Psychological Interventions for children and adolescents who have experienced war-related trauma: An argument for Narrative Exposure Therapy
Children and adolescents who have experienced severe losses and multiple traumatic events over long periods of time, as a result of war and organised violence, may experience many mental health difficulties, including post-traumatic stress disorder (PTSD), depression and anxiety. Increasingly clinicians are being asked to provide interventions for young refugees; however, evidence-based guidance remains scarce.Narrative Exposure Therapy is a short-term therapy which has been adapted for children and adolescents who have PTSD symptoms as a result of these traumatic experiences.
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This review investigates the impact of war-related trauma amongst children and adolescents and the current available literature on psychological interventions for this group. Emerging evidence suggests that Narrative Exposure Therapy is an effective treatment for children and adolescents who have been traumatized by conflict, even in settings that remain unstable and volatile.
Key Words: Refugee, children, adolescents, treatment, psychological interventions, post-traumatic-stress disorder, trauma, war.
Psychological Interventions for children and adolescents who have experienced war-related trauma: An argument for Narrative Exposure Therapy
Civilian populations have been increasingly targeted in recent wars, with victims comprising of an increasing number of children and adolescents whose lives have been disrupted by organised violence (United Nations High Commissioner for Refugees [UNHCR], 2004). United Nations Children’s Fund (UNICEF) has estimated that 80% of the victims in modern wars are women and children.According to UNICEF (1995), during the prior decade, over 300,000 children had been forcibly recruited to serve as soldiers, more than 2 million children were killed in war activities; 4-6 million were injured or left with a physical disability, more than 1 million were orphaned, and 12 million were left homeless. Supporting this assertion, The World Bank reports that the mortality rate of children under the age of five years has increased by 11% as a consequence of war (Collier et al. 2003).
In response to violence, many people are forced to flee their countries in search of safety. UNHCR (2009) recently stated that some 43.3 million people worldwide were forcibly displaced due to conflict and persecution, the highest number since the mid-1990s. UNHCR (2009) also reports that 43% of its population of concern are children under the age of 18. According to government statistics, an estimated 103,080 individuals applied for asylum in the United Kingdom in 2002. Of these applicants 6200 were unaccompanied children, aged 17 and under (UNHCR, 2004). Figures such as these demonstrate that there are a considerable number of young refugees living in the UK.
Children and adolescents are directly affected by violence aimed at them and their families. They are also indirectly affected by the distress caused to their families and they may be internally displaced or find themselves crossing borders as asylum seekers. Their experiences during and immediately after war means they are unlikely to develop in a safe, secure, and predictable environment, putting their mental health put at risk. It remains a challenge to develop appropriate guidelines and interventions for the treatment of traumatic stress in child survivors of organized violence and war.
This novel review is intended to be of benefit to clinicians and researchers working with children and adolescents who have experienced war-related trauma as it will summarise and critique the current state of the evidence base for interventions and suggest directions for future research.
Traumatic Experiences and Child Mental Health
Recent investigations from various war zones all over the world confirm that many survivors of organized violence and war develop long-term physical and emotional problems (Neuner at al., 2006; Schaal & Elbert, 2006). Trauma-related mental health difficulties are conceptualized as posttraumatic stress disorder (PTSD).PTSD is characterised by exposure to an extremely stressful or catastrophic event or situation followed by three core symptoms. The first of these symptoms is the re-experiencing of intrusive vivid memories of the trauma, e.g., through images or dreams of the event or re-enactment of the traumatic events through play in young children. However, these images and sensations are typically incomplete and disjointed. The reliving of these memories is reflected in a distortion in the sense of time such that the traumatic events seem to be happening in the present rather than belonging to the past (Brewin & Holmes, 2003). Secondly, the persistent avoidance of stimuli associated with the trauma with numbing of general responsiveness, derealisation and depersonalisation. The final symptom is hyper-arousal with increased vigilance and disturbed sleep (World Health Organisation, 1992). The requirements of DSM IV criteria for the diagnosis of PTSD in children are that children must exhibit at least one re-experiencing symptom, three avoidance or numbing symptoms and two increased arousal symptoms (American Psychiatric Association, 1994). From the age of 8–10 years, following traumatic events, children display reactions closely similar to those observed in adults. Below 8 years of age, and in particular below the age of 5 years, there is less agreement as to the range and severity of the reactions. Scheeringa et al., (1995) have suggested an alternative set of criteria for the diagnosis of PTSD in children, which places more emphasis on regressive behaviours and new fears, but these have yet to be fully validated.
Substantial evidence supports the cross-cultural validity of PTSD with post traumatic symptoms having been found following exposure to war and organised violence in children and adolescents from many different parts of the world, including Rwanda (Neugebauer et al., 2009), Somalia (Onyut et al., 2005), Sri Lanka (Catani et al., 2008) and Bosnia (Papageorgiou et al., 2000). The nature of trauma seems to be an important factor in the emergence of PTSD. As in adult literature, human made intentional abuse seems to be more traumatic for children and adolescents than natural disasters. Between 17 – 25% of children exposed to severe trauma, such as natural disasters, suffer from PTSD, whereas among victims of interpersonal trauma such as sexual abuse the rate is considerably higher, ranging from 40 to 58% (Punamaki, 2008). In parts of the world where war and organized violence exist such as Palestine, the PTSD prevalence has been documented to be 20–25% among children (Thabet et al., 2002).
