Innovation summary

Mental health and psychosocial problems are common among young people1. Poor mental health in young people affects their education, and has consequences for health, social and economic outcomes in adulthood. Millions of children and adolescents are living in communities affected by adversity (e.g. poverty, community violence, humanitarian emergencies), which has been shown to increase mental health problems. Without adequate access to evidenced-based care, young people are at increased vulnerability to experiencing persistent mental health difficulties2. Increasing the provision of evidence-based interventions for young people and building capacity in a non-specialist workforce for mental health are crucial principles towards a global vision which seeks to strengthen access to and quality of mental health care - particularly so for communities which have faced adversity. However, available evidence of interventions for young people in low-resourced settings is limited3.

In response, the World Health Organization has developed Early Adolescent Skills for Emotions (EASE), currently undergoing testing, which aims to support 10 to 14-year olds with internalizing problems (e.g. symptoms of depression, anxiety, distress), and their caregivers. EASE is a potentially scalable psychological intervention, because it is designed to be:

  • delivered to groups of young people and their caregivers;
  • brief, with 7 sessions for young adolescents and 3 sessions for caregivers;
  • delivered by trained and supervised non-specialist providers for mental health;
  • transdiagnostic (i.e. it is not restricted to one mental health condition; it can be used for a range of symptoms)
  • implemented for contexts with limited access to specialist child and adolescent mental health services;
  • adaptable for delivery in community, health, protection (i.e. at-risk child services) and education settings. 

Impact summary

  • The primary outcome is: psychosocial distress (reported by the child).  
  • Secondary outcomes reported by the children included: depression, post-traumatic stress, functioning, wellbeing. Secondary outcomes reported by caregivers include: psychosocial distress of the child, caregiver’s psychosocial distress, parenting skills and behaviours.
  • Feasibility will be determined by the number of young people and caregivers who complete the intervention.
  • Acceptability of the intervention to its recipients and other key stakeholders will be determined through process evaluations.

Innovation details

Early Adolescent Skills for Emotions (EASE) was developed to meet the needs of young people with symptoms of internalizing problems, such as anxiety and depression. EASE has been designed for delivery in contexts where young people’s mental health is compounded by living in adversity, with limited access to specialist mental health services, including a limited availability of a specialist mental health workforce.

EASE aims to reduce symptoms of internalizing disorders through four core empirically‐supported strategies: psychoeducation, stress management, behavioural activation, and problem solving. These strategies were identified through a component analysis of the most commonly used strategies in effective psychological interventions for young people, and through expert consultation4.

The potential scalability of EASE is further enhanced through the provision of brief training for non-specialist providers (facilitators), which includes classroom training, supervised in-field training and competency and fidelity assessments. Facilitators also receive training in identifying and managing (by referral) child or adult protection concerns, including identifying risk for suicide or self-harm. Facilitators are then supervised weekly in groups, throughout the duration of delivering the intervention. To enhance local capacity building, a training of trainers model is utilised. Supervisors receive training in the supervision methods for EASE, monitoring fidelity and competency and in EASE delivery itself.

EASE is comprised of seven weekly 90-minute sessions for young adolescents, delivered in groups of approximately 8-12. An intervention manual is used to guide the facilitator and co-facilitator to deliver each session. To maximise engagement, the core strategies are shared through a combination of group teaching, discussion, activities, pictures and drawings, and through a story.  Each session includes a welcome and review activity of the previous session’s content, followed by sharing or revising a core strategy, and ending with setting home practice to engage in between EASE sessions. The sessions are anchored by an illustrated storybook which depicts a character experiencing common difficulties faced by young people, as the character follows their way through the core EASE strategies. Young adolescents are also provided with an illustrated workbook for completing their home practice. For both children and caregivers, EASE has been designed to maximised accessibility in contexts where there is low literacy.

Caregivers of EASE-attending adolescents are invited to participate in three 90-minute caregiver group sessions, delivered to no more than 12 caregivers a group. The purpose of the caregiver sessions is to enhance existing strengths and promote adaptive parenting practices in order to improve the caregiver-child relationship and equip caregivers with skills to support their child living with distress. The caregiver sessions follow a similar approach to the young adolescent sessions – with session welcoming and review, imparting of the core content, and closing through setting home practice - using group teaching, pictures and discussion. Caregivers are kept informed about the EASE strategies which their children are receiving, without disclosing confidential or personal content about their child’s participation in the group (and vice versa).

The adolescent sessions are structured as follows:

  • Understanding my Feelings (core strategy: psychoeducation, including emotion identification)
  • Calming my Body (core strategy: stress management, including slow breathing)
  • Changing my Actions – part 1, part 2 (core strategy: behavioural activation)
  • Managing my Problems – part 1, part 2 (core strategy: problem-solving)
  • Brighter futures (maintenance and relapse prevention)

The caregiver sessions are structured as follows:

  • Understanding sadness, worry and stress (psychoeducation, active listening, quality time, stress management)
  • Boosting confidence (praise, considering children’s strengths, reducing physical punishment)
  • Caregiver self-care and brighter futures (caregiver stress management and basic self-care, maintenance and relapse prevention)

Key drivers

EASE has not yet been implemented outside of the research and field test settings. The following key drivers are likely to contribute to its success in implementation:

Feasibility testing and ongoing adaptations

  • Formative work with key stakeholders including young people and their caregivers was used to inform adaptations to enhance the acceptability, relevance, and comprehension of EASE, to each specific testing site and to identify common adaptations to inform a general version of EASE, adaptable to multiple contexts.
  • Lessons learned and feedback received during training of non-specialised facilitators, their supervision and through feasibility studies have informed ongoing adaptations to further refine the intervention and associated materials 

Adaptable delivery

  • EASE is designed to be delivered in various settings which young people access, including schools, the community, and camp-settings.
  • EASE could potentially be delivered by digital methods, in settings where privacy and protection concerns are well mitigated during remote delivery.
  • Where indicated, EASE could be delivered within a stepped care pathway, for example, following universal promotion and prevention interventions delivered in schools.

