This blog explores post-traumatic stress disorder (PTSD) in the context of developing early childhood interventions in low/middle income countries (LMIC’s). Children from LMIC’s have a higher probability rate of experiencing traumatic experiences, yet the vast majority do not have access to efficacious psychological treatments [1]. Improving access to mental health services is one of the grand challenges faced in global mental health research [2].  After outlining the background relevant research into the lifelong effects of adverse childhood experiences (ACE’s), this blog focuses on the benefits and challenges faced within school-based interventions for early childhood PTSD, before finishing with an example of a study of a school based intervention for PTSD in a LMIC that utilises paraprofessionals as facilitators.

Life Course Consequences

Felitti et al.’s 1998 study [3] into adverse childhood experiences retrospectively asked adult participants to identify adversity they experienced during childhood, and explored for correlation with physical health over the life span. There findings demonstrated how adversity experienced during childhood can translate into life-long health, social and cognitive implications, which can ultimately lead to an early death. Although this theoretical framing of trauma emerged from a population of adults from high income countries (HIC’s), studies have demonstrated that the ACE questionnaire also identified that the model applies to LMIC, some of which have particularly high rates of childhood adversity [4].

In extrapolating childhood adversity as an underlying causal factor in later adult health issues, the ACE study also alludes to the positive consequences of interventions that successfully address and resolve the adverse experiences therapeutically. Namely, that the consequences may span beyond immediate improvements to a participant’s mental health, altering their life course trajectory. This life course perspective is also adopted in the justification for increased investment into early childhood interventions [5] [6].

Applying this rationale onto working with children to address PTSD may also represent a valuable return on investment. To give a reductionist example to illustrate the point, it might be cost less to resolve the underlying adverse experiences through therapeutic interventions whilst the individual is still a child, otherwise if they later develop alcoholism, the subsequent remedial medical efforts because of their liver failure may be far more costly compared to the early childhood intervention.

The lack of LMIC research

In a meta analysis of 24 studies, Newman et al. found that psychological interventions, predominantly cognitive behaviour therapy based protocols, are an effective post-disaster treatments for children with PTSD [7]. However, there is a large paucity in research into child and adolescent mental health interventions in LMIC’s compared to HIC’s [8]. Indeed, between 2001 and 2010, 90% of randomised control trials into child and adolescent mental health disorders were on HIC populations [8][1].  

Regarding PTSD, of 1000 reviewed articles containing adult and child populations, only 12.7% contained sample populations outside of HIC’s [9]. making LMIC’s significantly under represented. Furthermore, 57% of the articles were only available through journal subscriptions, demonstrating a barrier to access where LMIC researchers often rely upon open access publications [9].

Why School based?

School based mental health programmes are a key strategy in addressing the paucity of mental health interventions for children in LMIC [1]. In a meta analysis of 19 studies, 8 of which were either LMIC’s or refugee populations, Rolfsnes and Idsoe found that school based interventions have a medium to large effect on reducing symptoms of child PTSD [10] Furthermore, interventions delivered in school settings led to considerably more students accessing and  completing free treatment for PTSD after Hurricane Kutrina, compared to treatment in a clinical setting [12]. This highlights how convenience of location and familiarity of setting are factors can affect treatment outcomes, and that placing interventions within the school setting can overcome particular barriers to access.

Challenged with school-based interventions for PTSD in LMIC

Utilising teachers that are already overburdened with their daily tasks and responsibilities is challenge faced with integrating mental health interventions in a school setting [1]. Despite this, studies have found that utilising existing professionals to deliver mental health interventions at schools can be successful [10]. Inadequately trained health care professionals and teachers, as well as parents, with a lack of mental health knowledge is a barrier in identifying and diagnosing children with mental health issues [1]. This is a particularly nuanced challenge, considering how PTSD shares multiple clusters of behaviours and symptoms with other diagnostic classifications, such as depression and anxiety based disorders [11].Furthermore, the fact that individuals will react differently to adversity even when they are shared traumatic experiences, and that not everyone will develop symptoms of PTSD [10], represents further challenges in selection criteria for access to interventions. Indeed, Dybdahl found that children’s symptoms of distress following similar exposures to combat violence widely differed [13].

