CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION

1 1 1

1

Northwest Center forPublic Health Practice

CHILD AND FAMILY

DISASTER RESEARCH

TRAINING AND EDUCATION

CHILD AND FAMILYDISASTER RESEARCH

TRAINING AND EDUCATION

CHILD & FAMILYDISASTER MENTAL HEALTH

RESEARCH TRAINING & EDUCATION

2 2 2

2


Federal Sponsors

NIMH National Institute of Mental Health

NINRNational Institute of Nursing Research

SAMHSA

Substance Abuse and Mental Health Services Administration

3 3 3

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 4 4

4


Children’s Psychosocial Services in Disasters

Gil Reyes, PhD

Associate Dean for Clinical Training at Fielding Graduate University

5 5 5

5


Learning ObjectivesUpon 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 6 6

6


Services

7 7 7

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 8 8

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 9 9

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 they’d received– Explore psychological effects of traumatic experiences– Discuss problems and methods of coping– Normalize response similarities

Reyes et al. 2005

10 10 10

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 11 11

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 12 12

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 13 13

13


Recommendations• National Initiatives modeled after the National Child

Traumatic Stress Network– Raise the profile and priority of children’s 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 14 14

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.– Don’t 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 15 15

15


Public Mental Health Approach

Pynoos, Goenjian, & Steinberg, 1998

16 16 16

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 17 17

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 interventionsPynoos et al. 1998

18 18 18

18


Guidelines

• Augment children’s 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 19 19

19


Disaster Mental Health Services for Children

Covell et al. 2006Hoven et al. 2002Stuber et al. 2002

Fairbrother et al. 2004Pfefferbaum et al. 2003

20 20 20

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 21 21

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 22 22

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 23 23

23


September 11 School-based Study

32

17

36

22 22

34

0

5

10

15

20

25

30

35

40

Schoolcounselor

Outsideprofessional

Either

Ground Zero

Remainder of NYC

~ 2/3 of children with PTSD and impaired functioning had not sought treatment 6 months after the attacks

Representative sample of > 8000 students in grades 4-12

6 months after the attacks Hoven et al. 2002

24 24 24

24


September 11 Counseling

25

2121

33

0

5

10

15

20

25

30

35

% receivingcounseling

school teacher

school psychologist

psychologist/psychiatrist

social worker

22% received counseling58% of those receiving counseling received them at school

Telephone survey of 112 parents in lower Manhattan5-8 weeks after incident

10

Stuber et al. 2002

25 25 25

25


September 11 Counseling

14

30

36

20

0

5

10

15

20

25

30

35

40

% receivingcounseling

school teachers

school psychologists/counselors

mental health

religious leaders/othersNYC parents 4-5 months after incident

10% received counseling44% in schools

Of those receiving counseling47% had severe or very severe

posttraumatic stress50% had moderate posttraumatic stress

3% had mild posttraumatic stress1/3 had received counseling before 9/11

Fairbrother et al. 2004

26 26 26

26


Early Psychological Interventions

NIMH 2002APA 1954

Everly and Flynn 2006NCTSN and NCPTSD 2006

ARCIFRC

27 27 27

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 28 28

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 29 29

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 30 30

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 31 31

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 32 32

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 33 33

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 34 34

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 35 35

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 36 36

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 37 37

37


Treatment

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

NIMH 2002

38 38 38

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 39 39

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 40 40

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 41 41

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 42 42

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 people’s right to their own feelings– Accept a person’s limitations as real.– Size up a casualty’s potentialities as accurately and quickly as possible.– Accept your own limitations in a relief role.

American Psychiatric Association 1954

43 43 43

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 44 44

44


• 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

Principles and practical procedures for acute psychological first aid training for

personnel without mental health experience.

45 45 45

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 46 46

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 47 47

47


American Red Cross (ARC) PFA - Actions

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

ARC, 2006

48 48 48

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 interventionsNCTSN & NCPTSD 2006

49 49 49

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 futureNCTSN & NCPTSD, 2006

50 50 50

50


Screening

Limitations and Rationale for Child Screening

51 51 51

51


Reasons Screening Needed

• Adults may not recognize or acknowledge children’s reactions and needs

• Identify need for services

• Focus limited services on those with greatest need

Stallard et al. 1999

52 52 52

52


Adults May Underestimate Children’s 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 53 53

53


Screening

• May increase communication about children’s reactions and concerns

• May facilitate service delivery decisions and the appropriate use of scarce resources

• May increase the demand for services


54 54 54

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


55 55 55

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

13

Cochrane and Holland 1971

56 56 56

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

13

Cochrane and Holland 1971

57 57 57

57


Interventions

58 58 58

58


Psychoeducation and

Supportive Group Therapy

Galante and Foa 1986

59 59 59

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 60 60

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 61 61

61


Session Objectives and Activities• Communicate about the event

– Draw and listen to stories about San Francisco’s 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 62 62

62


Change in Risk Scores

47

34

0

5

10

15

20

25

30

35

40

45

50

% at risk

6 months18 months

Galante & Foa 1986

63 63 63

63


Psychosocial Intervention After Hurricane Iniki

Chemtob et al. 2002

64 64 64

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 65 65

65


Sample

4285 in grades 2-6

3864 (91%) screened

248 met treatment criteria

65 in cohort 164 (99%) completed

101 in cohort 285 (84% completed)

82 in cohort 365 (79% completed)

Chemtob et al. 2002

66 66 66

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 67 67

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 68 68

68


Results

46 4744 45 46

4442 42 41

3639

4138

41 40 39 40 41

0

5

10

15

20

25

30

35

40

45

50

group 1 group 2 group 3 individual 1 individual 2 individual 3

pretreatment

posttreatment

follow-up

Chemtob et al. 2002

Post-treatment < Pre-treatmentFollow-up (1 year) < Pre-treatment but not Post-treatment

