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Psychological Treatments for Orphans and Vulnerable Children Affected by Traumatic Events and Chronic Adversity in Sub-Saharan Africa

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August 4, 2015

JAMA Pediatrics

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

Laura K. Murray, PhD; Stephanie Skavenski, MSW, MPH; Jeremy C. Kane, PhD; John Mayeya, MSc; Shannon Dorsey, PhD; Judy A. Cohen, MD; Lynn T. M. Michalopoulos, PhD; Mwiya Imasiku, PhD; Paul A. Bolton, MBBS

Importance Orphans and vulnerable children (OVC) are at high risk for experiencing trauma and related psychosocial problems. Despite this, no randomized clinical trials have studied evidence-based treatments for OVC in low-resource settings.

Objective To evaluate the effectiveness of lay counselor–provided trauma-focused cognitive behavioral therapy (TF-CBT) to address trauma and stress-related symptoms among OVC in Lusaka, Zambia.

Design, Setting, and Participants This randomized clinical trial compared TF-CBT and treatment as usual (TAU) (varying by site) for children recruited from August 1, 2012, through July 31, 2013, and treated until December 31, 2013, for trauma-related symptoms from 5 community sites within Lusaka, Zambia. Children were aged 5 through 18 years and had experienced at least one traumatic event and reported significant trauma-related symptoms. Analysis was with intent to treat.

Interventions The intervention group received 10 to 16 sessions of TF-CBT (n = 131). The TAU group (n = 126) received usual community services offered to OVC.

Main Outcomes and Measures The primary outcome was mean item change in trauma and stress-related symptoms using a locally validated version of the UCLA Posttraumatic Stress Disorder Reaction Index (range, 0-4) and functional impairment using a locally developed measure (range, 0-4). Outcomes were measured at baseline and within 1 month after treatment completion or after a waiting period of approximately 4.5 months after baseline for TAU.

Results At follow-up, the mean item change in trauma symptom score was −1.54 (95% CI, −1.81 to −1.27), a reduction of 81.9%, for the TF-CBT group and −0.37 (95% CI, −0.57 to −0.17), a reduction of 21.1%, for the TAU group. The mean item change for functioning was −0.76 (95% CI, −0.98 to −0.54), a reduction of 89.4%, and −0.54 (95% CI, −0.80 to −0.29), a reduction of 68.3%, for the TF-CBT and TAU groups, respectively. The difference in change between groups was statistically significant for both outcomes (P < .001). The effect size (Cohen d) was 2.39 for trauma symptoms and 0.34 for functioning. Lay counselors participated in supervision and assessed whether the intervention was provided with fidelity in all 5 community settings.

Conclusions and Relevance The TF-CBT adapted for Zambia substantially decreased trauma and stress-related symptoms and produced a smaller improvement in functional impairment among OVC having experienced high levels of trauma.

Peter Ventevogel, MD1; Paul Spiegel, MD, MPH1

JAMA Pediatr. Published online June 29, 2015. doi:10.1001/jamapediatrics.2015.0580

Millions of children globally live in poverty and face adversity. In sub-Saharan Africa, AIDS, conflict, and natural disasters have created large numbers of orphans and vulnerable children (OVCs). Until recently, children’s mental health conditions were not given very high priority in the global research and intervention agenda.1 This is changing now that there is greater recognition that adversity and chronic stress in childhood negatively affect health outcomes in later life.2 There is accumulating evidence supporting the use of psychological treatments for disorders related to traumatic experiences and acute stress.3 However, it is a challenge to integrate psychological interventions within existing national systems of care, which generally are overreliant on medication treatment alone.4 Health care professionals in sub-Saharan Africa facilities have overwhelming workloads and have insufficient time to provide time-consuming psychological interventions.

