A pilot study of a family focused, psychosocial intervention with war-exposed youth at risk of attack and abduction in north-eastern Democratic Republic of Congo

Highlights

• High attendance, low attrition, good sustainability and satisfactory intervention fidelity were observed.

• A weak/moderate effect was found for participants’ post-traumatic stress symptoms.

• Large reductions in internalising symptoms and moderate improvements in pro-social scores were recorded.

• Caregivers noted a moderate to large decline in conduct problems at 3-month follow-up.

• 22% of the sample of participants had been abducted by the LRA and 99% reported fear of attacks in the future.

Abstract

Rural communities in the Haut-Uele Province of northern Democratic Republic of Congo live in constant danger of attack and/or abduction by units of the Lord's Resistance Army operating in the region. This pilot study sought to develop and evaluate a community-participative psychosocial intervention involving life skills and relaxation training and Mobile Cinema screenings with this war-affected population living under current threat. 159 war-affected children and young people (aged 7–18) from the villages of Kiliwa and Li-May in north-eastern DR Congo took part in this study. In total, 22% of participants had been abduction previously while 73% had a family member abducted. Symptoms of post-traumatic stress reactions, internalising problems, conduct problems and pro-social behaviour were assessed by blinded interviewers at pre- and post-intervention and at 3-month follow-up. Participants were randomised (with an accompanying caregiver) to 8 sessions of a group-based, community-participative, psychosocial intervention (n = 79) carried out by supervised local, lay facilitators or a wait-list control group (n = 80). Average seminar attendance rates were high: 88% for participants and 84% for caregivers. Drop-out was low: 97% of participants were assessed at post-intervention and 88% at 3 month follow-up. At post-test, participants reported significantly fewer symptoms of post-traumatic stress reactions compared to controls (Cohen's d = 0.40). At 3 month follow up, large improvements in internalising symptoms and moderate improvements in pro-social scores were reported, with caregivers noting a moderate to large decline in conduct problems among the young people.

Trial Registration clinicalTrials.gov, Identifier: NCT01542398.

Introduction

In the last 65 years, 246 armed conflicts have been reported in 151 geographic locations, most of which are in lower- and middle-income countries (LMICs) (Themnér & Wallensteen, 2011). Currently, it is estimated that over 6 million children have been physically injured and an additional 20 million have been displaced as a result of armed conflict in the past decade (Betancourt, Brennan, Rubin-Smith, Fitzmaurice, & Gilman, 2010). Research on youth exposed to war and violence has documented increased risks for mental disorders, such as depression, anxiety, and posttraumatic stress disorder (PTSD) (Ertl et al., 2011, O’Callaghan et al., 2012, McMullen et al., 2012, Panter-Brick et al., 2008).

The Democratic Republic of Congo has been the scene of the world's deadliest conflict since World War II (Coghlan et al., 2006) with internal security threatened by numerous armed groups and militias. One of the militia groups currently operating in north-eastern DR Congo, where the study took place, is the Lord's Resistance Army (LRA); a rebel group founded by Joseph Kony in northern Uganda in the 1980s and whose dominant strategy since then has been the abduction of children and their forced recruitment as combatants and sexual slaves (Ertl et al., 2011). It is estimated that in excess of 30,000 children, some as young as seven years old, have been abducted by the LRA (Wessells, 2006). Following a military offensive against them, the LRA were forced out of Uganda in 2005 and relocated to the Central African Republic, South Sudan and north-eastern DR Congo (Kelly & Branham, 2012). Since 2011, the LRA have engaged in individual, small scale attacks in the Haut-Uele district of north-eastern DR Congo. These attacks are more widespread and sporadic and keep the population in constant fear (Kelly & Branham, 2012). A recent study on the impact of LRA violence in north-eastern DR Congo involving 33 semi-structured qualitative interviews with NGO staff and villagers in four communities in this region found trauma symptoms (e.g. nightmares), behavioural problems (e.g. exclusion of peers and aggression) and psychological problems (e.g. anxiety) among youth there (Kelly & Branham, 2012). The authors found that the formerly abducted children who presented with emotional and behavioural difficulties were often stigmatised by their communities and the report called for the strengthening of family support networks and community-wide cohesion to actively reduce trauma and stigma.

These findings are in line with research carried out among other war-affected communities, which observed that armed conflict distorts and undermines communal relationships in families and communities (Betancourt et al., 2010a, Klasen et al., 2010, McKay et al., 2010, Panter-Brick et al., 2011). Betancourt, Agnew-Blais, et al. (2010) found that community rejection of former child soldiers in Sierra Leone was correlated with poorer psychosocial adjustment and increased hostility among returnees, a finding supported by McKay et al. (2010) who noted that marginalisation and stigmatisation of female child soldier returnees was a central barrier to successful community integration. Meanwhile, two rare longitudinal study of mental health outcomes of war-affected youth in Afghanistan (Panter-Brick et al., 2011) and Uganda (Klasen et al., 2010) found that negative parent-child interactions resulted in poor mental health outcomes among young people who had otherwise showed resilience to substantial socioeconomic and war-related stressors while less exposure to domestic violence, better family socioeconomic situations and more perceived spiritual support led to fewer symptoms of psychopathology.

Although these studies were ground-breaking in the use of longitudinal, participatory and multi-site research, few reported specific interventions designed to meet the psychosocial and mental health needs identified. Of the handful of peer-reviewed interventions that documented specific interventions (e.g. Bolton et al., 2007, Ertl et al., 2011, McMullen et al., 2013) none involved direct caregiver participation, or the formation of community focus groups to identify challenges facing a war-affected community and proposing solutions to these challenges. Given the isolation of the two villages in this study, their security threat and the difficulties experienced accessing mental health services, a community-participatory model was considered a best fit to deliver a sustainable intervention that sought to target outcomes beyond post-traumatic stress and internalising symptoms and ensure the intervention was integrated with local health, education and social systems (Tol et al., 2011).

In summary, this intervention sought to improve the mental health and psychosocial outcomes of war affected young people living in immediate danger of attack and abduction in north-eastern DR Congo. A family focused, community-based psychosocial intervention was selected to achieve these aims since this approach allowed for integration of the intervention with local health, education and social systems and previous research with similar populations had demonstrated that systemic factors such as positive family interactions and community acceptance mediate both mental health and psychosocial outcomes among war-affected youth.