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Psychosocial Intervention for Postdisaster Trauma Symptoms in Elementary School Children
A Controlled Community Field Study
Claude M. Chemtob, PhD;
Joanne P. Nakashima, MEd;
Roger S. Hamada, PhD
Arch Pediatr Adolesc Med. 2002;156:211-216.
ABSTRACT
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Context Natural disasters negatively affect children's emotional and behavioral
adjustment. Although treatments to reduce psychological morbidity following
disasters are needed, it has been difficult to conduct treatment research
in postdisaster environments because of the sensitivity of victims to perceived
intrusiveness and exploitation.
Objective To evaluate the efficacy of a public health–inspired intervention
combining school-based screening and psychosocial treatment to identify and
treat children with persistent disaster-related trauma symptoms.
Design To identify children with continued high levels of trauma-related symptoms
2 years after a major disaster, we conducted a community-wide school-based
screening of disaster-exposed public elementary school children. Children
with the highest levels of trauma-related symptoms were randomly assigned
to 1 of 3 consecutively treated cohorts. Children in the cohorts awaiting
treatment served as wait-list controls. Within each cohort, children were
randomly assigned to either individual or group treatment to allow comparison
of the efficacy of the 2 treatment modalities.
Setting All 10 public elementary schools on the island of Kauai (one of the
Hawaiian Islands) 2 years after Hurricane Iniki.
Participants All 4258 children in second through sixth grade were screened. The 248
children with the highest levels of psychological trauma symptoms were selected
for treatment.
Intervention Children were randomly assigned to either individual or group treatment
provided by specially trained school-based counselors. Treatment comprised
4 sessions.
Main Outcome Measures The Kauai Reaction Inventory, a self-report measure of trauma symptoms,
and the Child Reaction Inventory, a semistructured clinical interview for
posttraumatic stress disorder symptoms.
Results After treatment, children reported significant reductions in self-reported
trauma-related symptoms. This symptom reduction was maintained at the 1-year
follow-up. Clinical interviews also indicated that treated children had fewer
trauma symptoms compared with untreated children.
Conclusions School-based community-wide screening followed by psychosocial intervention
seems to effectively identify and reduce children's disaster-related trauma
symptoms and may facilitate psychological recovery. While group and individual
treatments did not differ in efficacy, fewer children dropped out of the group
treatment. This approach may be applicable to screening and treating children
exposed to a variety of large-scale disasters.
INTRODUCTION
A GROWING literature documents the negative effects of natural disasters
on children's emotional and behavioral adjustment.1-7
Disaster-related symptoms include intrusive reexperiencing of the disaster,
avoidance of disaster reminders, and persistent hyperarousal and anger. Although
it seems that a substantial proportion of children can develop persistent
psychological impairment if left untreated,7-8
there is a paucity of research on effective postdisaster psychological interventions.9 This is consistent with the fact that treatment research
on child posttraumatic stress disorder (PTSD) is in its infancy.10-11
The treatment of psychological symptoms in elementary school–aged
children following a disaster has been evaluated in only 1 uncontrolled group
comparison study.12 Two uncontrolled studies
of postdisaster treatment compared treated with untreated groups of adolescents.13-14 While suggestive of the value of
postdisaster treatment for children, these studies were inconclusive because
of significant methodological limitations. Participants were not randomly
assigned; posttrauma symptoms were not specifically measured in the child
study; information on attrition was not provided; and the treatment was not
protocol-guided, making it difficult to know what was done. Significantly,
these studies were conducted with small samples of convenience and did not
address the problem of screening and treating large groups of children.
To our knowledge, this article describes the first randomized controlled
study of a psychosocial treatment for postdisaster trauma symptoms. Hurricane
Iniki struck Kauai, one of the Hawaiian Islands, on September 11, 1992, damaging
71% of the island's homes, and causing more than 2 billion dollars in damage.
Iniki is ranked one of the most destructive disasters in United States history.
Two years after Iniki, because school personnel reported continuing distress
among children, this intervention study was undertaken. The present study
addressed 2 clinical problems facing those proposing to intervene with children
following a disaster: (1) how to identify symptomatic cases in a large population
of children given that relatively few children are symptomatic, and that not
all symptomatic children outwardly display disordered behavior; and (2) the
feasibility and efficacy of providing treatment to relatively large numbers
of affected children.
