Dorsey Shannon, Lucid Leah, Martin Prerna, King Kevin M, O'Donnell Karen, Murray Laura K, Wasonga Augustine I, Itemba Dafrosa K, Cohen Judith A, Manongi Rachel, Whetten Kathryn
Department of Psychology, University of Washington, Seattle.
Center for Child and Family Health, Duke University, Durham, North Carolina.
JAMA Psychiatry. 2020 May 1;77(5):464-473. doi: 10.1001/jamapsychiatry.2019.4475.
Approximately 140 million children worldwide have experienced the death of one or both parents. These children, mostly in low- and middle-income countries, have higher rates of mental health problems than those who have not experienced parental death. Cognitive behavioral therapy (CBT) may improve the well-being of these children, but to our knowledge there have been no randomized clinical trials specifically focused on this population.
To test the effectiveness of trauma-focused CBT (TF-CBT) for improving posttraumatic stress (PTS) in children in Kenya and Tanzania who have experienced parental death, to test the effects of TF-CBT on other mental health symptoms, and to examine the feasibility of task-shifting with greater reliance on experienced, local lay counselors as trainers and supervisors.
DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial conducted in urban and rural areas of Tanzania and Kenya compared TF-CBT and usual care (UC) for 640 children aged 7 to 13 years who were recruited from February 13, 2013, to July 24, 2015. All children had experienced the death of one or both parents and had elevated PTS and/or prolonged grief. Interviewers were masked to study condition. Participants were followed up for 12 months after the randomized clinical trial. Statistical analysis was performed from February 3, 2017, to August 26, 2019. All analyses were on an intent-to-treat basis.
In the intervention condition, 320 children received 12 weeks of group TF-CBT delivered by lay counselors who were supervised weekly. In the UC condition, 320 children received community services typically offered to this population.
The primary outcome was PTS, evaluated using a continuous, standardized measure. Other mental health symptoms and child-guardian relationship were also measured.
A total of 640 children (320 girls and 320 boys; mean [SD] age, 10.6 [1.6] years) were included in the study. Trauma-focused CBT was more effective than UC for PTS in 3 of 4 sites after treatment (end of 3-month randomized clinical trial): 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, 0.10-0.80]). At 12-month follow-up, TF-CBT remained more effective than UC 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. At 12-month follow-up in Tanzania, children who received TF-CBT and UC had comparable rates of improvement (rural Tanzania, Cohen d = 0.09 [95% CI, -0.08 to 0.26]; urban Tanzania, Cohen d = 0.11 [95% CI, -0.09 to 0.31]). A similar pattern was seen for secondary outcomes, with stronger effects observed in Kenya, where children experienced greater stress and adversity (eg, more food scarcity, poorer guardian health, and greater exposure to traumatic events).
This study found that TF-CBT was more effective than UC in reducing PTS among children who experienced parental death in 3 of 4 sites in Kenya and Tanzania. At 12-month follow-up, TF-CBT was more effective in reducing PTS only among children in rural and urban Kenya.
ClinicalTrials.gov identifier: NCT01822366.
全球约有1.4亿儿童经历过父母一方或双方死亡。这些儿童大多生活在低收入和中等收入国家，与未经历父母死亡的儿童相比，他们出现心理健康问题的几率更高。认知行为疗法（CBT）可能会改善这些儿童的福祉，但据我们所知，尚无专门针对这一群体的随机临床试验。
测试创伤-focused CBT（TF-CBT）对改善肯尼亚和坦桑尼亚经历父母死亡的儿童创伤后应激（PTS）的有效性，测试TF-CBT对其他心理健康症状的影响，并检验更多依赖经验丰富的当地非专业咨询师作为培训师和督导员进行任务转移的可行性。
设计、地点和参与者：在坦桑尼亚和肯尼亚的城乡地区进行的一项随机临床试验，比较了TF-CBT和常规护理（UC）对2013年2月13日至2015年7月24日招募的640名7至13岁儿童的效果。所有儿童都经历过父母一方或双方死亡，且PTS升高和/或悲伤持续时间延长。访谈者对研究情况不知情。随机临床试验结束后，对参与者进行了12个月的随访。2017年2月3日至2019年8月26日进行了统计分析。所有分析均基于意向性分析。
在干预组，320名儿童接受了由非专业咨询师提供的为期12周的团体TF-CBT，咨询师每周接受督导。在常规护理组，320名儿童接受了该群体通常可获得的社区服务。
主要结局是PTS，使用连续的标准化测量方法进行评估。还测量了其他心理健康症状和儿童与监护人的关系。
共有640名儿童（320名女孩和320名男孩；平均[标准差]年龄为10.6[1.6]岁）纳入研究。在治疗后（3个月随机临床试验结束时），4个地点中有3个地点的创伤-focused CBT在改善PTS方面比常规护理更有效：肯尼亚农村地区（科恩d=1.04[95%CI，0.72-1.36]）、肯尼亚城市地区（科恩d=0.56[95%CI，0.29-0.83]）和坦桑尼亚城市地区（科恩d=0.45[95%CI，0.10-0.80]）。在12个月的随访中，TF-CBT在肯尼亚农村（科恩d=0.86[95%CI，0.64-1.07]）和城市（科恩d=0.99[95%CI，0.75-1.23]）地区仍然比常规护理更有效。在坦桑尼亚12个月的随访中，接受TF-CBT和常规护理的儿童改善率相当（坦桑尼亚农村地区，科恩d=0.09[95%CI，-0.08至0.26]；坦桑尼亚城市地区，科恩d=0.11[95%CI，-0.09至0.31]）。次要结局也呈现类似模式，在肯尼亚观察到的效果更强，那里的儿童经历了更大的压力和逆境（例如，更多的食物短缺、监护人健康状况较差以及更多地接触创伤性事件）。
本研究发现，在肯尼亚和坦桑尼亚的4个地点中有3个，TF-CBT在减少经历父母死亡儿童的PTS方面比常规护理更有效。在12个月的随访中，TF-CBT仅在肯尼亚农村和城市儿童中在减少PTS方面更有效。
ClinicalTrials.gov标识符：NCT01822366。
