Children and Global Adversity

The Research Program on Children and Global Adversity (RPCGA) works to close the global implementation gap between the realities facing children and families in adversity such as that due to communal violence/armed conflict and HIV/AIDS and the evidence base on promoting mental health and child development in low resource settings. Directed by Dr. Theresa S. Betancourt, Associate Professor of Child Health and Human Rights in the Department of Global Health and Population, the program operates at the crossroads between research, policy and program design, implementation and evaluation.  The RPCGA is engaged in applied research to contribute to stronger and evidence-based interventions to serve children and families in adversity worldwide.


Violence in many forms is increasingly a part of children’s lives. There is a robust literature describing significant psychiatric sequelae associated with exposure to violence both in war-affected and urban environments.  Although a great deal of research has provided detailed understanding of the risk factors that contribute to psychopathology in children exposed to violence, very little research has attended to protective processes that promote better mental health outcomes when children face such adversity. Dr. Theresa Betancourt’s primary research interest is to further elucidate protective factors and to explore protective processes and resilient outcomes in the mental health of children and adolescents exposed to adversity, particularly in populations affected by armed conflict and the HIV/AIDS epidemic. RPCGA research projects advocate for the translation of research to real-life problems in the field as well as invigorating the research community to initiate research on questions of interest to those working on the ground.

Current Projects

The Family Strengthening Intervention – Rwanda

Over the past year, the RPCGA has made important progress in its research on children and families affected by HIV/AIDS in Rwanda. This portfolio of work is the result of close collaboration with Partners In Health /Inshuti Mu Buzima (PIH/IMB) and the Rwanda Ministry of Health, and is focused on the development of mental health screening tools and preventive mental health interventions for HIV-affected families in the country’s Eastern Province.  This prevention-oriented research is seen as complementary to treatment services currently offered by PIH/IMB.  In 2012, RPCGA launched a 20-family pre-pilot and 80-family feasibility pilot of the Family Strengthening Intervention, a preventive intervention adapted from a US-based intervention, and implemented by local interventionists. The intervention study, which is funded by the National Institute of Mental Health (NIMH), will assess participants at three time points to evaluate intervention effects using locally-validated mental health assessments developed by the project from 2007-2011. Additional epidemiological research examining the prevalence of mental health problems and resilience in three samples of children from the area (those living with HIV/AIDS, those affected by HIV/AIDS, and children unaffected by HIV/AIDS) will be completed by the end of 2012.

The Longitudinal Study of War-Affected Youth – Sierra Leone

To date, one of the RPCGA’s major contributions to the global health field has been the application of (and advocacy for) longitudinal, culturally-informed research on children in adversity that is supported by communities and local collaborators. Dr. Betancourt’s Longitudinal Study of War-Affected Youth (LSWAY) has been ongoing in Sierra Leone since 2002, and is the first and only prospective longitudinal study of mental health and psychosocial adjustment in male and female former child soldiers to be performed in sub-Saharan Africa. Analyses of this unique cohort of over 500 youth continued in 2012 to examine, among other topics, how gender affects the long-term psychosocial trajectories of former child soldiers. A new phase of the project that will investigate the intergenerational effects of violence is planned to start in 2013. Measures development for this new phase and participant tracking has been ongoing throughout 2012 in preparation for this new stage. Longitudinal data have provided a robust evidence base for designing a psychosocial Youth Readiness Intervention for young men and women in Sierra Leone. In 2012, the team piloted the newly developed YRI in Freetown, as well as initiated a randomized-controlled trial testing the effectiveness of the YRI as a preparation for vulnerable, school-intending youth, together with CARITAS Freetown and EducAid.

The Somali Bantu Refugee Community Project

The RPCGA’s Boston-area research with Somali refugee parents and youth has also grown during 2012.  Analysis of data from recent collaborative qualitative research with Somali Bantu adults and children (an ethnic sub-group within the larger Somali resettlement population) is underway to identify services needs and preferences, as well as culturally relevant protective processes that deserve priority attention in intervention planning. Preliminary analyses highlight how family dynamics, including communication, values, and parenting, are influenced by acculturation stressors, including language barriers, limited access to services, and wide cultural gaps. This mixed methods participatory research has led to many opportunities for raising awareness about the psychosocial needs of these refugee groups in the Boston area and dissemination activities at the Massachusetts Department of Mental Health (School Based Mental Health program) and a collaborative presentation with the Somali Bantu refugee team at City Hall in Chelsea Massachusetts.  This project has been supported by strong Harvard student involvement and collaboration. The RPCGA has formed a new partnership in 2012 with MGH-Chelsea and Harvard Medical School in the “Bridging the Gap” program, in which volunteer medical, dental, and public health students are paired with a recent immigrant/refugee family in the Boston area.  Each volunteer works as a family advocate to provide service activities such as finding ESL resources, assistance with housing, and tutoring schoolchildren.