Challenges

  • Literacy: Following feasibility studies, EASE materials have been revised to enhance simplicity and reduce literacy requirements where possible, including training facilitators to adapt their delivery of certain activities where literacy is low in the participant group.
  • Caregiver engagement: caregivers have competing family and work demands which can affect their attendance in sessions. To address this: the three caregiver sessions have been shortened from original 120-minute content to 90-minute content, community engagement with caregivers, and offering caregiver sessions flexibly e.g. prior to the first child session to maximise caregiver’s involvement and their child’s.
  • School and family work: Majority of children attend school and some have family work priorities. Scheduling of EASE sessions requires collaboration with local education institutions to identify available times and gaining information (e.g. through interviews) on when young people may be expected to participate in family work. It also requires collaboration with protection agencies, particularly where child labour is common.
  • Convening gender-sensitive groups: All test sites have indicated a preference to have separate gender groups for young adolescents which has been implemented with little difficultly. In contrast, the vast majority of caregivers who attend are female. This poses challenges in resources required to run separate groups for male caregivers or to have mixed caregiver groups.

Continuation

It is expected that testing EASE will contribute to the evidence-base for potentially scalable psychological interventions for young people in adverse contexts. If demonstrated to be effective, the EASE intervention manual and associated materials will be published by WHO as a publicly accessible product, adaptable for implementation in varying contexts and cultures. 

Partners

Research trials of EASE are being conducted by the following partners, in collaboration with WHO:

Funders

  • Elrha’s Research for Health in Humanitarian Crises (R2HC) (feasibility and definitive testing in Jordan)
  • European Commission (STRENGTHS Consortium) (feasibility and definitive testing in Lebanon)
  • Jacobs Foundation (conceptualization and writing of initial package)
  • Medical Research Council (MRC), Department of International Development & National Institute for Health Research, NHS, UK (feasibility and definitive testing in Pakistan)
  • Oak Foundation (feasibility testing in Tanzania)
  • War Child Holland (conceptualization and writing of initial package)

Evaluation methods

Feasibility trials for EASE have been completed in Jordan, Lebanon, Pakistan and Tanzania, and publication of the findings and lessons learned is imminent. Definitivee randomized controlled trials are underway in Jordan and Lebanon and soon to commence in Pakistan.

The testing of EASE:

  • In Jordan and Lebanon is for predominantly Syrian refugee populations, with intervention delivery taking place in the community.
  • In Pakistan, EASE is delivered to local young people studying in public schools of rural Rawalpindi.
  • In Tanzania, EASE has been delivered to a refugee population from Burundi, delivered within a camp.

Common outcomes across test sites include the primary outcomes of child psychosocial distress; and other measures of mood and functioning, including measures of caregiver distress and parenting. Unique outcomes relevant to the context vary between settings. In addition to quantitative evaluation, qualitative process evaluations are included to gain vital information to inform intervention and implementation adaptation.

Cost of implementation

Cost-effectiveness will be evaluated by the definitive trial in Pakistan. Service utilization and associated costs will be evaluated by the definitive trial in Lebanon. 

Impact details

Early findings from the feasibility studies in all sites suggests that EASE implementation, and its evaluation through randomized trials, is feasible, acceptable, safe and relevant for delivery. The intervention has thus far been well received by young people, their caregivers and local facilitators with recommendations and lessons learned informing the further adaptation of the intervention and informing the procedures of the full trials. If successful, each site will have a locally adapted evidence-based intervention available for further scale-up.

The prospective definitive impact includes:

  • Improving symptoms of internalizing disorders (depression, anxiety) of young adolescents and their functioning (such as in education);
  • the availability of EASE for public release, adaptable to various contexts and cultures;
  • a potentially scalable product which increases access to psychological services for young people and their caregivers living in adverse contexts, benefiting contexts where specialised child and adolescent mental health services are unavailable or overburdened;
  • Opportunity for workforce development through capacity building of non-specialised facilitators and local trainers and supervisors.

References

  1. Kieling C, Baker‐Henningham H, Belfer M et al. Lancet 2011;378:1515‐25
  2. Patel V, Kieling C, Maulik PK et al. Arch Dis Child 2013;98:323‐7
  3. Purgato, M., Gross, A.L., Betancourt, T., Bolton, P., Bonetto, C., Gastaldon, C., Gordon, J., O'Callaghan, P., Papola, D., Peltonen, K. and Punamaki, R.L., 2018. Focused psychosocial interventions for children in low-resource humanitarian settings: a systematic review and individual participant data meta-analysis. The Lancet Global Health, 6(4), pp.e390-e400.
  4. Dawson, K.S., Watts, S., Carswell, K., Shehadeh, M.H., Jordans, M.J., Bryant, R.A., Miller, K.E., Malik, A., Brown, F.L., Servili, C. and van Ommeren, M., 2019. Improving access to evidence‐based interventions for young adolescents: Early Adolescent Skills for Emotions (EASE). World Psychiatry, 18(1), p.105. https://doi.org/10.1002/wps.20594
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Jordan, Lebanon, Pakistan, Tanzania, United Republic of

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