The Research Program on Children and Global Adversity is guided by a “risk and resilience” framework that focuses on core threats to the security of children. In considering intervention models, this approach first seeks to leverage naturally existing protective processes, then to supplement them with evidence based services. The program works from a social ecological perspective, which differs from individualized approaches in that it considers the socially-mediated impacts of adversity on children and families, and actively works to identify supports at the family, peer and community level. The program works from a child rights perspective that regards health, security, and opportunities for development as the birthright of every child, regardless of nationality, location, or socioeconomic status. The RPCGA’s research agenda is grounded in an integrated view of “health” as encompassing primary care, early childhood development, nutrition, mental health, and prevention services. The program targets children under the age of 18 as well as youth under the age of 25.

The program focuses on implementation science as it relates to the following core areas of a child’s basic security and developmental needs:

• Safety and protection from harm
• Physical and mental health
• Family and connection to others
• Education, livelihoods and opportunities to be productive

The team is presently engaged in two in-depth research studies, one on mental health care for children in Rwanda affected by HIV/AIDS, and the other exploring psychosocial adjustment and social reintegration among former child soldiers in Sierra Leone. A study of Somali Bantu refugee children and families in the Boston area is currently in development.

Overview

Inshuti Mu Buzima in Rwanda and the Harvard School of Public Health are collaborating on the Family Strengthening Intervention study (FSI) to improve mental health services for children and families.

Launched in 2007, the FSI will measure the prevalence of mental health problems and protective factors among children in the Rwinkwavu Hospital catchment area. Additionally, the FSI is working to develop, test, and refine an evidence-based intervention to prevent mental health problems in children affected by HIV/AIDS. The intervention is intended to address factors that may lead to family conflict, misunderstanding, and risky mental health trajectories in children whose families are facing chronic stressors.

Taken together, the FSI products will make an important contribution to the toolkit available to mental health service providers at PIH/IMB-supported health facilities and the Ministry of Health. Additionally, the FSI will provide important epidemiological data and screening tools for identifying mental health problems in children and adolescents which can be used to better address patient needs.

Using local language to talk about local problems

For service providers working cross-culturally, the valid measurement of mental health and related constructs remains a challenge. While symptoms of depression, anxiety, or conduct disorder are well-studied in developed countries, little research is available on how mental health problems manifest in children from, for example, sub-Saharan Africa. As a result, standard assessments of mental health may not be appropriate for use in settings like Rwanda.

Given these challenges, the FSI has performed extensive preliminary qualitative research to understand local experience of how emotional and behavioral problems are exhibited in Rwandan children. In 2007, the FSI conducted interviews with parents, young people and other community members to capture local terminology describing emotional and behavioral problems in children and adolescents. Findings revealed mental health constructs which shared some similarity with problems commonly identified in higher-income settings including many common symptoms of depression (Agahinda Kenshi) along with many other culturally and contextually-specific indicators such as indicators of conduct problems. The results of this research were published in the journal AIDS Care in 2010.

In 2009, the FSI team used similar techniques in a second qualitative study of factors contributing to resilience in HIV/AIDS affected children. These data revealed five core protective factors comprising individual, family, and community strengths such as kwihangana (patience/perseverance) and kwizerana (family trust).

Using qualitative findings to construct quantitative assessments

Over the past two years, the FSI team has used findings from the 2007 and 2009 qualitative studies to develop a range of mental health assessments that have broad applicability in Rwanda. By grounding these measurements in local language and understanding, the team aimed to create easy-to-use, understandable, and accurate tools that can be used by providers to assess problems and strengths in children.

Testing the tools

Following construction of the assessment tools, the FSI team engaged community children and caregivers in a process of pre-testing. Small samples of participants were interviewed about the clarity and comprehensibility of each survey item. Changes were made to improve the language, instructions, and response options of each measure.

Promising results

So far, the FSI team has found that the assessments are performing well. Preliminary analyses have shown that children referred to the study for having certain mental health problems tend to score above threshold on the corresponding measures. To strengthen this claim, the FSI team further triangulates results with the child’s score on a standard diagnostic tool, as well as with self-reports of problems.

Although analyses are ongoing, early findings suggest that the FSI mental health assessments may be successfully used not only in future FSI work, but also more broadly. Additionally, this innovative mixed qualitative and quantitative research stands to make an important contribution to global understandings of mental health in sub-Saharan Africa.

Next steps: Piloting the Family Strengthening Intervention

Few family-based prevention programs have been tested in Sub-Saharan Africa. However, our prior qualitative findings provided a basis for reviewing available evidence-based intervention models which have been used in culturally diverse settings. We found strong synergies between our primary protective processes of interest and those leveraged by the Family-Based Preventive Intervention (FBPI) developed by Dr. Bill Beardslee and colleagues at Children’s Hospital Boston. The intervention, originally developed for the prevention of depression in the offspring of depressed caregivers, is intended to leverage naturally existing protective processes within families and communities to increase resilience. As it is primarily a prevention intervention, the intent of the program is to bolster protective family processes such as connection, social support and communication, thus increasing the resources a young person can marshal to achieve resilient outcomes in the face of adversity (in this case, in the face of HIV/AIDS). 

