A controlled evaluation of a brief parenting ... - Springer Link

Soc Psychiatry Psychiatr Epidemiol (2013) 48:1851–1859 DOI 10.1007/s00127-012-0630-6

ORIGINAL PAPER

A controlled evaluation of a brief parenting psychoeducation intervention in Burundi M. J. D. Jordans • W. A. Tol • A. Ndayisaba I. H. Komproe

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Received: 17 October 2012 / Accepted: 19 November 2012 / Published online: 9 December 2012 Springer-Verlag Berlin Heidelberg 2012

Abstract Purpose Conduct problems and emotional distress have been identified as key problems among children and adolescents in post-war Burundi. This pilot study aims to evaluate the impact of a brief parenting psychoeducation intervention on children’s mental health. Methods This study employs a controlled pre and post evaluation design. The two-session psychoeducation intervention was offered to groups of parents of children (mean age 12.3 years, 60.8 % female) who had been screened for elevated psychosocial distress. Children in the intervention group (n = 58) were compared to a waitlist control group (n = 62). Outcome indicators included child-reported levels of aggression (using the Aggression Questionnaire), depression symptoms (using the Depression Self Rating Scale) and perceived family social support. Results The intervention had a beneficial effect on reducing conduct problems compared to the control condition

(Cohen d = 0.60), especially among boys, while not showing impact on depression symptoms or family social support. Parents evaluated the intervention positively, with increased awareness of positive parenting strategies and appropriate disciplinary techniques reported as the most common learning points. Conclusion A brief parenting psychoeducation intervention conducted by lay community counselors is a promising public health strategy in dealing with widespread conduct problems in boys living in violence-affected settings and not so for social and emotional indicators and for girls. An efficacy study is warranted to confirm these preliminary findings. Keywords Parenting Psychoeducation Evaluation Children Violence War

Introduction M. J. D. Jordans (&) W. A. Tol I. H. Komproe Research and Development Department, HealthNet TPO, LizzyAnsinghstraat 163, 1072 RG Amsterdam, The Netherlands e-mail: [email protected] M. J. D. Jordans Global Center for Mental Health, London School of Hygiene and TropicalMedicine, London, UK W. A. Tol Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA A. Ndayisaba Burundi Country Office, HealthNet TPO, Bujumbura, Burundi I. H. Komproe Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands

The current pilot study evaluates the effectiveness of a brief parenting psychoeducation intervention in reducing psychosocial distress among school-going children. This intervention was part of a larger psychosocial and mental health care package for children in low- and middle-income countries (LAMIC) [1]. The absence of a family-based intervention was considered a major gap in the care package, as well as in the published literature on interventions for children in complex emergencies [2]. Considering the available research demonstrating that difficulties in parent– child relationships is a common factor in the etiology of a variety of childhood disorders [3], more evidence for interventions aimed at improving parent–child relationships in LAMIC is required. Consequently, we pilot-tested a newly developed procedure to select intervention strategies

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in LAMIC. We were interested in identifying an intervention that could deal with the sense of disempowerment that parents experience to manage children’s mental health problems, as this was identified as a key problem in the Burundian context [4]. Results of the intervention development procedure, which systematically considered stakeholders’ perspectives, effectiveness, feasibility and acceptability of potential treatments, highlighted parenting psychoeducation as a key intervention strategy [4]. The underlying assumption for using parenting psychoeducation is that changes in parenting skills is a key mechanism for change in child behavior and reduction of children behavioral and emotional problems [5, 6]. Parenting psychoeducation typically targets dysfunctional parental roles that contribute to developing or sustaining of children’s psychopathology. Preventive parent education programs are frequently used, in part due to the relative ease of integration into community-based approaches [3, 5]. Recent systematic reviews of psychosocial and mental health practices in humanitarian settings consistently demonstrate psychoeducational interventions among the most frequently used, up to almost 20 %, of all implemented programs [2, 7]. Also in policy guidelines for preventive or non-specialist mental health interventions psychoeducation is commonly advocated [8, 9]. While no uniform definition for psychoeducation exists, it generally includes the provision and review of information about the development of mental health problems and how to cope with such problems. The reasons for its popularity, especially in LAMIC settings, can be found in high levels of mental health illiteracy and stigmatization combined with the relative low cost and simplicity in making large-scale implementation feasible. Despite their popularity, few psychoeducational interventions have been evaluated in humanitarian settings. To date, results for the effect of psychoeducation on improved mental health are mixed [7]. Within low-income settings two trials have demonstrated no improvements associated with psychoeducation [10, 11]. Yeomans and colleagues report on a trial that demonstrates that the inclusion of psychoeducation about PTSD reduced the beneficial effect of the reconciliation intervention among adults in Burundi. In a review (not limited to LAMIC) on the effect of psychoeducation to prevent PTSD, Wessely and colleagues [8] also report that, despite its ubiquity, good evidence is lacking. They report studies with positive results (including psychoeducation either as a treatment condition or a control condition), albeit generally with modest effects, as well as studies demonstrating that providing information may result in increase in symptomatology. The review concludes with challenging the notion that psychoeducation is inevitably helpful, but that given the potential for cost-effectiveness and easy dissemination there are enormous benefits in identifying effective psychoeducational interventions [8].