The SAFE Project

The SAFE Model, developed by the RPCGA, is a holistic rights-based framework that examines the four fundamental and interrelated domains of children’s security:  Safety and protection, access to health care and basic physiological needs, family and community relationships, and education and economic security. The model underscores the interdependence of children’s survival needs and accounts for both dangerous and adaptive survival strategies that children and families employ to cope with deficits in any of these four core security domains.  The SAFE toolkit, an application of the SAFE model, has been developed to monitor and evaluate the effects of development and interventions on children across a range of settings.  The toolkit is comprised of a qualitative component – the SAFE Child Impact Assessment (SCIA), and a quantitative component – the SAFE Checklist (under development).  In Rwanda, the SAFE team has worked closely with community based field partners to refine the SAFE toolkit through conducting a series of focus groups and key informant interviews with youth, caregivers and child protection experts.  Our findings highlighted important implications for designing preventive, integrated interventions that work across sectors to address child protection issues in myriad settings in Rwanda.  The SAFE toolkit has also been piloted in India, Haiti and Lesotho.  Results from our work in Haiti in the immediate aftermath of the Haiti earthquake, have served as a catalyst for the development of a SAFE-informed survey instrument that may also be adapted to other settings.  Additionally, the SAFE team conducted a Delphi exercise, engaging the knowledge of over 50 experts world-wide in the field of child protection to highlight core indicators for threats to child security in the four SAFE domains.  In 2012, the SAFE team formed a new collaboration with the Public Health Foundation of India, FXB Suraksha, and Mobile Creches to pilot the SAFE toolkit in three primary areas: infrastructure development projects in the National Capital Region in India, the Railways Children Project in Jaipur, and the National Childline Service.  Implementation of the toolkit within sites like these will serve the primary purpose of promoting holistic responses to child protection threats and provide an evidence base to inform targeted improvements in policies related to systems of care and protection for vulnerable children and families.

Publications and Additional Resources (2012)

Peer-Reviewed Publications

McBain R, Norton DJ, Morris J, Taghi MT, Betancourt TS. The Role of Health Systems Factors in Facilitating Access to Psychotropic Medicines: A Cross-Sectional Analysis of the WHO-AIMS in 63 Low- and Middle-Income Countries. PLoS Medicine 2012; 9(1).

Betancourt TS, Williams TP, Kellner SE, Gebre-Medhin J, Hann K, Kayiteshonga Y. Interrelatedness of child health, protection and well-being: An application of the SAFE model in Rwanda. Social Science & Medicine 2012; 74(10):1504-11.

Kimmel AD, Daniels N, Betancourt TS, Wood R, and Prosser LA.  Decision maker priorities for providing antiretroviral therapy in HIV-infected South Africans:  A qualitative assessment.  AIDS Care. 2012; 24(6):778-92.

Williams T, Binagwaho A, Betancourt TS. Transactional sex as a form of child sexual exploitation and abuse in Rwanda: Implications for child security and protection. Child Abuse & Neglect 2012; 36(4):354-361.

Betancourt TS, McBain R, Newnham EA, Brennan RT. Trajectories of internalizing problems in war-affected Sierra Leonean youth: Roles of conflict and post-conflict factors. Child Development. (In press).

Betancourt TS, Yudron M, Wheaton W, Smith-Fawzi MC. Caregiver and Adolescent Mental Health in Ethiopian Kunama Refugees Participating in an Emergency Education Program. Journal of Adolescent Health. 22 March 2012.

Betancourt TS, Newnham EA, Brennan RT, Verdeli H, Borisova I, Neugebauer R, Bass J, Bolton P. Moderators of Treatment Effectiveness for War-Affected Youth with Depression in Northern Uganda. Journal of Adolescent Health. 5 April 2012.

Betancourt TS, Salhi C, Buka S, Leaning J, Dunn G, Earls F. Connectedness, Social Support and Internalizing Emotional and Behavioral Problems in Adolescents Displaced by the Chechen Conflict. Disasters. Available online 23 March 2012.

Betancourt TS, Meyers-Ohki SE, Stevenson A, Mushashi C. Applying a Mixed-Methods Model to Planning and Evaluating Child Mental Health Interventions in Sub-Saharan Africa. In: Tomlinson M, Hanlon C, Swartz L, Cooper P, Sameroff A, eds. Infant and child development in Africa: Perspectives from the continent. Cape Town: University of Cape Town Press & United Nations University Press (In press).

Books and Monographs

Betancourt TS, Beardslee WR. The Consequences of Concentrated Adversity on Child and Adolescent Mental Health. In: Maholmes V, King R, eds. The Oxford Handbook of Poverty and Child Development. New York: Oxford University Press; 2012.

Betancourt, T. S., Meyers-Ohki, S. E., Stulac, S., Barrera, A. E., Mushashi, C., & Beardslee, W. R. (2012). Global Mental Health Programs for Children and Families Facing Adversity: Development of a Family Strengthening Intervention in Rwanda. In J. N. Corbin (Ed.), Children and Families Affected by Armed Conflicts in Africa: Implications and Strategies for Helping Professionals in the United States (pp. 113-142). Washington, DC: National Association of Social Workers Press.

Betancourt TS,  Tol W. Interventions for Children Affected by Armed Conflict: An ecological view. In: Muntasser S, Joshi P, Munoz R, eds. Children and war. New York: Springer. (In press).

Tol WA, Jordans MJD, Kohrt BA, Betancourt TS, Komproe IH. Promoting mental health and psychosocial wellbeing in children affected by political violence: current evidence for an ecological resilience approach. In: Fernando C, Ferrari M, eds. Handbook on Resilience in Children of War. New York: Springer. (In press).

Betancourt TS, Zaeh SE, Ettien A, Khan LN. Psychosocial Adjustment and Mental Health Services in Post-conflict Sierra Leone: Experiences of War-affected Youth, Families and Service Providers. In: Parmentier S, Sarkin J, Weitekamp E, eds. A New Series on Transitional Justice (title under revision). Antwerp: Intersentia. (In press).

Betancourt TS. Using Mixed Methods to Plan and Evaluate Mental Health Programs for War-Affected Children in Sub-Saharan Africa. In: Kleinman A, Akyeampong E, eds. African Psychiatry. Bloomington, IN: Indiana University Press. (In press).