School-based mental health intervention for children affected by political violence in Indonesia: a cluster randomized trial

JAMA. 2008 Aug 13;300(6):655-62. doi: 10.1001/jama.300.6.655.


Context: Little is known about the efficacy of mental health interventions for children exposed to armed conflicts in low- and middle-income settings. Childhood mental health problems are difficult to address in situations of ongoing poverty and political instability.

Objective: To assess the efficacy of a school-based intervention designed for conflict-exposed children, implemented in a low-income setting.

Design, setting, and participants: A cluster randomized trial involving 495 children (81.4% inclusion rate) who were a mean (SD) age of 9.9 (1.3) years, were attending randomly selected schools in political violence-affected communities in Poso, Indonesia, and were screened for exposure (> or = 1 events), posttraumatic stress disorder, and anxiety symptoms compared with a wait-listed control group. Nonblinded assessment took place before, 1 week after, and 6 months after treatment between March and December 2006.

Intervention: Fifteen sessions, over 5 weeks, of a manualized, school-based group intervention, including trauma-processing activities, cooperative play, and creative-expressive elements, implemented by locally trained paraprofessionals.

Main outcome measures: We assessed psychiatric symptoms using the Child Posttraumatic Stress Scale, Depression Self-Rating Scale, the Self-Report for Anxiety Related Disorders 5-item version, and the Children's Hope Scale, and assessed function impairment as treatment outcomes using standardized symptom checklists and locally developed rating scales.

Results: Correcting for clustering of participants within schools, we found significantly more improvement in posttraumatic stress disorder symptoms (mean change difference, 2.78; 95% confidence interval [CI], 1.02 to 4.53) and maintained hope (mean change difference, -2.21; 95% CI, -3.52 to -0.91) in the treatment group than in the wait-listed group. Changes in traumatic idioms (stress-related physical symptoms) (mean change difference, 0.50; 95% CI, -0.12 to 1.11), depressive symptoms (mean change difference, 0.70; 95% CI, -0.08 to 1.49), anxiety (mean change difference, 0.12; 95% CI, -0.31 to 0.56), and functioning (mean change difference, 0.52; 95% CI, -0.43 to 1.46) were not different between the treatment and wait-listed groups.

Conclusions: In this study of children in violence-affected communities, a school-based intervention reduced posttraumatic stress symptoms and helped maintain hope, but did not reduce traumatic-stress related symptoms, depressive symptoms, anxiety symptoms, or functional impairment.

Trial registration: Identifier: ISRCTN25172408.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adaptation, Psychological
  • Adolescent
  • Anxiety Disorders / etiology
  • Anxiety Disorders / therapy*
  • Child
  • Diagnostic and Statistical Manual of Mental Disorders
  • Female
  • Humans
  • Indonesia
  • Male
  • Mental Health Services*
  • Politics
  • Poverty
  • Psychiatric Status Rating Scales
  • Psychotherapy*
  • Research Design
  • School Health Services*
  • Stress Disorders, Post-Traumatic / etiology
  • Stress Disorders, Post-Traumatic / therapy*
  • Violence / psychology*

Associated data

  • ISRCTN/ISRCTN25172408