Children & Conflict: Leveraging Research to Inform Policy

Guest, Theresa Betancourt, ScD, MA, Harvard University

9 December 2016

Frank Boudon: Dr. Theresa Betancourt is an associate professor of child health and human rights at the Harvard T. H. Chan School of Public Health, and Director of the Research Program on Children and Global Adversity. Her central research interests include the developmental and psychosocial consequences of concentrated adversity on children, youth, and families, and applied cross-cultural mental health research. She is principle investigator of a longitudinal study of war-affected youth in Sierra Leone, which led to the development of group interventions now being scaled up in collaboration with the government of Sierra Leone and the World Bank. She has also developed and evaluated the impact of a family strengthening intervention for HIV affected children and families, and is now investigating the impact of a home-visiting initiative in Rwanda. Domestically she is engaged in research on family-based prevention of emotional and behavioral problems in refugee children resettled in the US.

So Dr. Betancourt, how did you get started out on your work on children and youth in conflict and vulnerable settings, and why did you choose to focus on this demographic instead of any other population?

Theresa Betancourt: Well thanks for welcoming me. Originally I’m from Alaska. I’m from part of Alaska called the Bush – Bethel, Alaska – which is a remote community mainly Yupik native Alaskan, and my parents worked in public health and education. My mother was involved with the infant learning program, which is a home visiting program for children at risk. Growing up in a setting like that I saw a number of different adversities facing very poor kids: Fetal alcohol syndrome was common, violence in families was common, extreme poverty and cultural loss. But also, living in a place like Alaska I saw tremendous strength and what it meant to draw from one’s culture to improve a sense of identity and resourcefulness. I became very interested in how we could support families to function better despite adversity. So I was always interested in children and families from a very young age from seeing my mother’s work, and my father was a math and science teacher.

Then I set up opportunities for myself to get more exposed to working with young people. I originally studied psychology, and went on to work in a crime victim assistance program. Eventually I got a masters degree and worked in school-based mental health in Oregon, and worked with a lot of refugee and immigrant families. I felt like in mental health we were band-aiding a lot problems again and again that related to violence and trauma. I wanted to think about prevention and go upstream. So I took leave in the summers, because I was involved in school-based health, and worked in 1995 in Latin America volunteering with a human rights organization that was covering the Beijing Conference on Women, and that exposed me to this world of United Nations agencies and non-governmental agencies working on a range of issues of children in adversity. I parlayed that into an opportunity to work for the UN High Commissioner for Human Rights. That happened to be the year of the 1996 Grassard Machel study of the impact of armed conflict on children.

So I was right in the middle of all these key stakeholders doing research on that topic, the United Nations and the non-governmental agencies. Instead of pursuing clinical psychology like I had planned, I decided instead to take more of a prevention route and met people at the Harvard Chan School of Public Health and decided to do my doctoral work there, and I’ve sort of continued on ever since. There were early opportunities to collaborate with the International Rescue Committee on children affected by armed conflict in the Kosovar crisis, the Chechnya crisis. These were people who were interested in the intersection of child mental health and human rights, and how to respond better and think in a more evidence-based way. So I started to do some collaborative research with the International Rescue Committee. Beyond those initial contacts, we also worked on the Ethiopian-Eritrea border area and the displacement of Kunama refugees. Eventually I was asked to work with them also in Sierra Leone as they were reintegrating child soldiers. So that was the beginning of my longitudinal study.

Boudon: Wow so based on all those experiences, what do you think should be program and policy goals globally with regards to children in war?

Betancout: Well I think a lot of our programming and policy when it comes to children in war doesn’t attend enough to the family context. By nature of focusing on children in armed conflict, sometimes programs too frequently focus on children in isolation of their social ecology – sort of the family systems and community systems around them – and I think research needs to unpack those leverageable factors that lead to more resilient outcomes and also leverageable risk factors across social ecology. Our interventions need to tap into the strengths that are inherent more in families and communities to also think about how to improve child outcomes, especially related to mental health. Working in the situation of children affected by war and child soldiers, I’ve yet to see really good randomized designs that look at what you get when you take a standard package that’s often given to reintegrated child soldiers such as education supplements and economic supplements, compared o when you match those things with family-based preventative work and reintegration supports. So preparing the young person himself to go home, preparing the caregivers and the family who have also been through trauma for the reintegration of the person, and then continuing to work with that family over time. We just aren’t doing good programs like that. We’re not seeing those funded. So I think there’s a lot more work left to do.

Boudon: So besides policy goals, what do you think should be on the research agenda in terms of youth and children in conflict and post-conflict settings?

Betancourt: So we certainly need more intervention research. As I just mentioned there are a lot of intervention studies that still haven’t been done, but we also need observational research that can inform this and this is research on leverageable, modifiable factors in the lives of children. In the post-conflict environment this matters a lot, we’ve seen that from our Sierra Leone research. It’s not just about the war exposures. There are too many studies that are done that look at accumulation of risk factors of violence exposures and war exposures and then how much psychopathology children have in a cross-sectional sense. What we really need to understand is development over time and how that plays out and what’s leverageable that we can tap into in interventions, including family functioning. We’re starting to see a few interventions emerging that have an evidence base; we’ve just recently published a review. But I think we need to understand what are the core active ingredients of these interventions that can be matched to different assessments and new settings given the presenting issues.

