice, funding, and evidence for interventions for mental health and psychosocial wellbeing in humanitarian settings. We studied practice by reviewing reports of mental health and psychosocial support activities (2007-10); funding by analysis of the financial tracking service and the creditor reporting system (2007-09); and interventions by systematic review and meta-analysis. In 160 reports, the five most commonly reported activities were basic counselling for individuals (39%); facilitation of community support of vulnerable individuals (23%); provision of child-friendly spaces (21%); support of community-initiated social support (21%); and basic counselling for groups and families (20%). Most interventions took place and were funded outside national mental health and protection systems. 32 controlled studies of interventions were identified, 13 of which were randomised controlled trials (RCTs) that met the criteria for meta-analysis. Two studies showed promising effects for strengthening community and family supports. Psychosocial wellbeing was not included as an outcome in the meta-analysis, because its definition varied across studies. In adults with symptoms of post-traumatic stress disorder (PTSD), meta-analysis of seven RCTs showed beneficial effects for several interventions (psychotherapy and psychosocial supports) compared with usual care or waiting list (standardised mean difference [SMD] -0·38, 95% CI -0·55 to -0·20). In children, meta-analysis of four RCTs failed to show an effect for symptoms of PTSD (-0·36, -0·83 to 0·10), but showed a beneficial effect of interventions (group psychotherapy, school-based support, and other psychosocial support) for internalising symptoms (six RCTs; SMD -0·24, -0·40 to -0·09). Overall, research and evidence focuses on interventions that are infrequently implemented, whereas the most commonly used interventions have had little rigorous scrutiny.