Improving Outcomes for Orphaned Youth: Implementation of Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Grief

Study Title: Improving Outcomes for Orphaned Youth: Implementation of Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Grief

Context: Approximately 50 million orphaned and abandoned adolescents currently live in sub-Saharan Africa. Previous studies have indicated that many of these children and adolescents, who often have mental health problems associated with parental loss, have high rates of other traumatic experiences and ongoing trauma exposure. Because the gap in mental health care is large in sub-Saharan Africa, with few individuals in need of treatment receiving even minimal support, more information regarding how to best implement effective interventions, like Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for orphaned and abandoned children (OAC) is needed. Cognitive behavioral therapy approaches have been shown to be effective in low- and middle-income countries with adults and in wealthier nations with children and adolescents. More research on the effectiveness of CBT approaches effect resource-poor settings is needed. It is also critical to identify what level of provider and supervisor support is needed for maximum effectiveness and local feasibility. 

Study Aims: This research will examine the effectiveness of TF-CBT for treating unresolved grief and traumatic stress for OAC and adolescents in two East African countries, Tanzania and Kenya. The randomized trial will examine the effectiveness of TF-CBT compared to receipt of services as usual in these countries. The study involves collaboration with local organizations in Tanzania and Kenya, in which nine local counselors in each country will be trained by both a US-based TF-CBT expert and Tanzanian lay counselors who gained TF-CBT expertise in a previous feasibility study of TF-CBT for OAC, to deliver group-based TF-CBT for childhood traumatic grief to children ages 7-13. This study will evaluate the effectiveness of TF-CBT compared to existing services as usual orphan supports. The study will also examine the impact of implementation factors (e.g., intervention fidelity, lay counselor-supervisor relationship, child/guardian attendance) to study how enhanced local involvement and responsibility (i.e., Tanzanian lay counselor involvement in co-training and supervision) impacts outcomes.

Methods: This study build on previous work demonstrating that TF-CBT is a feasible and acceptable approach for OAC and adolescents by including a control group to properly examine the effectiveness of the TF-CBT approach. The 18 counselors who are trained in TF-CBT will deliver the treatment in 20 groups in each country, 10 rural and 10 urban, resulting in a total of 320 children and adolescents receiving the treatment (40 groups). TF-CBT and mental health experts will oversee the training of the lay counselors and the treatment given to the groups.

Policy Implications:

• The study will examine the effectiveness of TF-CBT treatment for OAC and adolescents, as compared to receipt of services as usual in two East African Countries.
• Incorporating experienced lay counselors in providing training and supervision in TF-CBT will inform future efforts to build local expertise and sustainability. This work will inform not only TF-CBT for CTG efforts but also efforts for scale up of other mental health interventions.
• Generate important recommendations for OAC treatment and training approaches that are effective in low- and middle-resource settings.

M-Principal Investigators: Shannon Dorsey (University of Washington) and Kathryn Whetten (Duke University)

Investigators: Dafrosa Itemba (TAWREF), Kevin King (University of Washington), Rachel Manongi (KCMC), Karen O’Donnell (Duke University), Augustine Wasonga (ACE Africa)

Contact Information: duke.ovcstudies@gmail.com