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Furthermore, psychoeducation is often an integral component of several treatment approaches (e.g., CBT, psychological first aid), with no data on the effectiveness of that component as a standalone intervention. For example, a cluster randomized trial of a collaborative-stepped intervention for depression and anxiety in India, within which psychoeducation was the most constant component, provided evidence of modest beneficial effects [12]. There is more convincing evidence specifically for the effectiveness of brief psychoeducational parenting and family psychoeducation in high-income settings [3, 13, 14]. These interventions, though with varying levels of intensity, focus on empowering parents in child rearing principles and the management of children’s behavioral problems. However, to the best of our knowledge no studies have been evaluating brief psychoeducational parenting intervention for school-aged children in LAMIC. Promisingly, for parent-based interventions focused on early childhood development and parent–infant relationships, evidence is slowly accruing in LAMIC, for example in Bosnia-Herzegovina [15], Uganda [16], Pakistan [17] and South Africa [18]. Clearly, more evaluation of the impact of psychoeducation is needed to support or abandon the widespread use of the intervention in LAMIC settings. In addition, the focus of assessment should shift to include non-clinical problems, given that much of the current studies exclusively look into the effect of psychoeducation in reducing psychopathology. The current pilot study aims to evaluate the impact of a brief parenting psychoeducation intervention on children’s mental health. Our primary hypothesis is that the intervention leads to a reduction in aggressive behavior, and to a lesser degree in depressive symptoms. The secondary hypothesis is that we expect an increase in perceived family social support among children whose parents followed the intervention.

Methods Setting The Republic of Burundi is a relatively small land-locked country located in the Great Lakes region of Central Africa with an estimated population of 10 million people. The country has experienced cyclic outbreaks of violence along ethnic lines since its independence in 1962. In 1993, the assassination of the country’s first democratically elected president erupted in renewed ethnic violence and political instability, mainly as a result of power struggle and social differences between Burundi’s major ethnic groups Hutus and Tutsis (the latter being historically dominant economically and politically). The following 12-year long


protracted civil war demanded the lives of an estimated 300,000 Burundians, and hundreds of thousands were internally displaced [19, 20]. The signing of a peace agreement in Arusha in 2001 diminished the violence. In 2005 democratic elections were held, but some rebel groups have remained active until recently. The longstanding violence has resulted in a breakdown of social order and the destruction of the economy. Participants Study participants were school-going children living in especially difficult circumstances, included after screening for elevated psychosocial distress, whose parents were offered to participate in the parenting psychoeducation intervention. All children in the age range 10–14 years (classes 3–5) in the selected schools were targeted to participate. Screening took place to ensure the enrollment of parents with children with detected emotional or behavioral difficulties. Screening was conducted in schools using the child psychosocial distress screening (CPDS). The CPDS is a context-sensitive instrument that was developed for use in conflict-affected settings, and was validated in Burundi [21, 22]. Psychometric properties of the scale were found to be acceptable to good (AUC = 0.81), with sensitivity of 0.84 and specificity of 0.60 to detect indication for psychosocial intervention and test–retest reliability of 0.83. Two schools (i.e., intervention and control conditions) were selected in communities where an ongoing intervention program was scheduled to start its activities. Selection was done following pre-determined planning for phased program expansion to new schools in the implementation area (the order of planned expansion determined allocation of condition, with the first being the intervention school). Screening and the subsequent parenting psychoeducation intervention were conducted well before a series of other interventions in the targeted communities, to avoid contamination of the study sample by the other mental health interventions. There were no predetermined exclusion criteria. Figure 1 shows the flow of the participants during the study. Of the total screened population (N = 551), 97 children in the intervention groups scored above the locally validated cut-off point and 64 children in the control group. Among the parents of the former group that were invited to participate in the intervention, 58 followed both sessions of the intervention (completers), whereas parents of 39 children followed one session (i.e., partial completers, mainly parents that did not show up to the first session and were subsequently invited by program staff to participate in the second session). Within the control group two children were lost to follow-up, both due to illness. Primary analyses were done with the completers group (N = 58) and control group (N = 62).

