Effectiveness of a brief group behavioural intervention on psychological distress in young adolescent Syrian refugees: A randomised controlled trial

Abstract

Background Millions of young adolescents in low- and middle-income countries (LMICs) affected by humanitarian crises experience elevated rates of poor mental health. There is a need for scalable programs that can improve the mental health of young adolescents. This study evaluated the effectiveness of a nonspecialist delivered group-based intervention (Early Adolescent Skills for Emotions (EASE)) to improve young adolescents’ mental health. Methods and findings In this single-blind, parallel, controlled trial, Syrian refugees aged 10 to 14 years in Jordan were identified through screening of psychological distress as defined by scores ≥15 on the Paediatric Symptom Scale. Participants were randomised to either EASE or enhanced usual care (EUC) involving referral to local psychosocial services (on a 1:1.6 ratio). Participants were aware of treatment allocation but assessors were blinded. Primary outcomes were scores on the Paediatric Symptom Checklist (PSC; internalising, externalising, and attentional difficulty scales) assessed at week 0, 9 weeks, and 3 months after treatment (primary outcome time point). It was hypothesised that EASE would result in greater reductions on internalising symptoms than EUC. Secondary outcomes were depression, posttraumatic stress, well-being, functioning, school belongingness, and caregivers’ parenting and mental health. Between June 2019 and January 2020, 1,842 young adolescent refugees were screened for eligibility on the basis of psychological distress. There were 520 adolescents (28.2%) who screened positive, of whom 471 (90.6%) agreed to enter the trial. Overall, 185 were assigned to EASE and 286 to EUC, and 169 and 254 were retained at 3 months for EASE and EUC, respectively. Intent-to-treat analyses indicated that at 3 months, EASE resulted in greater reduction on the PSC-internalising scale than EUC (estimated mean difference 0.69, 95% CI 0.19 to 1.19; p = 0.007; effect size, 0.38) but there were no differences for PSC-externalising (estimated mean difference 0.24, 95% CI −0.43 to 0.91; p = 0.49; effect size, −0.10), PSC-attentional problem (estimated mean difference −0.01, 95% CI −0.51 to 0.54; p = 0.97; effect size, −0.01) scores, or on depression, posttraumatic stress, well-being, functioning, or school belongingness. Relative to EUC, caregivers in EASE had less psychological distress (estimated mean difference 1.95, 95% CI 0.71 to 3.19; p = 0.002) and inconsistent disciplinary parenting (mean difference 1.54, 95% CI 1.03 to 2.05; p < 0.001). Secondary analyses that (a) focused on adolescents with probable internalising disorders; (b) completed the 3-month assessment; and (c) controlled for trauma exposure did not alter the primary results. Mediation analysis indicated that for caregivers in the EASE condition, reduction in inconsistent disciplinary parenting was associated with reduced attentional (β = 0.11, SE 0.07; 95% CI 0.003, 0.274) and internalising (β = 0.11, SE 0.07; 95% CI 0.003, 0.274) problems in their children. No adverse events were attributable to the intervention. A limitation was that EUC was not matched to EASE in terms of facilitator attention or group involvement. Conclusions EASE led to reduced internalising problems in young refugee adolescents and was associated with reduced distress and less inconsistent disciplinary parenting in caregivers. This intervention has the potential as a scalable intervention to mitigate young adolescents’ emotional difficulties in LMIC. Trial registration Prospectively registered at Australian and New Zealand Clinical Trials Registry: ACTRN12619000341123.

Scalable interventions for refugees

“…The intervention also comprises three group sessions for caregivers that teach coping skills, positive parenting, and inform them of the strategies taught to the adolescents. One initial trial of the EASE program randomised young adolescent Syrian refugees in Jordan to either EASE or Enhanced Usual Care, and found that three months after the intervention the adolescents reported greater reductions in internalising problems relative to those in usual care (Bryant et al, 2022b ). Although this study indicated support for the EASE program, further studies are needed to validate the robustness of this effect.…”

A systematic review of non-clinician trauma-based interventions for school-age children and young people

“…Only nine out of the twenty-five studies identified were rated as strong or moderate quality, and among these, only seven reported significant improvements in mental health outcomes, including depression, anxiety, or PTSD (21,26,32,33,37,43,44). Among these seven, four adopted a CBT-based approach (21,26,43,44), while two followed a mindfulness approach (33,37). The most frequently studied CBT-based intervention was TRT (26,43,49).…”

“…Several of the included studies trialled interventions with refugee populations (21,29,30,43,46,49,50). This area has a growing evidence base, considering that refugees are often supported in low-resource environments such as refugee camps, where accessing specialised support can be challenging even after achieving settled status.…”

“…The studies in this review either recruited the study population based on likely exposure to trauma, measured exposure to traumatic events, or measured PTSD symptoms (or a mix of these). Seven studies directly measured exposure to traumatic events (21,22,25,30,35,40,44,47). Thirteen studies directly measured PTSD symptoms (22,24,29,34,40,42), and of these, seven used PTSD score as selection criteria (29,30,(33)(34)(35)37,43).…”

Feasibility randomised controlled trial of the Early Adolescent Skills for Emotions psychological intervention with young adolescents in Lebanon

“…This feasibility trial and a simultaneous study in Jordan [ 23 ] were conducted in preparation for the first full-scale evaluations of EASE in Lebanon and Jordan [ 24 , 25 ]. Additional studies have been conducted in Tanzania [ 26 ] and Pakistan [ 27 ].…”