PARTICIPANTS AND METHODS
SCREENING OF CHILDREN FOR TRAUMA SYMPTOMS
Treatment participants were drawn from a screening of the population
of all children on Kauai attending the second through sixth grades (N = 4258)
at Kauai's 10 public elementary schools. The school district's enrollment
rolls defined the population of elementary public school children on Kauai
and provided demographic information such as names, birth dates, grade, school
lunch status, and student ethnicity. Children in kindergarten or first grade
were not included in the screening because they were too young to respond
adequately to a self-report instrument. Parents were mailed notification of
the screening and given the opportunity to decline participation by their
child.
SCREENING MEASURES
Disaster Exposure
Four multiple-choice hurricane exposure questions were included to assess
disaster exposure. These items were keyed to the event exposure criteria for
PTSD diagnosis, as revised in the most recent Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)15 of the American Psychiatric
Association, permitting us to assess whether the children met the exposure
criterion for PTSD. The questions were: (1) During the hurricane, did you
think you would die or get hurt? (2) During the hurricane, did you think your
mom or dad or brother or sister, or other close relatives, would die or get
hurt? (3) How much did the hurricane hurt your home? (4) How scared were you
during the hurricane? The last 2 questions were rated on 5-point scales.
Trauma Symptoms
We used the Kauai Recovery Inventory (KRI)16
to measure trauma symptoms. The KRI is a 24-item self-report scale adapted
for elementary school children from the Reaction Index.17
The KRI includes items about intrusive reexperiencing of the disaster, avoidance
of reminders, and arousal symptoms such as hypervigilance and irritability.
With the exception of the event exposure criterion, these items are keyed
to the diagnostic criteria for PTSD contained in the DSM-IV.15 Children rated on a 3-point scale
("no," "sometimes," "almost all the time") the frequency of experiencing hurricane-related
trauma symptoms in the past week. The KRI has high internal consistency (Cronbach 
= .84) and adequate 4-week test-retest reliability ( = .77). The finding
that children with high exposure scores had significantly higher trauma symptoms
supports the validity of the inventory.16
Procedure
Each school's counselor coordinated screening administration. Second-
and third-grade teachers were given a standardized lesson plan used to teach
the children in those grades how to respond to a self-report measure. The
KRI was group-administered in the children's classrooms by their usual teachers.
Teachers read the items aloud to the children during the administration to
minimize the effects of variability in reading skills. Answer sheets were
designed for machine scoring, permitting rapid tally of responses. An arbitrary
cut-off score corresponding to the 94th percentile was used to identify the
children reporting the most severe trauma symptoms.
INTERVENTION DESIGN
Overview
Following the screening, children reporting the highest levels of trauma
symptoms were provided school-based treatment. Resource limitations restricted
our treatment capacity; consequently, children were randomly assigned to 1
of 3 consecutively treated treatment cohorts. This ensured equity with respect
to which child got treated when, and simultaneously provided for the randomized
allocation of participants to treatment cohorts required by our wait-list
design. Our design also permitted us to compare the efficacy of group treatment
with that of individual treatment through random assignment of children to
each treatment type, within treatment cohorts. Treatment efficacy was measured
using (1) self-reports of trauma symptoms pretreatment, posttreatment, and
at follow-up (obtained using the KRI measure described above); and (2) clinician
ratings of treated vs untreated children. The clinician raters were kept unaware
of whether the child they examined had been treated.
Randomization
Once treatment candidates were identified through screening, the randomization
facility of SPSS (Statistical Package for the Social Sciences, SPSS Inc, Chicago,
Ill) was used to randomly assign children to cohorts, and within each cohort,
to individual or group treatment. Following screening, children were randomly
assigned to 1 of 3 treatment cohorts. The children within each treatment cohort
were then randomly assigned to a treatment modality. For the first 2 cohorts,
we used a ratio of 1 participant in individual treatment to 4 in group treatment.
For the third cohort, we pragmatically increased participant allocation to
individual treatment to ensure adequate numbers for the analyses comparing
the 2 treatments.
