Child and Adolescent Mental Health 23, No. 4, 2018, pp. 351–358 doi:10.1111/camh.

12232

Effectiveness of life skills education and

psychoeducation on emotional and behavioral
problems among adolescents in institutional care in
Kenya: a longitudinal study
Victoria Mutiso1, Albert Tele1, Christine Musyimi1,2, Isaiah Gitonga1,
Abednego Musau1 & David Ndetei1,3
1
Africa Mental Health Foundation, Nairobi, Kenya
2
Vrije Universiteit, Amsterdam, The Netherlands
3
Department of Psychiatry, University of Nairobi, Nairobi, Kenya

Background: This study aimed to test the effectiveness of life skills education (LSE) and psychoeducation in the
reduction of Youth Self Report (YSR) scores on institutionalized children using structured activities supported
by trained facilitators. LSE involved participation of children in life skills activities to support development of
key psychosocial competencies and interpersonal skills. Methods: The study included 630 children from three
institutions. Of these, 171 were in the Intervention Group 1 (life skills education and psychoeducation), 162
were in the Intervention Group 2 (psychoeducation only), and 297 children were in the control group. A
researcher-developed socio-demographic questionnaire and the YSR were used. Baseline assessments were
conducted before the interventions and again at 3, 6, and 9 months. Differences between the two interven-
tion groups and the control group were investigated using least squares linear regression. Results: There was a
statistically significant reduction in scores in internalizing, externalizing, and total problem scores in both
intervention arms (p < .05) compared with the control arm at 3 months. At 6 months, no significant differ-
ences were found between the intervention Group 1 and control group for internalizing score (p = .594); how-
ever, there were significant differences in both intervention groups for both externalizing and total problem
scores (p < .05). At 9 months, significant differences were observed between control and both intervention
groups for externalizing scores; total problems for Intervention Group 1. Conclusions: A combination of Life
Skills Education and psychoeducation is effective in reducing emotional and behavioral problems in institu-
tionalized children.

Key Practitioner Message

• Mental health needs of children and adolescents are mostly neglected in low- and middle-income
countries.
• Psychoeducation and life skills education have been found to be ‘probably effective treatments’ for emo-
tional and behavioral problems among adolescents.
• To the best of our knowledge, no study has evaluated the effect of a combination of life skills education
and psychoeducation on emotional and behavioral problems in children and adolescents in institutional
care in low- and middle-income countries.
• This study has found that psychosocial interventions for adolescents in institutional care can produce posi-
tive emotional and behavioral outcomes.

Keywords: Behavior problems; emotional disorder; adolescence; child development

improving child mental health and supporting their

Introduction
Approximately 10% of children and adolescents in
Sub-Saharan Africa have a diagnosable mental disorder
(Cortina et al., 2013), although almost no services are
provided (Gore et al., 2011; Kieling et al., 2011). If no
interventions are provided in early life, they can lead to
life-long complications (Gore et al., 2011; Kieling et al.,
2011). Among the most studied interventions for
development are Life Skills Education (LSE) and psy-
choeducation (Bond & Anderson, 2015; Botha & Wolhu-
ter, 2015; Weichold & Blumenthal, 2016; Whitley,
Wright, & Gould, 2016).
Psychoeducation refers to the education of a person
with a mental disorder regarding its symptomatology,
causes, treatments available, and the prognosis (Xia,
Zhao, & Jayaram, 2013). Psychoeducation is not simply

© 2017 Association for Child and Adolescent Mental Health.

Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
352 Victoria Mutiso et al.
‘providing information’, but rather an empowerment
training for individuals whose target is to promote the
awareness, inform on treatment modalities available,
coping strategies and appropriate behavior and attitude
change to enhance effective response to the chronic con-
dition (Zhao, Sampson, Xia, & Jayaram, 2015).
A number of studies have generated evidence that psy-
choeducation is an effective remedy for a wide range of
mental disorders (Parker et al., 2016; Scholten et al.,
2013), whereas others have found it ineffective in various
disorders (Agberotimi, Olaseni, & Oladele, 2015; Barros
Pellegrinelli et al., 2013; Shah, Klainin-Yobas, Torres, &
Kannusamy, 2014).
Life skills education, however, has a long history of
supporting child development and health promotion
in many parts of the world (Babaei & Cheraghali,
2016; Katz et al., 2013). According to the WHO life
skills education manual page 1 (World Health Organi-
zation, 1997; Appendix S1), life skills are the ‘abilities
for adaptive and positive behavior that enable individ-
uals to deal effectively with the demands and chal-
lenges of everyday life’. Participation in life skills
activities has been established to support the devel-
opment of critical and creative thinking, coping with
emotions and stress, self-awareness and empathy,
decision-making and problem solving, communication
skills, and interpersonal relations (Maryam, Davoud,
Zahra, & Somayeh, 2011; Srikala & Kishore, 2010).
However, studies mostly done in LMICs have found
conflicting results regarding the efficacy of LSE and
psychoeducation as independent models for support-
ing child development and treatment for emotional
and behavioral problems (Babaei & Cheraghali, 2016;
Weichold & Blumenthal, 2016).
In a recent study conducted among orphans and vul-
nerable children (OVCs) in residential institutions in
Kenya, the prevalence of any mental disorder, based on
the DSM-IV criteria, as measured by the Youth Self
Report (YSR) syndrome scale was found to be 30.8%
(Mutiso, Musyimi, Tele, & Ndetei, 2016) which is way
above the 10% average of children in Sub-Saharan
Africa (Cortina et al., 2013). Most of the school literature
has been on normal schools and hardly on institutional-
ized children, hence this study. More so, all studies on
emotional and behavioral aspects of OVCs in Africa have
been nonexperimental. This study sought to investigate
the effectiveness of a combination of psychoeducation
and LSE and psychoeducation alone on mental disor-
ders among orphans and vulnerable children in institu-
tions of care in Kenya.
Methods
Study design
A longitudinal study design was used to test the effectiveness of
life skills education (LSE) and psychoeducation on emotional
and behavioral problems in adolescents under institutional
care.
Study sites
The participating institutions, all of which admitted OVCs and
adolescents, were selected from the Department of Children
Services national database in Kenya. Institutions that had been
deregistered by the parent ministry prior to this study were not
included in the final list of eligible institutions. Three institu-
tions were randomly selected from the final list of legally
Child Adolesc Ment Health 2018; 23(4): 351–8
registered institutions. The real names of these institutions
were replaced with names that concealed the identity of the
institutions. In this labels/titles, they will be referred to as
Experimental Group 1, Experimental Group 2, and control
group (treatment as usual).
Eligibility of participants
This study included adolescents who were residing in the
selected institutions at the time of the study and were aged
between 11 and 18 years. They were only included if they gave
assent to participate in the study. Participants who did not fall
within the age bracket of 11–18 years, did not give assent to
participate in the study, whose institutional heads (guardians)
did not give consent, and who were identified by the teachers as
having mental retardation to the extent that they could not par-
ticipate in the assessments were excluded.
An orphan was defined as a child below the age of 18 years
who had lost either their biological mother or biological father or
both due to any cause; a vulnerable child as one whose safety,
well-being, and development are, for various reasons, threat-
ened, including children who are emotionally deprived or
neglected or traumatized. Therefore, OVCs included all children
who have lost one or both parents from any cause or have been
determined by psychosocioeconomic disadvantages to be in the
greatest need. We categorized OVCs as; total orphan (a child
who has lost both biological parents), maternal orphan (a child
who has lost his/her biological mother), and paternal orphan (a
child who has lost his/her biological father).
Ethics and consent
Ethical approval was obtained from the Kenyatta National
Hospital/University of Nairobi Research and Ethics Committee.
Informed consent was sought from guardians and the institu-
tional heads, and assent was sought from the potential partici-
pants with the right to withdraw at any time of the study
without loss of any benefits or victimization. Admission num-
bers rather than names were used for each participant. A new
encrypted study code was then generated before data entry to
remove this identifier and was used to match the assessments
during each subsequent wave. This new unique code number,
which was used during each wave, was matched on the data-
base with the completed questionnaires.
Instruments
Socio-demographic profiles. We used a researcher-designed
questionnaire to capture gender, age, and length of institution-
alization and orphan type, among other variables.
The Youth Self Report (YSR). We used the YSR (Achenbach
& Rescorla, 2001b) to assess the participants’ emotional and
behavioral problems. The YSR is part of the Achenbach System
of Empirically Based Assessment forms (ASEBA; Achenbach,
1991) with a standardized rating form which consists of 112
items. The 112 items form continuous measures for eight
dimensions of psychological functioning which were derived
through empirical methods. These dimensions are as follows:
withdrawn, somatic complaints, anxious/depressed, social
problems, thought problems, attention problems, delinquent
behavior, and aggressive behavior.
These syndromes can be further categorized into two broad-
band scales: ‘externalizing’ and ‘internalizing’. The externalizing
component, which is a combination of the scores on aggressive
behavior and delinquent behavior, measures the behavioral
problems, while the internalizing component is a combination
of the scores on withdrawn, somatic complaints, and anxious/
depressed subscales. The 112 items are rated on a 3-point scale
with responses: ‘0’, not true; ‘1’, somewhat or sometimes true;
or ‘2’, very true or often true with reference to the past 6 months.
Some of the 112 items also have open-ended questions that help
to provide more information on the particular symptom elicited,
for example, ‘I hear sounds or voices that other people think
aren’t there (describe): ___’ or ‘I have thoughts that other people
would think are strange (describe) ___’.
© 2017 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12232 Effectiveness of life skills education 353