I think another big area is implementation science. We just don’t know enough about what works for whom under what conditions. We need to learn a lot more about quality improvement, sustainability, what are the training and supervision structures needed to sustain high-quality interventions for war-affected children, youth and families, and also issues of how to think about cost. So what do investments in these sorts of programs give governments or development actors? How can we compare these to other health conditions and other investments? A lot of times these are other knock-on effects, such as social functioning or family functioning, that don’t get costed by standard metrics that are focus on physical impairment and health. So we really need to broaden the tent of what we’re studying to look at context, sustainability issues, quality issues, and also look at cost in a way that captures broadly what we do, and we do mental health and social interventions with war affected children and families.

Boudon: With your Sierra Leone study in particular we can probably assume that a lot of the participants are adults themselves, now and parents. So how does that inform your opinion of the appropriate types of parenting interventions or policies?

Betancourt: So we do find that in our longitudinal study we’ve been following 529 young people who were 10-17 at the end of the war as they grow up. We do see that about half of them are parents now, and these are assessments that started in 2002, 2004, 2008, and now we are in our fourth wave in 2016. What’s exciting about this study is that we are re-enrolling the index participants, about a third of them are female, and we’re also enrolling their intimate partners and their children as well as the historic caregiver in the study. So it’s truly an intergenerational study of war. It has made us think a lot about the mechanisms that we can focus on in terms of family-based programs and also community supports. We know that stigma is a tremendously important issue in terms of how young people fair over time, if they’ve been involved with an armed group – so how to think about those community relationships. Also there is tremendous importance of relationships that we need to look at related to attachment, and what past trauma and present mental health mean for a parent’s ability to have healthy attachments and healthy interactions with their children. There are also issues of partner violence and family violence that we are exploring in that research. But we’re still very early on. We’re still completing the fourth wave. So we’re looking at these mechanisms, and hope, over time, to be able to come back and say more about what we’ve learned.

Boudon: Great, thanks. How have you used your research to advocate for greater investment in children and youth, and what have been the main challenges and enablers in transforming child and youth policies?

Betancourt: So I’ve been very interested in this virtuous cycle that Julius Richmond wrote about in talking about the scale up of the Head Start Program. He was the former US Surgeon General and really the mastermind behind taking that program to scale. He talked about how we need the evidence base to sort of galvanize political will and through social strategies enact and enhance policies and programs. So I see our role as researchers as contributing to that evidence base, but we have to be able to translate it to policy actors, to be able to make it digestible. We’ve found that sometimes having young people who’ve received interventions that we’ve been working on in collaboration with local stakeholders are some of the most powerful ways to raise awareness. Recently in Sierra Leone we’ve been studying this cognitive behavioral therapy based intervention, the Youth Readiness Intervention, which is being scaled up with the new programs, funded by the World Bank and the government. But we’ve had those young people who have been through the intervention come and give testimonials at the state house to ministers, and it’s been extremely powerful.

Also being able to offer information not just on impact, but on cost. So how much will these interventions cost you, how can you link them to other ongoing structures and systems – because it’s really not about one-off or randomized control trials that just get published. It’s about thinking about how we can link these interventions to systems of care and strengthening social services and mental health services in very fragile states and low resource settings – advocating for those investments. Being able to talk about impact and cost and how you can link to alternate deliver structures is really important. For instance, in Sierra Leone we’re linking evidence-based mental health to youth employment programs. In Rwanda we’re linking family home visiting interventions to promote ECD (early childhood development) and prevent violence, we’re linking those to the national poverty reduction strategies. So they are already planning for home visitation related to financial planning and health checkups.

We can link more enriched programs that work with vulnerable families, especially for the most extreme poverty-stricken families. So we have to think creatively about getting out there and reaching the most vulnerable families. Sometimes that means working across different structures or even different ministries. You know, looking at the education platforms, looking at youth employment platforms, and also working with the health system.

Boudon: So broadly speaking, how do you think early childhood development contributes to or is linked to violence prevention, peace promotion, and social transformation?

Betancourt: I think working on the home environment is critical to promoting peace from a very young age. What children see modeled in the home is likely to travel across generations, we know from a lot of research. So being able to equip families who experienced extreme adversity, especially violence and armed conflict, with the skills to self-regulate, to engage in good decision-making and priority-setting, to link to services, to engage with their children in a way that is promoting healthy interactions and self regulation that children can go on to have better school readiness and life success, these are really critical interventions to think from a prevention perspective. And we owe it to young people who have been through such experiences of violence and war to help them be the most productive parents possible and to hopefully look towards the future for their children characterized by peace and opportunity.

Boudon: Great. Well Dr. Betancourt, thank you for coming in and speaking today. We thank you so much for the work that you are doing for children around the world.