We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind The Kids. I'm Dr. Jane Gilmour, honorary consultant, clinical psychologist, and child development programme director at UCL. And I'm Umar Toseeb, professor of psychology at the University of York, focusing on children and young people's mental health and special educational needs. In each episode, we select a topic from the research literature, and in conversation with invited authors, sift through the data, dilemmas, and debates to leave you with our takeaways for academics and practitioners. Today, we'll be discussing community interventions in Afghanistan. This episode is called, delivering school intervention, culture, context, and conflict. I was really excited when this came across my inbox because I like talking about research that is done in the Global South. So much of what we know about children's development comes from research that's conducted in the Global North on populations in those contexts-- so people who live in Northern Europe, North America, Australia, et cetera, et cetera. And one of the criticisms of that body of work is that it lacks external validity. So it can't be generalised. And when I mark essays on any topic really, students always say, oh, this lacks generalizability. We can't generalise it. And I always say, my feedback is always, no, you need to be more specific. Like why is generalizability a problem for this specific research question in this specific paper? And so I just want to pick up on why a lack of external validity is problematic in the field of children and young people's development. So if we all-- and I always come back to Bronfenbrenner's ecological systems framework. And so within that, there are various layers of influence on the child. And one of those layers is the macro-system. So we think about social norms, the legal system, the economic system, and how that impacts upon the child and young person but how that impacts upon how the other layers of the system interact with each other. So I suppose here I'm particularly interested in research done in the Global South in children and young people's development because of that theoretical framework, because we know that what happens at the country level also impacts upon how interventions might work for children and young people. And I think this is-- I mean, I totally agree in terms of that challenge for directing students or, in fact, anybody to literature that has appropriate generalizability outside Western Europe or North America. And what was really noticeable about this particular paper was there was an international group. There was a patchwork of field partners, and there was a local community who were delivering the programme. So on so many levels, it reached the spot in terms of that there's a WHO 2020 initiative in terms of delivering intervention using a culturally-sensitive approach for adolescents in schools and so on. But here's my question, Umar, because I recently edited a commentary paper on cultural humility for the CAMH Journal, which is the Child and Adolescent Mental Health Journal. And the premise of that commentary was that although, of course, those cultural norms are relevant, it's the individual's interpretation of their culture, which is the only way to connect in an authentic way. A principle is a little bit like the trauma-informed discussions that we've had in another episode. So how would you embed that in your theory, or have you any takes on that, do you think? Yeah. I agree. I think the individual's interpretation of the culture and how they relate to it makes a difference. But the interpretation or the perception of it would be influenced by the culture itself. I suppose it depends on the context that we're talking about. Not any society specifically, but across the world, there are societies that exist on a continuum of how connected they are to the outside world. And the more connected you are to the outside world, the more influenced you might be by the outside world. So then your perception of it might be different. Whereas if you lived in a more closed society, then that's not connected to the outside world, then your perceptions might be influenced by the people in your immediate vicinity. That's very useful to think about the lens through which you consider your environment is personal, but it's also constructed by virtue of your context and your connectedness. That's a really pertinent point. It's good. Very full marks there, Umar, for your evolution of your theoretical thinking. [LAUGHTER] That gets you a distinction, I believe. But let's go back to this paper, which is so striking because it describes a programme embedded and tested in its local community. But it was also striking in terms of its geopolitical context, because, of course, it was described during the period of intervention was the period where the Republic of Afghanistan government collapsed. And, of course, the situation in Afghanistan is particularly complex for lots of reasons. But what is perhaps an overriding issue to think about is that we know that over 80% of girls in low-income countries, if we consider Afghanistan a group within that group, 81% or so of girls in low-income countries are out of education by secondary school. So there was a lot of thought-provoking theme within this paper because it was so clearly embedded in a cultural setting that is so often neglected. I think so, and I think this is why, on a personal level, this is interesting to me because my family background is Pakistani. So my parents were born in Pakistan, and that's my cultural heritage as well. And Afghanistan is the next door country. So whilst there are some similarities culturally, but there are also differences. And it's always really interesting to think about research and