The type of traumatic exposure also seems to be important. Personal exposure to severe violence and losses, such as the murder of a family member or witnessing someone being injured or tortured can result in prevalence as high as 69% (Elbedour et al., 2007). Research has revealed levels of PTSD of 75% among African children in Sudan (Morgos et al., 2008) and Rwandan orphans (Schaal & Elbert, 2006). There is also a high prevalence rate of PTSD in young refugees who have recently arrived in resettlement countries (Lustig et al., 2004). According to Hodes (2000), an estimated 40% of young refugees in Britain may have psychiatric disorders, including PTSD, depression and anxiety. It is therefore, a reality that significantly increased demands may be made of the NHS, both in primary and secondary child and adolescent mental health services following traumatic events.
The consequences of exposure to military violence are highly devastating and affect all levels of society from individuals, to families, school and communities. In a study of Palestinian children and adolescents living in the Gaza Strip, it was found that, approximately one-half (48.5%) of the participants reported the death of a family member, 15.7% had witnessed the demolition of homes and 7.91% the injury of a friend. Approximately one-third (34.1%) of participants indicated that the painful event cited had directly involved them (Elbedour et al., 2007). The disappearance of a family member also seems to be a risk factor. Researchers have found that individuals experience a high level of distress due to the uncertainty regarding death and the subsequent inability to grieve fully (Quirk & Casco, 1994). Concerning the individual themselves, pre-existing individual vulnerability, such as conduct problems or chronic physical illness, places refugee children at greater risk of developing mental health difficulties, whilst having the ability to respond to new situations and positive self-esteem seems to be a protective factor (Almqvist & Broberg, 1999).
In addition, excessive fears and internalizing and externalizing symptoms are common consequences of traumatic events (Yule, 2000). Among Middle Eastern refugee children and adolescents anxiety manifested itself most frequently by increasingly dependent behaviour, e.g. clinging to the parents and expressing fear of being left alone and fear of sleeping in darkness (Montgomery & Foldspang, 2005). Sleep disturbances were also prevalent in a third of these children. A high co-morbidity between PTSD and depressive symptoms has been found among children exposed to military violence and war trauma (Elbedour et al., 2007). A survey by Schaal and Elbert (2006) in children orphaned by the Rwandan genocide showed that, a decade later, almost half of the examined orphans suffered from chronic PTSD and co-morbid depression. Some research is available on war and military violence increasing children’s aggressive behaviour. A follow-up study among Bosnian children showed that war trauma in preschool age predicted aggression in adolescents, due to difficulties in emotional regulation and impulse control (Kerestes, 2006). A study among Israeli children who had witnessed a terrorist attack showed an increased level of aggressive behaviour (Greenbaum, 2005). There is also some evidence to suggest that adolescent refugees may be at increased risk of psychosis (Tolmac & Hodes, 2004).
If effective therapy is not received, the long-term effects of life-threatening, traumatic events in childhood can be devastating. These studies suggest that many children and adolescents, who have been traumatised by war, continue to suffer from distressing symptoms long after the trauma is over.
Traumatic Experiences and Cognitive, Emotional and Social Development
Traumatic events have been found to have particularly negative impacts on cognitive, emotional and social development, which place traumatized children at increased risk for subsequent psychopathology (Maughan & Cicchetti, 2002).
Researchers have found that it is impaired problem-solving skills and the biased and narrowed memory and attention processes that are the central issues in the negative consequences of trauma (Feeny et al., 2004). Trauma has been found to have a negative impact on verbal functioning and prefrontal executive skills in adults (Dickie et al., 2008). In support of this, research has determined that adolescents with PTSD had significantly lower scores on discrete measures of verbal intelligence in comparison to non-traumatized controls (Saigh et al., 2006). Punamaki et al., (2007) found that among Palestinian children, exposure to severe losses and home destruction was associated with impaired cognitive capacity for attention and concentration which also predicted increased PTSD and depression in adolescence.There is some research to suggest that when PTSD accompanies trauma, brain structures essential to long-term memory formation (e.g., the hippocampus) have been altered (Bremner et al., 2003) and that memory performance is poor in general even on measures of everyday memory (Moradi et al., 1999). Children who have been maltreated in Western countries have been found to show biased and poor recollection, especially of narrative episodes (Howe et al., 2004). The cognitive functions that trauma seems to impair are those that have been found be particularly important in protecting children’s mental health. It is the verbal, narrative and episodic memory which are important in successfully integrating traumatic experiences.
