The findings, from a group of researchers led by the Johns Hopkins Bloomberg School of Public Health, suggest that young people from poor nations can benefit from mental health treatment, even when health professionals do not provide it. Untreated childhood trauma, the researchers say, is linked to skills deficits and unhealthy decision-making as adults as well as long-term negative health outcomes and lower economic productivity.
A report on the study appears in the June 29 issue of JAMA Pediatrics.
“We found that children from very distressed backgrounds can really be helped by a prescribed set of sessions with trained lay workers who otherwise have absolutely no mental health education and barely a high school education,” says study leader Laura K. Murray, PhD, an associate scientist in the Bloomberg School’s Department of Mental Health. “This study demonstrates that evidence-based treatments can be done in low-resource countries with good outcomes. We need to make these interventions available to children so they aren’t set up for significant difficulties as adults.”
For the study, Murray and her colleagues brought a program called Trauma-Focused Cognitive Behavioral Therapy to vulnerable children between the ages of five and 18 in Lusaka, Zambia from August 2012 to December 2013. Roughly half of the 257 children were randomly chosen for the therapy intervention, while the other half received the “usual” treatment commonly given to orphans or vulnerable children in poor countries. The usual treatment varied, but often included such things as playing soccer, support groups, education, nutrition and HIV-related services such as voluntary counseling and testing. They were called or, if they had no phone, visited once a week to evaluate their safety including the need to be referred to other services such as medical assistance.
The intervention consisted of between eight and 12 one-hour sessions, conducted by workers with no prior formal training in counseling but who received some ongoing training and supervision by the research team. The children had time to get to know the lay counselors and were taught relaxation techniques, how to talk about their feelings and how they could choose how to think about their circumstances. They were walked through their traumatic experiences in detail to clear out the stories causing them nightmares. They learned how to think about the trauma in different ways and to see that it was not their fault. They also worked with counselors to plan how to avoid violent situations in the future in very specific ways. For example, detailed safety plans were developed with the children to avoid violence at home or in the community, such as going to a neighboring “auntie’s” house for the night when they sensed trouble brewing.
Those in the intervention group saw their trauma symptom scores—measures of sleep problems, feelings of sadness, the ability to talk about issues—fall by nearly 82 percent, on average, while those in the treatment-as-usual group had a reduction in their scores of 21 percent.
One limitation of the study is that it did not follow the children in the months after the treatment to see if the positive effect endured. But studies in the United States focused on child trauma in poor populations have found that Trauma-Focused Cognitive Behavioral Therapy is effective and has sustained benefits at six months to two years after treatment.
Murray says she believes that the program in Zambia should be generalizable to other sub-Saharan African nations.
The new study did not compare cost-effectiveness of the two types of treatment, but Murray says the findings raise the question of whether dollars are being spent in the most effective way to help orphans and vulnerable children.
“The United States spends billions in poor countries on programs for orphaned children and others who have experienced trauma, but the programs are often more social in nature and have not shown effectiveness in treating the mental health effects of trauma,” Murray says. “Our research suggests that treatments like the one we studied in Zambia may be able to provide better care for children with trauma-related mental health problems.”
The researchers say cost-effectiveness studies are needed to determine whether the usual treatment provided for this population is worth the money, or if it is better to put those funds where they can make a greater impact.
“Effectiveness of Trauma Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: A Randomized Controlled Trial” was written by Laura K. Murray, PhD; Stephanie Skavenski, MSW, MPH; Jeremy C. Kane, MPH; John Mayeya, MSc; Shannon Dorsey, PhD; Judy A. Cohen, MD; Lynn T.M Michalopoulos, PhD; Mwiya Imasiku, PhD; and Paul A. Bolton, MBBS. Collaborators are from the Zambian Ministry of Health, the University of Washington, Allegheny General Hospital, Columbia University and the University of Zambia.
The study was supported by the USAID Displaced Children’s and Orphans Fund.