psychological theory, a lot of which has been developed in the Global North, and trying to understand it within even my own context as living in the UK, because it doesn't always translate, and it doesn't always align. So then it's the need to develop these things in those specific contexts with people in those contexts. So I'm really looking forward to having that conversation around how it's not just a case of us in the Global North going over to a different part of the world and being like, you should do this because we know it works in our context. It's about, let's see how we can make this work in this context, based on your understanding and your cultural context. Absolutely. I think we should get some expert views on this, don't you-- Today we're joined by Professor Jean-Francois Trani from Washington University in St. Louis in the US. Jean-Francois is the lead author of the paper, improving child mental health and learning outcomes and reducing stigma and discrimination in a conflict setting, findings from a cluster randomised controlled trial of a classroom-based psychosocial intervention in rural primary schools in Afghanistan, published in the JCPP. Welcome, Jean-Francois. Thank you. Thank you for having me. Very happy to be here. It's great that you're joining us. And as you might have heard from our discussion earlier, one of the things that's particularly striking about this paper-- and there are many striking points-- is that the trial was delivered by an international group with a huge community and amount of network, essentially. How important was that to the success, do you think? Can you talk a bit about it? Yes, of course. This was central to the success. I don't think-- and that's probably the main originality of this paper compared to my colleagues who have been looking at improving learning outcomes or child mental well-being in conflict settings or in crisis settings, is this idea that everything is participatory. The training content, the base was developed by colleagues in Africa during COVID to help children be resilient after lockdown in different countries. But then we totally adapted it to the local cultural context with Afghans, teachers, and our team of facilitators have been working with for now seven years involved in the work, psychologist, educational experts, to really make the activities genuinely, locally understandable and talking to children, grade 3 to 6 or 9 to 12 years old. And we tested everything with the kids. The activities were delivered by the teachers with their own students within the classroom. And we learn together. We practise 30 to 40 activities. The delivery after the learning was done according to the teacher's preference, their own agenda, schedule within the classroom in the order they wanted, the quantity they wanted. Our only suggestion based on the reaction of children's across 40 schools and thousands of children involved was to make sure they have also some physical exercise, physical activity. So we throw balls and we say the person who throws the balls ask a question to the next kid who has to respond, and then throw the ball to another kid. These are classical things. But we were mindfulness. So activities around mindfulness, like yoga and breathing exercise, I mean, the context was a change of regime. People were particularly parents were stressed out. So this had repercussions for the mental health and the mental being of those kids, the anxiety. And so dealing with the stress distress, you can do games and classical physical activities that were always meaningful for life skills we were trying to build. Like if a child runs alone with a big pack of stones over chairs and tables and things we would put in the middle of the corridor of the school, for instance, or outside, depending on the local climate, the idea was some kids would come and help that child and help carrying the bag full of stones. And the discussion with the teacher after that would be, well, collective action, working as a group to solve the problem is important. And we can do it in class for mathematics, for reading, for all kinds of activities. So everything was really built around this complementary approach to physical activities and life skills and more classical academic learning processes. And I noticed when you were talking in your video abstract that you translated some of the activities into something that was more relatable to the young people. So you're not on a desert island. That doesn't mean anything to young person in Afghanistan. You talked about being isolated in the desert, I think. So I think that was a very elegant way of showing your mindfulness to your young people. Yeah. We try to adapt all examples from the direct environment of the school. So imagine 40 schools. The team was reflecting on what was working in one context. I mean Ghazni is very different from Badakhshan. So we had to really take into consideration the local context. And the good thing, the facilitation team being from, if not the close villages, at least the district, they knew exactly what was conveying the messages to the kids or to the parents because some of the activities with their parents at home talked in school but then applied at home. You mentioned something about collective action earlier where you get a child to help, somebody ask a child to help another child in a group activity. How much of that is trying to convince someone to do something when they're probably already doing it. And I say that because in lots of cultures, in different parts of the world, the collective good and being part of a community and the community well-being is often quite central to identity and societies and communities. Were you trying to convince people to do stuff that they were already doing? As in, was that an