The family frequently acts as a safeguard against post-traumatic stress.Unfortunately, poor parental mental health is associated with psychological distress in war traumatised and refugee children (Qouta, Punamaki, & Sarraj, 2005). Maternal mental distress in particular, is a significant mediator of their children’s mental health in times of conflict (Smith, Perrin, Yule, & Rabe-Hesketh, 2001). Supportive parenting styles were also found to predict low levels of emotional distress and PTSD symptoms among children despite war related trauma (Thabet et al., 2008). Exposure to war trauma has been found to negatively affect family functioning. Research has suggested conflicting and withdrawn relationships in traumatized veteran families due to overburdening and inability of the members to share their experiences (Orcutt et al., 2003). In Palestinian families exposed to war trauma, children experienced their parents as controlling and rejecting (Punamaki et al., 2006).
Social support is an important protective factor against the development of PTSD following a traumatic event (Brewin, Andrews, & Valentine, 2000). However, research has suggested that refugee children had less social support from friends than non-refugee children (Howard & Hodes, 2000). War trauma also has a detrimental effect on peer relationships. Paardekooper et al., (1999) demonstrated that Sudanese children who had been exposed to civil war were less satisfied with their peers than children had not experienced such trauma.
Theories of PTSD and its application across cultures
The official recognition of posttraumatic stress disorder (PTSD) in the DSM-III (American Psychiatric Association [APA], 1980) has prompted what is now a very considerable body of research into the psychology, biology, epidemiology, and treatment of the condition. In a review by Brewin & Holmes (2003) three main theories of PTSD were identified as having the most explanatory power for the current empirical findings and observed clinical symptoms in patients. These are emotional processing theory (Foa & Rathbaum, 1998), dual representation theory (Brewin, Dalgleish, & Joseph, 1996) and Ehlers and Clark’s cognitive model (Ehlers, Clark, Hackmann, McManus, & Fennell, 2005). There are several similarities between the models which all stress the importance of maladaptive processing of traumatic events. They also explain how a fragmented autobiographical memory, lacking in contextual information, results in a skewed sense of current threat, as the traumatic event is indistinguishable from the present context. However, whilst these models account for PTSD resulting from single event trauma, the relevance for complex PTSD that can follow multiple stresses over prolonged periods of time is less clear (Green et al., 2000). Children and adolescents who have fled from war regions often report a number of extremely stressful experiences such as physical and psychological torture, shelling, sexual violence, and other atrocities. Some authors have questioned whether contemporary notions of trauma, and especially a focus on the category of PTSD, are adequate in assessing the effects of such experiences (Silove, 1996, 1999). The category of PTSD may not fully capture the complex nature of the psychological responses that arise out of such human rights violations (Silove, 1996).
It has also been argued that PTSD itself is an unhelpful diagnosis which may not be culturally relevant to those who have experienced trauma associated with war and organised violence (Summerfield, 2001). It has been suggested that it is not ethical to apply western, biomedical classification to different cultures because it results in normal responses to abnormal situations being interpreted as abnormal states (Summerfield, 2000). The use of psychiatric diagnoses has been criticised as an inappropriate form of labelling that doesn’t consider the huge range of losses that have been suffered (Summerfield, 2001). Many children and adolescents who are affected by war are unable to safely escape their countries, instead moving to nearby regions that are often equally affected by military violence. In addition, many of these children are also living in poverty and suffering from malnourishment. These living conditions question the applicability of psychotherapeutic treatment approaches that have been developed for western PTSD populations. Maslow’s hierarchy of needs (Maslow, 1943), for instance, claims that treatment for psychological problems can’t be addressed as long as the basic needs of nutrition and safety remain unmet. It is also unclear how many refugees suffering from PTSD actually seek and accept aid.
However, the core PTSD symptom clusters have been found repeatedly in children and adolescents, across cultures, and following a wide variety of traumatic events (Barrett & Ollendick, 2004). It is a certainty that children and adolescents who have witnessed military violence will experience emotional reactions, as would anyone in such a situation. Therefore, one of the benefits of the conceptualisation of psychological models of PTSD has been the development of successful psychological treatments.
Psychological Interventions for Children and Adolescents Traumatised by War
Policy and Research Recommendations
When the diagnosis of PTSD was first formulated (APA, 1980) it was initially believed that it would not be relevant to children and adolescents. However, it is now accepted that children and adolescents can develop PTSD following traumatic events (National Institute for Clinical Excellence, 2005). A phased model of intervention has been described by Herman (1997) and this is supported by the NICE guidelines (2005) as an appropriate way of working with traumatised individuals who are still living in situations of threat. It consists of three phases; establishing safety and trust, followed by trauma-focused therapy and finally reintegration and rehabilitation. This approach is suggested to be of particular benefit when working with asylum seekers because emotional states are so greatly influenced by asylum status. However, as there is a lack of trial evidence to support this model, it reflects a purely pragmatic approach.