An Example of school-based child PTSD intervention in LMIC

In a study of 495 children, with a mean age of 9.9, Tol et al. designed a program of 15 group trauma therapy sessions, for children affected by political violence in Indonesia [14]. The program was manualised, based upon efficacious trauma processing creative activities, and was delivered by trained paraprofessionals after 5 weeks of training.

This simultaneously overcomes the challenge of over-burdened teachers, and the lack of mental health professionals in LMIC’s. Although the study only achieved modest results in decreasing PTSD symptoms of treatment group compared with the waiting list group, and had several methodological limitations, [14] it is included here because it represents a novel intervention design that attempts to overcome barriers to access of mental health interventions, by creating lower cost methods of implementation through the utilisation of paraprofessionals.

Conclusion

This blog has explored the nature of the life course effects of children’s experiences of adversity, whilst highlighting the current paucity in child mental health research in low  and middle income countries. School based interventions are a key strategy in improving attendance and outcome in interventions, and utilising paraprofessionals may help to overcome some of the current barriers to scaling the implementation of child PTSD interventions.

Thanks for reading!

References

 [1]. Patel, V., Kieling, C., Maulik, P. K., & Divan, G. (2013). Improving access to care for children with mental disorders: a global perspective. Archives of disease in childhood, 98(5), 323-327. http://dx.doi.org/10.1136/archdischild-2012-302079

[2] Collins, P. Y., Patel, V., Joestl, S. S., March, D., Insel, T. R., Daar, A. S., … & Glass, R. I. (2011). Grand challenges in global mental health. Nature, 475(7354), 27-30. https://www.nature.com/articles/475027a

[3] Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/S0749-3797(98)00017-8

 [4]. Manyema, M., & Richter, L. M. (2019). Adverse childhood experiences: prevalence and associated factors among South African young adults. Heliyon, 5(12), e03003. https://doi.org/10.1016/j.heliyon.2019.e03003

[5] Black, M. M., Walker, S. P., Fernald, L. C., Andersen, C. T., DiGirolamo, A. M., Lu, C., … & Devercelli, A. E. (2017). Early childhood development coming of age: science through the life course. The Lancet, 389(10064), 77-90. https://doi.org/10.1016/S0140-6736(16)31389-7

[6]. Doyle, O., Harmon, C. P., Heckman, J. J., & Tremblay, R. E. (2009). Investing in early human development: timing and economic efficiency. Economics & Human Biology, 7(1), 1-6. https://doi.org/10.1016/j.ehb.2009.01.002

[7] Newman, E., Pfefferbaum, B., Kirlic, N., Tett, R., Nelson, S., & Liles, B. (2014). Meta-analytic review of psychological interventions for children survivors of natural and man-made disasters. Current psychiatry reports, 16(9), 462. https://link.springer.com/article/10.1007/s11920-014-0462-z

[8]. Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., … & Rahman, A. (2011). Child and adolescent mental health worldwide: evidence for action. The Lancet, 378(9801), 1515-1525. https://doi.org/10.1016/S0140-6736(11)60827-1

[9] Fodor, K. E., Unterhitzenberger, J., Chou, C. Y., Kartal, D., Leistner, S., Milosavljevic, M., … & Alisic, E. (2014). Is traumatic stress research global? A bibliometric analysis. European Journal of Psychotraumatology, 5(1), 23269. https://doi.org/10.3402/ejpt.v5.23269

[10] Rolfsnes, E. S., & Idsoe, T. (2011). School‐based intervention programs for PTSD symptoms: A review and meta‐analysis. Journal of Traumatic Stress, 24(2), 155-165.  

https://doi.org/10.1002/jts.20622

[11]Amaya-Jackson, L., Socolar, R. R., Hunter, W., Runyan, D. K., & Colindres, R. (2000). Directly questioning children and adolescents about maltreatment: A review of survey measures used. Journal of Interpersonal Violence, 15(7), 725-759. https://doi.org/10.1177/088626000015007005

[12] Jaycox, L. H., Cohen, J. A., Mannarino, A. P., Walker, D. W., Langley, A. K., Gegenheimer, K. L., … & Schonlau, M. (2010). Children’s mental health care following Hurricane Katrina: A field trial of trauma‐focused psychotherapies. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 23(2), 223-231. https://doi.org/10.1002/jts.20518

