JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY Volume 24, Number 1, 2014 ª Mary Ann Liebert, Inc. Pp. 24–31 DOI: 10.1089/cap.2013.0061

Mental Health Interventions for Children Exposed to Disasters and Terrorism Betty Pfefferbaum, MD, JD,1 Elana Newman, PhD,2 and Summer D. Nelson, PhD 2

Abstract

Objective: The purpose of this review is to describe interventions used with children who are exposed to disasters and terrorism and to present information about the potential benefits of these interventions. Methods: A literature search conducted in January 2013 using relevant databases and literature known to the authors that was not generated by the search yielded a total of 85 studies appropriate for review. Results: Intervention approaches used with children exposed to disasters and terrorism included preparedness interventions, psychological first aid, psychological debriefing, psychoeducation, cognitive behavioral techniques, exposure and narrative techniques, eye movement desensitization and reprocessing, and traumatic grief interventions. The investigation of these interventions is complex, and studies varied in methodological rigor (e.g., sample size, the use of control groups, outcomes measured). Conclusions: Given the limitations in the currently available empirical information, this review integrates the literature, draws tentative conclusions about the current state of knowledge, and suggests future directions for study.

Introduction

addressing each of these specifics is insufficient to allow definitive conclusions about some issues. Moreover, the difficulty initiating and conducting research in the disaster environment has limited the number of intervention studies. Nonetheless, the field has matured sufficiently to stimulate interest in and offer tentative directions about the availability, appropriateness, and potential benefit of interventions for children exposed to disasters and to provide a preliminary evaluation of the evidence base.

M

ass trauma events in recent years have generated interest in children’s reactions, and stimulated the creation of interventions designed to address those reactions. Delivering interventions in disasters is inherently complex for several reasons. Disasters take many forms; they may be unpredictable and unpredicted, creating chaos and often damaging important community infrastructures. Alternatively, they may be predicted or reoccurring, or may cause minor or localized community disruptions. Similarly, children’s reactions to disasters vary. Most children do not develop psychiatric conditions as a result of their exposures but many experience distress that tends to subside naturally with time. Therefore, those developing, studying, and delivering disaster interventions must consider the various characteristics and needs of the population of interest. For example, public health wellness interventions are appropriate for children whose reactions involve distress, whereas clinical interventions may be needed for those with direct or interpersonal exposure and those who develop or are at risk for developing psychiatric conditions (Pfefferbaum and North 2013). Given the many different possibilities in the type of event, exposures and personal experiences, timing of and settings for intervention delivery, outcomes of interest, and therapeutic approaches, the number of studies

Literature Search Methodology and Results A literature search was conducted in January 2013 using the following databases: EMBASE, Education Resources Information Center (ERIC), MEDLINE, Ovid, Published International Literature on Traumatic Stress (PILOTS), PsycINFO, and Social Work Abstracts. Titles and abstracts identified in the search were considered for possible inclusion in this review. Literature known to the authors that was not generated by the search also was incorporated as appropriate. The review included only intervention studies that reported indices of measured outcomes. Although this review focuses on disasters and terrorism, studies addressing other types of non-interpersonal trauma, including ongoing political conflict, war, and single incidents such as accidents, were also reviewed. Interventions used in these contexts employ the same

1 Department of Psychiatry and Behavioral Sciences, College of Medicine, and Terrorism and Disaster Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. 2 The University of Tulsa Institute of Trauma, Abuse and Neglect, Department of Psychology, The University of Tulsa, Tulsa, Oklahoma. Funding: This work was funded in part by the Terrorism and Disaster Center (TDC) at the University of Oklahoma Health Sciences Center (Dr. Pfefferbaum). TDC is a partner in the National Child Traumatic Stress Network and is funded in part by the Substance Abuse and Mental Health Services Administration (1 U79 SM57278).

