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CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION. CHILD AND FAMILY DISASTER RESEARCH TRAINING AND EDUCATION. CHILD & FAMILY DISASTER MENTAL HEALTH RESEARCH TRAINING & EDUCATION. Federal Sponsors. NIMH National Institute of Mental Health NINR

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slide1

CHILD AND FAMILY

DISASTER RESEARCH

TRAINING AND EDUCATION

CHILD AND FAMILY

DISASTER RESEARCH

TRAINING AND EDUCATION

CHILD & FAMILY

DISASTER MENTAL HEALTH RESEARCH TRAINING & EDUCATION

federal sponsors
Federal Sponsors

NIMH

National Institute of Mental Health

NINR

National Institute of Nursing Research

SAMHSA

Substance Abuse and Mental Health Services Administration

principal investigators
Principal Investigators

Betty Pfefferbaum, MD, JDUniversity 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

children s psychosocial services in disasters

Children’s Psychosocial Services in Disasters

Gil Reyes, PhD

Associate Dean for Clinical Training at Fielding Graduate University

learning objectives
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
types of services
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

types of services8
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

types of services9
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

types of services10
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

types of services11
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

types of services12
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

recommendations
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

recommendations14
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

public mental health approach

Public Mental Health Approach

Pynoos, Goenjian, & Steinberg, 1998

organization
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

components
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

guidelines
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

disaster mental health services for children

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

september 11 project liberty services
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

project liberty services for children 1
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

project liberty services for children 2
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

september 11 school based study
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 > 8000

students in grades 4-12

6 months after the attacks

Hoven et al. 2002

september 11 counseling
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

september 11 counseling25
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

early psychological interventions

Early Psychological Interventions

NIMH 2002

APA 1954

Everly and Flynn 2006

NCTSN and NCPTSD 2006

ARC

IFRC

early psychological interventions27

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)

hierarchy of needs
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

assumptions and principles
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

key aspects of early intervention
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

technical assistance consultation and training
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

monitor rescue and recovery environment
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

outreach and information dissemination
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

fostering resilience and recovery
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

needs assessment
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

triage
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

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

NIMH 2002

follow up
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

expertise skills and training for providers of early intervention
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

research and evaluation
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

key research questions
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

psychological first aid
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

psychological first aid43
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

slide44
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

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

Everly & Flynn 2006

psychological first aid45
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
international federation of red cross and red crescent societies ifrc pfa modules
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

american red cross arc pfa actions
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

nctsn and ncptsd pfa core actions and goals 1
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

nctsn and ncptsd pfa core actions and goals 2
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

screening

Screening

Limitations and Rationale for Child Screening

reasons screening needed
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

adults may underestimate children s distress
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

screening53
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

McDermott & Palmer 1999

potential problems with screening
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

value of screening 1
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

value of screening 156
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

elementary school children exposed to earthquake in italy
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

treatment sample and program
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

session objectives and activities
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

change in risk scores
Change in Risk Scores

Galante & Foa 1986

methods
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

sample
Sample

Chemtob et al. 2002

treatment eligible sample
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

intervention
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

results
Results

Post-treatment < Pre-treatment

Follow-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

Chemtob et al. 2002

clinician ratings
Clinician Ratings

Random sample of 21 treated and 16 untreated

p = .01

Chemtob et al. 2002

sample and design
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

status at initiation of treatment
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

improvement
Improvement

Significant group differences occurred early and persisted

None relapsed

March et al. 1998

outstanding issues
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

trauma grief focused group psychotherapy after earthquake
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

results77
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

posttraumatic stress after treatment
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 < non-treated group

**3 Years: Treated: 3-year score < pretreatment

**3 Years: Not treated: 3-year score > 1.5-year score

Goenjian et al. 1997

depression after treatment
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 < 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

implications
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

cognitive behavioral therapy for childhood traumatic grief

Cognitive-Behavioral Therapy for Childhood Traumatic Grief

Stubenbort et al. 2001

Cohen et al. 2004

Cohen et al. 2006

group cbt for bereaved children
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

intervention sessions
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

methods84
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

intervention components
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

results86
Results

PTSD symptoms improved during the trauma-focused component

Grief improved during the trauma- and grief-focused components

*

**

*

*

**

Cohen et al. 2004

* p < .001

** p < .01

limitations
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

implications88
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

advantages of locating interventions in schools 1
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

advantages of locating interventions in schools 2
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

teachers as clinical mediators
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

role of teachers
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

sample94
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

methods95
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

instruments
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

intervention97
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

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

Wolmer et al. 2003

intervention sessions99
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

results at 6 weeks
Results at 6 Weeks

Trauma and dissociative symptoms decreased

Grief symptoms increased

Wolmer et al. 2003

increased grief symptoms
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

grief at follow up
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

Wolmer et al. 2003

severe to very severe posttraumatic stress
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

posttraumatic stress severity at 6 months for children who received the intervention
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

children without symptoms
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

three year follow up of teacher mediated intervention
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

follow up of children who received the intervention
Follow-up of Children Who Received the Intervention

Significant decrease post-intervention to 3 year follow-up

Wolmer et al. 2005

posttraumatic stress severity at 3 years for children who received the intervention
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

intervention and comparison group at three years
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

daily functioning in intervention and comparison groups at three years
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

Wolmer et al. 2005

summary of findings
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

conclusions 1
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
conclusions 2
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
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