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Instruments During prior qualitative research, conduct problems and depressive complaints were identified as key concerns of parents [4]. Therefore, we included these as primary outcomes. Perceived family social support was included as a secondary outcome variable, based on literature demonstrating the positive effect of parenting programs on promoting a supportive home environment for children [6]. Given the non-specialist nature of the intervention, we were interested to measure the change in levels of symptoms, rather than psychiatric disorders. Rating scales were selected based on applicability and previous use in Burundi or other low-income settings affected by violence [23–25]. The 18-item depression self rating scale (DSRS) assessed depression symptoms over the past week on a 3-point scale (range = 0–36; a = 0.74) [26]. Physical aggression and children’s ability to deal with aggression were measured with a 9-item subscale (range 0–36; a = 0.72) of the Aggression Questionnaire [27]. Family Social Support was assessed using a scale composed for the purpose of this study, consisting of 11 items adapted from the A-SCAT (range = 0–33; a = 0.82) [28]. Internal consistency of these scales was measured in the total sample (N = 120). Translation of the instruments was conducted following a systematic procedure developed for use in transcultural research that involves translation, back-translation, and focus groups [29]. While the effect of the intervention was measured primarily at the child level, we also included a brief post-intervention questionnaire for the parents. Besides demographics, this included a structured item on intervention satisfaction (responses range 0–3: not at all, a little, quite a bit, very much) and an open question about parents’ perspectives on intervention gains. Procedure Three local assessors with a bachelor’s degree in a social science received a 2-day training course to adequately administer the instruments. This training was an add-on to previously received courses on research basics, skills, and ethics. Assessors were selected for their previous experience in conducting similar studies in Burundi, and had around 6 years of experience [4, 21]. The baseline interview (T0) was administered to all children that scored above cut-off. The second interview (T1) took place approximately 3 weeks post intervention, with all children whose parents participated (partially or fully) in the intervention. Parents were asked to rate their satisfaction at the end of the second intervention session. All questionnaires were interview-administered. Prior to starting research activities, community meetings were organized in schools, including parents, teachers, community leaders, and principals, to explain research

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Fig. 1 Participant flowchart

551total children screened

262 children excluded 232 children did not meet inclusion criteria 30 children’s parents did not participate

359 children screened in treatment school

192 children screened in control school 128 children did not meet inclusion criteria

58 children of parents with full participation in intervention

64 children in waitlisted school

39 children of parents with partial participation

2 children lost to follow-up

58 children included in primary analyses

62children included in analyses

97 children included in secondary analyses

purposes and obtain consent. Individual informed written consent from parents and children was taken prior to starting the interview and confidentiality was assured by explaining participants about procedures of data storage and anonymity. Approval for the study was gained from local authorities (written authorization from the provincial Governor, and subsequently permission from the chef de colline, administrator of the smallest administrative unit in Burundi) and data collection procedures were consistent with the Declaration of Helsinki [30]. Intervention The brief psychoeducation intervention for groups of parents consisted of two sessions of on average 2.5 and 3.0 h, respectively. Each group consisted of approximately 20 parents. Parent–teacher associations served as the entry point for the program to discuss rationale and procedures of the intervention program. The group intervention combined increasing awareness and understanding on psychosocial and mental health problems of children (as commonly experienced within the target areas) with information on problem management strategies, adapted from a manual for parents in helping children cope with the stresses of political violence [31]. The first session aimed at increasing dialogue and understanding of problems affecting children (i.e., alcoholism of parents, maltreatment, gang-formation), as well as of ways of communicating with children. The second session focused on advising parents how to manage their children’s problems (i.e., setting limits, promote school attendance), specifically aiming to correct maladaptive disciplining strategies (e.g., instructions to avoid harsh corporal punishment). The intervention contained multiple foci that broadly adhere to formulated assumptions of psychoeducation [8], which include normalization