easy sell anyway? Well, you would think so. But then at the end of the day, each child is learning on in his own, in his small notebook. The traditional way of teaching and learning in Afghanistan is the teacher writing on the blackboard Either mathematics or Pashto or Dari or Islamic, some religious studies. But then the kid is alone listening and not repeating and taking notes or actually copying in their notebook, there is no collective activity. That was introduced really by us in the previous experiment we did. And that was continued with those activities. So not really. There is solidarity I totally agree at home, within the village, even within the community, but the way education happens is really the child with their notebook repeating what's written on the blackboard. So we did collective activities like reading cycles, where everyone has a role and needs to collaborate so that the story comes out well, these kind of things. Thank you. And you mentioned context a bit earlier. So I'm just going to pick up on that just so the people watching and listening have a better idea of the context within which this trial took place. So at the time in which you delivered the intervention, what was the situation in Afghanistan, and did it stay the same or did it change during the trial period? So it was just at the transition between the two political regime-- the fall of the Republic, the creating of the Emirate. So we really implemented the intervention during that time of transition. So as I said, there was a lot of concern about people about what will come next. And you talked about some themes in the paper because these interventions were happening during at that time of conflict. And you note that Afghanistan had been in a state of conflict, if you like, since 1979, at least for that phase. I know that the country has had a series of pretty volatile experiences in terms of conflict. So you talked about the idea of accumulated trauma. Could you differentiate between accumulated trauma and intergenerational trauma. Given that there has been conflict in Afghanistan since 1979, would we expect to see both accumulated trauma and intergenerational trauma, and how would we define these concepts, and how are they related? That's an excellent and not easy question, especially considering that there is not so much so many studies, at least in Afghanistan, that disentangle those two aspects. I would almost say there is this ongoing trauma or linked to events that happen at a point in time in Afghanistan. And this can be linked to an event, a violent event in the village, the exposure to violence of someone else or being the victim of violence. And this triggers a sense of distress in the kids. And they are exposed directly to an event. And then there is this accumulation of life stressors. To quote some of my colleagues, I'm thinking about Professor Panter-Brick, who worked on child mental health in Afghanistan that have been accumulating for years and decades. And then there's probably trauma transmitted by the previous generation. But this has not really, to my knowledge, to the best of my knowledge, this has not really been studied by psychologists, specifically in Afghanistan. I'm not even sure in what ongoing conflict context it has been done to date. Shall we talk about the intervention itself? So my experience of-- my limited experience of doing school-based or educational interventions is that you have the interventions. That's the activity that's happening. And then you have the outcomes. So the thing that you're measuring at the end to see whether that's changed or not. And then in the middle, you might have some measurement of the mechanisms of change. So how did you get to that point? So I wonder if you can just tell us a bit about what the intervention consisted of and then what your outcome measures were and what you were trying to have an impact upon? So the process was in different phase. So I mentioned already the preparation adapting activities, selecting first because there were more than we eventually kept-- so selecting those activities both for teachers and children in the classroom and then group of parents without children but still in the schools for questions of cultural context, again, bringing people together in one place to deliver those activities that will be then done by the family at home on different aspect positive discipline, self-care, family exchange, and discussions and so on and so forth. Share of chores, that's something we were really keen to promote that girls were less in charge of so many chores, so many more chores than their brothers at home. So that was the first phase. The second phase was really to do the training with the teachers, with the children in the classroom or in the corridor. There was not enough space, and some activities were outside, or going through them one by one in the order of the manual, which is available as a document online on the website of the journal, and then having some kind of debriefing with the teacher and the children for each activity like what worked well, what did not work so well. How do you convey the main message like the learning points from this activity? Checking with the kids they understood what the teachers was trying to convey, having the feedback of the kids on how much of what the teacher tried to convey was actually linked to the activity. And so that could last for several days going through all the activities up to a week. We try to keep it to within a week because of the number of schools. And then the third phase was really the teachers implementing the activities, writing in kind of big books what activities they have done, which day, for how long, what was the outcome, what was the feedback from the kids? And the facilitation team, all