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CHILD DISASTER MENTAL HEALTH INTERVENTIONS therapeutic approaches and techniques, and measure many of the same outcomes as do studies of disaster interventions. For example, political conflict and war may be more enduring than disasters, but they may be marked by unexpected and terrorizing acts and they have the potential to damage community infrastructures. Similarly, although accidents such as motor vehicle collisions typically do not damage the community at large, they are unanticipated and sudden. Technological accidents such as airplane crashes may affect larger community structures and may constitute a disaster. Therefore, including research about ongoing political conflict, war, and single incidents in this review provides a broader context for understanding interventions used with children experiencing noninterpersonal trauma such as disasters and terrorism. The final database included 35 disaster, 8 terrorism, 5 accident, and 30 war studies as well as 7 studies using heterogeneous samples. Intervention Approaches A variety of intervention approaches have been delivered and tested across all disaster phases from pre-event preparedness interventions to those designed for the acute aftermath, those delivered during the months and years post event, and those delivered years after an incident. These interventions have been administered for various conditions and delivered in schools, clinical settings, and various community sites. Many have been created specifically to address children’s clinical needs. Posttraumatic stress disorder (PTSD) and/or PTSD reactions were the predominant outcomes measured across studies, followed by depression and anxiety; other outcomes included behavior problems, traumatic grief reactions, and functioning. Nonclinical reactions and wellness concerns were less often measured as intervention outcomes. The terminology used to describe interventions was inconsistent across studies, and many if not most interventions described in the literature were eclectic and multimodal. The subsequent discussion focuses on the primary approaches used. Preparedness interventions, delivered in anticipation of future events, have focused on both natural disasters and terrorism. Interventions delivered in the early aftermath of an event included psychological first aid, which has garnered widespread interest, and debriefing, which has received much less attention than in application with adults. Psychoeducation was used alone or as a component in many interventions. Cognitive behavioral therapy (CBT) was the most widely reported in the reviewed literature. Exposure and narrative techniques also have been widely used, often together. Eye movement desensitization and reprocessing (EMDR) was used with some frequency, especially in settings outside North America. Interventions focused on traumatic grief have been especially important in mass disasters and war. Other interventions were administered and studied with less frequency, as the treatment or control condition in clinical trials. These included psychodynamic therapy (e.g., Gilboa-Schechtman et al. 2010), play therapy (e.g., Shen 2002), hypnosis (e.g., Lesmana et al. 2009), massage (e.g., Field et al. 1996), and novel techniques (e.g., Sadeh et al. 2008). Preparedness interventions Universal preparedness programs for general populations, regardless of risk or exposure, were delivered pre-event, and focused on disaster awareness, prevention, and resilience building. For example, one study, which compared a pre-event emergency management intervention involving teaching in emergency management and interaction with parents as well as reading and classroom discussion, to the usual hazard condition, which in-

25 volved reading and classroom discussions only, found that children in classrooms that received the emergency management program had greater home-based hazard adjustment and hazard knowledge than children in classrooms that received the usual hazard education intervention. Both conditions produced benefit with respect to hazard-related fears and perception of parental fears, and neither produced benefit in perceived emotional coping. An unexplained benefit with respect to hazard-related fears in the usual condition was stimulated, perhaps, by the children’s participation in the reading and discussion program and/or by completing the study measures. This work suggests that delivering preparedness interventions to children at school pre event has the potential to influence entire families and households prior to disaster exposure. Therefore, integrating these programs in school curricula is one approach to preparing communities; however, preparedness programs must be offered repeatedly across multiple venues to be effective (Ronan and Johnston 2001). Some preparedness programs were used selectively for children who were at risk because of exposure to harmful experiences. For example, after delivering a school-based psychoeducation intervention that incorporated skill training, art therapy, and narrative techniques, Israeli investigators found decreased posttraumatic distress and functional impairment in students with a range of terrorism exposures and distress (Berger et al. 2007). Other resilience-building interventions were effective in alleviating various reactions to past and ongoing terrorism in students with various forms of exposure to terrorist events (Gelkopf and Berger 2009) and in those who were exposed to continuous rocket attacks (Wolmer et al. 2011a,b). Such programs may mitigate the potentially negative effects of future events on children’s mental health and functioning (Gelkopf and Berger 2009). As preparedness assumes a larger role in the management of disasters, pre-event interventions constitute an important front for new work to bolster resilience in children residing in high-risk areas. Psychological first aid It is difficult to study interventions delivered in the acute and early aftermath of disasters, because of the urgency and chaos of the postdisaster environment, the priority of security and physical concerns, and the effort needed to organize and establish services. Psychological first aid is envisioned to address the problems that arise during this time period by providing comfort, mobilizing support and psychosocial assistance, offering accurate and timely information about disaster reactions and available resources, and providing opportunities to triage children and make referrals (Everly and Flynn 2006). Psychological first aid has not been well studied. Months after Hurricane Katrina, Cain and colleagues (2011) delivered a 6 week group intervention to 146 displaced elementary-school children, which was based on the principles put forth in the Psychological First Aid: Field Operations Guide (National Child Traumatic Stress Network [NCTSN] 2006) developed by the NCTSN and the National Center for PTSD (NCPTSD). The intervention focused on disaster knowledge, emotional expression, communicating needs appropriately, coping with anxiety and triggers, increasing self-worth, anger literacy and management, and experiencing positive affect. Although there was a statistically significant improvement post intervention, PTSD scores remained in the moderate range and there was no control group to account for the passage of time. Nevertheless, indices of fear, isolation, startle responses, memory problems, and distress at triggers improved. Unfortunately, the study did not constitute a