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of problems, providing relief to parents, modification of the problem through corrective information, augmenting help seeking and empowerment of participants through a focus on self-help strategies. The groups were conducted by two lay community counselors, trained for a period of 3 months to provide this and other psychosocial interventions. Analyses First, we analyzed comparability of baseline characteristics between study conditions with v2 tests for categorical data and independent sample t tests for continuous data. Second, mean-based analyses were performed to compare intervention and control conditions. Crude change scores were calculated and compared within groups with independent sample t tests. Next, between-group mean change scores were compared with paired sample t tests. As an index of relative treatment effectiveness we calculated effect sizes (d, Cohen’s d) [32]. The open question on the parents’ intervention evaluations (i.e., qualitative data) was analyzed following thematic content analysis. An initial categorization of responses was independently performed by two researchers, followed by a discussion to agree upon a common thematic framework. All responses were then coded by both researchers using this thematic framework, with any differences in final coding discussed and reattributed.

Results Participants and baseline characteristics The mean age of the participating children was 12.3 years (SD = 1.51), with a majority of girls (60.8 %). We found


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no statistically significant differences between the treatment and control group on demographic variables or outcome variables (see Table 1). The parents (N = 63) that received the intervention included mainly mothers (85.4 %). The average age of the participating parents was 41.3 years (SD = 10.4), and average family size was 6.1 (SD = 1.7). The majority of the parents (54.2 %) received no formal education or pre-school only, 14.6 % finished primary school, and 31.3 % finished secondary school or higher. Furthermore, no significant baseline differences existed between completers and partial-completers on all outcome variables; depression [t (df) = 0.494(92), p \ 0.623], family social support [t (df) = -0.379(95), p \ 0.705], aggression [t (df) = 0.290(95), p \ 0.772), and gender [v2 = 0.661; p \ 0.719). At baseline, partialcompleters were older [t (df) = 4.151(95), p \ 0.000). There were no significant baseline differences between children of the intervention group (completers and partialcompleters combined) and the children of parents who did not participate.

Outcomes of intervention and control groups Table 2 presents results of the independent and paired sample t tests. These analyses showed a statistically significant difference between intervention group and control group for mean change scores on aggression, which comprised a significant reduction of aggression in the intervention group and a significant increase in the control group (p \ 0.001). This mean difference represented a moderate effect size (d = 0.60). For depression symptoms and perceived family social support, we found no betweengroup differences. While not statistically significant, there was a tendency for worse outcomes in family social support in the intervention group. Next, we assessed whether there were treatment x gender effects for change in aggression. Comparisons of mean change scores between treatment and control conditions for Table 1 Baseline comparisons

Socio-demographics

boys-only group demonstrated a significant difference [t (df) = -3.303(45), p \ 0.002], while no such betweengroup difference was found within the girls-only group [t (df) = -1.449(71), p \ 0.152]. Analyses for baseline differences for the gender groups separately showed no significant difference between treatment and control groups for either gender (for boys: depression [t (df) = 0.388(43), p \ 0.700], family social support [t (df) = -0.748(45), p \ 0.458), aggression [t (df) = -0.531(45), p \ 0.598], and age [t (df) = 1.72(45); p \ 0.092). The majority of the parents (93.3 %) reported to be quite or very satisfied with the received intervention. This was reinforced by their reflections on what they learned from the intervention (see Table 3). Parents reported to have increased their understanding of child rearing styles and child development [‘‘I learned how to collaborate with my children, even if they commit faults’’ (FGD; mother)], specifically the importance of avoiding harsh punishment or ill-treatment of children [‘‘I have learned how to educate my children without beating them’’ (FGD; mother); ‘‘I learned of not ill-treating our children… not to give hard works that are not appropriate for their age’’ (FGD; mother)]. When comparing the completers group with the partialcompleters group, there were no significant differences for the change scores on all three outcome indicators between both groups (see Table 4). However, we did observe a trend towards better outcomes on aggression for completers (i.e., those participating both sessions of psychoeducation, p \ 0.061). The children in the partial-completers group did not show a decrease in aggression as compared to the children in the completers group, rather a lesser increase in aggression compared to the control group.