The YSR syndromes demonstrate significant associations
with the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (Weinstein, Noam, Grimes, Stone,
& Schwab-Stone, 1990). The syndromes include the following:
affective problems, anxiety problems, somatic problems, atten-
tion deficit hyperactivity problems, oppositional defiant prob-
lems, and conduct problems. There is no single cutoff for
diagnosis. Rather, the total score is a continuous variable.
Administration time ranged between 15 and 20 min depending
on the age and language competency of the participant. The
YSR has been validated in the Kenyan context (Harder et al.,
2014).
Study procedures
At different time periods (Figure 1), the participants completed
the similar questionnaires on four occasions (baseline, Follow-
up 1, Follow-up 2, and Follow-up 3). Baseline assessments were
done on socio-demographic characteristics and mental health
using the YSR. Subsequent assessments were done on their
mental health to establish any changes between and within the
three study sites.
Interventions
Psychoeducation and life skills training modules were adminis-
tered for 4 days after the first baseline by a 12-member team
which consisted of a multi-disciplinary team of clinical psychol-
ogists, counseling psychologists, child development workers,
and life skills instructors. The team underwent a 2-day training
on the protocol and the standard operating procedures for this
study. There were three training groups per site, with each
group having approximately 50 participants. During any partic-
ular session, which took 2 hrs, two trainers would alternately
deliver the interventions for 1 hr as the other made clarifica-
tions. The supervisor and her assistant would go round to
ensure that the trainers adhered to the study protocol and the
manual guidelines.
During each session, Experimental Group 1 received both
life skills (four sessions), comprising critical and creative
thinking, self-awareness and empathy, decision-making and
problem solving, communication skills, interpersonal rela-
tions and coping skills such as relaxation techniques, and
psychoeducation interventions (three sessions), which com-
prised the definition of mental health, causes and symptoms
of mental illnesses, and prevention and treatment measures.
These sessions were held in an interactive and participatory
manner. The Experimental Group 2 received only the psy-
choeducation component. Each of the groups was studied
independent of each other.
Interventions were provided immediately after the assess-
ments were completed (for both Experimental Groups 1 and 2)
but separate from each other. For the control group, only
assessment on their mental health was done within a 3-month
interval between each of the four assessments to assess the level
of psychopathology. However, there were no interventions for
this group.

All adolescents in residential care

Meeting inclusion criteria

Recruit Do not meet criteria Discard

Randomize

Experimental group 1 Experimental group 2 Control group

Baseline data Baseline data Baseline data
(Psychoeducation and life (Psychoeducation only) (No intervention)
skills)

3 months 3 months 3 months

Assessment 1 Assessment 1 Assessment 1

(Psychoeducation and (Psychoeducation only) (No Intervention)
life skills)

ANALYSES: Primary analyses, baseline, assessment 1, 2, and 3 analyses to determine changing

paerns of group psychopathology based on the type of intervenon and the control.