[13] Dybdahl, R. (2001). Children and mothers in war: an outcome study of a psychosocial intervention program. Child development, 72(4), 1214-1230. https://doi.org/10.1111/1467-8624.00343

[14] Tol, W. A., Komproe, I. H., Susanty, D., Jordans, M. J., Macy, R. D., & De Jong, J. T. (2008). School-based mental health intervention for children affected by political violence in Indonesia: a cluster randomized trial. Jama, 300(6), 655-662. doi:10.1001/jama.300.6.655

[15] Suhartono, M., Victor, D. 2019. Violence Erupts in Indonesia’s Capital in Wake of Presidential Election Results. Retrieved from: https://www.nytimes.com/2019/05/22/world/asia/indonesia-election-riots.html

[16] World Bank. 2016. Country Income Groups (World Bank Classification). Retrieved from: http://chartsbin.com/view/2438

The 46% rise in global pre-school enrolment between 1999 and 2010 has generally not been matched with the equivalent rise in developmental outcomes for these children [1].This is largely due to the education being of insufficient quality. Broadly speaking, it has been argued that the various government efforts have focused too heavily on increasing pre-primary education capacity, without enough attention on ensuring adequate levels of quality education [1].

Here are photo examples of two schools in Pakistan. It demonstrates the variety of structural quality in the education buildings that are used within a country.

The one on the left is a public school, the children are sat on the floor, the teachers desk seems dusty and the educative resources that are available seem small print and complicated, not necessarily appropriate for the age group.

Conversely, this photo of a private pre-primary school has age specific furniture, bright colours, and the education resources on the wall are simple, and reflective of the children’s developmental age.

However, the structure that the children’s education takes place in alone, is not indicative of the quality of education they are receiving. In order to assess the quality of education, and give meaningful and appropriate feedback to programs on how to improve, criteria for what is considered to be of high quality needed to be devised. Britto, Yoshikawa and Boller [2] proposed 5 key dimensions of quality which shall be explored and used to analyse aspects of quality in various early learning programs in Pakistan. It is worth noting that the dimensions explored in this blog are one of a number of models for analysing quality. If you are interested in more models, here is another example [1].

Malik, Rooney, Chronis-Tuscano and Tariq investigated a behavioural based intervention for parent’s with children between 4 and 12 with ADHD in Pakistan [3] .The therapists made ongoing adaptations to the parenting model, that was originally designed for American parents but being implemented in Pakistan, to disseminate the cultural differences of approaches to childcare. For example, rates of attendance dropped once the therapist introduced token economy systems to behaviour management. Once the therapist’s realised the parent’s struggled to understand the concept, they adjusted the intervention to spend more time delivering additional support to contextualise the token system in ways that made sense in the culture of Pakistan [3].

The Aga Khan Development Network [4] in Pakistan specialises in training pre-primary teachers. This program addresses resource levels by providing opportunities in rural Pakistan for advanced level teacher training. It also addresses the fifth quality dimension outlined below, as it focuses on student-centred learning by fostering independent thinking and problem-solving skills in children rather than memorising through rote learning.

It is estimated that 4.5 million children are in the public sector katchi-class, meaning ‘not mature’, or of pre-primary ages between 2 and 4 years old. Most government funded schools in Pakistan do not have separate classrooms for katchi classes, or specifically trained teachers [5] [6]. One way to mitigate this issue can be analysed using the quality dimensions, specifically 1, 2 and 4.  Sipahimalani-Rao and LaRocque [6] argue that the government should expand the concept of early childhood education beyond the current katchi-class age ranges, to encompass up to 8 year olds. This would become the globally recognised age range for early childhood interventions. This addresses dimension one, as it integrates the current community context of age range classification with global standards. Dimension two as it would alleviate the need to hire separate teachers, instead training one teacher in childhood pedagogy that is appropriate to the full age range. Dimension 4 because it would remove the current requirement of separate classrooms and facilities.