Given the magnitude of the problem (15.1 million OVCs in sub-Saharan Africa), one solution is to enable nonspecialists to perform tasks that should ideally be done by specialists. The use of brief, evidence-based psychological interventions that can be delivered by trained and supervised lay workers who live in the same communities as the children has potential to improve outcomes for mental disorders in low resource settings.5

In a study published in JAMA Pediatrics, Murray and colleagues6 reported results from a randomized clinical trial (RCT) conducted in Zambia to test the effectiveness of a relatively brief psychological intervention: trauma-focused cognitive behavioral therapy (TF-CBT) delivered by local lay counsellors. Orphans and vulnerable children with ages ranging from 5 to 18 years (n = 257) in the capital, Lusaka, were randomly assigned to receive either TF-CBT or treatment as usual. Trauma symptoms were reduced 82% by the intervention and 21% by treatment as usual. Functional impairment was reduced 89% by the intervention compared with a 68% reduction from treatment as usual.

These results are important because they are the first from an RCT on trauma symptoms among OVCs in low-resource settings. The outcomes add to a small but robust body of evidence demonstrating that focused psychological interventions for children affected by adversity can be successfully undertaken by trained and well-supervised lay workers.

The authors carried out their study in a difficult-to-reach population, including children without homes living on the street, and should be lauded for their exemplary handling of complex issues such as informed consent among children, safety protocols, and the training of lay workers. The study demonstrated a powerful effect of TF-CBT on symptoms of posttraumatic stress disorder (PTSD) among the whole group of respondents. The study participants were heterogeneous in age (5-18 years), sex, living circumstances, and severity of traumatic exposure. The chosen methodology, mixed-effects regression modeling, does not allow insight into who will benefit by specific categories. Further exploration of potentially moderating risk factors would have been interesting to gain further insight into which children this treatment is especially effective for and also to identify the most effective components of the intervention. Previous studies of school-based interventions with children exposed to traumatic events in low- and middle-income countries have shown moderation by age, sex, family-level variables, and types of adversity experienced.7Moreover, the clinical design of the study does not shed light on promotive and protective factors, such as hope and social support, that may mitigate the effect of exposure to traumatic events.8 Future research should have longer follow-up periods than the 1 month in the study by Murray et al,6 given the possibility of delayed or temporary treatment effects.

However, the authors could not report on secondary outcomes related to sexual behavior or alcohol and drug use because participants frequently changed their responses to these questions. This limitation highlights a challenge with self-reporting of past events. A recent study of war-affected children in Afghanistan showed a high malleability of report of traumatic experience that was associated with resiliency and vulnerability; those more severely affected with symptoms of posttraumatic distress were more likely to be consistent in their responses and less likely to forget trauma memories.9

A major issue for future research is whether lay worker–led psychological interventions among OVCs in low-resource settings can be further modified to facilitate scaling up to larger populations. Many psychological treatments are developed for, and tested with, a specific mental disorder, such as PTSD. It is unlikely that countries in sub-Saharan Africa will have sufficient resources and capacities to train lay workers on multiple treatment modalities, one for each disorder. Therefore, it is important to test transdiagnostic interventions that can be used to treat a range of common mental disorders and address comorbidities. In addition, pilot testing of promising interventions such as TF-CBT is only the beginning. Whether it is possible to implement such interventions outside the controlled research setting and bring them to scale by integrating them within existing systems of care without major loss of quality is an important issue that needs to be studied.

Psychotherapeutic interventions are not a panacea to the many problems of OVCs in sub-Saharan Africa. The study by Murray and colleagues6 found beneficial effects of psychotherapy on PTSD symptoms compared with generic, community-based, psychosocial support, such as peer education, support groups, and community outreach activities. This does not mean that generic community-based social interventions are irrelevant. Conversely, psychological treatment of PTSD symptoms will be insufficient to mitigate the social consequences of living in chronic adversity or modify the underlying causes. Focused psychological treatments for specific symptoms must thus be accompanied by broader social and family interventions to address chronic poverty, malnutrition, disease, exclusion, and structural violence that are the root causes of risk accumulation that damages the lives of large numbers of children worldwide.8 The results of the TF-CBT trial in Zambia are encouraging. More operational research and social action are needed to reach the millions of OVCs in sub-Saharan Africa who are in dire need of psychological and social support.

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