26 direct test of the NCTSN/NCPTSD psychological first aid intervention, given the timing of implementation of the intervention and its highly structured approach. An important future task in assessing the efficacy and effectiveness of psychological first aid will entail clear delineation of the specific aspects or versions of psychological first aid being tested, and matching the timing of administration with the questions under investigation. Psychological debriefing Psychological debriefing has been used widely with adult populations, but has not been well studied in children. Intended for delivery early after disaster exposure, debriefing entails a single individual or group session for survivors to describe their experiences and reactions, reconstruct the event, and discuss coping strategies (Litz and Maguen, 2007). Controlled trials with adult samples have found it to be ineffective and possibly harmful (Rose et al. 2003; Foa et al. 2005). Therefore, the few available child disaster debriefing studies are of interest despite the fact that these interventions varied across studies in timing, number of sessions, group or individual format, and involvement of parents. Yule (1992) found significant decreases in posttraumatic stress but not in anxiety or depression in child survivors of a maritime accident who received both a single debriefing session 10 days after the disaster and subsequent CBT group sessions, relative to those who did not receive the services. In another study, two weekly 3 hour group debriefing sessions 6 months after a minibus accident were effective in reducing posttraumatic intrusion symptoms, depression, and anxiety in children (Stallard and Law 1993). Vila and colleagues (1999) found that a modified debriefing intervention delivered to children and their parents 24 hours and again 6 weeks following a classroom hostage incident did not prevent the development of psychological disorders including PTSD at 18 month follow-up, but children who did not participate in the debriefings had worse outcomes. Shooshtary and colleagues (2008) also demonstrated efficacy of a four session eclectic cognitive behavioral group intervention that used debriefing as well as other techniques in adolescents exposed to a massive earthquake in Iran, but did not examine the specific components of the intervention; therefore, the results do not contribute to the debate about the efficacy of debriefing in children. Not all studies have found child psychological debriefing, or therapies that use debriefing as a component, superior to other interventions. In an investigation of children exposed to singleincident motor vehicle accidents, Stallard and colleagues (2006) found significant improvement in both those who received individual debriefing and those who received an unstructured discussion unrelated to the traumatic experience 4 weeks post event with no significant difference in outcomes between the two conditions, and no evidence that debriefing was harmful. Zehnder and colleagues (2010) used a similar approach, but included parents in their single-session intervention delivered 7–10 days after a motor vehicle accident. The results revealed no benefit relative to standard medical care in posttraumatic stress, depressive symptoms, or behavioral problems in the full sample of children and adolescents, but the intervention was effective in reducing depressive symptoms and behavioral problems in preadolescent children and there were no apparent harmful effects. In another study, a group crisis intervention using multiple group sessions modeled on traditional debriefing approaches was not effective in the context of ongoing war (Thabet et al. 2005). The extant research provides no clear evidence of benefit from psychological debriefing, but the use of the label ‘‘debriefing’’ in

PFEFFERBAUM ET AL. some studies was problematic, as it was not clear how closely the interventions delivered adhered to traditional conceptualizations of the intervention. This perpetuates confusion about what constitutes psychological debriefing, and, therefore, whether it is effective. For example, supporting Chemtob’s (2000) case for delayed debriefing, child applications have not been limited to delivery in the early aftermath of an event. Moreover, Stallard and Salter (2003) recommended that psychological debriefing not be delivered in the immediate aftermath of a disaster when numbness and hyperarousal may be prominent. If prevention is a goal of debriefing, delaying delivery too long may allow symptoms to solidify. Although the optimal timing for applying debriefing remains unclear, debriefing delivered months after an event almost certainly has different goals and expected outcomes than does debriefing delivered in the early aftermath, requiring modifications to address longer-term problems rather than using it as a prevention strategy or acute intervention. Furthermore, no matter when debriefing is implemented, Wraith (2000) cautions that children should not be exposed to information and emotions that they cannot process and integrate, or to material that may be upsetting to them. Psychological debriefing, like all interventions, must be tailored to the child’s developmental level and individual needs. Psychoeducation Psychoeducation, which entails providing information about mass trauma or a specific incident, potential reactions, adaptive coping, and services and resources, has been incorporated as a component of many intervention packages, and delivered during all phases of a disaster. The intervention has not been well studied except as part of other interventions. For example, Israeli investigators used psychoeducation along with skill training, meditative practices, sensory-motor strategies, and narrative techniques in school classrooms, as well as psychoeducation sessions with parents to address the threat of terrorism (Berger et al. 2007; Gelkopf and Berger 2009). Interventions also have coupled disaster education with a variety of other expressive, creative, artistic, and recreational activities (e.g., Gupta and Zimmer 2008; Zehnder et al. 2010). Several studies have focused directly on psychoeducation. In one study, written psychoeducation with information about children’s trauma reactions, self-help advice, and resources for assistance if needed were delivered to children who had sustained traumatic injuries, and their parents, within 72 hours of various types of accidents. Receiving the information was associated with a decrease in child anxiety and parent posttraumatic symptoms relative to a no-treatment control (Kenardy et al. 2008). Sahin and colleagues (2011) delivered psychoeducation seminars to children and parents *9 months after the 1999 Marmara earthquake in Turkey. Although most participants received information provided through other sources such as the general press, brochures, and handouts immediately after the earthquake, in the psychoeducation seminars, adult participants also received 2–3 hours of education about normal psychological reactions and how to talk with their children. The children engaged in activities such as drawing, sentence completion, and peer discussions as well as receiving information about coping and earthquake responses. Thus, other interventions were delivered along with psychoeducation. Children and parents perceived the seminars as beneficial. For parents, perceived benefit was related to the number of topics discussed, and for children, benefit was related to the number and variety of activities incorporated in the seminars. Children gained no more new

CHILD DISASTER MENTAL HEALTH INTERVENTIONS knowledge than those in a comparison group who did not attend the seminars, however. Recommendations for future efforts included increased use of participatory activities, concrete examples, role modeling of adaptive coping and communication skills, visual aids, repetition, and time for discussion. Among children in refugee camps in the Gaza Strip, Thabet and colleagues (2005) compared the use of a group crisis intervention using projective expression, a teacher psychoeducation intervention, and a no-treatment control. In the teacher education condition, teachers were taught the meaning and consequences of trauma and how to deal with it. They subsequently educated children with the aim of normalizing the children’s reactions. The study revealed no benefit from either active condition, and no significant difference among the three conditions in PTSD caseness or symptoms or in depression, perhaps because of the ongoing political conflict. Therefore, the evidence for psychoeducation in disaster interventions is inconclusive because, although it is a common element of many interventions, most studies have not specifically examined the information-sharing component. For interventions that couple psychoeducation with other activities or techniques, it may be the narrative, expression, and/or emotional processing that accompany the delivery of education, or natural recovery, that lead to benefit. Furthermore, although psychoeducation is widely used and generally supported, Wessely and colleagues (2008) questioned its benefit and its potential to create harm. Of particular concern is triggering, or creating an expectation for, adverse reactions (Sahin et al. 2011). Without psychoeducation, people will likely rely on their own social networks of family, friends, colleagues, general practitioners, religious leaders, and others for information and support (Wessely et al. 2008). Cognitive behavioral techniques The clear majority of child disaster interventions have been based on principles of CBT. Many of these interventions have used a combination of approaches such as exposure, narrative, anxiety reduction, relaxation, problem solving, anger management, and coping skill-building techniques. Interventions have addressed multiple outcomes including PTSD or PTSD reactions, depression, anxiety, behavior problems, grief, and functioning. Two popular manualized CBT intervention packages studied in disaster populations are Cognitive Behavioral Intervention for Trauma in Schools (CBITS) (Cohen et al. 2009; Jaycox et al. 2010) and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) (Brown et al. 2004, 2006; Cohen et al. 2009; CATS Consortium, 2010; Jaycox et al. 2010). CBITS, designed for children with moderate to severe PTSD symptoms, and using both group and individual sessions, is delivered in school settings by trained clinicians. Also designed for children with significant trauma reactions, TF-CBT can be administered to children individually or in groups, and is delivered in clinical settings by trained clinicians. Post Hurricane Katrina, Jaycox and colleagues (2010) compared CBITS delivered at school and TF-CBT delivered in a mental health clinic. Children benefited from both interventions, but 65% of children in the CBITS group and 43% in the TF-CBT group scored in the ‘‘at risk’’ range of PTSD at follow-up assessment 10 months later, suggesting the need to consider ways to enhance interventions beyond CBT using, for example, individual and family therapy, medication, and/or social support for children with enduring symptoms. The results also revealed the importance of accessibility, as children were more likely to use school-based services than services in

27 a clinic, and the need for engagement techniques, especially for children with clinical problems, for whom intervention may be most important. Exposure and trauma narrative Both in vivo and in vitro techniques have been used in child disaster interventions. CBT approaches often incorporate one or more of these techniques in conjunction with relaxation and breathing exercises, to help children manage their anxiety while practicing exposure. In vitro exposure emphasizes mastering traumatic memories, whereas in vivo exposure emphasizes encountering feared stimuli (e.g., people, places) associated with the traumatic event. In their sample of children with single-incident trauma, March and colleagues (1998) found that in vivo desensitization homework was effective in reducing PTSD symptoms immediately, and that benefit was maintained at 6 month follow-up. Saigh et al. (1996) reported benefit with in vitro desensitization in case studies of children and adolescents with posttraumatic stress symptoms associated with enduring political conflict in Lebanon. Using a staggered intervention design that provided a waitlist control group, Weems and colleagues (2009) found that a group intervention involving relaxation and gradual in vitro and in vivo (a mock examination) exposure was beneficial with respect to testtaking anxiety and academic performance in minority youth after Hurricane Katrina. Casting doubt on the superiority of exposure over other approaches in the long term, however, GilboaSchechtman and colleagues (2010) found exposure, using both in vivo and in vitro techniques, superior to time-limited psychodynamic therapy after treatment and at 6 month follow-up for PTSD symptoms and global functioning, but not at 17 month follow-up. Depressive symptoms subsided with both conditions, and were not significantly different after treatment. Effects on depression were maintained at 17 month follow-up. Many child disaster interventions contain a trauma narrative component, a form of in vitro exposure, in group or individual format. Ruf and colleagues (2010) found that relative to a waitlist control, refugee children experienced clinically significant improvement in PTSD symptoms and functioning with narrative exposure therapy, which was maintained at 12 month follow-up. Catani and colleagues (2009) failed to find a significant difference between the same narrative intervention and a meditation-relaxation intervention, however, in children affected by civil war and the 2004 Indian Ocean tsunami. In their study comparing the use of the trauma narrative and coping skill building in children exposed to Hurricane Katrina, Salloum and Overstreet (2012) found preliminary evidence suggesting that the trauma narrative may not be an essential component of child trauma interventions. Even the children who did not receive the narrative component, however, engaged in some discussion about their experiences, and the authors noted that the two interventions may not have been sufficiently different with respect to the narrative to adequately test this aspect of the intervention. The authors also acknowledged that the trauma narrative may be beneficial for children with clinically elevated symptoms. The theory behind the trauma narrative may influence the format of trauma interventions. If a conditioning model is posited as curative, then structured repeated retelling of the story where fear is safely experienced in sessions is needed so that children can (re)learn that the avoided and fear situations or triggers are now safe. If it is believed that telling one’s story helps reduce isolation and improves self-definitions of experiences, or that words offer some

28 sense of control, then a different intensity and format of trauma narrative may be appropriate. Additional research is needed to fully explore the importance of this seemingly elementary aspect of trauma intervention as well as to understand the mechanisms of change. EMDR EMDR is designed to process distressing memories or to reduce their effects by having the child focus simultaneously on the disturbing memory and on a therapist-directed attention stimulus (e.g., hand tapping, eye movement, auditory tones). Several studies have examined this approach as the primary treatment (e.g., Chemtob et al. 2002; Tufnell 2005; Fernandez 2007; Kemp et al. 2009) or as a component of another treatment (e.g., Ehntholt et al. 2005; Shooshtary et al. 2008). Tufnell (2005) described case studies using EMDR as part of a multimodal treatment package in four preadolescent children who had been involved in motor vehicle accidents; three of the four children had been diagnosed with PTSD. In an uncontrolled trial, Fernandez (2007) showed reduced posttraumatic stress symptoms over a period of 1 year with EMDR in child victims of an earthquake in Italy. Chemtob and colleagues (2002) used EMDR with children who met criteria for PTSD 1 year after receiving a psychosocial intervention for Hurricane Iniki and 3.5 years after the hurricane. Children showed large decreases in PTSD symptom levels and improvement with respect to anxiety and depression as well; improvement was maintained at 6 month followup. In a waitlist controlled trial of children with persistent PTSD symptoms after motor vehicle accidents, Kemp and colleagues (2010) found improvement in children, which was maintained at 3 month follow-up. Additional research is needed to determine if EMDR has an advantage over other approaches or natural recovery, and to identify the specific aspect or aspects of the intervention that is or are responsible for its benefit. Traumatic grief interventions Traumatic grief involves the interplay of trauma and grief in which trauma reactions interfere with the child’s ability to navigate the grief process (Cohen et al. 2004). Several interventions have been developed to specifically address traumatic grief. Cohen and colleagues (2004, 2006) developed a cognitive behavioral intervention with trauma-focused sessions on affect modulation, relaxation, trauma narrative, and cognitive processing and grieffocused sessions on recognizing and naming the loss, creating positive memories, and making meaning of the loss. In addition to individual sessions for the children, parent sessions provide behavioral management techniques and discussions of bereavement practices in the context of the family’s religion and culture (Brown et al. 2004). The intervention was used successfully in a case study of a child whose firefighter father died in the September 11 response effort (Brown et al. 2004). The UCLA trauma/grief-focused group psychotherapy intervention was delivered by trained school counselors to war-exposed adolescents in Bosnia (Layne et al. 2001, 2008). The intervention used psychoeducation; exposure, narrative, and various other CBT techniques; skill-building exercises; and process-oriented activities to focus first on the traumatic experience and then on trauma and loss reminders, postdisaster stresses and adversities, bereavement and the interplay between bereavement and trauma, and the developmental impact of the event and developmental progression. In their 2001 study, Layne and colleagues compared children who received full and partial treatment with the intervention. Posttrau-

PFEFFERBAUM ET AL. matic stress, depression, and grief symptoms decreased in adolescents who participated in the intervention, with no significant differences for those who received full or partial treatment (Layne et al. 2001). In their 2008 study, Layne and colleagues compared adolescents who received a classroom-based psychoeducation and skills intervention and those who received both the classroombased psychoeducation and skills intervention and the school-based trauma- and grief-focused group treatment. Posttraumatic stress and depression decreased significantly in both conditions, whereas maladaptive grief decreased significantly only in the group that received the trauma- and grief-focused group intervention. Salloum and Overstreet (2008) also demonstrated benefit in posttraumatic stress, depression, and traumatic grief reactions with their school-based trauma and grief intervention in children in New Orleans 3 years post Hurricane Katrina. The intervention, which used CBT techniques and narrative therapy through drawing, discussion, and writing, was delivered to children randomly assigned to individual or group format to reduce symptoms of posttraumatic stress, depression, and grief. The children assigned to the group condition also received an individual pullout session, and their parents were educated about grief and trauma and given guidance to support the children. There was no significant difference in outcome for the individual and group administration. Cohen’s group (2004, 2006) emphasized the importance of addressing trauma before the child can proceed through the grief process whereas Salloum and Overstreet (2008) noted that an ‘‘explicit’’ focus on grief and bereavement may facilitate the processing of trauma and decrease posttraumatic stress symptoms. The evidence base thus far suggests that trauma reactions and grief symptoms and issues related to loss may need to be addressed separately in helping children cope with the death of someone important to them in the context of disaster and terrorism. More research is needed to determine the importance of timing and sequencing of these intervention components. Methodological Issues in the Extant Research Although many of the studies examined for this review reported positive results for at least some of the outcomes measured, definitive conclusions about the status of the evidence base for any specific intervention approach must be suspended, given the limited number of studies examining some approaches and the variation in methodological rigor across studies. Table 1 displays the number of investigations in this review that used case study design or a controlled trial for each type of event. Foa and Meadows (1997) identified seven standards for methodological rigor in intervention studies: clearly defined target symptoms; reliable and valid measures; blinded evaluators; assessor training; manualized, replicable, specific treatment programs; unbiased assignment to treatment; and treatment adherence. Using these elements to examine the methodological rigor of 28 controlled trials assessing posttraumatic stress outcomes in children

Table 1. Research Design by Type of Event Type of event

Case studies

Controlled trials

Disasters Terrorism Accidents War Heterogeneous

10 2 2 10 5

25 6 3 20 2

CHILD DISASTER MENTAL HEALTH INTERVENTIONS exposed to disasters, terrorism, war, and other single-incident traumas such as accidents, Pfefferbaum and colleagues (in press) concluded that most studies used manualized or well-described treatment protocols and standardized instruments to measure outcomes, and many used random assignment and provided assessor training. Fewer studies used blinded assessment or established procedures to address adherence to treatment protocols, and the sample size in most studies was not adequate to detect small effects generally expected when comparing two active interventions. Other deficiencies in the extant research include the absence of attention to attrition in samples and the inconsistent use and length of follow-up. Relatively few studies compared two interventions, which has the potential to determine superiority of one over another. Unfortunately, studies using this design have been inconclusive, with most revealing no significant difference between competing interventions (e.g., Ronan and Johnston 1999; Thabet et al. 2005; Catani et al. 2009; Jaycox et al. 2010). For example, Gilboa-Schechtman and colleagues (2010) found prolonged exposure therapy superior to time-limited psychodynamic therapy after treatment and at 6 month follow-up but not at 17-month follow-up. Findings of the extant research have not definitely established the superiority of any specific intervention approach. This is consistent with the conclusion of Gillies and colleagues (2012, p. 21) that whereas there is ‘‘fair evidence for the effectiveness of psychological therapies,’’ especially CBT, in the treatment of PTSD in children, there is ‘‘no clear evidence’’ that any one therapy is superior to others. It is possible that some common factor or factors among interventions is or are responsible, at least in part, for the success of various interventions. These common factors include the therapeutic relationship, the expectation of therapeutic success, acknowledgement of difficulties, the process of confronting the trauma, and the opportunity to ventilate and/or gain mastery over the problem (Weinberger 1995). Related to the issue of common factors is the fact that the existing literature has not clarified which, if any, specific component of the available interventions is responsible for benefit. This dismantling of interventions will aid in determining therapeutic action. Layne and his group (2001) began to address this concern when they found no differences in outcome in children who received full (psychoeducation, skill building, adaptive grieving, and adaptive development) and partial (psychoeducation and skill building only) treatment using an eclectic cognitive behavioral intervention. Salloum and Overstreet (2012) found that the trauma narrative was not a necessary component in a grief and trauma intervention focused on coping skill building. Although this preliminary work suggests that some intervention components may not be essential, it has not established what constitutes the critical active ingredients in the interventions. Although it is difficult to conduct research in the chaos of the disaster environment, the studies reviewed for this report have established the feasibility of developing an evidence base for child disaster mental health interventions. The sheer number and sophistication of investigations illustrate that it is possible to conduct methodologically rigorous clinical research even in this field. Moreover, conducting clinical research in the disaster zone may bring resources to a community trying to rebuild its infrastructure, and may support the rapid dissemination and use of treatment. The byproducts of research (e.g., intervention manuals, formalized training procedures, adherence checklists) may enhance local practitioners’ capacity to provide evidence-based approaches to children. Therefore, clinicians and administrators should be

29 encouraged about the emerging evidence base for child disaster interventions and the potential immediate benefits of these interventions as well as the contributions to future knowledge. Statistical Significance The statistical significance of results in intervention studies alone is insufficient to assess their benefit. Intervention outcomes also must be meaningful. For example, whereas the results of an intervention may be statistically significant, the improvement in outcomes may be modest and short term. Deciding what constitutes a meaningful outcome can be challenging, especially given the range of conditions and reactions child disaster interventions are intended to address and the populations in which they are studied. For children directly involved in a disaster or those whose relatives are directly involved, a clinically meaningful outcome may be measured in terms of diagnostic status or symptom severity. It is more difficult to identify meaningful outcomes for children whose disaster experiences result in transient distress and for whom it is not appropriate to examine diagnosis. For example, assessing diagnosis may be inappropriate in preparedness studies or in studies of psychoeducation intended to normalize children’s reactions. Whereas it may be unclear what constitutes meaningful change—as opposed to statistically-significant change—in children receiving these nonclinical interventions, an appropriate focus may be on nonclinical wellness outcomes such as fear, anxiety, stress, social behavior, academic functioning, and hope (Wolmer et al. 2005; Jordans et al. 2010; Wolmer et al. 2011). Conclusions A number of issues related to disaster mental health services have been addressed in the emerging literature, and although the evidence base in this field has generated some answers, it also has raised many questions. With respect to answers, the current evidence has identified several interventions that are helpful; specifically, preparedness interventions appear promising. CBT in multiple forms appears beneficial for children postdisaster, but children may require additional interventions or the intervention may need to be further refined or enhanced to help eliminate rather than reduce PTSD symptoms. Exposure and narrative interventions and EMDR appear beneficial, but it is unclear at this point if these interventions are superior to other treatments. Traumatic grief interventions appear promising to address symptoms related to traumatic loss. Other interventions are promising but need more attention. Psychological first aid, a popular, well thought-out set of intervention principles remains to be fully tested. Inconsistently defined, the existing studies of psychological debriefing do not constitute a fair assessment of this approach. The evidence for psychoeducation in disaster interventions is inconclusive, because although it is a common element of many interventions, most studies have not specifically examined the information-sharing component. In addition to determining whether any approach is superior to others, is the question of whether it is some common element across interventions that is the source of benefit. Given that many interventions are eclectic, using a variety of techniques, it also is unclear what component of any specific treatment is responsible for the benefit. Another need is to identify and/or create tools that measure meaningful change. A lack of uniformity across interventions raises questions about the importance of factors such as the number and length of sessions and the optimal timing and setting for intervention delivery. Sequencing of treatment components, especially

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in relationship to grief, is another area for future study. Moreover, intervention approaches may vary for different types and locations of events, for various outcomes addressed, and for children with diverse personal characteristics (e.g., presence of pre-existing conditions) and specific trauma exposures and experiences. Like other areas involving children, their developmental level, various family factors, and culture always are considerations for examination. Further research with more rigorous attention to design is needed to advance the field. Clinical Significance This review of child disaster mental health intervention studies identified several intervention approaches that are helpful or, at a minimum, are not harmful. Specifically, preparedness interventions appear promising, and CBT in multiple forms and traumatic grief interventions appear beneficial. Exposure and narrative interventions and EMDR have positive outcomes, but it is unclear if these interventions are superior to other treatments. In the next generation of studies, it will be important to determine if some approaches are superior to others and/or if some common element across interventions is the source of benefit. Disclosures No competing financial interests exist. References Berger R, Pat-Horenczyk R, Gelkopf M: School-based intervention for prevention and treatment of elementary-students’ terror-related distress in Israel: A quasi-randomized controlled trial. J Trauma Stress 20:541–551, 2007. Brown EJ, McQuaid J, Farina L, Ali R, Winnick–Gelles A: Matching interventions to children’s mental health needs: Feasibility and acceptability of a pilot school-based trauma intervention program. Educ Treat Children 29:257–286, 2006. Brown EJ, Pearlman MY, Goodman RF: Facing fears and sadness: Cognitive-Behavioral therapy for childhood traumatic grief. Harvard Rev Psychiatry 12:187–198, 2004. Cain DS, Plummer CA, Fisher RM, Bankston TQ: Weathering the storm: Persistent effects and psychological first aid with children displaced by Hurricane Katrina. J Child Adolesc Trauma 3:330– 343, 2010. Catani C, Kohiladevy M, Ruf M, Schauer E, Elbert T, Neuner F: Treating children traumatized by war and tsunami: A comparison between exposure therapy and meditation-relaxation in North-East Sri Lanka. BMC Psychiatry 9:1–11, 2009. CATS Consortium: Implementation of CBT for youth affected by the World Trade Center disaster: Matching need to treatment intensity and reducing trauma symptoms. J Trauma Stress 23:699–707, 2010. Chemtob CM: Delayed debriefing: After a disaster. In: Psychological Debriefing: Theory, Practice and Evidence, edited by B. Raphael, J.P. Wilson. New York, Cambridge University Press, 227–240, 2000. Chemtob CM, Nakashima JP, Carlson JG: Brief treatment for elementary school children with disaster-related posttraumatic stress disorder: A field study. J Clin Psychol 58:99–112, 2002. Cohen JA, Jaycox LH, Walker DW, Mannarino AP, Langley AK, DuClos JL: Treating traumatized children after Hurricane Katrina: Project Fleur-de Lis. Clin Child Fam Psychol Rev 12:55–64, 2009. Cohen JA, Mannarino AP, Knudsen K: Treating childhood traumatic grief: A pilot study. J Am Acad Child Adolesc Psychiatry 43:1225– 1233, 2004.

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Address correspondence to: Betty Pfefferbaum, MD, JD Department of Psychiatry and Behavioral Sciences College of Medicine University of Oklahoma Health Sciences Center P.O. Box 26901, WP-3470 Oklahoma City, OK 73126-0901 E-mail: [email protected]