CHILD AND FAMILY

1
CHILD AND FAMILY DISASTER RESEARCH TRAINING AND
EDUCATION
CHILD AND FAMILY DISASTER RESEARCH TRAINING AND
EDUCATION
CHILD FAMILY DISASTER MENTAL HEALTH RESEARCH
TRAINING EDUCATION
2
Federal Sponsors

• NIMH
• National Institute of Mental Health
• NINR
• National Institute of Nursing Research
• SAMHSA
• Substance Abuse and Mental Health Services
  Administration

3
Principal Investigators

• Betty Pfefferbaum, MD, JD University of Oklahoma
  Health Sciences Center
• Alan M. Steinberg, PhD University of California,
  Los Angeles
• Robert S. Pynoos, MD, MPHUniversity of
  California, Los Angeles
• John Fairbank, PhDDuke University

4
Childrens Psychosocial Services in Disasters

• Gil Reyes, PhD
• Associate Dean for Clinical Training at Fielding
  Graduate University

5
Learning Objectives

• Upon completion of this Module, participants will
  be able to

• Recognize the current status and limitations of
  child
• disaster mental health services and
  interventions
• Describe the goals and elements of psychological
  first aid and other early interventions
• Identify the reasons screening is needed after
  disasters
• Describe the rationale for providing child
  disaster
• mental health interventions in schools

6
Services
7
Types of Services

• Educational Interventions
• Pre-disaster preparedness
• Red Cross Masters of Disaster
• Injury prevention
• Coping self-efficacy
• Stress-inoculation
• Post-disaster coping education
• Mastery of reactions
• Verbal group processing of reactions and coping
• Class-room projects
• Coloring books

Reyes et al. 2005
8
Types of Services

• Crisis Intervention
• Psychological First Aid (e.g., Pynoos Nader,
  1988)
• Establishing rapport and comforting presence
• Protecting and reassuring
• Mobilizing support
• Connecting with significant others
• Crisis Hotlines (e.g., Ponton Bryant, 1991)
• Suicide prevention
• Substance abuse intervention
• Coping assistance
• Often operate indirectly through parenting
  assistance

Reyes et al. 2005
9
Types of Services

• Crisis Intervention (continued)
• Psychological debriefing (e.g., Stallard Law,
  1993)
• Adapted from adult format (e.g., CISD)
• Verbal group processing of reactions and coping
• 1 or 2 lengthy (e.g., 3 hr.) group sessions
• Share perceptions, thoughts, and feelings about
  the event
• Reflect on treatment theyd received
• Explore psychological effects of traumatic
  experiences
• Discuss problems and methods of coping
• Normalize response similarities

Reyes et al. 2005
10
Types of Services

• Crisis Intervention (continued)
• Caregiver Support
• Parenting support
• Informational support
• Coping support
• Respite care
• Disaster Childcare
• Critical Response Childcare (aviation events and
  terrorism)

Reyes et al. 2005
11
Types of Services

• Community Outreach
• Mobilization, Consultation, and Capacity-Building
• Political and Social Leaders
• Primary Healthcare Systems
• Pediatric facilities and providers
• Mental Health Systems
• Community mental health centers
• Public and private provider networks
• Childcare facilities and providers
• Schools
• Teacher and other personnel education
• Screening
• Direct education of students

Reyes et al. 2005
12
Types of Services

• Group Interventions
• General emphasis groups
• Addressing fears and concerns
• Stress management education
• Coping education and modeling
• Issue oriented groups
• Grief groups (Saltzman et al. 2001)

Reyes et al. 2005
13
Recommendations

• National Initiatives modeled after the National
  Child Traumatic Stress Network
• Raise the profile and priority of childrens
  psychosocial needs following potentially
  traumatic events.
• Improve dissemination of accurate and useful
  information and training.
• Developing a National Public Health Model for
  disaster mental health
• Address and redress the existing inadequacies
  (surge capacity).
• Emphasize population level preventive efforts.
• De-emphasize immediate direct clinical
  intervention.
• Define and incorporate key roles for
  pediatricians, schools, and other systems of care
  for children (not mental health specific).
• Coordinate efforts across multiple disaster
  systems of care.

