The present study examined the impact of a novel intervention for children at risk for substance use or actively using substances that was provided to 783 children between 4 and 18 years of age in Afghanistan. They received the Child Intervention for Living Drug-free (CHILD) protocol while in outpatient or residential treatment. CHILD included age-appropriate literacy and numeracy, drug education, basic living safety, and communication and trauma coping skills. A battery of measures examined multiple child health domains at treatment’s start and end and 12 weeks later. For younger children, there were no significant Gender or Gender X Time effects (all
With an estimated population of more than 30 million inhabitants, Afghanistan is composed of more than ten ethnic and tribal groups, most of whom have lived together in the country for centuries. These include the majority Pashtuns, who constitute almost one-half of the population, followed by a quarter of the population of Tajiks (27%) and sizeable communities of Uzbecs (9%) and Hazara (9%). Turkmen (3%), Aimaq (4%), Baluch (2%), and small communities of Brahui, Nuristani, Pashaie, Pamiri, Khirgiz, and Qizilbash are also represented. Each of these groups has developed its own forms of languages, culture, and religious beliefs over the course of Afghanistan’s history. However, the centuries-long interaction between all these groups, though distinguishable by accent and clothing (as examples), has resulted in a cultural blending of various Afghan ethnic and tribal traditions. The country is almost exclusively Muslim with a majority Sunni population (80%) and an estimated 19% Shi’i population. Afghan, Persian, or Dari is the official language, spoken by about one-half of the population, with Pashtu, also an official language, spoken by some 35% of the population. Turkic languages are also spoken by some groups (11%), as well as another thirty minor languages that have been identified (e.g., Baluchi and Pashai). Many individuals speak more than one language.
Afghanistan experienced a long period of relative peace until 1978. Up until that point, it was a relatively thriving and vibrant nation that provided women and children with many appropriate health and social services and freedoms. A short period of unrest and then establishment of a Soviet-allied regime followed, leading to invasion by Soviet troops in 1979. This invasion led to 10 years of armed resistance against Soviet troops, resulting in a mass exodus of approximately 25% of the total Afghan population, a majority of whom were women and children [
The result of this continuing warfare and violence in Afghanistan has been multifold. Afghanistan is now one of the poorest, most ravaged countries in the world. Figures for 2012 indicate that its population has an average life expectancy of 60.5 years, and its infant mortality rate is one of the highest in the world. The percentage of children moderately or severely underweight is 33%. Among adults living in Afghanistan, the most common stressful events experienced include lack of shelter (70%) and lack of food and water (56%). Anxiety, depressive symptoms, and posttraumatic stress disorder (PTSD) were identified in 72%, 68%, and 42% of respondents, respectively. Women were found to have worse mental health status relative to men [
With more than 30 years of war and conflict, the educational system of Afghanistan is extremely strained. Figures from 2011 [
A survey in 2010 [
Gupta [
The literature regarding the state of affairs in Afghanistan illustrates several important themes that serve as the basis for an intervention targeting children. These themes include opium use, lack of formal education, lack of basic health education, high rates exposure to stressful living situations, violence and trauma, and related comorbid mental health problems. The Child Intervention for Living Drug-free (CHILD) Protocol [formerly known as the Child Addiction Treatment (CAT) protocol] (described in detail, below) is a novel, culturally sensitive psychosocial intervention designed to address the multidimensional nature of problems faced by these children in a residential setting that also provided supportive services for the children. CHILD was not a research protocol; rather, it was an empirically based intervention developed to meet the needs of substance-using children in Afghanistan. However, it collected outreach, pretreatment, posttreatment, and follow-up data to inform the treatment staff of progress of each child during and after treatment.
The purpose of the present study is twofold: (1) describing the implementation of the CHILD intervention protocol and (2) reporting preliminary outcome data in regard to its impact.
The study protocol, including informed consent procedures, was reviewed and approved by the Johns Hopkins University Institutional Review Board as well as the Ministry of Public Health of Afghanistan’s Institutional Review Board.
All participants and/or their legal guardian(s) provided written informed consent to take part in the study. The aims of the study were explained and participants were informed that they could withdraw at any time without any further obligation to provide data, and they would continue in residential treatment but would not be provided with the CHILD treatment components. Consent was read to the parent(s)/guardian and if they could not write, they applied a thumb print to stamp the consent. In addition, during outreach the outreach team used assent (oral consent) because in outreach it was very difficult to obtain written consent based on the general Afghans culture beliefs and practices to such a request as well as the low literacy rate.