Figure 1. Methodology flow chart [Colour figure can be viewed at wileyonlinelibrary.com]

© 2017 Association for Child and Adolescent Mental Health.

354 Victoria Mutiso et al.
Data management and statistical analysis
The YSR data were double entered (during the second entry, the
data entry software automatically prompts the data entry staff
to correct if the entry does not correspond with the first entry)
and scored by the Assessment Data Manager (ADM) software
version 9.1, a software developed by the Achenbach System of
Empirically Based Assessment (ASEBA) team (Achenbach &
Rescorla, 2001a). The ADM scores each assessment and pro-
duces a summation of all problem items separately for boys and
girls. Both raw and scored datasets, as well as the socio-demo-
graphic data, were converted into SPSS through A2S [a one-way
utility designed to process data from ADM or Ratings-to-Scores
(RTS) into SPSS already scored form].
The scoring profile provides raw scores; T-scores and per-
centiles for total competence, two competence scales (activities
and social), eight syndrome scales, six DSM-oriented scales,
internalizing, externalizing, and total problems. The YSR inter-
nalizing scale is the sum of scores for the anxious/depressed,
withdrawn/depressed, and somatic complaints syndromes.
The YSR externalizing scale is the sum of scores from the rule-
breaking behavior and aggressive behavior syndromes.
Exploratory data analysis technique was used to understand
the distribution structure of the study variables and to identify
outliers using descriptive statistics. Analysis was done accord-
ing to intention to treat using SPSS version 21. Scores of partici-
pants who were lost to follow-up were imputed using five
randomly generated scores based on their baseline scores, gen-
der, allocation group and age. Sensitivity analysis was done
using complete cases only.
Differences between the two intervention groups and the con-
trol group were investigated using least squares linear regres-
sion. Between-group analyses are expressed as both
unadjusted and adjusted differences to cater for potential con-
founders and effect modifiers using hierarchical multiple linear
regression models on the three outcome variables (corrected for
score at baseline, age, class category, gender, orphan type, and
length of institutionalization).
To adjust for multiple analysis, Bonferroni correction was
applied to each pairwise comparison between intervention and
control to maintain a 5% Type 1 error across the three compar-
isons made.
Assessment of effectiveness of the intervention on YSR mea-
surements across the four time points was analyzed using Gen-
eralized Linear Model technique (repeat measure) in order to
understand the effect of variation due to groups (between-
groups effect) and due to follow-up time (within-groups effect).
An interaction term between groups and follow-up time was also
fitted to test its effect. Level of statistical significance was fixed
at .05 (p < .05) with a 95% confidence interval. When sphericity
assumption was not met, the Huynh-Feldt correction was
applied.
Results
Social demographic characteristics
Although 730 participants met the criteria to be included
in the study, only 630 completed the full questionnaires
at baseline (overall response rate of 86.3%). The
response rates per group are as follows: Experimental
Group 1, 90.5%; Experimental Group 2, 70.6%; and
control group, 94.6%. Table 1 presents the numbers per
group (Experimental Group 1, 27.14%; Experimental
Group 2, 25.72%; and control group, 47.14%). The com-
bined response rates in subsequent assessments were
as follows: second wave of assessment was 75.0%, third
wave of assessments was 62.2%, while the fourth wave
of assessments was 60.8%.
Table 1 presents the social demographic characteris-
tics of the participants by groups (sites) at baseline. As
shown in Table 1, there was a statistically significant
Child Adolesc Ment Health 2018; 23(4): 351–8
group difference among the participants in terms of gen-
der, age, length of stay at the institution, orphan type,
class category, internalizing, externalizing, and total
problem scores (p < .05) in terms of proportions and
mean scores in the three groups. Participants in Experi-
mental Group 2 had higher means of internalizing and
total problems baseline scores as compared with other
groups.
The primary outcome was syndrome scores reduction
at 3 months. Table 2 presents the reduction in scores
from baseline and subsequent assessments.
All the groups including the control group achieved a
statistically significant reduction in internalizing scores
with Experimental Group 1 achieving the greatest
mean reduction of 7.12, while Experimental Group 2
had a mean reduction of 7.10 and controls had a 3.52
reduction.
There was a statistically significant overall increase in
externalizing scores from baseline to 3 months, the
highest increase being among the controls followed by
Experimental Group 2 and the lowest increase was in
Experimental Group 1.
At 6 months, there was a statistically significant
reduction in internalizing scores across the three
groups. Externalizing scores reduced in Experimental
Group 1 and Experimental Group 2, but Experimental
Group 2 did not achieve the threshold of statistical sig-
nificance. There was a statistical significant increase in
scores in the control group. At 9 months, there was an
overall reduction in internalizing, externalizing, and
total problem scores across all the three groups; how-
ever, only control group reached the threshold of statisti-
cal significance for externalizing scores.
Results from linear regression are presented in
Table 3, only Experimental Group 1 had a statistically
significantly greater reduction of scores in internalizing,
externalizing, and total problems scores than the control
group at 3 months. However, after adjusting for baseline
scores, age, gender, class category, orphan type, and the
duration of institutionalization, both the experimental
groups achieved a statistically significant reduction in
scores as compared with the control group. Experimen-
tal Group 1 had higher reduction (effect size 0.4-med-
ium) as compared with Experimental Group 2 (effect size
0.1-small). At 6 months after adjusting for baseline
scores and the socio-demographic profiles, only Experi-
mental Group 2 achieved a statistically significantly
greater reduction in internalizing scores than the control
group. Both Experimental Groups 1 and 2 achieved a
reduction in externalizing scores as compared with con-
trol group. At 9 months, only Experimental Group 1
achieved a statistically significantly greater reduction in
total problem scores than the control. However, in exter-
nalizing scores, both the intervention groups achieved a
statistically significant reduction in externalizing scores
as compared with the control group.
Results from repeated measures analysis of variance
(ANOVA) of changes in scores, with time measurement
(Baseline vs. Follow-up 1 vs. Follow-up 2 vs. Follow-up
3) as within-subjects factor was conducted (Table not
shown). The sphericity assumption was not met and
Huynh-Feldt correction was applied. The main effect
of time was significant, p < .001. Adjusting for other
factors, variability of total problem scores between
study groups (between subject factor) was statistically
© 2017 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12232 Effectiveness of life skills education 355