Reyes et al. 2005
14
Recommendations

• Develop culturally sensitive and appropriate
  approaches for serving a diverse range of
  communities
• Recognize subtle cultural differences and how
  they inform differential responsiveness to a
  generalized model of care.
• Adapt generalized models of care in collaboration
  with key cultural informants.
• Dont assume that proximity or similarity confer
  equivalency.
• Living nearby
• Looking alike
• Migrating from the same country, region, or
  continent
• Sharing a salient demographic characteristic
• Age
• Gender
• Sexual orientation

Reyes et al. 2005
15
Public Mental Health Approach

• Pynoos, Goenjian, Steinberg, 1998

16
Organization

• Sources of population-based mental health
  interventions for children involve three levels
  of organization
• Governmental and Social Institutions
• Mobilization of public, private, and volunteer
  resources
• Educational Systems
• Healthcare Systems
• Mental Health Systems
• School-based services
• Community-based intervention teams

Pynoos et al. 1998
17
Components

• Screening
• Triage and assessment
• Traumatic exposure (objective and subjective)
• Loss exposure
• Acute difficulties
• Ongoing adversities
• Traumatic reminders
• Recent traumatic exposure or loss (one year)
• Current levels of distress
• Mental health interventions

Pynoos et al. 1998
18
Guidelines

• Augment childrens self-report with other
  sources
• Parent reports
• Teacher reports
• Conduct periodic screening to track the course of
  recovery
• Surveillance for more than trauma
• Depression
• Adverse circumstantial stressors
• Choose continuous scales over categorical
  decisions
• Use results to promote effective dedication of
  mental health resources where most needed
• Example of school-based services

Pynoos et al. 1998
19
Disaster Mental Health Services for Children

• Covell et al. 2006
• Hoven et al. 2002
• Stuber et al. 2002
• Fairbrother et al. 2004
• Pfefferbaum et al. 2003

20
September 11 Project Liberty Services

• 753,015 service logs (inception through 2003)
• Group education
• Individual (including family) counseling
• Agencies
• Large and small mental health agencies
• Consumer-run organizations
• Faith-based social service agencies
• Agencies serving particular ethnic, cultural, or
  racial groups

Covell et al. 2006
21
Project Liberty Services for Children 1

• 15 of service logs for first and follow-up
  visits were for children either individually or
  in family counseling
• 9 of first visits were for children
• Significantly fewer than represented in census
  data
• 69 of first visits for children were for those
  aged 12 to 17 years
• 41 of first visits for children were provided in
  schools
• Children were more likely than adults to receive
  follow-up visits

Covell et al. 2006
22
Project Liberty Services for Children - 2

• Elementary school children were more likely than
  older (12-17 yr) children to exhibit
• Isolation and withdrawal
• Anxious and fearful reactions
• Concentration difficulties
• Older children more similar to adults and more
  likely than younger children to exhibit
• Avoidance and numbing reactions
• Abuse of substances
• Possible major depressive disorder and PTSD
  appeared to increase with age

Covell et al. 2006
23
September 11 School-based Study
2/3 of children with PTSD and impaired
functioning had not sought treatment 6 months
after the attacks
Representative sample of gt 8000 students in
grades 4-12 6 months after the attacks
Hoven et al. 2002
24
September 11 Counseling
22 received counseling 58 of those receiving
counseling received them at school
Telephone survey of 112 parents in lower
Manhattan 5-8 weeks after incident
Stuber et al. 2002
10
25
September 11 Counseling
10 received counseling 44 in schools
Of those receiving counseling 47 had severe or
very severe posttraumatic stress 50 had
moderate posttraumatic stress 3 had mild
posttraumatic stress1/3 had received counseling
before 9/11
NYC parents 4-5 months after incident
Fairbrother et al. 2004
26
Early Psychological Interventions

• NIMH 2002
• APA 1954
• Everly and Flynn 2006
• NCTSN and NCPTSD 2006
• ARC
• IFRC

27
Early Psychological Interventions

• Recommendations from
• Mental Health and Mass Violence Evidence-Based
  Early Psychological Intervention for
  Victims/Survivors of Mass Violence. A Workshop to
  Reach Consensus on Best Practices
• (NIMH 2002)