Participants were 699 children (373 girls, 326 boys), 4–7 years of age, and 84 older children (1 girl, 83 boys) 8–18 years of age. No additional demographic information was collected from the children.
The data on the children reported in this paper is for the first 783 children who came in contact with the CHILD program and were among the first of several thousand children who were screened by the program and entered treatment. Moreover, of these participants, 144 younger children were screened and went directly to residential treatment, with no outpatient period, and 8 directly entered residential treatment without screening, while 30 older children entered outpatient treatment without screening. These variations to the screening protocol were largely based on treatment need.
The Child Intervention for Living Drug-free (CHILD) protocol was implemented in the Kabul, Herat, Balkh, Nangarhar, and Badakhshan provinces of Afghanistan. The project has three interconnected components: outreach services, outpatient services, and residential substance use treatment. There were 12 outreach teams, 10 outpatient centers, and 10 substance use treatment centers, with a total of 325 beds (120 beds for children, 70 beds for women, 110 beds for male adolescents, and 25 beds for female adolescents). Treatment duration for residential treatment was 45 days for children and 180 days for older children.
Outreach activities involved trained staff circulating in the capital city of each province as well as nearby secure districts to identify children who were at risk of substance use or actively using substances. Outreach staff did not leave the secure areas for safety reasons. Outreach staff approached children under one of three different scenarios. In the first scenario, they approached a family with a child who had been identified as using illicit substances by a community leader; in the second, they approached children directly on the street; in the third, they approached children in orphanages. Each outreach team used a screener form (see Measures). A respondent who scored positive (one or more true responses) in any of the above five screening areas was referred to an outpatient center for assessment.
Trained staff in the outpatient centers assessed the children with a battery of assessment instruments (see Measures). A child positive for substance use was referred to a residential center for treatment, while a child negative for substance use but deemed at risk for such use would visit an outpatient center every day for eight weeks to receive a comprehensive psychosocial intervention that included education, life skills, and individual counseling. Outpatient centers also provided treatment for minor ailments as well as lunch and snacks. A child with severe medical or psychological problem was referred for appropriate services in the community.
Children who were deemed to be at risk for psychoactive substance use or were actively using such substances were referred to residential centers, where they were assessed prior to treatment with the same measures as used in outpatient center assessments to develop a treatment plan. If a child had a family member who was using psychoactive substance(s), then staff considered the child as at risk, while if the child himself or parent(s) were reporting that the child was actively using psychoactive substances then s/he was considered using a psychoactive substance. The length of time between outpatient and residential intake assessment was variable and dependent on when the child appeared at the residential treatment center but typically was between 2 and 7 days. Upon completion of treatment, the patients were again assessed to evaluate the treatment progress.
After discharge from the residential treatment center the child or adolescent was followed in the community on a weekly basis by an outreach team. At the end of 12 weeks in the community, outreach staff conducted a reassessment to determine the need for further services or to determine that the weekly visits could be terminated.
Outreach staff were experienced social workers and psychologists trained both in how to carryout outreach activities and in the CHILD protocol.
Outpatient staff were psychologists, social workers, and a medical doctor, all of whom were trained in how to conducted assessment activities and in the CHILD protocol.
Interventionist staff were members of a multidisciplinary team consisting of experienced psychologists, social workers, nurses, and medical doctors, all of whom were trained on the CHILD protocol.
CHILD is a comprehensive psychosocial intervention built on multiple prevention and treatment platforms and so employs motivational interviewing techniques, contingency management, skill-building education, traditional education, trauma-informed care, and art therapy techniques. It was developed for use with children either at risk for or actively using psychoactive substances.
The CHILD psychosocial program was provided 5 times a week to participants whom screening indicated were at risk for or actively using psychoactive substances while they were inpatient (45 days for children and 180 days for adolescents). Each group session lasted approximately 1 hour. An example schedule of inpatient components of treatment for the younger children can be found in Table
Example schedule of intervention components that younger children receive while in residential inpatient treatment for 45 days.
Week | Sunday | Monday | Tuesday | Wednesday | Thursday |
---|---|---|---|---|---|
1 | (i) Appropriate basic education | (i) Nutrition | (i) Appropriate basic education | (i) Hygiene | (i) Appropriate basic education |
2 | (i) Appropriate basic education | (i) Nutrition | (i) Appropriate basic education | (i) Hygiene | (i) Appropriate basic education |
3 | (i) Appropriate basic education | (i) Nutrition | (i) Appropriate basic education | (i) Hygiene | (i) Appropriate basic education |
4 | (i) Appropriate basic education | (i) Nutrition | (i) Appropriate basic education | (i) Hygiene | (i) Appropriate basic education |
5 | (i) Appropriate basic education | (i) Nutrition | (i) Appropriate basic education | (i) Hygiene | (i) Appropriate basic education |
6 | (i) Appropriate basic education | (i) Nutrition | (i) Appropriate basic education | (i) Hygiene | (i) Appropriate basic education |
The components of the CHILD protocol were as follows.
