Open Access Research article

School-based mental health intervention for children in war-affected Burundi: a cluster randomized trial

Wietse A Tol12*, Ivan H Komproe23, Mark JD Jordans24, Aline Ndayisaba5, Prudence Ntamutumba5, Heather Sipsma6, Eva S Smallegange7, Robert D Macy8 and Joop TVM de Jong10119

Author Affiliations

1 Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Hampton House R863, Baltimore, MD 21205-1996, USA

2 Department of Research & Development, HealthNet TPO, Amsterdam, the Netherlands

3 Faculty for Behavioral & Social Sciences, Utrecht University, Utrecht, the Netherlands

4 Centre for Global Mental Health, Institute of Psychiatry, Kings College London, London, UK

5 HealthNet TPO Burundi, Bujumbura, Burundi

6 Department of Women, Children, and Family Health Science, University of Illinois at Chicago College of Nursing, Chicago, IL, USA

7 Department of Childhood and Educational Sciences, University of Amsterdam, Amsterdam, the Netherlands

8 International Trauma Center & Harvard School of Medicine, Boston, MA, USA

9 Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, the Netherlands

10 Boston University School of Medicine, Boston, USA

11 Rhodes University, Grahamstown, South Africa

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BMC Medicine 2014, 12:56  doi:10.1186/1741-7015-12-56

Published: 1 April 2014



Armed conflicts are associated with a wide range of impacts on the mental health of children and adolescents. We evaluated the effectiveness of a school-based intervention aimed at reducing symptoms of posttraumatic stress disorder, depression, and anxiety (treatment aim); and improving a sense of hope and functioning (preventive aim).


We conducted a cluster randomized trial with 329 children in war-affected Burundi (aged 8 to 17 (mean 12.29 years, standard deviation 1.61); 48% girls). One group of children (nā€‰=ā€‰153) participated in a 15-session school-based intervention implemented by para-professionals, and the remaining 176 children formed a waitlist control condition. Outcomes were measured before, one week after, and three months after the intervention.


No main effects of the intervention were identified. However, longitudinal growth curve analyses showed six favorable and two unfavorable differences in trajectories between study conditions in interaction with several moderators. Children in the intervention condition living in larger households showed decreases on depressive symptoms and function impairment, and those living with both parents showed decreases on posttraumatic stress disorder and depressive symptoms. The groups of children in the waitlist condition showed increases in depressive symptoms. In addition, younger children and those with low levels of exposure to traumatic events in the intervention condition showed improvements on hope. Children in the waitlist condition who lived on their original or newly bought land showed improvements in hope and function impairment, whereas children in the intervention condition showed deterioration on these outcomes.


Given inconsistent effects across studies, findings do not support this school-based intervention as a treatment for posttraumatic stress disorder and depressive symptoms in conflict-affected children. The intervention appears to have more consistent preventive benefits, but these effects are contingent upon individual (for example, age, gender) and contextual (for example, family functioning, state of conflict, displacement) variables. Results suggest the potential benefit of school-based preventive interventions particularly in post-conflict settings.

Trial registration

The study was registered as ISRCTN42284825

Children; PTSD; Depression; Efficacy; Treatment; Prevention; Psychosocial intervention; Violence; War