28
Hierarchy of Needs

• Early assessment and intervention should focus on
  a hierarchy of needs
• Survival
• Safety
• Security
• Food
• Shelter
• Health (physical and mental)
• Triage
• Orientation (to immediate service needs)
• Communicate with family, friends, and community
• Other forms of psychological first aid

NIMH 2002
29
Assumptions and Principles

• In the immediate post-event phase, expect normal
  recovery
• Presuming clinically significant disorder in the
  early post-event phase is inappropriate except in
  those with a pre-existing condition

NIMH 2002
30
Key Aspects of Early Intervention

• Psychological first aid
• Needs assessment
• Monitoring the recovery environment
• Outreach and information dissemination
• Technical assistance, consultation, and training
• Fostering resilience, coping, and recovery
• Triage
• Treatment

NIMH 2002
31
Technical Assistance, Consultation, and Training

• Improve capacity of organizations and caregivers
  to provide what is needed to
• Reestablish community structure
• Foster family recovery and resilience
• Safeguard the community
• Provide assistance, consultation, and training to
  relevant organizations, other caregivers and
  responders, and leaders

NIMH 2002
32
Monitor Rescue and Recovery Environment

• Observe and listen to those most affected
• Monitor the environment for toxins and stressors
• Monitor past and ongoing threats
• Monitor services that are being provided
• Monitor media coverage and rumors

NIMH 2002
33
Outreach and Information Dissemination

• Offer information/education and therapy by
  walking around
• Use established community structures
• Distribute flyers
• Host websites
• Conduct media interviews and programs and
  distribute media releases

NIMH 2002
34
Fostering Resilience and Recovery

• Foster but do not force social interactions
• Provide coping skills training
• Provide risk assessment skills training
• Provide education on
• Stress responses
• Traumatic reminders
• Coping
• Normal versus abnormal functioning
• Risk factors
• Services
• Offer group and family interventions
• Foster natural social supports
• Care for the bereaved
• Repair organizational fabric

NIMH 2002
35
Needs Assessment

• Assess current status of
• Individuals
• Groups
• Populations
• Institutions/systems
• Ask
• How well needs are being addressed
• What the recovery environment offers
• What additional interventions are needed

NIMH 2002
36
Triage

• Conduct clinical assessments using valid and
  reliable methods
• Refer when indicated
• Identify vulnerable, high-risk individuals and
  groups
• Provide for emergency hospitalization

NIMH 2002
37
Treatment

• Reduce or ameliorate symptoms or improve
  functioning through
• Individual, family, and group psychotherapy
• Pharmacotherapy
• Short- or long-term hospitalization

NIMH 2002
38
Follow-up

• Follow-up should be offered to those at risk of
  developing adjustment difficulties including
  those
• Who have ASD or clinically significant symptoms
• Who are bereaved
• Who have preexisting psychiatric disorder
• Who have required medical or surgical attention
• Whose exposure was intense and of long duration
• Who request it

NIMH 2002
39
Expertise, Skills and Training for Providers of
Early Intervention

• Providers must
• Practice within the scope of their expertise and
  education
• Practice within the structure responsible for
  coordinating the response
• Make referrals when appropriate
• Avail themselves of training

NIMH 2002
40
Research and Evaluation

• The scientific community has an obligation to
  examine the relative effectiveness of early
  interventions
• A national strategy should be developed to ensure
  that adequate resources are available for
  research
• A standard taxonomy and terminology are needed
  for program evaluation to identify
• The most significant variables to monitor
• Post-event physical and psychosocial environment
• Subgroups of the affected population including
  responders
• Mental health interventions that are provided
• Characteristics of those deemed the most
  appropriate providers
• The broader research community should be informed
  of need for research

NIMH 2002
41
Key Research Questions

• What ethical issues are introduced by widespread
  use of unproven interventions?
• How acceptable is research to potential subjects?
• What is the best process for seeking informed
  consent what information should be given in the
  consent process?
• Can a standard taxonomy and terminology be
  developed?
• How effective is public education?
• Is screening in itself an effective intervention?
• Can screening cause harm if so, what is the
  nature of the harm and is the risk offset by risk
  of failing to screen?
• Is it acceptable to screen if care is not
  provided or accessible?
• How feasible are studies of early interventions ?
• How can clinical demand be balanced with
  inadequacies in the empirical evidence-base?