Afghans from local context, from the same local context, will come back and discuss with the teachers how they felt about it and how effective it was and also assisting to some of the activities and talking with the kids. And finally, we did community-based system dynamics, which is basically looking at the system of factors influencing child happiness and well-being. We didn't talk so much about mental health or resilience or distress, anxiety, because kids are-- I mean, parents will understand that, probably teachers as well, but kids 6 to 9 or 6 to even 12, if they repeated class, it's a difficult concept. Happiness, well-being, that was easy to convey in local languages. And then we will sit for almost a day with parents, teachers, and children separately. And they will build this causal loop diagram with feedback loops using pen and colour pen and just paper on the wall. And in some cases, the kids will take the pen from the facilitators and draw the connections on their own, discussing when there was disagreement. Oh, I'm not sure it goes in that direction. That poverty creates more work for us. Some boys might discuss that, while girls would say, oh yes, that's definitely the case. And once you have a system, we will say, OK, how can we intervene in that system? What can we do at school, at home that will improve child happiness and mental well-being and child well-being mostly? And, kids, teachers, parents will come with some ideas. And at some point, we will say, and what about what we are doing in class, what we are doing at home? Is there anything in all those activities that you think might improve some aspect of the system that will eventually have an impact on the child happiness? And so we actually had a lot of response. They were all added to the causal loop diagram. And then we use ecological analysis to see to what extent what we were doing was actually improving or was considered by the kids, the teachers, and the parents that it would improve the happiness of children. And you touched on some gender differences there. Girls said this, and we thought about boys in this context and so on. How did gender impact on the trial? It's a very good point. So some girls, some schools are only girls, and some schools are only boys. But they were, at the time, still some schools where we had boys and girls. Especially this is pre-adolescence. So the new government is not so concerned by contact between boys and girls before adolescence, at least at the time. So we had those discussions where girls will really engage with community-based in the workshop. They will be really active even in the activities we will do. And when we will ask, and so what do you think? Why are we doing this activity? They will be the first one to raise their hand and propose some ideas. You're doing it because-- it was a lot around collaboration and affirming yourself and showing you know something and being keen to share what you learned and about discussing, in case of disagreement. We had a great activity where we were giving roles to the kids, and they were playing with a ball. And some of them were actively asked secretly by the facilitation team to disrupt the game. And so to see how the other ones who were supposed to have a certain emotional character, if you want, or playing another part will interact, there was the negotiator, the kind of diplomat-- the child who will be the diplomat. And then there was the one who was shy and would like to stay away and was often the victim of the one who was bullying. And then we will interpret. So how do we solve a conflict in the classroom or at home or in the village between friends? And there was the whole discussion about that. What was really interesting-- and I'm not going to make generalities-- but one thing that was interesting is that despite whatever we want to say about the cultural context, the fact is when you give a chance to girls, to intervene and to talk and to share emotions and to share ideas, they will do it without any difficulty. So I found it where boys-- and maybe it's a question of maturity at this age-- primary school we're more shy and more discreet. So we will have to push them a little bit more to engage. But because it was enjoyment and game and these activities, it was very safe. It was a safe environment, and kids were really happy to engage. It was so different from rote repetition where you sit for hours. And even for the teacher, because kids were so engaged and participating, it was really gratifying for them as well. And I think that comment about creating a context that the young people wanted to engage with and they could fly, I think is a testament to the connectedness that the young people felt. And they felt safe. It was wonderful. Lots of people watching or listening to this might also be interested in delivering interventions in the Global South, in settings where we might consider them low-resource settings. And you've adopted this approach called task-shifting within this trial. Can you tell us about why task-shifting is necessary within this context and what it involves. What is task-shifting? Well, the first obvious reason for it is that we were trying to improve child resilience, child mental health, reduce distress. And therefore, if you want to involve professionals, you face a simple difficulties, which is we have only-- we used to have before the change of government, about 100 psychologists, psychiatrists, and other mental health professionals in the country. Many of them left. So just calculate the countries the size of twice the UK, the population is 33 million. What do you do with 50 mental health professionals? You have to find a way to train people with high school or bachelor's degree level of education to be able to deliver some psychosocial