Study Finds Group Interpersonal Psychotherapy Reduces Symptoms of Depression Among Adolescent Girls Affected by War in Northern Uganda

Prior research indicates that war-affected youth are at increased risk of mental health issues, and many humanitarian organizations have been implementing interventions to ameliorate these problems. Yet, few rigorous evaluations have been conducted and even fewer have implemented a randomized control design. Using a randomized control design, Bolton et al. (2007) examined the effectiveness of a group interpersonal psychotherapy intervention (IPT-G) and a creative play intervention (CP), as compared to a wait-list control group, in decreasing depression symptoms, anxiety symptoms, and conduct problems among war-affected adolescents. The authors first developed locally derived measures for depression, anxiety, conduct problems, and functioning to create the Acholi Psychosocial Assessment Instrument (APAI), which was found to have strong test-retest reliability and criterion validity. Stage one of the screening asked community leaders, teachers, community workers, and adolescents to create a list of 14 to 17-year-olds who exhibited at least one of the locally-derived depression symptoms. Stage two of the screening process administered the locally derived instrument to community-identified children to determine who should be included in the study. The study employed a pretest-posttest control group design, with participants randomly assigned to one of the three groups. The authors found that all three groups experienced decreased symptoms of depression. However, only girls experienced statistically significant reductions in their depressive symptoms after participating in IPT-G. Neither IPT-G nor CP were associated with improvement in anxiety, conduct problems, or functioning.

Based on previous RCTs in sub-Saharan populations, the authors recognized that attrition could pose a threat to the study’s validity by decreasing sample size and power and compromising the integrity of the random assignment. To address this, the authors employed intent-to-treat analysis, using pretreatment data from subjects who have dropped out as both pre- and post-test data. Intent-to-treat analysis also provided a conservative test of the hypothesis, making the effect of IPT-G all the more compelling. To decrease attrition further, the experimenters used a unique method of obtaining informed consent from the sample, both before the administration of the pre-intervention measure and after random assignment to one of the three groups. This study contributes to the growing knowledge base about ways to address the effects of war among adolescents, and proves that randomized control study designs can be implemented in difficult contexts with vulnerable populations.

Reference:
Bolton, P., Bass, J., Betancourt, T., Speelman, L., Onyango, G., Clougherty, K.F., Neugebauer, R., Murray, L., and Verdeli, H. (2007). Interventions for depression symptoms among adolescent survivors of war and displacement in Northern Uganda: A randomized control trial. Journal of the American Medical Association, 298(5), 519-527

Mind-Body Skills Intervention Decreases Symptoms of Post-Traumatic Stress Disorder in Postwar Kosovar Adolescents

Incidence of post-traumatic stress disorder (PTSD) has been reported among war-affected children and adolescents. Yet few studies have evaluated the effectiveness of PTSD treatment programs for this population. Gordon, et al. (2009) conducted a randomized control trial to determine the effectiveness of an intervention aimed at ameliorating the effects of PTSD in adolescents. All children in Jeta e Re (“New Life”) High School in Kosovo were screened to participate in the study. Eighty-two students met the criteria for PTSD and were randomly assigned to two groups: (a) intervention group and (b) delayed intervention group. The intervention group participated in a comprehensive mind-body skills group program, a 12-session program consisting of meditation, guided imagery, breathing exercises, relaxation activities, therapeutic discussion, and art therapy. The delayed intervention group received the same intervention once the intervention group had completed the program, approximately 6 weeks later. The study shows that students receiving the mind-body skills group program had significantly reduced levels of PTSD symptoms as compared to the delayed intervention control group.

This study is the first randomized control study to examine the effects of a therapeutic intervention on war-affected adolescents. The study design overcomes the ethical dilemma of withholding promising treatment from the control group by providing treatment to the control group after the intervention group has completed post-intervention interviews. Nevertheless, expectation bias poses a threat to the study’s internal validity, because the results of the improved outcomes may be due to the participants’ expectations that the intervention would be effective. This threat to internal validity is supported by the fact that the intervention was piloted in the school prior to the study, building even more anticipation, as students are bound to share their experiences with other students. This is also be related to the process of testing, which could be a threat to internal validity, because students may become familiar with the measures being used. Because teachers both facilitated the intervention and administered the measures, unintentional expectancy effects pose a threat to the study’s construct validity. In this case, teachers may have subconsciously expected students to show fewer PTSD symptoms in the post-test. Similarly, the students may have wanted to please the facilitators by showing improvements in the post-test. Despite the authors’ explanation that these students would only be comfortable speaking with a familiar adult, future studies should utilize external experimenters to administer the pre- and post-test, because they will be naïve to which students received the intervention and will have no vested interest in the outcome of the intervention.


Reference:
Gordon, J.S., Staples, J.K., Blyta, A., Bytyqi, M., and Wilson, A.T. (2008). Treatment of posttraumatic stress disorder in postwar Kosovar adolescents using mind-body skills groups: A randomized controlled trial. Journal of Clinical Psychiatry, 69(9), 1469-1476.