Four measures (SDQ, CRIES, ASCL, and SRQ-20) are already available in Afghanistan in Dari and Pashto versions; two (SCARED and QOL) were translated into Dari/Pashto and fully backtranslated into English by members of the research team who were fluent in both Dari/Pashtu and English and then modified as necessary to permit culturally sensitive administration of the items. Although all measures were originally developed as self-report instruments, because of the low literacy rate in the country and very low literacy rate among the substance-using child population all instruments were administered by clinic staff who had been trained in their administration. Administration was in the language chosen by the child.
Measures were chosen to be age-appropriate, so that there was one set of measures for younger children and another set for older children. Only one measure was in common to both groups, other than the screening instrument.
A Microsoft Access database was written and developed to enter and store all data. Staff at the health facilities level were trained in how to enter data and use the database. All data were double-checked at the central hub data center in Kabul.
Because the length of residential treatment was different for the younger and older children, analyses were conducted separately for each group.
A general linear mixed model (GLMM) analysis was conducted on the scores on the scales and/or subscales of the above-named measures, as appropriate to the measure, with all scale and subscale scores assumed to follow a normal distribution in the population. For analysis of the child data, there were three effects in the model: gender as the fixed between-subjects factor, time (outreach, residential intake, posttreatment, and follow-up) as the fixed repeated factor, and their interaction; for the adolescent data, the one female observation was omitted, and so there was a single effect: time (outreach, residential intake, posttreatment, and follow-up) as the fixed repeated factor. A familywise error rate was used to set
Individual interviews with project staff and participants showed high rates of participation and high levels of satisfaction (both over 90%) from participants and staff. Although each of the education, life skills, and one-to-one sessions was scheduled for a 60-minute time slot, some sessions consistently ran over the allotted time because children were particularly engaged. Comments about the intervention were positive (e.g., I liked the art and games; I always learn something). Overall, staff members also reported a high level of satisfaction with the intervention and expressed the need for continued implementation.
The treatment completion rate (residential intake assessment to posttreatment assessment) was 88% for younger children and 98% for older children, both outstanding considering the war-torn intervention setting and the fact that treatment dropout rates reported by inpatient drug studies have ranged from 19% to 63% [
Internal consistency reliability Cronbach’s
Internal consistency reliability at residential treatment entry, estimated marginal means (
Evaluation measure | | Outpatient assessment | Residential treatment entry | Residential treatment completion | Community follow-up |
---|---|---|---|---|---|
| | | | ||
Child Revised Impact of Events Scale (CRIES) | .95 | | | | |
| |||||
Self-Report for Childhood Anxiety Related Emotional Disorders (SCARED) | |||||
Panic Disorder | .94 | | | | |
Generalized Anxiety Disorder | .91 | | | | |
Separation Anxiety Disorder | .88 | | | | |
Social Anxiety Disorder | .83 | | | | |
School Avoidance | .88 | | | | |
| |||||
Total SCARED Score | .95 | | | | |
| |||||
Child Strengths and Difficulties Questionnaire (SDQ) | |||||
Emotional Symptoms | .81 | | | | |
Conduct Problems | .75 | | | | |
Hyperactivity | .70 | | | | |
Peer Problems | .56 | | | | |
Prosocial | .74 | | | | |
| |||||
Total SDQ Score | .91 | | | | |
Internal consistency reliability at residential treatment entry, estimated marginal means (
Evaluation Measure | | Outpatient entry | Residential treatment entry | Residential treatment completion | Community follow-up |
---|---|---|---|---|---|
| | | | ||
Afghan Symptom Checklist (ASCL) | .96 | | | | |
| |||||
Self-Reporting Questionnaire-20 (SRQ-20) | .93 | | | | |
| |||||
Child Strengths and Difficulties Questionnaire (SDQ) | |||||
Emotional Symptoms | .85 | | | | |
Conduct Problems | .92 | | | | |
Hyperactivity | .90 | | | | |
Peer Problems | .78 | | | | |
Prosocial | .74 | | | | |
| |||||
Total SDQ Score | .97 | | | | |
| |||||
Quality of Life scale (QOL) | |||||
Physical Health | .93 | | | | |
Mental Health | .84 | | | | |
Friends | .82 | | | | |
Home | .72 | 6.9 (.27) | 6.7 (.27) | 7.3 (.28) | 7.1 (.37) |
| |||||
Total QOL score | .92 | | | | |
There were no significant Gender or Gender X Time effects (all
The time main effect was significant for all outcomes (all
In order to provide greater context to the impact of the intervention, we asked 3 interventionist staff to provide brief summaries of their contact with a child, including information about the presenting problem, the impact of the CHILD intervention, and the outcome of treatment (The name of each child given below is a pseudonym, to protect the identity of the child.)
