Effectiveness of a School-Based Group Psychotherapy Program for War-Exposed Adolescents: A Randomized Controlled Trial

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Abstract

Objective

To evaluate the comparative effectiveness of a classroom-based psychoeducation and skills intervention (tier 1) and a school-based trauma- and grief-focused group treatment (tier 2) of a three-tiered mental health program for adolescents exposed to severe war-related trauma, traumatic bereavement, and postwar adversity.

Method

A total of 127 war-exposed and predominantly ethnic Muslim secondary school students attending 10 schools in central Bosnia who reported severe symptoms of posttraumatic stress disorder (PTSD), depression, or maladaptive grief and significant impairment in school or relationships were randomly assigned to one of two experimental conditions. These included either an active-treatment comparison condition (tier 1), consisting of a classroom-based psychoeducation and skills intervention alone (n = 61, 66% girls, mean age 16.0 years, SD 1.13) or a treatment condition composed of both the classroom-based intervention and a 17-session manual-based group therapy intervention (tier 2), trauma and grief component therapy for adolescents (n = 66, 63% girls, mean age 15.9 years, SD 1.11). Both interventions were implemented throughout the school year. Distressed students who were excluded from the study due to acute risk for harm (n = 9) were referred for community-based mental health services (tier 3).

Results

Program effectiveness was measured via reductions in symptoms of PTSD, depression, and maladaptive grief assessed at pretreatment, posttreatment, and 4-month follow-up. Analysis of mean-level treatment effects showed significant pre- to posttreatment and posttreatment to 4-month follow-up reductions in PTSD and depression symptoms in both the treatment and comparison conditions. Significant pre- to posttreatment reductions in maladaptive grief reactions were found only in the treatment condition. Analyzed at the individual case level, the percentages of students in the treatment condition who reported significant (p < .05) pre- to posttreatment reductions in PTSD symptoms (58% at posttreatment, 81% at 4-month follow-up) compare favorably to those reported in controlled treatment efficacy trials, whereas the percentages who reported significant reductions in depression symptoms (23% at posttreatment, 61% at follow-up) are comparable to, or higher than, those found in community treatment settings. Lower but substantial percentages of significant symptom reduction were found for PTSD (33% at posttreatment, 48% at follow-up) and depression symptoms (13% at posttreatment; 47% at follow-up) in students in the comparison condition. The odds of significant symptom reduction were higher for PTSD symptoms at both posttreatment and 4-month follow-up and for maladaptive grief at posttreatment (no follow-up was conducted on maladaptive grief). Rates of significantly worsened cases were generally rare in both the treatment and comparison conditions.

Conclusions

A three-tiered, integrative mental health program composed of schoolwide dissemination of psychoeducation and coping skills (tier 1), specialized trauma- and grief-focused intervention for severely traumatized and traumatically bereaved youths (tier 2), and referral of youths at acute risk for community-based mental health services (tier 3) constitutes an effective and efficient method for promoting adolescent recovery in postwar settings. J. Am. Acad. Child Adolesc. Psychiatry, 2008; 47(9): 1048–1062.

Section snippets

Study Objectives

The purpose of this study was to evaluate, using a randomized controlled design, the comparative effectiveness of two tiers of a three-tiered school- and communitybased intervention program for adolescents exposed to severe trauma, traumatic bereavement, and adversity. The program was implemented by local school and community professionals with war-exposed adolescents attending 10 secondary schools located in postwar central Bosnia during the 2000–2001 school year. Effectiveness was evaluated

Participants

Participants were adolescent students attending 10 secondary schools located throughout Central Bosnia. The schools comprised the total set of schools implementing the UNICEF program in the Federation of B&H during that school year. The treatment condition included 66 students, approximately 63% girls and 34% boys (sex not reported for two), ranging in age from 13 to 18 years (

= 15.9, SD 1.11) and from the first to the third year of high school. The comparison condition included 61 students,

Exposure to Trauma and Severe Adversity

Approximately 73% of the students participating reported experiencing direct life threat arising from close proximity to exploding shells or rifle fire, 36% reported witnessing during the war violent death or serious injury, 12% reported witnessing torture, and 46% reported the serious injury of a person to whom they were close. Furthermore, 55% reported abandoning their homes, and 54% reported having to change schools because of the war. Moreover, 14% reported the violent death during the war

Discussion

This study compared the effectiveness of the first two tiers of a three-tiered school- and community-based mental health intervention for war-exposed adolescents, as delivered on a large scale in a war-ravaged nation by locally trained and supervised school counselors.5 The successful implementation of both the tier 1 comparison condition (composed of classroom-based psychoeducation and skills) and the tier 2 treatment condition (composed of TGCT plus the tier 1 classroom-based intervention)

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    Financial support was provided by UNICEF Bosnia and Herzegovina, the Brigham Young University Family Studies Center, the David M. Kennedy Center for International Studies, the Bing Fund, and Tony Bennett. The authors thank Drs. Michael Lambert and Joseph Olsen for statistical consultation, John-Paul Legerski and Benjamin Carter for help with the literature review, and Preston Finley for manuscript preparation. The authors are also indebted to Rune Sturland, M.S., formerly of UNICEF Bosnia and Herzegovina, for his pioneering work and support.

    Article Plus (online-only) materials for this article appear on the Journal's Web site:www.jaacap.com.

    This article is the subject of an editorial by Dr. Judith A. Cohen in this issue.

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