Study in Afghanistan Finds Trauma Exposure and Caregiver Mental Health Predict Risk of Negative Mental Health Outcomes in War-Affected Youth

Research conducted in war-affected situations has found an association between exposure to traumatic events and mental health outcomes. However, there have been few studies focusing on the mental health outcomes of children and adolescents affected by war. Panter-Brick, et al. (2009) conducted a study aimed at determining a causal relationship between war and mental health problems, specifically looking at associations related to gender, traumatic events, caregiver mental health, and socio-demographic characteristics. The sample targeted children ages 11 to 16, who were randomly drawn from randomly selected schools in three purposively chosen regions of Afghanistan. Data were gathered from three informants (children, caregivers, and teachers), who were interviewed with a variety of brief measures. Measures were chosen because they had high reliability in other contexts of instability. To increase instrument diagnostic validity, measures were translated, back-translated, and reviewed by a multi-disciplinary team. The research found that the variables of exposure to multiple trauma and caregiver mental health were predictive of psychopathology for in-school Afghan adolescents. Previous research corroborates this finding and adds to the study’s external validity. Furthermore, the study found that girls were more likely than boys to develop poor mental health outcomes, such as depression.

The authors explore the quality of traumatic events to include not just war-related events, but accidents, corporal punishment, illness, death of a relative. The quality of the particular incident is not indicative of predicting poor mental health, but rather the accumulation of traumatic events contribute to risk factors for mental health problems. The study includes a few threats to validity. By only sampling school children, the study neglects out-of-school youth, who may be at high risk of developing psychopathology. Furthermore, even though the sample of in-school youth was stratified to include accurate proportions of boys and girls, the focus on in-school youth disproportionately excludes girls, because boys are more likely to attend school than girls. The school samples were restricted to three urban areas, affecting external validity and indicating that future research might consider including a sample from a rural setting. Despite its limitations, this study indicates the value of working within the school system to assess children’s mental health needs and proves the value of school-based mental health services. Furthermore, the findings contribute to the small but much needed knowledge base about the mental health of war-affected children.

Reference:
Panter-Brick, C., Eggerman, M., Gonzalez, V., and Safdar, S. (2009). Violence, suffering, and mental health in Afghanistan: a school-based survey. The Lancet, 374, 807-816.

Quality of Parental Involvement More Relevant Than Use of Child Corporal Punishment in Development of Negative Adolescent Outcomes

Child development researchers have long suggested that corporal punishment is a predictor of negative behavioral outcomes in children. However, because they suffer from serious methodological limitations, studies on the effects of corporal punishment have yet to definitively determine if corporal punishment is causally related to negative adolescent outcomes. In this study, the authors attempt to determine the extent that quality of parental involvement and corporal punishment independently predict adolescent maladjustment, specifically adolescent aggressiveness, delinquency, and psychological well-being. The authors used a prospective study design, interviewing 332 families annually over a three-year period. Interviews consisted of parent self-reports, adolescent reports, and observed ratings of family interaction tasks. Corporal punishment was determined by time (i.e., consistent use of physical discipline over the three-year study period), age-appropriateness (i.e., continuing during adolescence, indicating harsh discipline), and type (i.e., use of object, being shoved or pushed.) Quality of parental involvement was determined by display of warmth and affection, monitoring and supervision, consistency of discipline, and use of inductive reasoning to explain rules and expectations. The authors found that once other dimensions of parenting are controlled for, there exists a significant relationship between quality of parental involvement and adolescent outcomes. Contrary to past research on this topic, the study found no significant relationship between corporal punishment and the adolescent outcomes.

This study’s main strength lies in its design aimed at isolating other parenting behaviors to determine that quality of parental involvement, rather than corporal punishment, was a predictor of maladaptive behavior among adolescents. The study’s use of self-reports from parents and adolescents, combined with observation of family interactions, created a more comprehensive depiction of family interaction. However, the sample selection presents some limitations to the study. Firstly, the sample represents a rural population, highlighting the need for the study to be replicated in an urban setting. Furthermore, though 451 families were recruited for the study, only 404 families completed all four waves, 19 families were not eligible after divorcing during the study period, and there was incomplete data for 53 of the families. Secondly, the authors emphasize that corporal punishment should not be confused with physical abuse, for in this study, the corporal punishment wasn’t extreme enough to be considered physical abuse; therefore, additional studies should be conducted to examine the effects of physical abuse on adolescent outcomes, independent of other parental behaviors. Thirdly, there might be other adolescent dimensions not addressed in this study that would be important indicators of maladjustment; the authors suggest looking at autonomy, self-reliance, and creativity in future research.

Reference:
Simons, R.L., Johnson, C., and Conger, R.D. (1994). Harsh corporal punishment versus quality of parental involvement as an explanation of adolescent maladjustment. Journal of Marriage and the Family, 56(August 1994), 591-607.