NIMH 2002
42
Psychological First Aid

• Goals
• Should be concerned only with the immediate
  situation.
• Restore people to reasonably good functioning.
• Make people as comfortable as possible until more
  complete care can be arranged.
• Five types of reactions
• Normal reactions to stress (transient states, not
  to be confused with abnormal adjustment).
• Panic (a rare, but contagious risk).
• Immobility or numb detachment.
• Hyperactivity and over confidence (hypomanic).
• Somatic complaints.
• Four principles of care
• Accept peoples right to their own feelings
• Accept a persons limitations as real.
• Size up a casualtys potentialities as accurately
  and quickly as possible.
• Accept your own limitations in a relief role.

American Psychiatric Association 1954
43
Psychological First Aid

• Protect survivors from further harm
• Reduce physiological arousal
• Mobilize support for those who are most
  distressed
• Keep families together and facilitate reunions of
  loved ones
• Provide information and foster communication and
  education
• Use effective risk communication techniques

NIMH 2002
44
Principles and practical procedures for acute
psychological first aid training for personnel
without mental health experience.

• Physical First Aid
• Stabilize physiological functioning
• Mitigate physiological distress and dysfunction
• Achieve return to acute adaptive physiological
  functioning
• Facilitate access to next level of care

• Psychological First Aid
• Stabilize psychological and behavioral
  functioning by meeting physical needs and then
  addressing psychological needs
• Mitigate psychological distress and dysfunction
• Achieve return to acute adaptive psychological
  and behavioral functioning
• Facilitate access to continued care

Everly Flynn 2006
45
Psychological First Aid

• Several organizations have developed manuals to
  guide the delivery of psychological first aid
• International Federation of Red Cross and Red
  Crescent Societies
• American Red Cross
• National Child Traumatic Stress Network and
  National Center for PTSD

46
International Federation of Red Cross and Red
Crescent Societies (IFRC) PFA - Modules

• Community-based Psychological Support (PFA)
• Stress Responses and Coping Skills
• Developing Supportive Communication
• Promoting Community Self-help
• Caring for Populations with Special Needs
• Helping the Helper

IFRC, 2003
47
American Red Cross (ARC) PFA - Actions

• Psychological first aid actions
• Make a connection
• Help people be safe
• Be kind, calm, and compassionate
• Meet peoples basic needs
• Listen
• Give realistic reassurance
• Encourage good coping

ARC, 2006
48
NCTSN and NCPTSD PFA Core Actions and Goals - 1

• Contact and engagement
• To respond to contacts initiated by survivors, or
  initiate contacts in a non-intrusive,
  compassionate, and helpful manner
• Safety and comfort
• To enhance immediate and ongoing safety and
  provide physical and emotional comfort
• Stabilization
• To calm and orient emotionally overwhelmed or
  disoriented survivors
• Information gathering current needs and concerns
• To identify immediate needs and concerns, gather
  additional information, and tailor PFA
  interventions

NCTSN NCPTSD 2006
49
NCTSN and NCPTSD PFACore Actions and Goals - 2

• Practical assistance
• To offer practical help to survivors in
  addressing immediate needs and concerns
• Connection with social supports
• To help establish brief or ongoing contacts with
  primary support persons or other sources of
  support, including family members, friends, and
  community helping resources
• Information on coping
• To provide information about stress reactions and
  coping to reduce distress and promote adaptive
  functioning
• Linkage with collaborative services
• To link survivors with available services needed
  at the time or in the future

NCTSN NCPTSD, 2006
50
Screening

• Limitations and Rationale for Child Screening

51
Reasons Screening Needed

• Adults may not recognize or acknowledge
  childrens reactions and needs
• Identify need for services
• Focus limited services on those with greatest
  need

Stallard et al. 1999
52
Adults May Underestimate Childrens Distress

• Concordance between parent- and child-report of
  disaster reactions is low
• Children do not want to burden parents
• Parents deny problems in children
• Parental distress decreases ability to identify
  child suffering

McDermott Palmer 1999
53
Screening

• May increase communication about childrens
  reactions and concerns
• May facilitate service delivery decisions and the
  appropriate use of scarce resources
• May increase the demand for services

