Presently, over one billion children live in countries affected by armed conflict, and in many cases these children are directly involved in the violence. In the context of Sierra Leone's 11-year civil war (1991-2002), conscription of children into armed forces was routine. As a result, children often witnessed or were forced to commit acts of extreme violence;those uprooted from their families were typically coerced to function as front- line soldiers, spies and human shields. A growing literature continues to outline the psychosocial effects of such war exposures, which includes heightened levels of anxiety, depression, and posttraumatic stress. Psychosocial interventions for war-affected youth have been implemented in a diversity of post-conflict settings. In most instances, interventions represent a package of empirically-supported behavioral treatments (ESBTs) which integrate elements of psycho-education, problem-solving skills, as well as cognitive-behavioral therapy and interpersonal therapy techniques, which have been shown to affect outcomes ranging from reductions in PTSD symptoms to improvements in adaptive behavior. However, in most studies only a limited array of mental health outcomes are investigated, often with little attention to broader functional outcomes such as family relations or educational attainment. Likewise, the longer-term effects of interventions are not typically reported, leaving unanswered whether intervention benefits accrue over time. Lastly, financial costs are rarely documented. As such, it remains unclear whether replication of interventions is financially feasible. This proposal builds off of a prospective longitudinal study in Sierra Leone, which has chronicled the development of war-affected youth over the past ten years. The sponsor of this proposal, Dr. Theresa Betancourt, will be implementing a randomized wait-listed control trial of an ESBT for youth who continue to demonstrate poor psychosocial functioning. Utilizing a series of measures which have been validated and culturally-adapted, the impacts of this intervention will be measured in terms of improvements in mental health (depression, anxiety, hostility, posttraumatic stress reactions and prosocial behavior) as well as functional outcomes including community and family relations, education and employment. The intention of this proposal is to extend this effort by helping conduct a three month follow-up with the initial treatment cohort (n=64), as well as by relating the portfolio of measured benefits to the programmatic costs of the intervention. While three month follow-up will investigate whether intervention benefits continue to accrue over time and lend further evidence regarding intervention effectiveness, collection of data on programmatic costs will provide an index of the intervention's financial feasibility and efficiency in terms of dollars per outcome. Together, these two components will provide a realistic picture of the utility of a community-based psychosocial intervention for war- affected youth. Ultimately, the evidence base generated by this effort can serve to inform policies and programs for war-affected populations globally, including refugee populations in the United States.

Public Health Relevance

Building on a unique longitudinal study of war-affected youth in Sierra Leone, the proposed research intends to address several critical gaps in the current literature on psychosocial interventions for war-affected youth. Embedded within a randomized wait-listed control trial, this project will measure the effects of a community-based psychosocial intervention at three months follow-up in 64 youth ages 15-24, providing important information on the accumulated benefits of such efforts, and measuring benefits across an array of outcomes including mental health, community and family relations, education and employment. Furthermore, benefits for all youth participating in the trial (n=128) will be related to the programmatic costs of the intervention in order to provide a more comprehensive representation of the intervention's efficiency and financial feasibility.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Predoctoral Individual National Research Service Award (F31)
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Special Emphasis Panel (ZMH1-ERB-M (04))
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Hill, Lauren D
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Harvard University
Public Health & Prev Medicine
Schools of Public Health
United States
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McBain, Ryan K; Salhi, Carmel; Hann, Katrina et al. (2016) Costs and cost-effectiveness of a mental health intervention for war-affected young persons: decision analysis based on a randomized controlled trial. Health Policy Plan 31:415-24
Betancourt, Theresa S; McBain, Ryan; Newnham, Elizabeth A et al. (2014) A behavioral intervention for war-affected youth in Sierra Leone: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 53:1288-97