The NICE guidelines (2005) state that conclusions about the effectiveness of psychological interventions for children and adolescents with PTSD are drawn from other areas, principally work on PTSD with sexually abused children and psychological interventions for adults. They suggest that considerable caution is required in drawing conclusions, particularly when drawing on results from research done with adults. However, even with the limited psychological trials available, NICE recommend that ‘trauma-focused cognitive behavioural therapy (TFCBT) should be offered to children with severe post-traumatic symptoms or with severe PTSD in the first month after the traumatic event’ (NICE, 2005, p. 123). The NICE guidelines report that no other psychological intervention has yet established a comparable evidence base to TFCBT, but other interventions such as Eye Movement Desensitisation and Reprocessing (EMDR) show promise.
Interventions for adults with PTSD are well studied in victims of traumatic events who live in Western societies. A large number of studies have shown that cognitive behavioural therapy (CBT) is effective in treating PTSD with those who experienced sexual assault (Foa et al., 1999) as well as those recovering from physical assault or accidents (Tarrier et al., 1999). Trauma-focused psychological interventions are generally effective for the treatment of PTSD in adults but only a limited evidence base exists for children and young people (Cohen et al., 2000). In addition, much of the evidence is drawn from work with children who have developed PTSD as a result of childhood sexual abuse (Ramchandani & Jones, 2003) and therefore the evidence base for interventions for PTSD arising from other traumas is weaker. The knowledge about the treatment of PTSD in populations of civilians who have been affected by war is even more limited. The NICE guidelines refer to the very little clinical research has been conducted on how to adequately support and treat these groups. The high number of survivors of military violence previously reported supports the notion that psychosocial services in refugee camps need guidelines on how to assist traumatised individuals in war-affected societies. There are also many problems with generalising the results of randomised control trials of psychological treatments for PTSD. One of the main difficulties is that not all PTSD sufferers are able to attend treatment in the usual clinical settings. The NICE guidelines (2005) do make reference to treatment innovations that may help deliver effective interventions to PTSD sufferers in remote locations. Narrative Exposure Therapy (NET) is highlighted and described as ‘encouraging’ (NICE ,2005, p. 62). Support for NET includes studies in traumatised communities affected by disaster (Basoglu et al., 2003, 2005) and studies in non-Western societies (Neuner et al., 2004).
Research assessing the efficacy of psychotherapy treatment for children and adolescents diagnosed with PTSD is generally underrepresented in the empirical literature. Since the inclusion of PTSD in the DSM-III, the majority of Randomised Control Trials (RCT’s) treating children with PTSD have focused on the use of variations of cognitive behavioural therapy including TFCBT. In 2007 an expert panel presented written evidence to the House of Commons relating to the general problems in implementing NICE guidelines in mental health (Barkham, 2007). NICE guidelines classify RCT evidence as the highest level of evidence (termed grade A), and the structured nature of a CBT approach ‘fits’ with an RCT design, however, there are other effective psychological therapies which are being overlooked because they do not have RCT evidence to support them. This issue relates to the lack of funding for other psychological therapies which does not necessarily equate to a lack of effectiveness, and as government initiatives increasingly rely on treatments tested only by RCTs, patient choice becomes restricted. NICE admits that the provision of psychological services for suffers of PTSD varies hugely across the UK and that some people may have to go through many steps before they can obtain referral to a treatment service, as well possibly facing unreasonably long delays (NICE, 2007). The guidelines emphasize a need for the NHS to develop a pathway of care that offers prompt, evidence-based services in local communities, supported by specialist services for individuals with more complex problems.
Research Evaluating Psychological Interventions
This review will now turn to a discussion of research studies that have attempted to evaluate interventions for children and adolescents who have experienced war-related trauma. A search of the literature was conducted; the search terms ‘PTSD’ and ‘war-trauma’ were used with ‘children’, ‘adolescents’ and ‘psychological interventions’. This review does not have the scope to systematically review the research studies evaluating the range of interventions that can be used with children and adolescents experiencing PTSD symptoms. The following section will therefore focus primarily on interventions that have been carried out with children and adolescents who have experienced war-related trauma. However, as mentioned previously, RCT evidence in the area of war trauma and refugees remains scarce. It has been suggested that the lack of research studies in this area is because this population are more difficult to treat (Bisson et al. 2007), possibly because of the severe and often multiple traumatic incidents occurring in war contexts (Silove, 1999).