"Retest Only" Group
To control for the possibility that simply repeating testing might account
for KRI score reductions through practice effects, we drew a sample of 42
children from the screened population whose KRI scores were in the next highest
scoring range of distress (ie, the 90th to 93rd percentile). This sample was
administered the KRI twice, approximately 1 month apart, to approximate the
time between measurements before and after treatment. Sixty-one percent of
this sample were girls, with a mean age of 8.47 years (SD = 1.17 years).
TREATMENT OUTCOME ASSESSMENT
Kauai Recovery Inventory
The KRI16 was used to measure trauma
symptoms pretreatment, posttreatment, and at follow-up. It was administered
individually to treatment participants. As noted above, the KRI measures the
frequency of reexperiencing, avoidance, and arousal symptoms in the previous
week.
Child PTSD Reaction Index
The Child PTSD Reaction Index (CRI)18
is a widely used semistructured clinician-administered interview that assesses
psychological trauma symptoms experienced by children. Test-retest interitem
agreement across 7 days has been reported as 94% with a  coefficient
of 0.88. Because of limited availability of interviewers, the CRI was used
to compare a randomly drawn sample of treated children with a randomly drawn
sample of untreated children.
TREATMENT
Treatment was manual-guided and consisted of 4 weekly sessions. As there
were no postdisaster trauma treatment manuals in existence, we designed a
developmentally appropriate treatment manual for the individual treatment
and another for group treatment. The intervention philosophy incorporated
in the treatment assumed that most children recover naturally from a disaster.
We posited that to recover from a disaster, children must master disaster-related
psychological challenges. These include restoring a sense of safety; grieving
losses and renewing attachments; adaptively expressing disaster-related anger;
and achieving closure about the disaster to move forward. Our intervention
was designed to provide a context in which children would be prompted to review
their experiences in a structured way, while receiving support to master the
psychological tasks that had not been completed. The treatment manual comprised
session-by-session protocols that outlined each session's content and provided
a specific repertoire of activities designed to elicit material relevant to
each session. Therapists were provided a standard box of play and art materials
to use. Treatment groups were conducted with 4 to 8 children. The primary
foci for each session were defined as follows: Session 1: "Safety and Helplessness";
Session 2: "Loss"; Session 3: "Mobilizing Competence and Issues of Anger";
and Session 4: "Ending and Going Forward." For example, in Session 2, children
were asked whether they had lost pets or favorite toys. They were engaged
in play intended to help them identify any losses, express feelings about
the losses, think about the present significance of the losses, and finally,
come up with forward-looking ways of integrating the loss into the present.
This was done through a combination of play, use of expressive art, and talk.
Similar activities were used in both treatments, except that in group treatment,
children were engaged in adaptations of the treatments that involved cooperative
play and discussion.
Therapists
There were 2 male and 2 female therapists. All were experienced at working
with children in schools. Three were school counselors; 1 was a clinical social
worker. Therapists received 3 days of training regarding postdisaster trauma
psychology and a day and a half of didactic training specific to the treatment
manual.
Treatment Fidelity
To facilitate learning the treatments, therapists were given lighter
workloads during the first cohort's treatment period. Therapists were provided
identical play therapy kits to help standardize treatment activities. Therapists
received 3 hours of group supervision weekly to encourage adherence to the
treatment protocol. They took turns presenting their work orally and received
supervision aimed at promoting treatment uniformity.
Human Subjects Oversight
The work reported here was conducted as part of the program evaluation
of a school disaster recovery program that the Hawaii State Legislature directed
the Department of Education to design and implement. The program was considered
by the Department of Education to be an extension of its school counseling
function. The authors took several specific steps to safeguard student and
family rights. This included establishing an advisory committee that reviewed
proposed activities and materials and periodically reviewed program progress.
The committee comprised representatives of parents, local child researchers,
teachers, mental health service providers, community leaders, school counselors
and administrators, and included among its active members, the chairman of
the Hawaii Board of Education (Honolulu). Our written procedural plans were
submitted for review and comment to the Department of Education's Assessment
and Measurement Office, and were reviewed by the office's director and assistant
director (both of whom were experienced researchers in educational measurement).
We also submitted our plans for independent review and approval by the district
superintendent and the state superintendent of education and their staffs.