Table 1. Characteristics of participants at baseline overall and according to intervention arm (percentages) unless stated otherwise

Experimental Experimental
Overall Group 1 Group 2 Control
Characteristic Category (N = 630) (n = 171) (n = 162) (n = 297) p-Value

Gender Female 346 (54.9) 77 (22.3) 123 (35.5) 146 (42.2) <.001
Males 284 (45.1) 94 (33.1) 39 (13.7) 151 (53.2)
Age years Mean (SD) 15.1 (2.0) 14.8 (2.1) 16.5 (1.2) 14.5 (1.8) <.001
Length of <1 year 157 (24.9) 38 (24.2) 56 (35.7) 63 (40.1) <.001
institutionalization 1–5 years 285 (45.2) 81 (28.4) 37 (13.0) 167 (58.6)
>5 years 107 (17.0) 42 (39.3) 21 (19.6) 44 (41.1)
Missing 81 (12.9)
Orphan type Not known 57 (9.0) 17 (29.8) 12 (21.1) 28 (49.1) <.001
Total orphan 263 (41.7) 46 (17.5) 29 (11.0) 188 (71.5)
Maternal orphan 55 (8.7) 16 (29.1) 12 (21.8) 27 (49.1)
Paternal orphan 105 (16.7) 39 (37.1) 28 (26.7) 38 (36.2)
Nonorphan 105 (16.7) 53 (50.5) 37 (35.2) 15 (14.3)
Missing 45 (7.1)
Class category Lower primary 82 (13.0) 5 (6.1) 0 (0.0) 77 (93.9) <.001
Upper primary 296 (46.8) 87 (29.4) 18 (6.1) 190 (64.4)
Secondary and 208 (33.0) 79 (38.0) 100 (48.1) 29 (13.9)
above
Missing 45 (7.1)
Baseline Mean (SD) 60.3 (10.5) 59.0 (10.1) 62.7 (10.6) 59.8 (5.0) .003
internalizing score
Baseline Mean (SD) 51.7 (9.9) 49.8 (8.5) 51.6 (9.0) 52.9 (4.8) .005
externalizing score
Baseline total score Mean (SD) 55.6 (11.0) 53.1 (10.2) 56.6 (10.6) 56.4 (5.1) .002

Experiment Group 1, Life skills and psychoeducation; Experiment Group 2, Psychoeducation only; Control, Treatment as usual.