Discussion While mental health is getting increasing attention, also in humanitarian settings, there is a dire need for evaluations

Intervention group (N = 58) N (%)

Control group (N = 62) N (%)

Comparison v (df); p

Male

27 (47.5)

23 (37.0)

0.565 (1); 0.471

Female

32 (53.5)

39 (63.0)

Gender

a

For depression and aggression, a higher score denotes higher levels of symptoms, for family social support, a higher score denotes higher perceived support

Mean (SD)

Mean (SD)

t (df); p

12.12 (1.52)

12.44 (1.50)

1.140 (118); 0.256

Aggression

13.59 (4.10)

13.73 (5.52)

0.155 (118); 0.877

Depression

16.40 (5.15)

17.79 (5.69)

1.379 (115); 0.171

Family social support

12.65 (4.49)

11.56 (4.99)

-1.247 (118); 0.215

Age Outcome indicators

a

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Table 2 Within- and betweengroup mean differences Indicator

Intervention group comparisons (N = 58)

Control group comparisons (N = 62)

Between group comparisons

Mean change

% Change

t (df); p

Mean change

% Change

t (df); p

t (df); p

Effect size (Cohen’s d)

Aggression

-1.38 (4.82)

-10.15

2.181 (57); 0.033*

1.81 (5.81)

13.11

-2.440 (61); 0.017*

3.257 (118); 0.001**

0.60

Depression

1.02 (4.45)

-0.897 (60); 0.373 -1.625 (61); 0.109

-0.449 (113); 0.654 1.730 (118); 0.086

0.08

-0.56 (5.06)

0.61 (5.28) 1.02 (4.92)

3.44


-1.681 (53); 0.099 0.845 (57); 0.402

6.18 -4.42

8.82

0.32

*p \ 0.05 **p \ 0.01

Table 3 Parental intervention evaluation Intervention gains

N (%)

Increased awareness of (positive) parenting skills and child rearing

23 (30.6)

Increased understanding about the undesirability of illtreatment or severe punishment

14 (18.7)

Increased awareness about children’s developmental issues and understanding of their problems

11 (14.7)

Increased awareness and change in parent–child relationship

9 (12.0)

Increased awareness about helping and (emotionally) supporting children with problems

6 (8.0)

Nothing new learned or acquired Increased awareness about available community support

5 6.7) 4 (5.3)

Being a role model as a parent

2 (2.7)

Received emotional support as a parent

1 (1.3)

There is obvious overlap between different categories, especially the first two, but since reduction of ill-treatment was specifically mentioned in many of the responses it has been included as a separate category Table 4 Completers versus partial completers Indicator

Completers (N = 58) Mean change (SD)

Partial completers (N = 39) Mean change (SD)

Between-group comparison t (df); p

Aggression

-1.38 (4.82)

0.64 (5.63)

1.893 (95); 0.061

Depression

1.01 (4.45)

-0.63 (5.82)

-1.540 (90); 0.127


0.56 (5.06)

0.10 (4.27)

0.673 (95); 0.502

of interventions that target families [2, 33]. The present study is among the first rigorous evaluations of a parental support intervention for school-aged children in a lowincome country. The urgent need for more rigorous

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scrutiny of commonly used interventions especially in humanitarian settings has recently been advocated [7]. In summary, this study demonstrated that a brief parenting psychoeducation intervention has short-term effects in reducing conduct problems among boys, compared to a control group, with a moderate effect size. We saw no intervention benefits for depressive symptoms or perceived family social support. This means that a relatively simple intervention can result in significant gains in management of behavioral difficulties among boys, an area of problems that was identified as a crucial child and adolescent mental health issue by stakeholders in Burundi. To place this finding in perspective, the treatment effect of this parent-focused intervention in reducing aggression outweighs that of a 15-session classroom-based psychosocial intervention in Nepal [25]. This may indicate that, at least with regard to behavioral problems, and assuming that the severity of the problems and circumstances are comparable, more can be achieved with fewer resources when working directly with parents. This resonates with research that demonstrates parental functions and positive parent–child relationships to buffer against stressful events, thereby constituting a potentially key modifiable protective factor for children in situations of adversity [34, 35]. In other words, it reinforces the argument to direct interventions at parents of school-aged children, especially in settings where formal care structures are often absent and the importance of family networks ubiquitous, specifically to instruct them to recognize children’s distress and advice them to use appropriate techniques to address these [36]. While this is seemingly evident, so far preventive interventions for children in areas of political violence have primarily focused on individual or group interventions [2, 37]. It is important to note that on the basis of the current study the above holds true for conduct problems, not for depressive symptoms. A possible explanation for this is that brief psychoeducation can alter direct parental