McDermott Palmer 1999
54
Potential Problems With Screening

• False positives may result in
• Unnecessary treatment with attendant cost and
  inconvenience
• Inappropriate labeling of children
• Focus on illness behavior
• False negatives may create a barrier to later
  care-seeking

McDermott Palmer 1999
55
Value of Screening - 1

• Simplicity
• Easy to administer
• Administered by paraprofessional
• Acceptability
• Acceptable to those being screened usually
  voluntary
• Accuracy
• True measure of what is being assessed

Cochrane and Holland 1971
13
56
Value of Screening - 1

• Expense
• Cost is reasonable in relation to benefit of
  early detection
• Precision (Repeatable)
• Consistent results in repeated trials
• Sensitivity
• Test is positive when the condition is present
• Specificity
• Test is negative when the condition is not present

Cochrane and Holland 1971
13
57
Interventions
58
Psychoeducation and Supportive Group Therapy

• Galante and Foa 1986

59
Elementary School Children Exposed to Earthquake
in Italy

• Three phase process
• Pretest at 6 months
• Treatment with children in village with largest
  number of children at risk according to pretest
• Posttest at 18 months

Galante Foa 1986
60
Treatment Sample and Program

• Sample
• All grade 1-4 students in village with largest
  number of children at risk
• Techniques included
• Normalizing reactions
• Projective techniques
• Psychoeducation
• Review of death, funerals, and the future
• Survival techniques

Galante Foa 1986
61
Session Objectives and Activities

• Communicate about the event
• Draw and listen to stories about San Franciscos
  recovery
• Discuss fears and demonstrate that fear was
  common
• Draw and listen to story about frightened child
  too shy to ask for help
• Discuss drawings and feelings including what they
  did when afraid
• Discuss myths and beliefs about earthquakes
• Draw and listen to story about child fearful that
  the earthquakes would recur
• Discuss beliefs
• Discharge feelings about the earthquake and place
  earthquake in the past
• Make joint drawing of the community
• Focus on what children did to resume a normal
  life after the earthquake
• Release the power of death images and focus on
  the future
• Role play and funeral rituals
• Discuss the future of a new village
• Develop the idea that children can take an active
  role in their own survival
• Role play being parents teaching children to
  survive various emergencies
• Raise topics associated with closure
• Free drawing and discussion

Galante Foa 1986
62
Change in Risk Scores
Galante Foa 1986
63
Psychosocial Intervention After Hurricane Iniki

• Chemtob et al. 2002

64
Methods

• Sample
• 4258 children in grades 2 6 from all 10 public
  elementary schools on island of Kauai (91 of the
  enrolled children) were screened to identify
  children for the intervention study
• 248 children met criteria for treatment and were
  randomly assigned to
• Group (176 children)
• Individual (73 children)
• 214 completed treatment
• Methods
• 2 years after hurricane, children with highest
  levels of trauma symptoms were randomly assigned
  to 1 of 3 consecutively treated cohorts
• Children in the cohorts awaiting treatment served
  as wait-list controls
• Within each cohort, children were randomly
  assigned to either individual or group treatment
  to allow comparison of the efficacy of the two
  treatment modalities
• Instruments
• Reaction Index
• Semi-structured interview

Chemtob 2002
65
Sample
Chemtob et al. 2002
66
Treatment Eligible Sample

• Demographics
• 6 to 12 years of age (mean 8.2, SD 1.3)
• Race/ethnicity
• Hawaiian/part-Hawaiian 30
• White 25
• Filipino 20
• Japanese 9
• Compared to all screened children, treatment
  eligible children were more likely to
• Fear death or injury to self
• Fear death or injury to family
• Have more intense fear reactions to hurricane
• Be girls
• Be poor

Chemtob et al. 2002
67
Intervention

• Groups included 4 to 8 children
• Manual-based intervention with 4 weekly sessions
  using protocols that outlined session content and
  activities to elicit relevant material
• Session 1 safety and helplessness
• Session 2 loss
• Session 3 mobilizing competence and anger
• Session 4 ending and going forward