Table 2. Reduction of scores (crude and imputed if missing) internalizing, externalizing, and total problems at 3, 6, and 9 months. Values
are means (95% CI)

Experimental 1 Experimental 2 Control

(Psychoeducation (Psychoeducation (Treatment as
Syndromes and life skills) alone) usual)

Mean reduction of scores at 3 months

Internalizing imputeda 7.12 (5.6–8.6)** 7.10 (5.3–8.9)** 3.52 (2.3–4.8)**
Internalizing complete cases onlyb 7.10 (5.5 to 8.7)** 7.03 (4.8 to 9.3)** 2.85 (1.5 to 4.3)**
Externalizing imputeda 2.82 ( 4.2 to 1.5)** 4.40 ( 5.9 to 2.9)** 4.26 ( 5.4 to 3.1)**
Externalizing complete cases onlyb 3.43 ( 4.9 to 2.0)** 5.13 ( 7.0 to 3.3)** 4.42 ( 5.8 to 3.1)**
Total problems imputeda 1.65 (0.2 to 3.1)* 0.62 ( 1.0 to 2.2) 0.58 ( 1.9 to 0.7)
Total problems complete cases onlyb 1.71 (0.1 to 3.3)* 0.34 ( 1.7 to 2.3) 0.64 ( 2.1 to 0.8)
Mean reduction of scores at 6 months
Internalizing imputeda 4.53 (3.0 to 6.1)** 2.92 (1.2 to 4.7)** 4.93 (3.7 to 6.2)**
Internalizing complete cases onlyb 4.22 (2.4 to 6.1)** 2.72 ( 0.2 to 5.6) 4.55 (3.0 to 6.1)**
Externalizing imputeda 2.54 (1.2 to 3.9)** 1.69 ( 0.1 to 3.5) 2.29 ( 3.6 to 1.0)**
Externalizing complete cases onlyb 2.14 (0.4 to 3.8)* 2.07 ( 0.5 to 4.6) 2.77 ( 4.3 to 1.2)**
Total problems imputeda 4.45 (2.9 to 6.0)** 2.71 (0.9 to 4.5)* 1.47 (0.2 to 2.8)*
Total problems complete cases onlyb 4.33 (2.5 to 6.2)** 2.87 (0.0 to 5.7)* 1.83 (0.3 to 3.4)*
Mean reduction of scores at 9 months
Internalizing imputeda 6.04 (4.2 to 7.9)** 5.18 (3.2 to 7.2)** 4.90 (3.3 to 6.5)**
Internalizing complete cases onlyb 4.70 (2.4 to 7.0)** 4.69 (1.5 to 7.9)* 5.38 (3.5 to 7.3)**
Externalizing imputeda 0.63 ( 1.0 to 2.3) 1.16 ( 0.6 to 2.9) 1.88 (0.2 to 3.6)*
Externalizing complete cases onlyb 0.87 ( 1.0 to 2.7) 0.80 ( 1.8 to 3.4) 2.72 (0.8 to 4.6)*
Total problems imputeda 6.01 (4.2 to 7.8)** 5.35 (3.3 to 7.4)** 5.24 (3.5 to 7.0)**
Total problems complete cases onlyb 4.34 (2.2 to 6.5)** 4.05 (1.0 to 7.1)* 5.31 (3.3 to 7.4)**
a
Primary analysis.
b
Sensitivity analysis.
*p < .05 (paired t-test from baseline); **p < .001 (paired t-test from baseline).

significant, F(2,630) = 6.72, p < .001 for internalizing
problems; F(2,630) = 23.42, p < .001 for externalizing
problems; F(2,630) = 19.01, p < .001 for total problems
and class category; F(2,630) = 4.91 p = .008 for exter-
nalizing problems; and F(2,630) = 5.82 p = .003 for total
problems. Post hoc multiple comparison using
Bonferroni revealed significant differences between
specific interventions.
The estimated marginal means were comparable
between Experimental Group 1 (50.09) and Experimental
Group 2 (52.86), p = .063; but there were significant dif-
ferences between the estimated marginal means of

© 2017 Association for Child and Adolescent Mental Health.