The intervention addresses several key challenges for children affected by HIV/AIDS, particularly in the Rwandan context.  Its specific aims are to: 

1.     Reduce stigma and address misinformation and misconceptions about the illness in the family and community through psychoeducation

2.     Provide parenting support and involve both children and parents/caregivers actively in the intervention

3.     Address caregiver fears and concerns (e.g. who will care for the child if the parent/caregiver dies or becomes too ill to provide care?)

4.     Provide hope for the future

5.     Focus on risk and protective factors that are relevant to HIV/AIDS as well as poverty and lingering psychosocial consequences of the 1994 genocide

6.     Integrate the intervention into existing systems of care including primary healthcare, schools and community support services

Advisory groups to the project comprise Rwandan mental health professionals, social workers, community health workers/accompagnateurs, members of the local community (both youth and adult), and representatives of the government who are helping to adapt the FSI intervention to fit the Rwandan context. A pilot of the intervention began in October 2011. Upon completion of the research and through strong partnerships with the Rwandan government, this evidence-based intervention has the potential to be integrated into existing systems of care and potentially scaled up at the national level.

In 2002, Dr. Betancourt began a longitudinal study of psychosocial adjustment and community acceptance among former child soldiers and other war-affected youth in Sierra Leone. The study was designed to examine the risk and protective factors that shape social reintegration and psychosocial adjustment over time with equal attention to both war related experiences and post conflict factors. Dr. Betancourt and her team returned in 2003/2004 to collect follow-up data on the same cohort of youth, and completed a third wave of data collection in 2008/2009. This research has led to several publications about how war-related and post-conflict experiences affect the longer term mental health and psychosocial adjustment of former child soldiers. The study is the first longitudinal study of its kind to involve male and female former child soldiers and other war-affected youth in Sub-Saharan Africa. Among the issues examined in this study are the challenges and successes that these youth experience in securing a livelihood, caring for families, completing school, avoiding high-risk behavior, and contributing to civil society. The goals of the research are to identify naturally existing supports and protective processes that can be targeted in the design of psychosocial interventions, and to highlight priority issues for policy makers and program developers. This research contributes to one of the major goals of the RPCGA by developing an evidence base to help drive policy reform that supports improved protections and services for children facing adversity. To this end, Dr. Betancourt presented findings from the first two waves of data to the United Nations Special Representative of the Secretary-General for Children and Armed Conflict in July 2008. In October 2009, the FXB Center collaborated with Sierra Leonean government ministries as well as UN and NGO partners to coordinate a symposium on evidence-based approaches to addressing youth issues in Sierra Leone. Aimed at linking research and practice, the symposium provided a platform for dialogue among more than 100 stakeholders representing a broad range of government offices, NGOs, UN agencies, youth groups, student organizations, and universities. The event highlighted critical issues confronting children and youth, promising intervention approaches, and agenda-setting for future research and action. Building on this work, the RPCGA is also exploring the potential to conduct a pilot intervention study with war-affected youth in Sierra Leone that will integrate mental health and psychosocial services along with other components such as accelerated learning and livelihoods activities.

The intent of this project is to understand perceptions of relevant mental health problems and service needs among Somali Bantu refugees in the greater Boston area, where numerous Somali Bantu refugee families have resettled since 2004. This work will be conducted in collaboration with Children’s Hospital Boston/Center for Refugee Trauma (CHB/CRT) in association with the National Child Traumatic Stress Network (NCTSN) and several local mutual assistance organizations. Data collection is planned for 2010 and will involve qualitative interviews with Somali refugees, including Somali Bantu youth, families, and community members. The RPCGA team will work in partnership with members of the Somali Bantu community, and with community organizations serving this population. A local research team of Somali Bantu refugees will be recruited and trained to work closely with our team in conducting research interviews and data collection. Ultimately, this research will inform the development of family-based preventive interventions in collaboration among Somali mutual assistance organizations and Children’s Hospital Boston and its Center on Refugee Trauma and Resilience.

The SAFE model is a rights-based, holistic framework for examining four fundamental and interrelated domains of children's security including: Safety/protection, Access to health care and basic physiological needs, Family/connection to others, and Education/economic security. This model underscores the interdependence of children’s survival needs and accounts for the survival strategies (dangerous and adaptive) that children and families employ to cope with deficits in any core domain. The intended goal of this project is to develop a broader series of SAFE-informed tools that can be readily adapted and applied to consider child protection and security within a wide range of contexts. This project includes field work in Rwanda, India, and post-earthquake Haiti. A key component of the SAFE Toolkit is the SAFE Child Impact Assessment (SCIA), designed to evaluate and promote the development of improved systems of care and protection for children and families. The SCIA methodology will be applied to different contexts of development and globalization ranging from construction zones in urban centers to post-disaster reconstruction and development efforts.