Chemtob 2002
68
Results
Post-treatment lt Pre-treatment Follow-up (1 year)
lt Pre-treatment but not Post-treatment
Group and individual treatments did not differ in
efficacy Fewer children dropped out of group
treatment
Chemtob et al. 2002
69
Clinician Ratings
Random sample of 21 treated and 16 untreated
p .01
Chemtob et al. 2002
70
Cognitive Behavioral Group Psychotherapy

• March et al. 1998

71
Sample and Design

• 14 participants with PTSD completed treatment
• 10 to 15 years of age
• Single-incident stressor
• 10 had 2 or more stressors
• Recruited through schools
• 18 weekly group sessions
• Single case across setting design

March et al. 1998
72
Status at Initiation of Treatment

• As a group, at the start of treatment,
  participants experienced mild to moderately
  severe
• PTSD
• Anxiety
• Depression
• Children with severe disruptive behavior were
  excluded
• Average duration of PTSD symptoms was
• 1.5 years for younger participants
• 2.5 years for older participants
• None had received mental health treatment
• Most were doing reasonably well in school

March et al. 1998
73
Improvement
Significant group differences occurred early and
persisted None relapsed
March et al. 1998
74
Outstanding Issues

• The study did not ascertain
• If CBT was unique in its effectiveness
• Which specific aspects of the intervention were
  responsible for outcomes
• If results would extend to children with more
  severe illnesses or comorbid conditions

March et al. 1998
75
Trauma/Grief Focused Group Psychotherapy

• Goenjian et al. 1997

76
Trauma/Grief Focused Group Psychotherapy After
Earthquake

• Early adolescents in severely damaged schools
  after a massive Armenian earthquake
• 35 students received intervention
• 29 students received no therapy
• Intervention
• Delivered over a 6 week period 1.5 years after
  earthquake
• Included
• 4 ½-hour group sessions in classroom
• an average of 2 1-hour individual sessions
• Focused on
• Trauma
• Traumatic reminders
• Post disaster stresses and adversities
• Bereavement and the interplay of trauma and grief
• Developmental impact

Goenjian et al. 1997
77
Results

• Treated group
• Improved in posttraumatic stress
• No worsening in depression
• Non-treated group
• Worsening in posttraumatic stress
• Worsening in depression
• Treatment benefits did not appear transient and
  were evident 1.5 years after the intervention

Goenjian et al. 1997
78
Posttraumatic Stress after Treatment
Severity decreased in treated Severity increased
in not treated
1.5 Years No difference between treated and
non-treated groups 3 Years Treated lt
non-treated group 3 Years Treated 3-year
score lt pretreatment 3 Years Not treated
3-year score gt 1.5-year score
Goenjian et al. 1997
79
Depression after Treatment
Severity did not change in treated Severity
increased in not treated
1.5 years No difference between treated and
non-treated groups 3 years Treated lt
non-treated 3 years Treated no change from
1.5 years 3 years Non-treated score increased
from 1.5 years
Goenjian et al. 1997
80
Implications

• Treatment may prevent worsening of posttraumatic
  stress and depression
• Worsening in posttraumatic stress may be due to
  reminders treatment may have decreased
  reactivity to reminders
• Increased severity of depression may have been
  due to
• Increased severity of posttraumatic stress
• Persistent severe posttraumatic stress
  interfering with grief resolution
• Difficulty coping with secondary adversities

Goenjian et al. 1997
81
Cognitive-Behavioral Therapy for Childhood
Traumatic Grief

• Stubenbort et al. 2001
• Cohen et al. 2004
• Cohen et al. 2006

82
Group CBT for Bereaved Children

• Sample 12 children (aged 5 12 years) and 18
  adults some parents of the children
• Event Airplane crash with dramatic media
  portrayals of the event
• Intervention 7 weeks of treatment with parallel
  child and adult groups

Stubenbort et al. 2001
83
Intervention Sessions

• Introduction, definition, group treatment rules
• Psychoeducation to normalize the experience and
  increase coping skills
• Coping with traumatic death
• Strengthening group cohesion by exploring loss
  and unfinished business
• Continuing to explore loss and unfinished
  business
• Increasing coping skills
• Closure and moving on