Cognitive behavioural interventions are the most studied for treating PTSD in children and among the trauma therapies (Saxe, MacDonald & Ellis, 2007). CBT interventions for PTSD are based on learning and information-processing theories (Smith, Perrin, & Yule, 1999). According to learning theory, the traumatic event becomes an unconditioned stimulus which is triggered by non-traumatic stimuli (reminders), resulting in intense feelings or reactions such as fear, panic, dread and helplessness. Information-processing theory proposes that cognitions influence behaviour and so changing cognitions can also lead to subsequent changes in behaviour and affect. Cognitive behavioural interventions with children generally draw on both of these theories by relying on the use of behavioural techniques, as well as considering the cognitive interpretations and attributions about events made by children. Most CBT protocols include a variety of specific components. These range from psycho-education work, problem-solving strategies and skills teaching to behaviourally based exposure methods (creating a new narrative of the traumatic event) or cognitive techniques aimed at modifying distorted cognitions. Foa, Keane, and Friedman (2000) reviewed eight different CBT interventions for PTSD in young people with the aim of discovering with element was the most effective. These interventions included: exposure therapy, systematic desensitization, stress inoculation training, cognitive processing therapy, cognitive therapy, assertiveness training, biofeedback and relaxation training, and combination approaches. They reported that for cognitive therapy there was ‘initial evidence’, whereas for exposure ‘no other treatment component has such strong evidence for its efficacy’ (Foa, Keane, & Friedman, 2000, p.52). Other researchers have also suggested that ‘some form of exposure to trauma-related stimuli’ is required to bring about ‘effective emotional processing of the event’ (Barrett & Ollendick, 2004, p. 228).
The Ehlers and Clark (2000) cognitive model of PTSD has been successfully used with refugee children and this is described in two case vignettes (Vickers, 2005).This model differs from previous ‘conditioning’ models of PTSD in that it has cognitions and the personal meaning of events at its core. Graded exposure to aspects of the trauma and triggers of unwanted re-experiencing of the event are conducted alongside cognitive techniques that promote the search for a new meaning. It provides a clear framework for changing the dysfunctional beliefs the sufferer holds about the meaning of the trauma for them. This model has been described as s a useful way to explain the symptoms of PTSD in young people who are also refugees (Vickers, 2005). However, one of the young people in this case study dropped out of treatment before the course had finished and the author agrees with Yule (2004), who argued that, although CBT has an important place in helping young refugees, attention also needs to be given to other social and psychosocial interventions as well.
A controlled study (n = 26) evaluated the effectiveness of a school-based group intervention for children who had experienced war-related trauma (Ehntholt, Smith, & Yule, 2005). The treatment group (n = 15) received six sessions of group CBT, while the control group (n = 11) were placed on a waiting list. Children in the CBT group showed a statistically significant decrease in PTSD symptoms, whereas the children on the waiting list did not show any improvement over the same period. Based on a manual (Smith et al., 2000), this school based intervention focused on psycho-education, normalising reactions to trauma and developing coping strategies. Within the sessions children also engaged in trauma-focused exposure therapy using dual attention techniques. However, follow-up data, which were only available for eight of the children, suggest the improvements in the CBT group were not maintained at two-month follow-up. It is possible that the six session treatment is too brief when delivered in a group format. The researchers also highlight the difficulty of implementing exposure in a group session and suggest that graded exposure programmes could have been encouraged for children who had more idiosyncratic forms of avoidance (Ehntholt, Smith, & Yule, 2005).
Eye Movement Desensitization and Reprocessing (EMDR) is a fairly recently discovered treatment that uses bilateral stimulation when processing traumatic memories in individuals with PTSD (Shapiro, 1995). It was initially used for treating adults with PTSD, however over recent years an adapted protocol with age appropriate modifications has been suggested for use with children (e.g., Alder-Tapia & Settle, 2008). There is no well established theory that explains the way EMDR works. However, according to Shapiro (2007), who founded the method, EMDR is guided by the adaptive information processing model. When a traumatic or distressing experience occurs, it may overwhelm usual ways of coping and the memory of the event is inadequately processed with the memory subsequently being stored in an isolated memory network. This theory suggests EMDR works directly with memory networks and enhances information processing by forging associations between the distressing memory and more adaptive information contained in other memory networks. It is thought that the distressing memory is transformed when new connections are made with more positive and realistic information resulting in a neutralization of the traumatic memories. Once neutralized, the traumatic memory becomes available to the normal information processing in the brain leading to the normal healing process and a decrease in the post-traumatic stress symptoms (Shapiro, 2007). Exposure to the memories of the traumatic event is a central feature of both EMDR and TFCBT, and it has been suggested that the therapies that did not focus on the trauma itself but instead focused on past or present problems were not as effective in reducing PTSD (Rodenburg et al., 2009). Although the eye movements are integral to the basic procedure (Shapiro, 1995), some researchers have argued that they are not necessary and that EMDR is best understood as an exposure technique (Davidson & Parker, 2001).
To date there has been only one study conducted using EMDR with children and adolescents who have experienced trauma in the context of war and organised violence. A case study series (n = 13) reports significant improvements in both PTSD and depression symptoms following the use of EMDR in a psychodynamic context (Oras, Cancela de Ezpeleta, & Ahmad, 2004). However, due to the small sample size, lack of a control group and the mixture of psychotherapeutic methods with EMDR, these findings should be interpreted with caution.
A further therapy, testimony psychotherapy was developed specifically for adults who have suffered multiple traumas over a prolonged period of time. Testimonial psychotherapy is distinguished from other approaches, by its basis in the social and political aspects of trauma. Testimonials involve the retelling of an individuals account to a therapist who documents the narrative, and, through a joint process of reviewing it, a written document is produced which may be used for documentary or political purposes. The testimonial process also allows the victim to gain some distance from the event, and to focus on different aspects of the story, such as the individual’s personal resources that led to survival (Lustig, Weine, Saxe & Beardslee, 2004).