emotional interventions that are simple enough, but that you psychologists have been testing locally or in similar contexts that might work to really improve resilience, self-esteem, reduce anxiety and depression and distress. I'm not a psychiatrist. I know psychiatrists will say immediately, severe depression, severe anxiety. You need more than that. You probably need some medication. And that's not what we are talking about. We are talking about any kids in thousands of kids in mainstream schools of the country. So we are talking about let's qualify them as common disorders, common mental disorders, which is mild to moderate anxiety, depression but that prevent kids from learning, that make them sad enough that they don't enjoy going to school. They don't enjoy life in general. That's what the context was for many of them. So how do fight that really? I mean, that context that you-- sorry, Umar. I was going to say, but that context you're talking about and the shift that we know that one of the most stressful things that can happen to a human being is a change and adapting to a change is problematic. So for these young people, there was a huge flux in so much around them for them, for the families, and so on. So in some ways, my question is-- I don't know if this is a naive question-- but is it not extraordinary that there were any improvements on any of the indices, given that it was probably a very challenging time for those young people participating in the trial, for those community members delivering the trial? I mean, is that a naive question? No. It's not. And in the paper, we show that unfortunately for girls, we did not reduce significantly anxiety and depression, which we did for boys. And everybody knows the situation for girls and women in the country. And that explains largely, I think, why we could improve learning academic achievement and outcomes-- reading, writing, simple mathematics, even problem-solving in arithmetics. But we're not able to really and particularly when we were closer to the end of the trial, 2023, we were not able to really reduce the level of anxiety and depression. It worked with boys. There's no reason why the same activities would not work with girls. It's just the level of distress was more important. And that's why also I think having a training that was not only for school but also at home with parents, where we will create spaces for those little girls to breathe and to do their homework and to play and not only taking care of all the chores that they have to take care of with little children, with older adults, with animals, with water, with making food and the fire and everything around those activities was absolutely essential. I'm sure if we were able to implement more fully and in an ongoing way, which might be the case by our teachers, maybe they continue with-- as we know, right now international NGOs are not allowed to go directly intervening in schools, but we believe some of the teachers continue. And we should measure again today maybe this improvement eventually happened. Thank you. So I suppose I'm just conscious of the time. So I just wanted to ask you a wrap up question, which is where next with this line of work? That's also a very important and excellent question. So two things. Locally in the country, I'm an optimist, as you can imagine. I've been working 20 years in Afghanistan. So you have to be a bit of an optimist or in conflict settings elsewhere as well. So one thing is I think we should try to do implementation science. We should try to continue working with the Ministry of Education to really say, well, this pedagogy, this new approach is of benefit for the children of this country. So because you have at heart the interest of the population of your own country, it's going to take time, but we should try to continue implementing these methods and train teachers, future teachers, to use them because it's beneficial for the kids. And that's what we are interested in. So that's in Afghanistan. In Afghanistan, we also are looking at mental health of youth but also how programmes that might improve life skills and employment might have an impact on the mental well-being, positive mental well-being of youth. That's a current project we just started. In other countries, I really hope to disseminate not the content, but the process, the approach, the methods. Engaging with kids, making sure they are involved in the teaching and learning process is what works. And we need to really make this try that in other contexts. And it can be conflict. It can be low income. It can be the US as well. I tested my approach with my own kid in his classroom when we started years ago in the US in St. Louis, which is a very specific context. The city is very diverse in terms of ethnicity, in terms of race. And it was a mixed race schools, and we tested as well. And there was some positive reaction as well to the approach. So other countries hopefully colleagues will do it. I'm already asked eventually to work in Palestine using the method. So let's see. And by the way, the next paper will be about the same tools and methods used in Pakistan in primary rural schools of Punjab and Sindh. Well, all that's left to say there is thank you so much for that really insightful conversation and especially in a context that we rarely get to speak about. So it's been really nice. Thank you so much for having me. I mean, I really enjoy sharing that work. And again, one last thing. It's a teamwork. This is we are talking across both Afghanistan and Pakistan we are talking about 60 people involved on a daily basis. So it probably 80 even. So I really insist on the collective action and collective intervention. It was fantastic. Thank you so much. Thank you. Really nice meeting you. And talk to you again, I