Stubenbort et al. 2001
84
Methods

• Sample
• 22 children (aged 6-17 years) with significant
  child traumatic grief and posttraumatic stress
  disorder symptoms
• Childrens primary caretakers
• Intervention
• 16 week manual-based individual treatment with
  sequential trauma- and grief-focused components
• 2 joint parent-child sessions in each module
• Design open uncontrolled treatment design

Cohen et al. 2004
85
Intervention Components

• Trauma-focused components
• Improve affective modulation and stress reduction
  (sessions 1 to 4)
• Trauma-specific exposure and cognitive processing
  (sessions 5 to 8)
• Grief-focused components
• Naming and accepting the loss (sessions 9 to 12)
• Preserving positive memories and making meaning
  of the loss (sessions 13 to 16)
• Two joint parent-child sessions in each module

Cohen et al. 2004
86
Results
PTSD symptoms improved during the trauma-focused
component Grief improved during the trauma- and
grief-focused components





Cohen et al. 2004
p lt .001 p lt .01
87
Limitations

• Lack of a control group makes it impossible to
  determine if improvements represented treatment
  response or natural recovery
• The small sample size, with no minority children
  other than African Americans, makes it impossible
  to generalize to diverse groups

Cohen et al. 2004
88
Implications

• The study lends tentative support to the
  conceptualization of traumatic grief as the
  impingement of trauma symptoms on the normal
  grief process and to the importance of sequential
  treatment of trauma and grief
• The final four sessions addressing positive
  aspects of grieving may have contributed to grief
  resolution or grief may have resolved on its own
  once trauma symptoms were treated
• The study suggests the importance of including
  parents in treatment of children

Cohen et al. 2004
89
Teacher-mediated Intervention after 1999
Earthquake in Turkey

• Wolmer et al. 2005

90
Advantages of Locating Interventions in Schools -
1

• Disaster reactions may emerge in the context of
  school
• School settings provide access to children and
  the potential for enhanced compliance
• School personnel are familiar with, and deal
  with, situational and developmental crises
• School personnel have opportunities to observe
  children
• Schools are a natural support system where stigma
  associated with treatment is diminished
• Services in schools help normalize childrens
  experiences and reactions
• Classroom settings are developmentally-appropriate
  

Wolmer et al. 2003 Wolmer et al. 2005
91
Advantages of Locating Interventions in Schools -
2

• Classroom settings provide
• Predictable routines
• Consistent rules
• Clear expectations
• Immediate feedback
• Stimulus for curiosity and engaging learning
  skills
• School-based interventions facilitate peer
  interactions and support which may prevent
  withdrawal and isolation
• Supervision, feedback, and follow-up are possible
• School curricula already address prevention in
  other mental health areas

Wolmer et al. 2003 Wolmer et al. 2005
92
Teachers as Clinical Mediators

• Teachers may help as clinical mediators because
  they
• Occupy a central role in childrens lives
• Are trusted by children and parents
• May be amenable to being trained

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Role of Teachers

• Model childrens responses
• Provide factual information and correct rumors
• Reinforce coping skills
• Facilitate mutual support
• Identify children who are suffering
• Prepare the class for future experiences
• Encourage students to contribute to their family,
  school, and community

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Sample

• 202 displaced children
• 44 boys, 56 girls
• Mean age 8.2 years grades 1-5
• Comparison sample of 101 children 300 miles away
  who were not directly affected
• 46 boys, 54 girls
• Mean age 8.83 years

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Methods

• Teachers interviewed children individually at
  school 4 months after the earthquake and before
  any interventions
• Intervention lasted 4 weeks with 2 meetings per
  weeks
• Assessed 6 weeks after the intervention series
  was completed

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Instruments

• Traumatic Dissociation and Grief
• Grief factor
• Irritability
• Guilt/anhedonia
• Dissociative factor
• Body/self distortions
• Perceptual distortions
• Child PTSD Reaction Index
• 20 reactions
• Traumatic exposure questionnaire
• Risk index reflected extent of risk ranging from
  0 to 5

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Intervention

• Trained, supervised, and supported school
  leadership and teachers
• Intervention consisted of 8 two-hour sessions of
  psychoeducation and cognitive-behavioral
  techniques
• Teachers conducted the intervention over the
  course of 4 weeks

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Intervention Modalities

• Modalities
• Psychoeducational modules
• Cognitive-behavioral techniques
• Play activities
• Documentation in personal diaries