The written testimonial serves a particularly important function with refugees from countries where psychotherapy may be uncommon or even stigmatizing (Lustig, Weine, Saxe, & Beardslee, 2004). The written document alters the focus of the therapy to political, not clinical and is therefore more culturally acceptable. Testimonial psychotherapy is likely most suitable within cultures that acknowledge the oral tradition of storytelling, and a belief in the possibility of changing the future, whereas cultures that believe one’s fate is predetermined would be much less likely to embrace testimonials (Weine, Kulenovic, Pavkovic, & Gibbons, 1998). Testimonial psychotherapy has been found to be effective in a case series study with adult Bosnian refugees (n = 20), who all showed improvement in depressive symptoms and PTSD symptoms at post-treatment, as well as at two and six month follow-up (Weine, Kulenovic, Pavkovic, & Gibbons, 1998). However, results of this study should be interpreted cautiously, because there was no control group, and PTSD symptoms among refugees can improve over time without treatment. Testimonial psychotherapy has also been described as being effective in three case studies of Sudanese refuges (Lustig, Weine, Saxe & Beardslee, 2004). However, it is impossible to determine the efficacy of testimonial psychotherapy in this study as they did not assess the individuals for symptoms of PTSD before and after giving testimony. Also, the success of testimonial psychotherapy relies heavily upon the cultural acceptability of sharing personal stories, which cannot be universally presumed (Lee, 1988).
Narrative Exposure Therapy as a new model for treating PTSD
Narrative Exposure Therapy (NET) is a new approach that has been devised specifically for the victims of military violence, incorporating elements of testimonial psychotherapy with cognitive behavioural techniques and theory (Schauer, Neuner, & Elbert, 2005). It was developed as a short-term treatment, originally devised to be used in refugee camps in emergency settings; it has now been trialled with asylum seekers and refugees in western countries (Ruf et al., 2010). NET is based on the assumptions of cognitive behavioural exposure therapy but using an adapted narrative approach to exposure. It relies on principles of habituation of fear networks and how they can be activated in the brain (Foa & Rathbaum, 1998). It also draws on the theoretical understanding of both autobiographical memory (Conway, 2001) and the framework it provides in understanding intrusive symptoms (Ehlers & Clark, 2000).
In the development of NET, a distinction was made between declarative and non-declarative memory. These memory systems differ in the retrieval of information: declarative memory is retrieved deliberately and accessed verbally, whereas non-declarative memory is activated automatically by environmental cues (Squire, 1994).
The declarative part of episodic memory has been termed “autobiographical memory” (Conway & Pleydell-Pearce, 2000) and is the primary base for the narration of events, as well as being the main resource for the retrieval of information about one’s life. To allow rapid access of information, autobiographical memory is stored at different levels of organization. At the top of the organization is information relating to ‘lifetime periods’ that have identifiable beginnings and endings (Neuner & Catini, et al., 2008), such as where a person lived or their occupation over a certain period. The next level is the memory for general events, which can be divided into repeated events (e.g. the journey into work) and specific events (e.g. the first day at a new job).
The non-declarative part of episodic memory contains sensory information, as well as cognitive and emotional perceptions (Brewin et al., 1996). The retrieval of sensory information is fundamentally different from the retrieval of autobiographic information. The contextual facts stored in auto biographic memory are retrieved as verbally accessible knowledge, whereas, the retrieval of sensory information is perceived as an experience of the information itself. For traumatic events, sensory perceptual representations are known as ‘fear networks’ (Lang, 1993). The associations between items within these fear networks are extremely strong, so that when an individual later comes across one external or internal stimulus within the fear network, it results in activation of the entire network. Flashbacks in PTSD are thought to occur when the whole fear network is activated (Neuner & Catini, et al., 2008). The fear network can be activated easily, because many environmental cues resemble the items in the fear structure. This activation is experienced as an intrusive sensory, emotional and physiological re-experiencing of the traumatic event, which is the primary symptom in PTSD. As a result, the traumatized individual learns to prevent the activation of the fear structure by avoiding cues that remind them of the trauma. This avoidance includes both internal and external cues and eventually the individual acquires a pattern of avoidance behaviour. In addition, the lack of contextual information means that the person maintains a sense of current threat when the memory is activated (Neuner, Catani, et al., 2008) and the autobiographical memory is disrupted. This disruption in autobiographical memory means that the individual is unlikely to be able to provide a consistent chronological account of events, which explains how repeated or multiple events are more likely to result in severe psychological disturbance. As fear networks increase and become more readily activated through repeated experiences, intrusive memories are accompanied by the sensation of current and continued threat, even thought the event might have happened years ago (Elbert et al., 2006).