Although the government has created and reviewed a curriculum specifically for early learning years, it has largely not been implemented [5] [6]. Changes to education policy address the current issues of quality in early childhood education [7], yet decision making processes at the government level are embroiled with party politics, bureaucracy and relationship conflict, which hinder effective implementation [8].

Changes teacher training curriculum has attempted to move away from teacher-as-dictator, towards teacher-as-facilitator [8]. Hunzai has noted that it is common in Pakistan for the profession of early years teaching to be viewed as a last resort, not requiring special expertise and knowledge [8]. This represents the multiple levels in which communication and interaction is an important factor in the quality of education. On the micro level, to improve children’s outcomes, teachers should be trained in child lead techniques such as positive appraisal and encouragement, rather than corporal punishment. In a macro level, early childhood programs has the opportunity to communicate and interact with communities in redressing the views of the job role as being a skilled and worthwhile profession.

This blog has explored examples of early childhood programming in Pakistan, as well as the policy level contexts in which those interventions sit. Britto, Yoshikawa and Boller’s five dimensionshas been adopted as a lens in which to access quality, and identify areas that require improvement to improve pre-primary intervention outcomes [2]. If you have any questions, please write a comment below!

References

[1] UNICEF. (2017). Overview: MELQO: Measuring early learning quality and outcomes. UNESCO Publishing. Retrieved from https://books.google.co.uk/books?hl=en&lr=&id=S50zDwAAQBAJ&oi=fnd&pg=PA3&dq=MELQO&ots=6ZlRE5WZF4&sig=OuvJmM3pq3fOcjmO0dIr-zSYq20&redir_esc=y#v=onepage&q=MELQO&f=false

[2] Britto, P. R., Yoshikawa, H., & Boller, K. (2011). Quality of Early Childhood Development Programs in Global Contexts: Rationale for Investment, Conceptual Framework and Implications for Equity and commentaries. Social Policy Report, 25(2), 1-31.https://srcd.onlinelibrary.wiley.com/doi/pdf/10.1002/j.2379-3988.2011.tb00067.x

[3] Malik, T. A., Rooney, M., Chronis-Tuscano, A., & Tariq, N. (2017). Preliminary efficacy of a behavioral parent training program for children with ADHD in Pakistan. Journal of attention disorders, 21(5), 390-404. https://doi.org/10.1177/1087054714524158

[4] The Aga Khan University. n.d. Institutes for Education Development. Retrieved from:  https://www.akdn.org/our-agencies/aga-khan-university/institutes-education-development-ied

[5] Khan, M. A. (2018). The status of early childhood education in Pakistan: Inside stories. Contemporary Issues in Early Childhood, 19(3), 310-317. https://doi.org/10.1177/1463949118757049

[6] Sipahimalani-Rao, V., LaRocque, N. 2019. School Education in Pakistan: A Sector Assessment. Asian Development Bank.  Retrieved from http://dx.doi.org/10.22617/TCS190039

[7] Arshad, M., & Zamir, S. (2018). Situational Analysis of Early Childhood Education in Pakistan: Challenges and Solutions. Journal of Early Childhood Care and Education, 2, 135-149. http://jecce.aiou.edu.pk/wp-content/uploads/2019/01/10-Situational-Analysisi-of-Early.pdf

[8] Hunzai, Z. N. (2009). Teacher education in Pakistan: Analysis of planning issues in early childhood education. Journal of Early Childhood Teacher Education, 30(3), 285-297. https://doi.org/10.1080/10901020903084421

[9] Aga Khan Development Network. (n.d) Retrieved from https://www.akdn.org/where-we-work/south-asia/pakistan/education-pakistan

[10] Barkley, R. A. (2013). Defiant children: A clinician’s manual for assessment and parent training. Guilford press. Retrieved from: https://www.goodreads.com/book/show/926791.Defiant_Children

[11] Rahim, Bushra. 2014. Pakistan: Children in primary schools should be taught in their mother tongue. Retrieved from: https://gemreportunesco.wordpress.com/2014/10/16/pakistan-children-in-primary-schools-should-be-taught-in-their-mother-tongue/

Pre-Primary Education in Rural Pakistan.

