Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2020 May 1;77(5):464-473.
doi: 10.1001/jamapsychiatry.2019.4475.

Effectiveness of Task-Shifted Trauma-Focused Cognitive Behavioral Therapy for Children Who Experienced Parental Death and Posttraumatic Stress in Kenya and Tanzania: A Randomized Clinical Trial

Shannon Dorsey  1 , Leah Lucid  1 , Prerna Martin  1 , Kevin M King  1 , Karen O'Donnell  2 , Laura K Murray  3 , Augustine I Wasonga  4 , Dafrosa K Itemba  5 , Judith A Cohen  6 , Rachel Manongi  7 , Kathryn Whetten  8
Affiliations
Randomized Controlled Trial

Effectiveness of Task-Shifted Trauma-Focused Cognitive Behavioral Therapy for Children Who Experienced Parental Death and Posttraumatic Stress in Kenya and Tanzania: A Randomized Clinical Trial

Shannon Dorsey et al. JAMA Psychiatry. .

Abstract

Importance: 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.

Objectives: 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.

Interventions: 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.

Main outcomes and measures: The primary outcome was PTS, evaluated using a continuous, standardized measure. Other mental health symptoms and child-guardian relationship were also measured.

Results: 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).

Conclusions and relevance: 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.

Trial registration: ClinicalTrials.gov identifier: NCT01822366.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Dorsey reported being a trauma-focused cognitive behavioral therapy trainer and receiving payment to provide trauma-focused cognitive behavioral therapy trainings. Ms Itemba reported receiving grants to the Tanzania Women Research Foundation during the conduct of the study. Dr Cohen reported receiving grants from the Substance Abuse and Mental Health Services Administration, receiving royalties from Guilford Press during the conduct of the study, and receiving royalties from Medical University of South Carolina outside the submitted work. Drs Dorsey, Murray, and Cohen reported receiving honoraria and consultancies for trauma-focused cognitive behavioral therapy and grants funding research on trauma-focused cognitive behavioral therapy. Dr Whetten reported receiving grants funding research on trauma-focused cognitive behavioral therapy. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. CONSORT Diagram of Study Participants
There were no adverse events among study participants; withdrawal and loss to follow-up were unrelated to experiences of harm or adverse events. TF-CBT indicates trauma-focused cognitive behavioral therapy; UC, usual care. aTreatment completion was defined as any child who attended 10 or more sessions. bA total of 11 children in both groups were interviewed 1 week outside the study-specified 2-week window. cAll study participants were assessed at each time point regardless of number of treatment sessions attended.
Figure 2.
Figure 2.. Treatment Effects on Child-Reported Posttraumatic Stress at 12 Months by Country and Area
A, Urban Kenya (Cohen d = 0.99 [95% CI, 0.75-1.23]). B, Rural Kenya (Cohen d = 0.86 [95% CI, 0.64-1.07]). C, Urban Tanzania (Cohen d = 0.11 [95% CI, −0.09 to 0.31]). D, Rural Tanzania (Cohen d = 0.09 [95% CI, −0.08 to 0.26]). Model-predicted values are presented. Filled circles are the data (model-predicted values) underlying the distributions illustrated in the plots. TF-CBT indicates trauma-focused cognitive behavioral therapy; UC, usual care.
See this image and copyright information in PMC

Comment in

References

    1. UNICEF The state of the world’s children 2016: a fair chance for every child. https://www.unicef.org/publications/files/UNICEF_SOWC_2016.pdf. Published June 2016. Accessed January 7, 2019.
    1. UNICEF Orphans. https://www.unicef.org/media/media_45279.html. Updated June 16, 2017. Accessed June 12, 2019.
    1. Atwine B, Cantor-Graae E, Bajunirwe F. Psychological distress among AIDS orphans in rural Uganda. Soc Sci Med. 2005;61(3):555-564. doi:10.1016/j.socscimed.2004.12.018 - DOI - PubMed
    1. Foster G, Makufa C, Drew R, Mashumba S, Kambeu S. Perceptions of children and community members concerning the circumstances of orphans in rural Zimbabwe. AIDS Care. 1997;9(4):391-405. doi:10.1080/713613166 - DOI - PubMed
    1. Urassa M, Boerma JT, Ng’weshemi JZL, Isingo R, Schapink D, Kumogola Y. . Orphanhood, child fostering and the AIDS epidemic in rural Tanzania: project to support AIDS control in Mwanza Region. Health Transit Rev. 1997;7(suppl 2):141-153.

Publication types

Associated data