Several studies have shown that traumatic memory differs significantly from everyday memory (Brewin, 2007). The content of traumatic memory is dominated by sensory elements and is highly distressing and repetitive, as well as narrations being more fragmented (Harvey & Bryant, 1999). Furthermore, it has been shown that disorganization of the narration and a dominance of sensory elements in the trauma memory immediately after the event predicts the development of chronic PTSD (Jones et al., 2007).
In NET the traumatic events are worked through with the client in sequential order to integrate thoughts, feelings and body reactions associated with the traumatic events within the autobiographic memory (Schauer et al., 2005). The individual learns that the fear triggered by thoughts about the past events can be overcome by talking in detail about what has happened, hence, in stopping to avoid thoughts about the trauma. In NET the life history of the client with all trauma events is written up in the narration and at the end of therapy handed over to the client (Neuner & Catini, et al., 2008).
Implications for treatment
In line with the previously discussed theory of PTSD, one of the aims of NET is to construct a consistent autobiographical representation of the traumatic event. This representation helps the individual to realise that the activity of the fear structure is just a memory and therefore the sense of current threat is reduced. Initial theories of exposure therapy (Foa & Rothbaum, 1998) were based on fear extinction but more recently, research has supported the importance of constructing autobiographical knowledge (Neuner, Catani, et al., 2008). It has also been demonstrated that traumatized individuals who mange to construct a coherent narration of the event during exposure therapy benefit most from treatment (Foa, Molnar, & Cashman, 1995), suggesting that whilst habituation to the memory of the traumatic event is crucial, constructing a meaningful narrative of the event is also important in assisting recovery (Neuner & Catani, et al., 2008).
Consequently, NET aims to construct a consistent autobiographical representation of traumatic events within the context of a narrative of the individual’s whole life. Previous exposure therapies for PTSD tend to target the worst traumatic event, however, as NET has been developed for individuals who have experienced war trauma, they are likely to have experienced multiple traumatic events, making it impossible to identify one event as ‘worse’ (Catini et al., 2009). Instead of a using single event as a target for therapy, the aim is to narrate all stressful life events in chronological order from birth to the present day.
Research Evaluating Narrative Exposure Therapy for Children and Adolescents
With encouraging finding from NET studies in adults, a version of this therapy has been adapted for use with children and adolescents (KIDNET). It has been demonstrated that children and adolescents who have experienced war-related trauma are at risk of developing moderate to severe PTSD (Catani, Jacob, Schauer,
Kohila, & Neuner, 2008; Catani, Schauer, et al., 2009; Schaal et al., 2009; Yule, 2000). In addition to the debilitating and distressing effects of PTSD, individuals may also experience impairment in social and educational functioning and cognitive development (Elbert et al., 2009).
In contrast to the adult version, KIDNET involves play and visual instruction to help children to elaborate on their experiences, for example, during the life-line exercise, a rope is used to represent the child’s lifeline, with flowers being used to mark positive experiences and stones to mark negative and traumatic experiences (Schauer et al., 2003). Children are also encouraged to extend their narrative beyond the present so that it describes their hopes and wishes for the future. To date there have been four published studies investigating the use of KIDNET (Catani, Kohiladevy, et al., 2009; Onyut et al., 2005; Ruf, Schauer, et al., 2010; Schauer et al., 2004), and all but one were conducted in low and middle income settings.
In a case study, KIDNET was used with a thirteen year old Somali refugee, Mohammed, who presented in the severe range for PTSD (Schauer et al., 2004). Mohammed had suffered multiple traumatic events. In the course of one year, he had experienced multiple traumas, including; being shot at and wounded; seeing dead bodies floating in the water; being beaten in the face with a gun; witnessing the rape of his best friend; a village raid; a car accident, where he was sat in the passenger seat and witnessed the driver being shot in the head and killed. Mohammed attended a psycho-educational session before receiving four sessions of KIDNET, each lasting 60-90 minutes. The post-test revealed that Mohammed’s symptoms had reduced to a level below the diagnostic threshold for PTSD. Avoidance intrusive symptoms had also disappeared almost completely. His symptoms of hyper arousal were still present occasionally, but they no longer interfered with his functioning to the extent that he felt he was out of control. The results of this case study suggest that it is possible that well-established knowledge about the efficacy of exposure techniques for the treatment of PTSD (Foa, 2000) may be applied to child refugee populations, even when living in unstable conditions. In contrast to a variety of other cognitive behavioural approaches, KIDNET is shorter and the procedure is more pragmatic. This makes the method especially suitable in war and disaster areas.
In a pilot study of KIDNET, in an African refugee settlement, six Somali refugees aged 13–17 years were treated (Onyut et al., 2005). All of the children were assessed for depression and PTSD and attended a psycho-educational session before receiving four to six sessions of KIDNET, each lasting 1-2 hours. All children accepted the offer of KIDNET and completed the full course of treatment. Pre- and post-tests were conducted measuring depression and PTSD and all patients were followed up at nine months. Prior to treatment all children had moderate to severe scores for PTSD, and four children presented with clinically significant depression.
