Mediators of Focused Psychosocial Support Interventions For Children In Low-Resource Humanitarian Settings: Analysis From An Individual Participant Dataset With 3,143 Participants

Purgato M, Tedeschi F, Betancourt TS, Bolton P, Bonetto C, Gastaldon C, Gordon J, O’Callaghan P, Papola D, Peltonen K, Punamaki RL, Richards J, Staples JK, Unterhitzenberger J, de Jong J, Jordans MJD, Gross AL, Tol WA, Barbui C.

2020

This was a mediation study to determine potential pathways through which psychosocial interventions work to reduce PTSD symptoms. The study is co-authored by Drs. Gordon and Staples.

Abstract (NO OPEN ACCESS)

Background

Research on psychosocial interventions has been focused on the effectiveness of psychosocial interventions on mental health outcomes, without exploring how interventions achieve beneficial effects. Identifying the potential pathways through which interventions work would potentially allow further strengthening of interventions by emphasizing specific components connected with such pathways.

Methods

We conducted a preplanned mediation analysis using individual participant data from a dataset of 11 randomized controlled trials (RCTs) which compared focused psychosocial support interventions versus control conditions for children living in low- and middle-income countries (LMICs) affected by humanitarian crises. Based on an ecological resilience framework, we hypothesized that (a) coping, (b) hope, (c) social support, and (d) functional impairment mediate the relationship between intervention and outcome PTSD symptoms. A systematic search on the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed, PyscARTICLES, Web of Science, and the main local LMICs databases was conducted up to August 2018. The hypotheses were tested by using individual participant data obtained from study authors of all the studies included in the systematic review.

Results

We included 3,143 children from 11 studies (100% of data from included studies), of which 1,877 from six studies contributed to the mediation analysis. Functional impairment was the strongest mediator for focused psychosocial interventions on PTSD (mediation coefficient 0.087, standard error 0.040). The estimated proportion of effect mediated by functional impairment, and adjusted for confounders, was 31%.

Conclusions

Findings did not support the proposed mediation hypotheses for coping, hope, and social support. The mediation through functional impairment may represent unmeasured proxy measures or point to a broader mechanism that impacts self-efficacy and agency.

Focused Psychosocial Interventions For Children In Low-Resource Humanitarian Settings: A Systematic Review And Individual Participant Data Meta-analysis. Focused Psychosocial Interventions For Children In Low-resource Humanitarian Settings: A Systematic Review And Individual Participant Data Meta-analysis.

Purgato M, Gross AL, Betancourt T, Bolton P, Bonetto C, Gastaldon C, Gordon J, O’Callaghan P, Papola D, Peltonen K, Punamaki RL, Richards J, Staples JK, Unterhitzenberger J, van Ommeren M, de Jong J, Jordans MJD, Tol WA, Barbui C

2018

This is a meta-analysis of individual participant data from 3143 children exposed to traumatic events on the effectiveness of psychosocial interventions. The study is co-authored by Drs. Gordon and Staples and CMBM’s randomized controlled study in Kosovo is included in the meta-analysis.

Abstract (OPEN ACCESS)

Background

Results from studies evaluating the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in humanitarian settings in low-income and middle-income countries have been inconsistent, showing varying results by setting and subgroup (eg, age or gender). We aimed to assess the effectiveness of these interventions, and to explore which children are likely to benefit most.

Methods

We did a systematic review and meta-analysis of individual participant data (IPD) from 3143 children recruited to 11 randomised controlled trials of focused psychosocial support interventions versus waiting list. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, PsycArticles, Web of Science, and the main local low-income and middle-income countries (LMICs) databases according to the list of databases relevant to LMIC developed collaboratively by Cochrane and WHO Library, up to November, 2016. We included randomised controlled trials that assessed the effectiveness of focused psychosocial support interventions in children exposed to traumatic events in LMICs, compared with waiting lists (eg, inactive controls). We excluded quasirandomised trials, studies that did not focus on psychosocial support interventions, and studies that compared two active interventions without control conditions. We requested anonymised data from each trial for each of the prespecified variables for each child who was randomly assigned. The main outcomes considered were continuous scores in post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, and anxiety symptoms assessed
with rating scales administered immediately (0–4 weeks) after the intervention. We harmonised all individual items from rating scales using item response theory methods.

Findings

We identified a beneficial effect of focused psychosocial support interventions on PTSD symptoms (standardised mean difference [SMD] –0·33, 95% CI –0·52 to –0·14) that was maintained at follow-up (–0·21, –0·42 to –0·01). We also identified benefits at the endpoint for functional impairment (–0·29, –0·43 to –0·15) and for strengths: coping (–0·22, –0·43 to –0·02), hope (–0·29, –0·48 to –0·09), and social support (–0·27, –0·52 to –0·02). In IPD meta-analyses focused on age, gender, displacement status, region, and household size we found a stronger improvement in PTSD symptoms in children aged 15–18 years (–0·43, –0·63 to –0·23), in non-displaced children (–0·40, –0·52 to –0·27), and in children living in smaller households (<6 members; –0·27, –0·42 to –0·11).

Interpretation

Overall, focused psychosocial interventions are effective in reducing PTSD and functional impairment, and in increasing hope, coping, and social support. Future studies should focus on strengthening interventions for younger children, displaced children, and children living in larger households.

Mind-Body Skills Groups for Posttraumatic Stress Disorder in Palestinian Adults in Gaza

Gordon, J. S., Staples, J. K., He, D. Y., & Atti, J. A. A.

2016

A mind-body skills group (MBSG) program was evaluated to determine its effect on symptoms of posttraumatic stress disorder (PTSD), depression, anxiety, and quality of life in adults in Gaza.