Ahmad was an innocent 14-year-old boy, born into a poor family. His father was dependent on drugs and Ahmad was always dreaming of life without financial problems like other kids. Every night he was dreaming for a better tomorrow, which never came. Ahmad wishes if his father gets treatment but unfortunately his father was not ready for the treatment. Ahmad’s mother requests him to work and contribute to the family. Ahmad searched for a job but could not get one. Then he joined a group of peers who were smoking cigarettes and using hashish, opium, heroin, and alcohol for the last two years. Ahmad also used these substances. To find money to fund his substance use and support his family, Ahmad began commercial sex work. However, he felt ashamed and depressed for what he was doing, yet he had no other opportunities for income. Thus, Ahmad was open to a helping hand to move him out of his situation. Our project outreach team found Ahmad and they talked with him about the children substance use treatment facilities in Kabul, which he indicated he was willing to enter. He received treatment in a residential facility where he was provided with the CHILD intervention. He very much liked the child modules of the CHILD interventions such as art therapy, personal safety, and drug education. At the conclusion of his treatment he stopped using psychoactive substances and he returned to his family and is more hopeful for future.
Aziz was approximately 9 years old and was unaware that he would face problems due to drug use disorders. Aziz was the only son in his family and his parents were looking for and expecting a bright future for him. In fact, they placed all their hopes and dreams in him.
But poverty had other ideas, not allowing Aziz’s parents to see his bright future comes to pass and destroying their own future ambitions. Aziz was not able to tolerate his family problems and economic fortunes. He had five sisters, who seemed satisfied with what their father was able to bring them to the family. They seemed to totally overlook their future hopes, ambitions, and wishes.
On the other hand, Aziz was neither satisfied nor pleased with the hardship and poverty of the family. He never valued his family life and was always thinking of ways to earn money and live a better life. When he turned seven, he left home and lived with his peers in the streets. Later he started working in bus stations as a conductor. Gradually he realized his hopes and dreams were gone.
He joined another group of youngsters who were pickpockets. During this time, he was exposed to psychoactive such as heroin, hashish, and wine. He spent two years with this group using various illicit substances. Finally, the outreach team found him on the street and convinced him to stop using. He participated in regular meetings before going to outpatient services, where he received psychosocial counseling, opportunities for hygiene care, and social services for about one month. The outreach team contacted his family several times to get their consent for Aziz to participate in a residential drug treatment program.
Finally both the family and Aziz gave consent, and he was placed in a residential program. He spent 45 days in the residential treatment program receiving psychosocial support through implementation of the CHILD protocols. The outreach team visited him regularly to provide support and prepare him for the transition back to the community.
After completing his residential program in residential setting, he is a totally substance-free boy. Both the outpatient and treatment programs helped him to reconnect with his family. Aziz and his family appreciated the importance of the CHILD program to Aziz and the family. Aziz is currently maintaining his substance-free status, he is happy, he continues to work, and he helps to support his family. Success for Aziz means having not only a substance-free but also a productive life.