A reduction in PTSD scores was evident at post-hoc and after nine months, four of the six children no longer met the criteria for PTSD. Two of the children still fulfilled PTSD criteria, but now at borderline levels and with a reduction in functional impairment. None of the children met the criteria for clinically significant depression at the post-test or the nine months follow-up. However, this study has several methodological limitations, including a small sample size and the lack of a control group. In addition, the researchers cannot be sure that improvement in symptoms is attributed solely to treatment as it may also be caused by spontaneous remission. Nevertheless, given the data available, on the high prevalence of PTSD in the Somali refugee population (Onyut et al., 2004), it seems unlikely that spontaneous remission could have occurred at this rate.
In a Sri Lankan study of KIDNET, children who had been traumatized by Tsunami and war, was conducted. This study was carried out in response to an initial needs assessment for children affected by the tsunami, which found a 45% prevalence rate of PTSD in the part of the country affected by the tsunami. The study included six sessions of KIDNET compared with six sessions of meditation and relaxation in 31 children (aged 8–14) who had been diagnosed with PTSD (Catani, Kohiladevy, et al., 2009). Both treatments consisted of six sessions lasting 60-90 minutes. To rule out a possible therapist effect, each therapist provided the same number of treatments in both conditions. The meditation protocol involved relaxation exercises, encouraging the child to be mindful of their experiences with the aim of helping them control their fear without re-exposure to the traumatic event. It was developed by local counsellors and had high cultural validity. Results showed that in both treatments, PTSD symptoms were reduced after one month post-test with no significant difference between treatments. Improvements were maintained at the six month follow-up where 81% of the children who were treated with KIDNET and 71% of children treated with meditation no longer met diagnostic criteria for PTSD. In addition to the reduction of PTSD, improvements were also shown in psychosocial functioning, including in social relationships and everyday tasks. The major limitation of this study is that the lack of a control group, however, because of the high level of need for trauma interventions among the population, the decision not to include a non-treated group was made because of ethical concerns (Catani, Kohiladevy, et al., 2009). Furthermore, if diagnostic interviews had been conducted several months after treatment, it could have provided more insight into therapy effects, as previous studies using NET with adults have shown that PTSD reduction at one year follow-up is more evident than effects at three to four month post-tests (Neuner et al., 2004: Schaal et al., 2008).
One trail of KIDNET has been carried out on refugee children living in Germany (Ruf, Schauer, et al., 2010). In this trial, 26 children aged between 7–16 years with PTSD were randomly allocated to either the KIDNET group (n = 13) or to a wait list control group (n = 13). The two groups (KIDNET vs. waiting list) did not differ significantly in terms of traumatic events experienced and all the children have lived under the threat of potential deportation to their home country. Children in the KIDNET group received 7-10 sessions on a weekly basis. Only one child dropped out of the treatment but requested to restart therapy after 2 years, as his suffering had continued. Results from this trial showed that KIDNET effectively reduced PTSD across all three symptom clusters (intrusions, avoidance and hyperarousal) between pre- and post-test, whereas the waiting list control group showed no improvement. These results were maintained at both 6 month and 12 month follow-up. Given the unstable status of the families as asylum seekers and the background of highly traumatic experiences, the success of KIDNET is substantial both in terms of clinical symptoms and mental functioning. It is clear that the treatment itself was highly accepted by the children, due to the low drop-out rate. In addition, as the treated group consisted of children from five different ethnic groups, it would seem to suggest that KIDNET is an approach which is suitable for children of different backgrounds. Limitations of the study include the relatively small sample size and the lack of an active control group, which means it is impossible to state explicitly that the improvement in the KIDNET group is due to the specific treatment approach and not as result of the attention and empathic understanding children had received.
However, the sustainable clinical effects, compared to treatment attempts reported in the literature suggest that it is possible to effectively treat refugee children suffering from PTSD even while the children and their families are still living in refugee centres.
This review has highlighted the multiple traumatic events and severe losses that children and adolescents from war-affected regions are frequently subjected to. Although many of these young people are extremely resilient, some will undeniably develop mental health difficulties. Clinicians should be aware that even though PTSD is frequently diagnosed, it often co-exists with a range of other mental health difficulties, such as anxiety, depression and grief. The promising results obtained for KIDNET suggest that co-morbid difficulties and functional problems may also be improved with this therapy. Researchers have highlighted the importance of continuing to develop and improve existing treatments as well as to be innovative in creating new treatments to reduce drop out rates and treatment failures (Cukor, Spitalnick, Difede, Rizzo, & Rothbaum, 2009). The dropout rates of trials of KIDNET have been consistently low and it has been demonstrated to be effective in a number of different settings and in both high and lower income countries. In addition, the efficacy of KIDNET in reducing PTSD symptoms in diverse populations demonstrates the transferability of the intervention across cultures and adds further evidence to suggest the importance of exposure to traumatic memories in reducing PTSD symptoms.
This review, thus suggests that KIDNET should be further explored for the psychological rehabilitation of children and adolescents who have experienced war-related trauma, irrespective of their particular background and history.
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