Trauma-focused cognitive behavioral therapy, or TF-CBT, more effectively reduced post-traumatic stress than usual care among children who experienced parental death in Kenya and Tanzania, according to results of a randomized clinical trial published in JAMA Psychiatry.
“Approximately 140 million children worldwide have experienced the death of one or both parents, most of whom live in low- and middle-income countries (LMICs),” Shannon Dorsey, PhD, of the department of psychology at the University of Washington in Seattle, and colleagues wrote. “These children, considered single orphans (one parent died) or double orphans (both parents died) by the United Nations Children’s Fund’s definition, have higher rates of post-traumatic stress (PTS), prolonged grief, depression, anxiety and behavior problems than nonorphaned children. Orphaned children are exposed to stressors associated with parental death, including loss of social support, disrupted education, unstable living situations and orphan-related stigma.”
According to the researchers, WHO recommends TF-CBT for addressing PTS and prolonged grief — specifically, task shifting delivered by supervised lay counselors since LMICs typically experience a shortage of mental health professionals. In the present study, they listed three objectives:
- To determine TF-CBT’s effectiveness for improving PTS in orphaned children in Kenya and Tanzania;
- to determine its effect on other mental health systems in this patient population; and
- to examine the feasibility of task-shifting with greater reliance on experienced, local lay counselors as supervisors and trainers.
The trial was conducted in urban and rural areas of the two countries and compared TF-CBT with usual care among 640 children aged 7 to 13 years, all of whom experienced the death of one or both parents and exhibited elevated levels of PTS and/or prolonged grief. A total of 320 children received the intervention delivered by lay counselors who were supervised weekly, and 320 children received community services typically offered to this population.
The researchers reported that TF-CBT was more effective than usual care for PTS in three of four sites after treatment, including rural Kenya (Cohen d = 1.04; 95% CI, 0.72-1.36), urban Kenya (Cohen d = 0.56; 95% CI, 0.29-0.83) and urban Tanzania (Cohen d = 0.45; 95% CI, 0.1-0.8). TF-CBT remained more effective than usual care at 12-month follow up in both rural (Cohen d = 0.86; 95% CI, 0.64-1.07) and urban (Cohen d = 0.99; 95% CI, 0.75-1.23) Kenya. Children in Tanzania who received TF-CBT and usual care had comparable rates of improvement at 12-month follow up. Dorsey and colleagues observed a similar pattern for secondary outcomes. Stronger effects were seen in Kenya, where children experienced greater adversity and stress because of higher rates of food scarcity, poorer guardian health and greater exposure to traumatic events.
“Positive outcomes in Kenya are notable, given greater reliance on lay counselor training and remote supervision,” they wrote. “Our findings suggest a need for treatment studies with longer follow-up periods and inclusion of children in varying contexts to understand which children most need treatment and are unlikely to improve without intervention.”
In a related editorial, Brandon A. Kohrt, MD, of the department of psychiatry and behavioral sciences at The George Washington University in Washington, D.C., and colleagues highlighted the importance of multisite studies of this kind.
“The study by Dorsey and colleagues is an important starting point for multisite psychological treatment studies to aid policy makers,” they wrote. “A habit of using these approaches can build research capacity so that it becomes standard practice to collaborate with policy makers.” – by Joe Gramigna
Disclosures: Dorsey reports being a TF-CBT trainer and receiving payment to provide TF-CBT trainings. Please see the study for all other authors’ relevant financial disclosures. The editorial authors report no relevant financial disclosures.