Improving access to evidence‐based interventions for young adolescents: Early Adolescent Skills for Emotions (EASE)
Authors: Katie S. Dawson, Sarah Watts, Kenneth Carswell, Melissa Harper Shehadeh, Mark J.D. Jordans, Richard A. Bryant, Kenneth E. Miller, Aiysha Malik, Felicity L. Brown, Chiara Servili, Mark van Ommeren
Journal: World Psychiatry (2019)

About half of all mental disorders emerge by 14 years of age1. In adolescents, depression is the main cause of disability, anxiety is ranked seventh, and suicide is the third leading cause of death1. An estimated 10-20% of adolescents worldwide suffer from mental disorders2, which are associated with health and social problems, such as poor academic attainment, substance misuse, and economic difficulties3. Consequently, adolescence is a critical period in which to intervene. Adolescents living in low- and middle-income countries (LMICs) may be especially at risk of mental disorders when they are exposed to adversity, such as extreme poverty and violence4. While advances have been made, access to evidence-based psychological treatments for adolescents in LMICs is rare4. There is a growing literature on effectiveness of psychosocial interventions for youth in LMICs. A recent systematic review and meta-analysis of individual participant data from 3,143 children affected by conflict recruited to eleven randomized controlled trials found that focused psychosocial interventions can be effective in reducing post-traumatic stress disorder (PTSD) symptoms and in increasing hope, coping and social support, and reducing functional impairment5. The World Health Organization (WHO) is seeking to strengthen the quantity and quality of mental health services. As part of the Mental Health Gap Action Programme (mhGAP), the WHO is developing and testing the effectiveness of brief, transdiagnostic psychological interventions, including those for young adolescents, that can be implemented by trained and supervised non-specialists in multiple settings, including health, protection and education6, 7. Building on ongoing work to develop and test potentially scalable psychological interventions for adults8, the WHO has developed a group intervention for young adolescents (about 10 to 14-year-olds) exhibiting internalizing problems (e.g., symptoms of depression or anxiety). The intervention is called Early Adolescent Skills for Emotions (EASE). Central to the development of EASE was the capacity to address comorbid emotional problems in one intervention and promote scale-up in LMICs with the use of briefly trained non-specialists. The formative process to develop EASE included a narrative review, the identification of empirically-supported strategies that were most commonly used in effective interventions according to the PracticeWise9 database, and extensive expert consultation (a concept note on the development of EASE is available upon request). EASE aims to mitigate symptoms of internalizing disorders, such as depression and anxiety, by the provision of four core empirically-supported strategies delivered face-to-face over seven group sessions with adolescents, and three group sessions with their caregivers. Strategies with young adolescents are introduced in order of complexity, thus each session reviews and rehearses previously introduced strategies, with practice between sessions encouraged. Sessions are designed to last 90 min. They include pictures, stories and activities to encourage youth engagement. The first session aims to build rapport with participants and develop group cohesion. Psychoeducation is presented, informing participants about adversity and emotional distress. Participants are also taught how to appropriately identify their own emotions ("Understanding My Feelings") which is seen as fundamental to basic emotional regulation. Session 2 addresses problems of physical arousal associated with stress, anxiety and anger, and introduces slow breathing ("Calming My Body") to promote arousal reduction. Participants are encouraged to engage in meaningful activities to improve their mood in sessions 3 and 4 ("Changing my Actions"). Based on behavioral activation, this strategy aims to address symptoms of inactivity and help engage adolescents in more meaningful activities. Sessions 5 and 6 promote independent problem solving skills via a simplified problem solving technique called "Managing my Problems". Embedded within this strategy are questions to prompt participants to seek social support. Finally, session 7 focuses on relapse prevention and helps participants prepare to use the strategies independently in the future. Given difficulties with engagement of employed or overburdened caregivers, and in the context of a brief intervention, only three two-hour group caregiver sessions are included. They aim to build on existing strengths and promote adaptive parenting practices to improve the caregiver-child relationship and enhance confidence when responding to adolescent distress. In the first session, caregivers are provided with psychoeducation and skills to better equip them to respond and provide comfort to their child when they are overwhelmed by feelings of distress. Emotion identification, active listening and slow breathing are taught and practiced. The second session focuses on positive parenting strategies including praise, boosting their child's confidence and the discontinuation of physical discipline. Finally, caregiver self-care (e.g., sleep, nutrition, stress reduction strategies) is covered in session 3. This session aims to enhance caregiver's capacity to cope with challenges related to the environment and to parenting an adolescent experiencing significant distress. Education about relapse prevention is also provided in this final session. Practice and application of strategies is encouraged between sessions. In addition, across all sessions, caregivers are informed of the strategies being taught in the adolescent sessions. Beyond the caregiver and youth sessions, facilitators are trained to monitor and identify indicators of threats to adolescents' wellbeing in the home environment and to make referrals as indicated. The capacity to effectively implement and scale up this intervention in LMICs is critical. Adopting a responsibly implemented (e.g., including ongoing supervision and support) task-sharing approach by employing non-specialists makes EASE more affordable and scalable. Facilitators of this intervention are expected to have at least high-school education, but are not required to have previous mental health experience. They will complete eight to ten days of training in basic mental health education, counseling and group management skills and the EASE intervention, and receive weekly supervision. Similar task-sharing approaches have been employed in studies demonstrating effectiveness in adults10. Access to effective psychological interventions for adolescents is essential to promote healthy development into adulthood. EASE is a brief, transdiagnostic intervention that aims to mitigate symptoms of emotional distress in young adolescents. If proven effective, it can potentially be scaled-up in many settings. The effectiveness of EASE is currently being tested through randomized controlled trials in Lebanon, Jordan, Pakistan and Tanzania.