 356
Victoria Mutiso et al.

Table 3. Differences in scores reduction at 3, 6, and 9 months between the intervention and control groups

3 Months 6 Months 9 Months

Crude Adjusted Crude Adjusted Crude Adjusted

Mean Mean Mean Mean Mean Mean

Intervention difference differencea difference differencea difference differencea
Score group (95% CI) p-Value (95%CI) p-Value (95% CI) p-Value (95%CI) p-Value (95% CI) p-Value (95%CI) p-Value

Internalizing Experimental 4.38 ( 6.39 .000 5.79 ( 7.96 .000 0.39 ( 2.45 .712 0.60 ( 2.80 .594 1.92 ( 3.90 .057 1.75 ( 4.14 .148
Group 1 to 2.37) to 3.62) to 1.67) to 1.61) to 0.06) to 0.63)
Experimental 0.72 ( 2.77 .488 4.97 ( 7.73 .000 4.86 (2.77 .000 2.97 (0.16 .038 2.58 (0.57 .012 2.99 ( 0.03 .052
Group 2 to 1.32) to 2.21) to 6.96) to 5.77) to 4.59) to 6.02)
Control Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference
Externalizing Experimental 4.54 ( 6.27 .000 4.75 ( 6.61 .000 7.92 ( 9.25 .000 8.23 ( 10.28 .000 1.84 ( 3.88 .079 3.42 ( 5.42 .006
Group 1 to 2.80) to 2.89) to 3.49) to 6.19) to 0.21) to 0.98)
Experimental 1.23 ( 3.00 .171 3.28 ( 5.63 .006 5.35 ( 3.25 .000 7.03 ( 9.61 .000 0.64 ( 2.73 .544 3.15 ( 6.15 .046
Group 2 to 0.53) to 0.92) to 3.49) to 4.44) to 1.44) to 0.06)
Control Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference
Total Experimental 5.58 ( 7.59 .000 5.44 ( 7.55 .000 6.33 ( 3.25 .000 5.57 ( 7.77 .000 4.11 ( 6.36 .000 5.27 ( 7.27 .000
problems Group 1 to 3.57) to 3.33) to 3.49) to 3.37) to 1.86) to 2.59)
Experimental 0.99 ( 3.03 .343 4.31 ( 6.97 .002 1.02 ( 3.12 .340 3.57 ( 6.34 .012 0.12 ( 2.17 .921 2.99 ( 6.36 .082
Group 2 to 1.06) to 1.65) to 1.08) to 0.80) to 2.40) to 0.39)
Control Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference

Negative difference favors intervention arm. p values adjusted to maintain overall 5% Type 1 error rate across the three groups at 95% level of confidence.
a
Adjusted for score at baseline, age, class category, gender, orphan type, and length of institutionalization.

© 2017 Association for Child and Adolescent Mental Health.