hope. Hopefully, yes. So Umar, how did you react to that fascinating conversation? So it was interesting. It's always difficult to talk about a subject or a context where you're like, oh, I don't know what we can say and what we can't say. But I think that we got all of the OI definitely. I felt like everything that I wanted to ask, I was able to ask. And I got the information that I wanted. I really liked the point towards the end of the guest made, which was around finding common ground. So I think it's not about whether I agree with your politics or those kinds of things. It's we have a common interest here. Like you're interest is in the well-being of the population potentially, and my interest is in as an organisation or a research project are interested in is in the child's well-being and the individual levels. We have that common ground that we share. So let's work on that. And I think that's a nice approach to take when you're in any context, really, where you're working with people who you may or may not agree with. And I'm not saying this is about a specific country. It could be me and you working on a project together. You always have you come to it with different views and different points of view and different experiences, but you have a shared objective, and you want to achieve a similar thing. So then you work on that based on that shared understanding. And I think that sensitivity to the cultural context, that was so clear from the community network that this project had developed is the reason that it is rolling forward, or at least was until the recent past and in a context that otherwise it may not have done. So it may be not the full provision that was planned, but some solution is better than no solution. So I think that's a testament to the team there. I also it made me think a little bit about the differences between universal provision and targeted provision, because, of course, we touched on that 2020 WHO paper that called for universal intervention, which is obviously what this particular project offered. And yet in a lot of the recent episodes, we've been talking about the importance of figuring out specific and individual responses and different subgroups. But here, I wonder, given the cultural context, perhaps the fact that the delivery is universal is actually one of the most important things because one of the questions was about stigmatisation and so on. And if one was in a targeted group, one's experience might be different, but if that universal provision allows all the children to benefit, then there will be a positive outcome for all to greater or lesser degrees. I guess my other question is, really what I touched on earlier in our discussion is what would have happened if the programme had run in a period of relative stability? So maybe we're talking about a low income context but one that was stable. So there are two challenges there. And I think the question about whether that programme stopped further decline is maybe it can only be a hypothesis, but I think it's a key issue. Big questions, big topics. What's your takeaway? I was thinking about the guest said about the task-shifting approach. So there's a different conversation to have with somebody else about this. And it makes sense in a low-resource setting or a low middle-income country. But I also think it might make sense in our context in Northern Europe or North America or wherever else it might be, because task-shifting involves you as a researcher or the academic or clinical expert training up another person who then delivers the intervention. I think that's my understanding of it. But then in doing that, you're providing multiple points of contact within the community, and that community might change in the way they think about certain things, because you've got multiple key people dotted around that system. And it makes sense to do that, for example, in the UK too. Maybe the answer is that not just to rely on CAMHS, say, in the primary, secondary, or tertiary care, but think about how we can have this task-shifting approach in multiple spaces in which the child is involved in-- so school, neighbourhoods, or wherever. So then it's not just, oh, if you need support, you go to CAMHS, or you go to a professional, but there are these people that exist in various circles that you also interact in or interact with that could help you and support you. And I think part of the appeal of that is then what happens is professional support, whether that's the GP, low intensity, psychotherapy or CAMHS or whatever it might be, it's for problems that have got to a point where they need professional input, but if you can provide that low-level support through this task-shifting approach at the community level, then those problems might not escalate. So they might not need to get to that point where they need professional input. So I suppose my takeaway is actually flipped. It's for clinical people rather than-- That's OK, though. Interestingly, I think my takeaway is not exactly clinically-pertinent. I think it's a general takeaway, because I think it's the approach that I think we discussed that is interesting. And an approach that was taken in this context is a real testament to the partnership between the research team and the strength of the local networks that they built. And these community members were delivering a programme that could only inspire practitioners or researchers, whatever the nature of work with young people. That's it from us for this series. So we've had a third series of Mind The Kids. And we've had a fantastic time talking to lots of people during this particular series but also the previous ones. And don't forget, if you go to ACAMH Learn, you can get a CPD CME certificate for listening to these podcasts. [BRIGHT MUSIC]