Abstract (NO OPEN ACCESS)

A mind-body skills group (MBSG) program was evaluated to determine its effect on symptoms of posttraumatic stress disorder (PTSD), depression, anxiety, and quality of life in adults in Gaza. The 10-session mind-body skills groups (MBSGs) included meditation, guided imagery, breathing techniques, autogenic training, biofeedback, genograms, and self-expression through words, drawings, and movement. Data were analyzed from 92 adults meeting criteria for PTSD. Significant improvements in PTSD, depression, and anxiety symptoms and significant improvements in quality of life (QOL) were observed immediately following participation in the program. At 10-month follow-up, the improvements in the PTSD, depression, anxiety, overall QOL and health scores, and the physical health and social relationship domains of QOL were fully maintained. Improvement was partially maintained for the psychological QOL domain but was not maintained for the environment domain. MBSGs are easily taught to health professionals and can reduce PTSD, depression, and anxiety symptoms, and improve QOL in adults affected by war and political violence.

Mind-Body Skills Groups for Posttraumatic Stress Disorder and Depression Symptoms in Palestinian Children and Adolescents in Gaza

Staples, J. K., Abdel Atti, J. A., & Gordon, J. S.

2011

A mind-body skills group (MBSG) program was evaluated to determine its effects on symptoms of posttraumatic stress disorder (PTSD) and depression, and on hopelessness in children and adolescents in Gaza.

Abstract (NO OPEN ACCESS)

A mind-body skills group program was evaluated to determine its effects on symptoms of posttraumatic stress disorder (PTSD) and depression, and on hopelessness in children and adolescents in Gaza. The 10-session mind-body skills groups included meditation, guided imagery, breathing techniques, autogenic training, biofeedback, genograms, and self-expression through words, drawings, and movement. Data were analyzed from 129 children and adolescents meeting criteria for PTSD. Significant improvements in PTSD and depression symptoms and a significant decrease in a sense of hopelessness were observed immediately following participation in the program. At 7-month follow-up, the improvements in the total PTSD and depression scores were largely maintained and the decreased sense of hopelessness was fully maintained despite ongoing violent conflict and economic hardship.

Treatment of Posttraumatic Stress Disorder in Postwar Kosovar Adolescents using Mind-Body Skills Groups: A Randomized Controlled Trial

Gordon, J. S., Staples, J. K., Blyta, A., Bytyqi, M., & Wilson, A. T.

2008

A mind-body skills group (MBSG) program was evaluated to determine its effects on symptoms of posttraumatic stress disorder (PTSD) in postwar Kosovar adolescents. This was the first randomized controlled trial of any intervention with war-traumatized adolescents.

Abstract (NO OPEN ACCESS)

Objective

To determine whether participation in a mind-body skills group program based on psychological self-care, mind-body techniques, and self-expression decreases symptoms of posttraumatic stress disorder (PTSD).

Method

Eighty-two adolescents meeting criteria for PTSD according to the Harvard Trauma Questionnaire (which corresponds with 16 of the 17 diagnostic criteria for PTSD in DSM-IV) were randomly assigned to a 12-session mind-body group program or a wait-list control group. The program was conducted by high school teachers in consultation with psychiatrists and psychologists and included meditation, guided imagery, and breathing techniques; self-expression through words, drawings, and movement; autogenic training and biofeedback; and genograms. Changes in PTSD symptoms were measured using the Harvard Trauma Questionnaire. The study was conducted from September 2004 to May 2005 by The Center for Mind-Body Medicine at a high school in the Suhareka region of Kosovo.

Results

Students in the immediate intervention group had significantly lower PTSD symptom scores following the intervention than those in the wait-list control group (F = 29.8, df = 1,76; p < .001). Preintervention and postintervention scores (mean [SD]) for the intervention group were 2.5 (0.3) and 2.0 (0.3), respectively, and for the control group, 2.5 (0.3) and 2.4 (0.4), respectively. The decreased PTSD symptom scores were maintained in the initial intervention group at 3-month follow-up. After the wait-list control group received the intervention, there was a significant decrease (p < .001) in PTSD symptom scores compared to the pre intervention scores.

Conclusions

Mind-body skills groups can reduce PTSD symptoms in war-traumatized high school students and can be effectively led by trained and supervised schoolteachers.

Treatment of Posttraumatic Stress Disorder in Postwar Kosovo High School students using Mind-Body Skills Groups: A Pilot Study

Gordon, J. S., Staples, J. K., Blyta, A., & Bytyqi, M.

2004

A preliminary study to examine whether the practice of mind-body techniques decreases symptoms of posttraumatic stress in adolescents.

Abstract (POSTED WITH PUBLISHER PERMISSION)

This preliminary study examined whether the practice of mind-body techniques decreases symptoms of posttraumatic stress in adolescents. Posttraumatic Stress Reaction Index questionnaires were collected from 139 high school students in Kosovo who participated in a 6-week program that included meditation, biofeedback, drawings, autogenic training, guided imagery, genograms, movement, and breathing techniques. Three separate programs were held approximately 2 months apart. There was no control group. Posttraumatic stress scores significantly decreased after participation in the programs. These scores remained decreased in the 2 groups that participated in the follow-up study when compared to pretest measures. These data indicate that mind-body skills groups were effective in reducing posttraumatic stress symptoms in war-traumatized high school students.

Currently Being Prepared for Publication:

Mind-Body Skills Groups for Behavioral Problems in a Boys Secondary School in Gaza

A mind-body skills group (MBSG) program was evaluated to determine its effects on behavioral and emotional problems, aggression, and symptoms of posttraumatic stress disorder in a boys secondary school in Gaza compared to a control school.

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