disciplining behavior, but it is insufficient to alter other mechanisms associated with internalizing symptoms such as stimulating and modeling positive coping, reducing negative coping or maternal mental health. In support of this argument, changes in perceived family support were also not different between study conditions. It appears that the intervention particularly reduced harsh parenting techniques, in turn impacting children’s levels of aggressivity. This assumption needs to be tested in the future. But it is important to note that positive parenting practices play a protective role in child development and mental health, and particularly in the prevention of child maltreatment in low-income settings [38]. Given these results and the limited evidence for the effectiveness of psychoeducation, measured almost exclusively in terms of psychopathology (i.e., depression, PTSD), we argue that the impact of brief psychoeducational interventions is more adequately measured by concrete behavioral changes rather than changes of clinical constructs. The present study complements existing evidence for the effectiveness of parent-based interventions for infants and pre-school children in LAMIC, suggesting that non-specialist parenting interventions can reduce negative parenting practices [17, 18]. Moreover, while mostly for a younger age group, there is overwhelming evidence for parenting programs in high-income settings to treat conduct disorder [39] and also in high-risk multi-ethnic community settings [40]. However, evidence-based parenting interventions (e.g., parent management training—PMT) are more focused and treatment-intensive than the evaluated psychoeducational intervention in the present study. The latter should be positioned as an integrated component, adjunctive intervention [14] or as the first step within a stepped care approach—especially in low-resource settings. In doing so it seems of importance that the psychoeducational intervention includes a distinct parenting component (e.g., advice about the use of more appropriate disciplinary techniques). Given the lack of a significant difference between completers (followed both sessions) and partial completers (followed second session), albeit with a clear trend towards better results among the completers, we hypothesize that the intervention’s impact is chiefly achieved through the content of the second session. Further research is needed to test that assumption. The second session was mostly focused on facilitating adaptation and included more active parenting advice. The fact that the intervention (and especially the second session) delivered a clear message about reducing harsh punishment styles may be what accounts for positive outcomes. This is congruent with the argument put forward by Wessely and colleagues [8], who, in their review of evidence for psychoeducation for PTSD, posit that psychoeducation that comprises constructive information that proactively encourages resilience

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and empowerment is associated with effectiveness, rather than psychoeducation that consists of the description and understanding of symptoms. There are a few limitations that need to be noted. First, even though baseline values for socio-demographic and outcome indicators between intervention and control condition were not significantly different, the lack of randomization is an important shortcoming of this study as it might have introduced bias. Second, the absence of a follow-up measurement does not allow the evaluation of sustained effects over time. Third, we are not able to substantiate causality between observed improvements among children with post-intervention parental changes, as individual child-level responses could not be linked to individual parent-level responses. For this reason, it was not possible to adjust for possible clustering in the data. Fourth, the absence of a detailed intervention protocol may have hampered standardization between groups, even though the same pair of service providers conducted the intervention. Future research should employ a randomized controlled trial design to evaluate efficacy of parenting psychoeducation for conduct problems, including examination of long-term effects and mechanisms of change.

Conclusion This study showed that brief parenting psychoeducation, conducted by lay community counselors in rural Burundi, holds ample potential as an effective and scalable intervention dealing with externalizing problems of boys in a post-conflict setting. This conclusion should be taken cautiously given the limitation inherent to the study design. Still, these promising results have several implications. Given that the intervention is brief and relatively easy to deliver by non-specialists and to add to routine health services, it lends itself well to reach large populations with few resources. It therefore provides with an important public health strategy to contain high levels of conduct problems among boys that are so common in areas of political violence. While this is the case for targeting conduct problems among boys, the same does not go for dealing with depressive symptoms or for behavioral problems among girls. Further intervention development, potentially with more attention for teaching positive parenting techniques or in conjunction with more comprehensive parent management programs, is required to make parenting psychoeducation a more broadly usable intervention strategy. Similarly, further research is needed to test the efficacy of brief parenting psychoeducation in reducing aggression in conflict-affected settings.

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Key points •

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Psychoeducation is among the most commonly used interventions in humanitarian settings, yet rigorous evaluations are lacking. A brief parenting psychoeducation intervention is effective in reducing aggressivity among boys, while it has no beneficial effect on depression symptoms or perceived social support. Results provide with an important public health strategy to contain high levels of conduct problems among boys in areas of political violence.

11.

12.

13.

14. Acknowledgments This study was conducted with funding from War Child Holland (BU046WC). We would like to thank Dr. Marian Tankink for her contribution to this study.

15.

No competing interests need to be disclosed for

16.

Conflict of interest any of the authors.

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