Children are often excluded from pre-primary education because there are not enough schools. Those schools that are available are usually overcrowded. Poor infrastructural conditions within schools, such as lack of furniture, no access to gendered toilets, and out of date curriculum materials leads to high drop-out rates. The major task in overcoming these issues is in addressing mismanagement, unclear roles and responsibilities and un-coordinated efforts at the government leadership levels [2].

What is LEAPS?

LEAPS (Learning and Education achievement in Pakistan Schools) is a research initiative engaging in a series of interventions to improve education and learning outcomes in Pakistan [6]. In 2016/17, LEAPS piloted a pre-primaryeducation program in the Sindh district, that trained 18 to 24 year-old females to deliver education programs for 3.5 to 6.5 year old children. The program was designed to simultaneously get children ready for primary school by developing their executive functioning skills and their readiness for school, whilst providing economic and professional opportunities for young adults [1] [7] [8]. 

 A Snapshot of this project:

The Community Youth Leaders

• 10 females aged between 18 and 24 with 10 years of education were recruited.
• They received one month’s basic training, and bi-monthly on the job supervision.
• They were responsible for running two, three-hour long classes five days a week with classes of 20 children.
• They received 5000 Pakistani rupees per month (£25.00), which at the time of implementation aligned with the government recommendations, and lower than the average pre-school teacher’s salary in the area.

The Children

• Children are aged between 3.5 and 6.5 years of age
• 170 children received the intervention.

The Community

• Family members and volunteers from the community were invited to help support in practical ways, such as filling water coolers, and supporting transport.
• Monthly community meetings, parent’s evenings and consultations were central to the program’s curriculum.

Results from the Pilot project.

LEAPS’ (2018) study compared 170 children enrolled in the LEAPS intervention, with 170 children who accessed the pre-existing available local education. Children’s readiness for primary school was measured using Save The Children’s international development and early learning assessment [9] tool, and a battery of executive functioning tasks.

Results found that children exposed to the LEAPS’ intervention were more ready for primary school, and had higher levels of executive functioning compared to those who did not receive the intervention. [8]

Also, findings from a focus group found that the young adults delivering the program developed professional skills such as leadership and communication, particularly as a result of the on-going mentoring component of the intervention [7]. These findings combined support LEAPS’ argument that cross-generational programming is a novel and innovative approach to achieving the UN’s Sustainable Development Goals.

The United Nation’s Sustainable Development Goals (SDG’s) is a non-legally binding goal based governance model designed to steer countries and institutions towards a set of global targets by the year 2030, and contains 17 key goals [10] [16]

How does LEAPS meet UN’s sustainability development Goals?

Pre-primary learning programs such as LEAPS are effectively nurturing the various foundation’s required for young children to get the most out of their future education experiences. These programs thereby improve access to pre-primary education by funding the interventions, and they also bolster the quality of a child’s education in the future, by developing the child’s readiness for primary school. Also, the intergenerational approach to LEAPS’ Pilot meant the program also delivered quality education to 18-24 year olds, whom are also at a sensitive developmental age, and are under-served by the current education system in Pakistan. This differs from other similar projects train adults into the para-professional positions.

Also getting married at a young age, and becoming a parent, even further restricts women’s opportunities for education, training, and employment[13].  Despite this,of the 10 women employed through LEAPS’ pilot intervention, 3 were married, and a further 1 had a child (Yousafzai, 2018). Not only does recruiting women actively address gender equality by positive discrimination, it also contributes towards the normalising of women in various life stages occupying professional roles, slowly disrupting a communities learnt views on gender inequality.

Also, early childhood programming has been demonstrated to significantly increase a child’s future earnings. This means that pre-primary education’s effect spans into an individual’s adulthood by increasing their economic productivity, and thereby stimulating the growth of the country [15].

The benefits of early childhood interventions on an individuals’ life course trajectory are well documented. Alongside this, programs such as LEAPS demonstrates how interventions can address multiple UN Sustainable development goals simultaneously. The challenge now is in co-ordinating the implementation of programs on a larger scale, to reach the wider population of at-risk young children in low middle-income countries such as Pakistan.