Child Adolesc Ment Health 2018; 23(4): 351–8
doi:10.1111/camh.12232
Experimental Group 1 and control (56.24), p < .001 and
between Experimental Group 2 and control, p < .026.
There were significant differences between upper primary
participants (51.57) and secondary and above partici-
pants (55.35), p = .002.
Discussion
The mean age of the participants in this study was
15 years with 46.8% of all the participants enrolled in
upper primary school (grades 4–8), and as is expected of
OVCs, some of the participants were not in age appropri-
ate classes. This is usually because of lost parental atten-
tion and care. In addition, some children might have had
to take care of surviving parent (for partial orphans) or
help with the housework, and therefore, they might not
have devoted as much time as they needed for school
work. Other social disruptions, for example, during sepa-
rations from their extended families to the streets and
the institutions of care might have resulted in joining
school at a late age, a lower academic performance and
therefore repeated classes. Other studies (Bicego, Rut-
stein, & Johnson, 2003) have also found that being
orphaned increases the chance of being in an inappropri-
ate class level with peers.
More than half of the participants (62.2%) in this
study had lived in the institutions for more than 1 year
and that there were no statistically significant differ-
ences in internalizing and externalizing problems
between the orphan types. It would appear that after
parental death, some orphans may experience emotional
and behavioral symptoms during the first year, but then
these symptoms may reduce in subsequent years as was
found in previous studies (Linda, 2000), although other
studies have found total orphans and maternal orphans
to be more at risk of experiencing emotional and behav-
ioral problems compared with other types of orphans
(Baar & Webb, 2008; Zhao et al., 2010). The co-occur-
rence of emotional and behavioral problems in this vul-
nerable group is common as documented in an earlier
article by the same authors (Mutiso et al., 2016) and in
other studies (Puffer et al., 2012).
Our study revealed a statistically significant reduction
in total problems in the group that received a combina-
tion of life skills training and psychoeducation. Simi-
larly, other studies found significant positive outcomes
on participants who received similar interventions (Bon-
hauser et al., 2005; Caldwell, Patrick, Smith, Palen, &
Wegner, 2010), self-esteem increased in the study group
as compared with the control group after life skills train-
ing (Barry, Clarke, Jenkins, & Patel, 2013). The fact that
there was a significant reduction in the scores for exter-
nalizing, internalizing, and total problem scores in both
intervention arms as compared with the control arm at
3 months confirms that indeed life skills training and
psychoeducation has great potential for wide applica-
tion, not only in schools where most of these interven-
tions have been found effective (Agberotimi et al., 2015;
Babaei & Cheraghali, 2016) but also among children in
institutions of care. However, it is important to note that
combination of life skills training and psychoeducation
led to the highest improvement in syndrome scores
compared with psychoeducation alone. Therefore, based
on the high prevalence of mental disorders and co-occur-
© 2017 Association for Child and Adolescent Mental Health.
Effectiveness of life skills education 357
ring disorders among the orphans and vulnerable chil-
dren in these institutions (Mutiso et al., 2016), there is
an urgent need to develop a care package that incorpo-
rates life skills training and psychoeducation as a prior-
ity in order to holistically promote the mental well-being
of the children in these institutions. In the context of
resource-strained countries like Kenya and other LMICs
where there is still a huge mental health treatment gap
for child and adolescent mental health (Patel, 2007),
these findings add to the evidence base that life skills
and psychoeducation package is an effective package
even among the institutionalized children.
This study had a number of limitations; all the partici-
pants who were randomized to a specific arm were given
the same intervention hence the quasi-experimental
design. Also it was difficult to identify the specific cir-
cumstances each participant was exposed to either prior
to or during the study period (especially when relying on
self-reports). Further the group that recorded the high-
est improvements in syndrome scores had received a
combined package of life skills and psychoeducation, as
such we were not able to test the individual components
so as to ascertain which one would be the most effective.
Conclusions
Despite the gap that exists and paucity of research in
this area, this article provides the foundation for further
research to confirm or refute these findings. The evi-
dence demonstrated in this article shows that effective
psychosocial interventions for young people in institu-
tions of care produce positive emotional and behavioral
outcomes. These interventions can be delivered within
the institutions of care and by trained caregivers. These
findings also confirm that institutionalization is not
entirely detrimental to child development but may pro-
vide a healthy environment while the child is on transi-
tion to either foster care or other forms of care. Further
research is, however, needed to examine the effective-
ness of individual components of the intervention pack-
age and any contextual factors that may affect their
delivery and efficacy.
Acknowledgements
This work is based on a PhD Thesis in Clinical Psychology by
the first author at the Department of Psychiatry, University of
Nairobi, and supervised by David Ndetei, Muthoni Mathai, and
Kamaldeep Bhui. It was funded by the Africa Mental Health
Foundation Research Support Fund. The authors have declared
that they have no potential or competing conflicts of interest.
Ethical information
Ethical approval was obtained from the Kenyatta National
Hospital/University of Nairobi Research and Ethics Com-
mittee. Informed consent was sought from guardians and
the institutional heads, assent was sought from the poten-
tial participants with the right to withdraw at any time.
Correspondence
Victoria Mutiso, Africa Mental Health Foundation, P.O.
Box 48423-00100, Nairobi, Kenya. Email: vmuti-
so@amhf.or.ke
358 Victoria Mutiso et al.
Supporting information
Additional Supporting Information may be found in the online
version of this article:
Appendix S1. Questions and training given to participants.
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Accepted for publication: 30 May 2017
Published online: 25 July 2017
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