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Intervention Sessions

• Introductory session with parents to
• Engage them
• Provide information related to the program
• Educate them about childrens disaster reactions
• 8 two-hour sessions with children to
• Restructure traumatic experiences
• Deal with intrusive thoughts
• Establish a safe place
• Learn about the earthquake and prepare for future
  earthquakes
• Mourn the ruined city
• Control body sensations
• Confront posttraumatic dreams
• Understand reactions in the family
• Cope with loss, guilt, and death
• Deal with anger
• Extract life lessons
• Plan for the future

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Results at 6 Weeks
Trauma and dissociative symptoms decreased Grief
symptoms increased
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Increased Grief Symptoms

• Normal grief may have begun after other symptoms
  were relieved
• Interventions may not have addressed depression
  adequately
• Children may have been more comfortable
  expressing grief symptoms after the intervention

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Grief at Follow-up

• 26 children who still had moderate to severe
  posttraumatic stress were interviewed 6 months
  after treatment
• Their grief score was significantly lower at
  follow-up than post-treatment and significantly
  higher than at pre-treatment

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Severe to Very Severe Posttraumatic Stress

• The percent of children with severe to very
  severe posttraumatic stress, associated with a
  diagnosis of PTSD, decreased from 30 to 18, the
  latter similar to the 15 found in the baseline
  control sample

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Posttraumatic Stress Severity at 6 Months for
Children Who Received the Intervention

• 33.5 remained stable
• 39 decreased in severity
• 27.5 increased in severity

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Children Without Symptoms

• Reasons children without risks or without
  symptoms should participate
• Only a minority were without risk or symptoms
• Intervention had a preventive element and focused
  on rehabilitation of the whole school and intent
  to prevent children who participate from being
  labeled
• Asymptomatic children lent support to others and
  served as models for coping
• Increase in grief was moderate and significantly
  decreased 6 months later

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Three Year Follow-up of Teacher-mediated
Intervention

• Sample 287 children from 3 schools
• 9-17 years (mean 11.5)
• 67 children participated and 220 did not
  participate in the earlier intervention
• All 3 schools included both children who did and
  did not participate in the intervention
• Groups were comparable on sex, age, and risk
• Studied 3.5 years after the event with child,
  mother, and teacher (blind to which children
  participated) ratings

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Follow-up of Children Who Received the
Intervention
Significant decrease post-intervention to 3 year
follow-up
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Posttraumatic Stress Severity at 3 Years for
Children Who Received the Intervention

• 30 remained stable
• 41 decreased
• 29 increased
• 18 continued to have severe trauma symptoms

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Intervention and Comparison Group at Three Years

• No significant differences between the two groups
  at 3 years in child self-report for
• Posttraumatic stress
• Grief
• Dissociation

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Daily Functioning in Intervention and Comparison
Groups at Three Years
Intervention group had significantly higher
daily functioning in Academic performance Social
behavior General conduct
Predictors of daily functioning Functioning
before disaster Group (intervention v. no
intervention) Trauma symptoms
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Summary of Findings

• Significant trauma and dissociative symptom
  decrease and grief symptom increase 6 weeks after
  the intervention
• Significant symptom decrease over 3 years in
  posttraumatic stress, grief, and dissociation
• A large proportion of both treated and untreated
  children reported moderate 30-35) or severe
  (17-18) posttraumatic stress
• In some children, symptoms appeared within 6
  months and crystallized into the full-blown
  syndrome months or years later
• Symptom levels similar in treated and untreated
  groups at 3 years
• Teacher-rated functioning better in treated than
  untreated children
• Correlations between childrens symptoms and
  daily functioning were small and non-significant
  supporting previous findings that children can
  function despite internal struggles

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Conclusions
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Conclusions - 1

• There is some evidence that treatments
  (psychosocial, psychoeducation, CBT, EMDR) are
  effective for posttraumatic stress grief and
  depression may be especially difficult to treat
• There is some evidence for the sequential
  treatment of trauma and grief

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Conclusions - 2

• It remains unclear what elements of an
  intervention are responsible for effects
• Interventions have not been compared thus, it is
  unclear if some interventions are better than
  others
• It remains unclear if interventions are superior
  to natural recovery