References

[1]. Andrabi, T., Das, J., Khwaja, A. (2018). LEAPS: Learning and educational achievement in Pakistan Schools. Retrieved from https://epod.cid.harvard.edu/sites/default/files/2018-11/LEAPS%20Brochure.pdf

[2]. UNICEF. (2013). Out-of-school children in the Balochistan, Khyber Pakhtunkhwa, Punjab and Sindh provinces of Pakistan. Islamabad, Pakistan: UNICEF Pakistan. https://unesdoc.unesco.org/ark:/48223/pf0000224501

[3]. Rees, N., & Anthony, D. (2015). Unless we act now: the impact of climate change on children. United Nations International Children’s Fund (UNICEF). https://www.unicef.org/publications/index_86337.html

[4]. Black, M. M., Walker, S. P., Fernald, L. C., Andersen, C. T., DiGirolamo, A. M., Lu, C., … & Devercelli, A. E. (2017). Early childhood development coming of age: science through the life course. The Lancet, 389(10064), 77-90. https://doi.org/10.1016/S0140-6736)16)31389-7

[5] Gulf Today. (2019). Video: Over 160 killed as heavy rain wreaks havoc in Pakistan. Retrieved from: https://www.gulftoday.ae/news/2019/08/12/over-160-killed-as-heavy-rain-wreaks-havoc-in-pakistan

[6] Harvard Kennedy School. (n.d) Retrieved from  https://epod.cid.harvard.edu/initiative/leaps-program#about

[7] Franchett, E. E., Yousafzai, A. K., Rasheed, M. A., Siyal, S., Reyes, C. R., & Ponguta, L. A. (2019). Experiences of community youth leaders in a youth-led early childhood education program in rural Pakistan. Zeitschrift für Psychologie. https://doi.org/10.1027/2151-2604/a000362

[8] Yousafzai, A. K., Rasheed, M. A., Rizvi, A., Shaheen, F., Ponguta, L. A., & Reyes, C. R. (2018). Effectiveness of a youth-led early childhood care and education programme in rural Pakistan: A cluster-randomised controlled trial. PloS one, 13(12). https://doi.org/10.1371/journal.pone.0208335

[9] Save the Children. (n.d) IDELA Data. Retrieved from: https://idela-network.org/

[10] Biermann, F., Kanie, N., & Kim, R. E. (2017). Global governance by goal-setting: the novel approach of the UN Sustainable Development Goals. Current Opinion in Environmental Sustainability, 26, 26-31. https://doi.org/10.1016/j.cosust.2017.01.010

[11] Arnold, C., Bartlett, K., Gowani, S., & Merali, R. (2007). Is everybody ready? Readiness, transition and continuity: Lessons, reflections and moving forward. background paper for the EFA Global Monitoring Report. https://www.akdn.org/sites/akdn/files/media/documents/various_pdf_documents/2006_akf_edu_-_ecd_-_is_everybody_ready.pdf

[12] Lloyd, C., Mete, C., & Grant, M. (2007). 4 Rural girls in Pakistan: Constraints of policy and culture. https://www.researchgate.net/publication/313557083_Rural_Girls_in_Pakistan_Constraints_of_Policy_and_Culture

[13] Patton, G. C., Sawyer, S. M., Santelli, J. S., Ross, D. A., Afifi, R., Allen, N. B., … & Kakuma, R. (2016). Our future: a Lancet commission on adolescent health and wellbeing. The Lancet, 387(10036), 2423-2478.https://doi.org/10.1016/S0140-6736(16)00579-1

[14] Yousafzai, A. K., Rasheed, M. A., Siyal, S., Franchett, E., Sudfeld, C., Ponguta, L, A., Reyes, C., Fink, G. (2019). LEAPS: a strategy to benefit young children and youth. Retrieved from https://earlychildhoodmatters.online/2019/leaps-a-strategy-to-benefit-young-children-and-youth/#heading_4

[15] Engle, P. L., Fernald, L. C., Alderman, H., Behrman, J., O’Gara, C., Yousafzai, A., … & Iltus, S. (2011). Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet, 378(9799), 1339-1353. https://doi.org/10.1016/S0140-6736(11)60889-1

[16] UN. (n.d) Sustainable Development Goals: Knowledge Platform. Retrieved from https://sustainabledevelopment.un.org/