Children and War

Manual

“Teaching Recovery Techniques” (Smith et al, 1999).

This is a psycho-social-educational programme. It is designed to be delivered by people with a minimum of experience, but with supervision from someone with more mental health expertise. We intend to develop and refine the package since there is clearly a great demand for effective, low-cost early interventions that can be used with large numbers of children following a broad range of catastrophes.

The philosophy behind the manual is that wherever possible, the advice should be based on good empirical evidence. However, we recognise that children cannot wait while all the evidence is collated. Therefore, some of the suggestions are drawn from our own clinical experience and that of others. Because of this, we see it as vital that whoever uses the manual must evaluate its effects. To that end, we supply an up-to-date version of our core battery of screening and outcome measures and insist that those who use the package, under licence, send their outcome data to us so that we can adapt the package in the light of new evidence.

The flexible materials address common early distressing reactions experienced by children so as to help them on the road to recovery. The early intervention consists of three half-day modules for all children followed by a fourth meeting for those who have been bereaved. An essential element of the package is a one-session meeting for parents to explain the intervention and give suggestions on how to help their children in the early aftermath of a traumatic incident.

To date, the materials have been used with child survivors of the 1999 earthquakes in Turkey, Greece, and Iran with good results. They have also brought reductions in distress among child refugees in London and children exposed to child sexual abuse in Finland.

The three main sessions concentrate on helping children deal with the troubling symptoms of intrusion, arousal and avoidance. Children are taken through various warm-up exercises and helped to adopt a problem-solving and group-sharing approach to these difficulties. With regard to intrusion, they are taught about how traumatic reminders can upset them. They practice various imagery techniques to demonstrate to themselves that they can gain some control over the intrusive images that may have troubled them. They are introduced to distraction techniques, dual attention techniques (similar to some of the EMDR techniques) and how to manage frightening, repetitive dreams.

To reduce arousal, they are first helped to identify their reactions and are then taught the skills that enable them to relax at will. They are encouraged to make use of their own techniques to induce relaxation and where possible bolster these by breathing exercises and muscle relaxation. They are helped to schedule their activities, to look at better sleep hygiene and to develop and practice coping self-statements.

With respect to avoidance, the exercises introduce the children and adolescents to the concept of graded exposure, giving short practice in imaginal exposure followed by self-reinforcement. They are encouraged to draw, write and talk about the incidents and above all to look to the future rather than the past.

We were reluctant to release the manuals until they had been field- tested. They have been used successfully with children following the 1999 earthquakes in both Turkey and Greece. In Athens, Greece, Giannopolou (2000) used the programme with two small groups of children badly upset by the earthquake. The co-leaders had never used techniques like this before. They used a Greek translation of the manual and also tested the children before and after running the groups.

As can be seen, following the sessions, the first group on the left showed significant drops in both the traumatic stress and depression scores. Of course, time had passed and cynics might argue that the children would have improved in any case, and the changes had nothing to do with the intervention. However, they ran a second group a few weeks later. If anything, these children were reporting even higher distress at the start of the programme, so that the passage of time had not helped them. Immediately after they had been given the sessions, their distress also dropped dramatically. Thus, by assessing the children routinely and systematically before and after the intervention, the helpers are able to demonstrate not only that the children improved, but also that the improvement was related to the intervention and not merely the passage of time.

In 2006 the results were published: Giannopoulo, J., Dikaiakou, A., & Yule, W. (2006). Cognitive–behavioural group intervention for PTSD symptoms in children following the Athens 1999 earthquake: A pilot study. Clinical Child Psychology and Psychiatry, 11, 543–553.

The abstract for this article is as follows:

This study examined the effects of a short-term group cognitive-behavioural intervention in children who were experiencing PTSD symptoms following the Athens 1999 earthquake. Twenty children, aged 8–12 years, referred for treatment to a local child mental health team were assigned, depending on timing of referral to two groups – Group 1 (N = 10), which started treatment 2 months after the earthquake and Group 2 (N = 10), which started treatment at 4 months postearthquake. A statistically significant reduction in overall PTSD (Posttraumatic Stress Disorder) symptoms across the three PTSD symptom clusters – intrusion, avoidance, and arousal – as well as in depressive symptoms was reported immediately after the intervention. The treatment also produced a statistically significant improvement in children’s psychosocial functioning. Further significant improvement was reported in children at an 18-month follow-up. Treatment gains were maintained at a 4-year follow-up. Despite several limitations to this study, short-term group CBT (cognitive-behavioural therapy) was found to be a useful treatment approach, which can be offered in clinical settings, particularly if resources are limited.

It can be seen that the manual seem to have positive effects on several aspects of children’s functioning following disaster.

In Turkey, it was first tried out with about 300 children and then rolled out to help many others. Unfortunately, to date the results have not been formally published although the data we have seen are again very positive.

The manual has also formed the basis for interventions with young refugees seeking asylum in the UK. Sessions in schools helped reduce the adolescents’ distress, although the effects were not as marked as in the post-disaster studies, probably because of the complexities of the pupils’ lives and the uncertainty surrounding their future (Ehntholt et al 2005).

The most exciting use of the manual has been in Iran, following the earthquake in Bam, Iran in 2003. The Iranian Director of Mental Health, Dr Yasamy, had asked for help after an earlier, less devastating earthquake, and through UNICEF had arranged for training in the manual through colleagues from the Center for Crisis Psychology. When the Bam earthquake happened, they trained a further 400 psychologists and psychiatrists, and 1,380 teachers to use the manual and a variant of it with over 55,000 survivors in the first 7 months after the earthquake. They measured distress before and after the intervention and found that around 85% of survivors greatly benefited. This is currently being written up for publication but must rank as one of the largest mental health interventions in history, and the manual was at the centre of it.

In another study from Iran conducted by Shooshtary, Panaghi and Moghadam the manual also showed its efficacy in alleviating posttraumatic stress following the earthquake.

The abstract for this article is as follows:

Purpose: The authors evaluated the effectiveness of cognitive behavioral therapy (CBT) among adolescents exposed to the 2004 earthquake in Bam, Iran. Methods: Four months after the earthquake, 135 adolescents as a case group and 33 adolescents as a comparison group were evaluated with the Impact of Event Scale Revised (IES-R). Two therapists were trained in CBT in 3-day classes according to a manual provided by mental health services. After conducting CBT in the case group, both groups were evaluated again with IES-R. Results: The severity of post-traumatic stress symptoms significantly decreased among the subjects given CBT in the case group. The improvement in posttraumatic stress symptoms was attributable to improvement in each of three-symptom categories (intrusion, avoidance, and arousal) and in the total score of posttraumatic stress disorder (p <.05). Conclusions: The findings demonstrate the efficacy of CBT in alleviating posttraumatic stress symptoms among adolescents after a catastrophic disaster.

Shooshtary, M. H., Panaghi, L., & Moghadam, J. (2008). Outcome of cognitive behavioral therapy in adolescents after natural disaster. Journal of Adolescent Health, 42, 466–472.

In Finland Kirsti Pekkarinen, Raija-Leena Punamäki and Soili Poijula have used it with a group of boys who were sexually abused by the same perpetrator. The results show that there was a significant reduction of posttraumatic symptoms when measured by the Children’s Impact of Event Scale (CRIES-13). The results were presented at the European Conference on Traumatic Stress in Opatia, Croatia in June 2007. The presentation can be seen here.