One day our outreach team saw a weak, skinny 13-year-old boy among other adults and children in a “drug hotspot.” He had heroin over cigarette paper and a lighter under the heroin paper. The outreach team arrived on the scene and found that he was sweaty, senseless, and laying down on the ground and the team feared that he might be on the verge of death. The outreach team transported him to an outpatient center. When he awoke he was very hungry, and he ate, took a bath, and changed into clean clothes, and he looked much better. He then started crying and weeping, indicating that this was the first time anyone had showed him such love and empathy. During his outpatient visit our staff found that he had no home and was living under a bridge during very cold winter. After his basic needs were met, he was referred to a treatment center. On intake, Farid indicated he was living in Kabul. He reported that his father said at 6 months of age his mother died, and so his aunt cared for him for three years. His father had remarried after one year of Farid’s mother’s death. Due to a weak economy condition his aunt and her family immigrated to Iran and returned Farid to his father and stepmother. Farid indicated he wanted to go to school but his stepmother forbade this. She would “always” beat, abuse, and insult him. She would give him a bucket to sell water. When Farid gave her “much” money she was happy; otherwise she beat him. He saw other children that they were laughing and playing and wearing new clothes. He became hopeless and wished his mother was alive to love and care for him. He had a stepbrother, and his stepmother loved him and bought him new clothes. Farid said he loved him too, but his stepmother would not let him play with his stepbrother. One day his stepmother told his father either she or Farid can live in this house. Farid’s father cast him out of the house. Farid awoke crying at which point he met a man and he asked Farid to work in the man’s hotel for three meals a day and spending money if he needed it. Farid washed dishes and cleaned tables and reported he was very happy with free time at night to go outside. Farid reported that one day he met three boys with red eyes who gave him a paste that was “smooth and with black color.” Farid used it and liked it. Some time later he met the boys who told him he would now need to pay for his opium. He would steal money to pay for his opium but was caught by the owner who dismissed him. Farid’s life “went to darkness,” and he found himself living in dirty places and under bridges. After completion of CHILD treatment at children inpatient treatment facility, Farid was reunited with his father. Farid’s father told Farid that he is happy that he found his son after such a long time. Farid was able to go home and play with his brother and to attend school.
Findings strongly suggest that use of the assessment measures with children in Afghanistan yielded reliable scores on the constructs being measured. This inference is supported by the generally excellent internal consistency of the scales and subscales, suggesting the measures were highly reliable, and the consistency in mean changes in scores, suggesting the measures were sensitive to change in the participants.
Results indicate that both younger and older children entering treatment had widespread psychological and social problems that could be considered serious. Scores on the Afghan Symptom Checklist suggest serious symptomatology relative to previous research with Afghan students 11–16 years of age, whose mean score on the ASCL was 1 standard deviation lower than the mean score of the present sample of older children at residential treatment entry [
Third, our findings suggest that CHILD had a positive impact on those children who were assessed at posttreatment, and, for the smaller subsamples of children assessed at follow-up, impact of treatment endured from posttreatment to follow-up assessment. The CHILD intervention can be viewed as having had a strong impact during the course of residential treatment. However, results for the CRIES suggest that, given the severity of trauma in Afghan society, 45-day residential treatment for younger children may not provide sufficient time to produce improvements in child posttraumatic stress symptoms. As such, it may be important that trauma coping skills for children be continued in the outpatient and aftercare phases following 45-day residential treatment. Nonetheless, it cannot be discounted that the positive impact of CHILD could be due to a more general positive response to treatment impact rather than the specific impact of the CHILD intervention. This positive response may be a result of being given the opportunity to live without exposure to psychoactive substances and reside in a place that is physically and emotionally safe. And, despite the small sample sizes at follow-up, there is a clear and consistent suggestion of enduring impact, at least for some children. There were several limitations to the present study. The major limitation was that the CHILD treatment was not administered as part of a research project. Rather, the CHILD protocol was designed to meet the treatment needs of children, based on a needs’ assessment. An assessment component was built into the CHILD protocol to guide treatment planning. The analysis of these assessment measures shed light on the treatment needs of children in Afghanistan and the promise of the CHILD protocol at addressing their needs for treatment of substance use. A corollary limitation is that there are no data describing the children or their families, due to the fact that recording such data was deemed not cost-effective to the project. A related corollary is that the project was necessarily a single-group study that focused on change within a treated group, and there is neither a control group nor, given the instability and extreme poverty in the country, the ability to identify any comparison group. However, it should be noted that the CHILD treatment protocol was developed because treatment programs already in place in Afghanistan for children had largely been unsuccessful in bringing about change.
Findings suggest that the CHILD intervention shows promise of producing significant change in deprived and traumatized children who are at risk for or are in need of treatment for psychoactive substance use. Results indicate that the CHILD intervention was both broadly impactful and perhaps enduring. A systematic, longer-term evaluation of the CHILD intervention compared to residential usual care is needed.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
The authors thank the following organizations for their support: The United Nations Office on Drug Control for supporting the development of the protocols and establishing treatment services for children; the Colombo Plan for supporting treatment services to 97 treatment programs in Afghanistan, including women and children’s programs, and for coordinating the Afghan National Drug Use Survey; and the US Department of State’s Bureau of International Narcotics and Law Enforcement Affairs (INL) for its substantial contribution to addressing substance use in Afghanistan.