Group and individual treatments did not differ in efficacy Fewer children dropped out of group treatment

69 69 69

69


Clinician Ratings

12

20

0

5

10

15

20

25

Posttraumaticstress

treated

untreated

Random sample of 21 treated and 16 untreated

Chemtob et al. 2002

p = .01

70 70 70

70


Cognitive Behavioral Group Psychotherapy

March et al. 1998

71 71 71

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 72 72

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 73 73

73


Improvement

71

19

74

4

33

12

54

2

148

45

2

0

10

20

30

40

50

60

70

80

PTSD Depression Anxiety Global

Baseline

Final

Follow-up

Significant group differences occurred early and persistedNone relapsed

March et al. 1998

74 74 74

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 75 75

75


Trauma/Grief Focused Group Psychotherapy

Goenjian et al. 1997

76 76 76

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 77 77

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


78 78 78

78


Posttraumatic Stress after Treatment

32.2

45.3 47.2

41.1

0

5

10

15

20

25

30

35

40

45

50

1.5 Years* 3 Years**

Treated

Not Treated

*1.5 Years: No difference between treated and non-treated groups**3 Years: Treated < non-treated group

**3 Years: Treated: 3-year score < pretreatment **3 Years: Not treated: 3-year score > 1.5-year score


Severity decreased in treated Severity increased in not treated

79 79 79

79


Depression after Treatment

16.816

15.3

20.2

0

5

10

15

20

25

1.5 Years* 3 Years**

Treated

Not Treated

*1.5 years: No difference between treated and non-treated groups**3 years: Treated < 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

Severity did not change in treatedSeverity increased in not treated

80 80 80

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


81 81 81

81


Cognitive-Behavioral Therapy for Childhood Traumatic Grief

Stubenbort et al. 2001

Cohen et al. 2004

Cohen et al. 2006

82 82 82

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


83 83 83

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


84 84 84

84


Methods• Sample:

– 22 children (aged 6-17 years) with significant child traumatic grief and posttraumatic stress disorder symptoms

– Children’s 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 85 85

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 86 86

86


Results

9.25

17

6.8

11.4

1.81.4

1.95

4.5

0

2

4

6

8

10

12

14

16

18

PTSD Symptoms Traumatic Grief

Pre-4 weeks

4-8 weeks

8-12 weeks

12-16 weeks

Cohen et al. 2004

*

*

**

**

* p < .001** p < .01

*

PTSD symptoms improved during the trauma-focused componentGrief improved during the trauma- and grief-focused components

87 87 87

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 88 88

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 89 89

89


Teacher-mediated Intervention after 1999 Earthquake in Turkey

Wolmer et al. 2005

90 90 90

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 children’s

experiences and reactions• Classroom settings are developmentally-appropriate

Wolmer et al. 2003;

Wolmer et al. 2005

91 91 91

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 areasWolmer et al. 2003;

Wolmer et al. 2005

92 92 92

92


Teachers as Clinical Mediators

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

Wolmer et al. 2003;

Wolmer et al. 2005

93 93 93

93


Role of Teachers

• Model children’s 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

Wolmer et al. 2003

94 94 94

94


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

Wolmer et al. 2003

95 95 95

95


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

Wolmer et al. 2003

96 96 96

96


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

Wolmer et al. 2003

97 97 97

97


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

Wolmer et al. 2003;

Wolmer et al. 2005

98 98 98

98


Intervention Modalities

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

Wolmer et al. 2003

99 99 99

99


Intervention Sessions• Introductory session with parents to

– Engage them– Provide information related to the program– Educate them about children’s 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 Wolmer et al. 2003

100 100 100

100


Results at 6 Weeks

32

18

13

28

22

12

0

5

10

15

20

25

30

35

Trauma Grief Dissociation

Before

After

Trauma and dissociative symptoms decreasedGrief symptoms increased

Wolmer et al. 2003

101 101 101

101


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

Wolmer et al. 2003

102 102 102

102


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

20

17

23

0

5

10

15

20

25

Pre-treatment

Post-treatment

Follow-up

Grief

Wolmer et al. 2003

103 103 103

103


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

Wolmer et al. 2003

104 104 104

104


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

Wolmer et al. 2003

105 105 105

105


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

Wolmer et al. 2003

106 106 106

106


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

Wolmer et al. 2005

107 107 107

107


Follow-up of Children Who Received the Intervention

30

23

13

24

10

4

0

5

10

15

20

25

30

35

Posttraumaticstress

Grief Dissociation

Post-intervention

3 Year Follow-up

Significant decrease post-intervention to 3 year follow-up

Wolmer et al. 2005

108 108 108

108


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

Wolmer et al. 2005

109 109 109

109


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

Wolmer et al. 2005

110 110 110

110


Daily Functioning in Intervention and Comparison Groups at Three Years

4.3

3.3

3.83.9

4.1

3.8

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Academicperformance

Socialbehavior

Generalconduct

Intervention

Comparison

Intervention group had significantly higher daily functioning in:

Academic performanceSocial behaviorGeneral conduct

Wolmer et al. 2005

Predictors of daily functioning:Functioning before disaster

Group (intervention v. no intervention)Trauma symptoms

111 111 111

111


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 children’s symptoms and daily functioning were

small and non-significant supporting previous findings that children can function despite internal struggles

Wolmer et al. 2003;

Wolmer et al. 2005

112 112 112

112


Conclusions

113 113 113

113


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

114 114 114

114


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

CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION

Documents

Transcript of CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION