Child disaster mental health interventions, part I: Techniques, outcomes, and methodological considerations

A Critical Review of Effective Child Mass Trauma Interventions: What We Know and Do Not Know from the Evidence

Over the last 20 years, numerous interventions have been developed and evaluated for use with children exposed to mass trauma with six publications reporting meta-analyses of randomized controlled trials of child mass trauma interventions using inactive controls to examine intervention effects on posttraumatic stress, depression, anxiety, and functional impairment. The current report reviews the results of these meta-analytic studies to examine the status of the evidence for child mass trauma mental health interventions and to evaluate potential moderators of intervention effect and implications for practice. The meta-analyses reviewed for the current report revealed a small to medium overall effect of interventions on posttraumatic stress, a non-statistically significant to small overall effect on depression, a non-statistically significant overall effect on anxiety, and a small overall effect on functional impairment. The subgroup analyses suggest that interventions should be matched to the populations being served and to the context. Additional research is needed to tailor future interventions to further address outcomes other than posttraumatic stress including depression, anxiety, and functional impairment.

Oxytocin Response Following Playful Mother-Child Interaction in Survivors of the Great East Japan Earthquake

BACKGROUND

Children who are exposed to natural disasters are at greater risk of developing mental and behavior problems. Prior studies have suggested that positive parenting practices could prevent child mental and behavior problems among those who were exposed to natural disasters. Parent-child interaction increases oxytocin level in parents and infants; however, studies assessing the change in oxytocin level after positive parent-child interaction and its effect on child behavior problems among preadolescents who were exposed to natural disasters are lacking. This study investigated whether playful interaction stimulated oxytocin levels in 34 mother-child dyads who experienced the 2011 Great East Japan Earthquake in Kesennuma City in Miyagi Prefecture, Japan, and the effect of the maternal oxytocin changes on child behavior problems.

METHODS

Participants were recruited in 2012 after the Great East Japan Earthquake. Annual surveys were conducted from 2012 to 2017. Salivary oxytocin level was assessed before and after the playful interaction in 2015. Behavior problems were evaluated by caregivers, using the Child Behavior Checklist (CBCL) in 2017. Fixed effect regression analyses were conducted to determine the effect of playful mother-child interaction on oxytocin level by comparing the change in the 10 min after the interaction with the change in the 10 min before the interaction. We also examined the effect of maternal oxytocin changes before and after the playful interaction on the onset of child behavior problems in 2017.

RESULTS

A significant increase in maternal oxytocin level was detected following playful interaction, especially among mothers of first-born boys (2.63 pg/mg protein. 95% CI: 0.45, 4.81). Maternal psychological distress and trauma were also negatively associated with an increase of oxytocin levels. The increase in maternal oxytocin level was significantly associated with lower externalizing problem score of children 2 years later.

CONCLUSION

Our results might suggest a rational for potential preventive intervention for child behavior problems through playful mother-child interaction after natural disasters.

Basal blood DHEA-S/cortisol levels predicts EMDR treatment response in adolescents with PTSD

OBJECTIVE

In literature, recent evidence has shown that the hypothalamic-pituitary-adrenal (HPA) axis can be dysregulated in patients with post-traumatic stress disorder (PTSD) and HPA axis hormones may predict the psychotherapy treatment response in patients with PTSD. In this study, it was aimed to investigate changing cortisol and DHEA-S levels post-eye movement desensitization and reprocessing (EMDR) therapy and the relationship between treatment response and basal cortisol, and DHEA-S levels before treatment.

METHOD

The study group comprised 40 adolescents (age, 12-18 years) with PTSD. The PTSD symptoms were assessed using the Child Depression Inventory (CDI) and Child Post-traumatic Stress Reaction Index (CPSRI) and the blood cortisol and DHEA-S were measured with the chemiluminescence method before and after treatment. A maximum of six sessions of EMDR therapy were conducted by an EMDR level-1 trained child psychiatry resident. Treatment response was measured by the pre- to post-treatment decrease in self-reported and clinical PTSD severity.

RESULTS

Pre- and post-treatment DHEA-S and cortisol levels did not show any statistically significant difference. Pre-treatment CDI scores were negatively correlated with pre-treatment DHEA-S levels (r: -0.39). ROC analysis demonstrated that the DHEA-S/cortisol ratio predicts treatment response at a medium level (AUC: 0.703, p: .030, sensitivity: 0.65, specificity: 0.86).

CONCLUSION

The results of this study suggested that the DHEA-S/cortisol ratio may predict treatment response in adolescents with PTSD receiving EMDR therapy. The biochemical parameter of HPA-axis activity appears to be an important predictor of positive clinical response in adolescent PTSD patients, and could be used in clinical practice to predict PTSD treatment in the future.

Communicating with children and adolescents about the risk of natural disasters

A vast number of people annually are affected by natural disasters. Children are at risk of losing their lives and suffer mentally or physically after such events. The fostering of resilience and preparedness ahead of disasters can reduce untoward effects of disastrous events. Risk communication and disaster education are considered important aspects of disaster preparedness, but little is known about whether such strategies influence children's behaviour when natural disasters occur or how they cope in the aftermath. This paper presents and discusses various strategies that promote preparedness activities to save lives. To a minor extent, it also includes strategies that can promote coping in the aftermath. Strategies such as informational campaigns, educational activities, psychoeducation and parental guidance are addressed. The literature to date indicates that schools are a suitable arena for risk communication, and that adolescents themselves should be involved and engaged in the communication strategies. However, the relationship between knowledge of preparedness strategies and the resulting preparedness actions is largely unknown. It is unknown whether changes in awareness and attitudes have resulted in actual behaviour change. It is advocated that preparedness activities and parental involvement should supplement information-based strategies.

Clinical Decision-Making Following Disasters: Efficient Identification of PTSD Risk in Adolescents

The present study aimed to utilize a Receiver Operating Characteristic (ROC) approach in order to improve clinical decision-making for adolescents at risk for the development of psychopathology in the aftermath of a natural disaster. Specifically we assessed theoretically-driven individual, interpersonal, and event-related vulnerability factors to determine which indices were most accurate in forecasting PTSD. Furthermore, we aimed to translate these etiological findings by identifying clinical cut-off recommendations for relevant vulnerability factors. Our study consisted of structured phone-based clinical interviews with 2000 adolescent-parent dyads living within a 5-mile radius of tornados that devastated Joplin, MO, and northern Alabama in Spring 2011. Demographics, tornado incident characteristics, prior trauma, mental health, and family support and conflict were assessed. A subset of youth completed two behavioral assessment tasks online to assess distress tolerance and risk-taking behavior. ROC analyses indicated four variables that significantly improved PTSD diagnostic efficiency: Lifetime depression (AUC = .90), trauma history (AUC = .76), social support (AUC = .70), and family conflict (AUC = .72). Youth were 2-3 times more likely to have PTSD if they had elevated scores on any of these variables. Of note, event-related characteristics (e.g., property damage) were not related to PTSD diagnostic status. The present study adds to the literature by making specific recommendations for empirically-based, efficient disaster-related PTSD assessment for adolescents following a natural disaster. Implications for practice and future trauma-related developmental psychopathology research are discussed.

Genetic and psychosocial predictors of alcohol use trajectories among disaster-exposed adolescents

BACKGROUND AND OBJECTIVES

Adolescent alcohol misuse is associated with numerous long-term adverse outcomes, so we examined predictors of alcohol use among disaster-exposed adolescents, a group at-risk for alcohol misuse.

METHODS

The current study (n = 332) examined severity of tornado-related exposure, posttraumatic stress disorder (PTSD) symptoms, emotional support, and a genetic risk sum score (GRSS) as predictors of alcohol use trajectories.

RESULTS

Severity of exposure interacted with the GRSS to predict both intercept (12-month follow up quantity of alcohol use) and growth rate. Emotional support also interacted with adolescent PTSD symptoms to predict intercept and growth rate.

DISCUSSION AND CONCLUSIONS

Adolescents with greater severity of disaster exposure and high genetic risk comprise a high risk group, on which efforts to prevent alcohol use should be focused. Additionally, emotional support is essential in buffering the effects of PTSD symptoms on alcohol use outcomes among adolescents.

SCIENTIFIC SIGNIFICANCE

Toward the aim of reducing adolescent alcohol misuse following disaster exposure, there is utility in inserting immediate supports (e.g., basic resources) into communities/families that have experienced significant disaster-related severity, particularly among adolescents at high levels of genetic risk for alcohol use/misuse. Additionally, prevention efforts aimed at improving emotional supports for adolescents with more PTSD symptoms may reduce propensity for alcohol misuse following disaster. This information can be easily incorporated into existing web-based interventions. (Am J Addict 2017;26:623-631).

Schools and Disasters: Safety and Mental Health Assessment and Interventions for Children

This article draws on experiences and lessons from global disasters and utilizes the United Nations Comprehensive School Safety Framework to highlight the necessary role of safe schools in protecting children, as well as adult staff, from the immediate threats and long-term implications of disasters. Specifically, we focus on three well-established pillars of school safety: Pillar I: Safe Learning Facilities; Pillar II: Disaster Management; and Pillar III: Risk Reduction and Resilience Education. In addition, we propose a potential fourth pillar, which underscores the function of schools in postdisaster mental health assessment and intervention for children. We argue that schools offer a central location and trusted institutional space for mental health assessment and intervention after disasters. We also examine the important linkages between schools, child mental health, and household and family recovery. We conclude with recommendations for filling gaps in research and practice related to ensuring the safety of schools and the associated health and well-being of children in the face of future disasters.

Public Disaster Communication and Child and Family Disaster Mental Health: a Review of Theoretical Frameworks and Empirical Evidence

Children have been identified as particularly vulnerable to psychological and behavioral difficulties following disaster. Public child and family disaster communication is one public health tool that can be utilized to promote coping/resilience and ameliorate maladaptive child reactions following an event. We conducted a review of the public disaster communication literature and identified three main functions of child and family disaster communication: fostering preparedness, providing psychoeducation, and conducting outreach. Our review also indicates that schools are a promising system for child and family disaster communication. We complete our review with three conclusions. First, theoretically, there appears to be a great opportunity for public disaster communication focused on child disaster reactions. Second, empirical research assessing the effects of public child and family disaster communication is essentially nonexistent. Third, despite the lack of empirical evidence in this area, there is opportunity for public child and family disaster communication efforts that address new domains.

Child Disaster Mental Health Services: a Review of the System of Care, Assessment Approaches, and Evidence Base for Intervention

Several decades of research have informed our knowledge of children's reactions to disasters and the factors that influence their reactions. This article describes the system of care for child disaster mental health services using population risk to determine needed services and a stepped care approach built on assessment and monitoring to advance children to appropriate services. To assess the evidence base for disaster interventions, recent reviews of numerous child disaster mental health interventions are summarized.

Web Intervention for Adolescents Affected by Disaster: Population-Based Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of Bounce Back Now (BBN), a modular, Web-based intervention for disaster-affected adolescents and their parents.

METHOD

A population-based randomized controlled trial used address-based sampling to enroll 2,000 adolescents and parents from communities affected by tornadoes in Joplin, MO, and several areas in Alabama. Data collection via baseline and follow-up semi-structured telephone interviews was completed between September 2011 and August 2013. All families were invited to access the BBN study Web portal irrespective of mental health status at baseline. Families who accessed the Web portal were assigned randomly to 1 of 3 groups: BBN, which featured modules for adolescents and parents targeting adolescents' mental health symptoms; BBN plus additional modules targeting parents' mental health symptoms; or assessment only. The primary outcomes were adolescent symptoms of posttraumatic stress disorder (PTSD) and depression.

RESULTS

Nearly 50% of families accessed the Web portal. Intent-to-treat analyses revealed time × condition interactions for PTSD symptoms (B = -0.24, SE = 0.08, p < .01) and depressive symptoms (B = -0.23, SE = 0.09, p < .01). Post hoc comparisons revealed fewer PTSD and depressive symptoms for adolescents in the experimental versus control conditions at 12-month follow-up (PTSD: B = -0.36, SE = 0.19, p = .06; depressive symptoms: B = -0.42, SE = 0.19, p = 0.03). A time × condition interaction also was found that favored the BBN versus BBN + parent self-help condition for PTSD symptoms (B = 0.30, SE = 0.12, p = .02) but not depressive symptoms (B = 0.12, SE = 0.12, p = .33).

CONCLUSION

Results supported the feasibility and initial efficacy of BBN as a scalable disaster mental health intervention for adolescents. Technology-based solutions have tremendous potential value if found to reduce the mental health burden of disasters.

CLINICAL TRIAL REGISTRATION INFORMATION

Web-based Intervention for Disaster-Affected Youth and Families; http://clinicaltrials.gov; NCT01606514.

Bounce Back Now! Protocol of a population-based randomized controlled trial to examine the efficacy of a Web-based intervention with disaster-affected families

Disasters have far-reaching and potentially long-lasting effects on youth and families. Research has consistently shown a clear increase in the prevalence of several mental health disorders after disasters, including depression and posttraumatic stress disorder. Widely accessible evidence-based interventions are needed to address this unmet need for youth and families, who are underrepresented in disaster research. Rapid growth in Internet and Smartphone access, as well as several Web based evaluation studies with various adult populations has shown that Web-based interventions are likely to be feasible in this context and can improve clinical outcomes. Such interventions also are generally cost-effective, can be targeted or personalized, and can easily be integrated in a stepped care approach to screening and intervention delivery. This is a protocol paper that describes an innovative study design in which we evaluate a self-help Web-based resource, Bounce Back Now, with a population-based sample of disaster affected adolescents and families. The paper includes description and justification for sampling selection and procedures, selection of assessment measures and methods, design of the intervention, and statistical evaluation of critical outcomes. Unique features of this study design include the use of address-based sampling to recruit a population-based sample of disaster-affected adolescents and parents, telephone and Web-based assessments, and development and evaluation of a highly individualized Web intervention for adolescents. Challenges related to large-scale evaluation of technology-delivered interventions with high-risk samples in time-sensitive research are discussed, as well as implications for future research and practice.

Child disaster mental health interventions: therapy components

Children face innumerable challenges following exposure to disasters. To address trauma sequelae, researchers and clinicians have developed a variety of mental health interventions. While the overall effectiveness of multiple interventions has been examined, few studies have focused on the individual components of these interventions. As a preliminary step to advancing intervention development and research, this literature review identifies and describes nine common components that comprise child disaster mental health interventions. This review concluded that future research should clearly define the constituent components included in available interventions. This will require that future studies dismantle interventions to examine the effectiveness of specific components and identify common therapeutic elements. Issues related to populations studied (eg, disaster exposure, demographic and cultural influences) and to intervention delivery (eg, timing and optimal sequencing of components) also warrant attention.

Meta-analytic review of psychological interventions for children survivors of natural and man-made disasters

Although many post-disaster interventions for children and adolescent survivors of disaster and terrorism have been created, little is known about the effectiveness of such interventions. Therefore, this meta-analysis assessed PTSD outcomes among children and adolescent survivors of natural and man-made disasters receiving psychological interventions. Aggregating results from 24 studies (total N=2630) indicates that children and adolescents receiving psychological intervention fared significantly better than those in control or waitlist groups with respect to PTSD symptoms. Moderator effects were also observed for intervention package, treatment modality (group vs. individual), providers' level of training, intervention setting, parental involvement, participant age, length of treatment, intervention delivery timing, and methodological rigor. Findings are discussed in detail with suggestions for practice and future research.

Child disaster mental health interventions, part II: Timing of implementation, delivery settings and providers, and therapeutic approaches

This review summarizes current knowledge on the timing of child disaster mental health intervention delivery, the settings for intervention delivery, the expertise of providers, and therapeutic approaches. Studies have been conducted on interventions delivered during all phases of disaster management from pre event through many months post event. Many interventions were administered in schools which offer access to large numbers of children. Providers included mental health professionals and school personnel. Studies described individual and group interventions, some with parent involvement. The next generation of interventions and studies should be based on an empirical analysis of a number of key areas.