At each step of the project, our communications with parents and children
fully disclosed project goals, procedures, and potential risks. Participation
in the screening was based on passive consent. If following notification,
a parent did not communicate that they wanted their child excluded, consent
was assumed. Following screening, as a condition of enrollment in treatment,
parents were informed personally, and written consent was obtained for counseling.
Importantly, we emphasized to both parents and children that participation
was voluntary and could be discontinued at any time.
RESULTS
PARTICIPANT SCREENING
The screening KRI was completed by 90.7% of the grade-eligible children
(second through sixth grades). There were 248 children who met the treatment-screening
criteria on the KRI. The KRI items were keyed to the core symptoms, which
comprise the diagnostic criteria for PTSD. This permitted estimating whether
the children met DSM-IV16
criteria for self-reported PTSD based on the child's endorsing "sometimes"
or "almost all the time" for the required pattern of symptoms (1 reexperiencing
symptom, 3 avoidance symptoms, and 2 arousal symptoms). This should be considered
with caution, as diagnosis requires clinical evaluation and because our data
did not include a measure of functional impairment. Eighty-eight percent of
the children who entered the study met DSM-IV criteria
for self-reported PTSD. Treatment-eligible children ranged in age from 6 to
12 years (mean age, 8.2 years; SD, 1.3 years). The largest ethnic groups represented
were Hawaiian and part-Hawaiian (30.1 %), white (24.9 %), Filipino (19.7 %),
and Japanese (9.2 %). Compared with the total population of screened children,
those identified as having the highest levels of trauma symptoms were significantly
more likely to have feared death or injury to self ( 21 = 80.9, P<.001) and family (21 = 53.2, P<.001), and had more
intense fear reactions to the hurricane (24 = 279.2, P<.001). Girls were significantly more likely to be
among the KRI-identified group (60.9% vs 46.2%) than their representation
in the population (22 = 20.4, P<.001). Treatment-eligible children were also poorer, as indexed
by eligibility for subsidized school lunches (24
= 20.2, P<.001) (Figure 1).
TREATMENT FINDINGS
Treatment was completed by 214 of the KRI-identified children (86.3%).
There were 176 children who were assigned to receive group treatment, while
73 children were assigned to individual treatment. Parents asked that 6 children
(2.4%) be excluded; 13 children (5.2%) started treatment but did not attend
all sessions; the remaining 15 children (5.6%) did not start treatment for
many reasons, including family moves. Among the treatment completers, there
were 152 girls (61.4%) and 97 boys (38.6%). Noncompleters were significantly
older (mean age = 8.85 years) than completers (mean age = 8.22 years); t246 = 2.6; P<.01.
There were no significant differences in sex or ethnicity between treatment
completers and noncompleters.
Effect of Treatment on Self-reported Trauma Symptoms (KRI)
To assess the efficacy of treatment within waves, we used a repeated-measures
analysis of variance (ANOVA) in which treatment wave and treatment type (group
or individual) were the between-group factors, and trauma symptoms (pretreatment
and posttreatment assessment) was the repeated measure. The within-subject
treatment factor was significant (F1,208 = 51.34; P<.001). The effect size for this repeated-measures analysis was
0.50, and is comparable with an effect size of 0.70 in an unmatched-samples t test.19 There were no
significant main effects for treatment cohort (F1,208 = 1.97) or
for treatment type (individual vs group) (F1,208 = 1.55; neither P nor any of the interactions was significant). A 1-way
ANOVA confirmed that the pretreatment scores were comparable despite the passage
of time (F = 1.35; P = .26). Table 1 presents means and confidence intervals.
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Table 1. Means and Confidence Intervals for Pretreatment and Posttreatment
Points of Assessment by Type of Treatment and Treatment Cohort
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To further examine possible effects of treatment type, we compared treatment
attrition using a 2 analysis. Children were significantly
more likely not to complete individual treatment (14.6%) than group treatment
(5.1%) (21 = 7.1; P<.01).
In our design, children in each treated cohort were administered the
KRI measure 1 time more than the untreated next cohort. Therefore, treatment
effects could have been due to the additional administration of the KRI. To
control for the possible effects of repeated administration of the KRI, the
retest-only group was administered the KRI measure twice, without intervening
treatment. There was no discernible change in KRI scores between these 2 administrations
(paired sample t41 = 0.15, P = .88).
Child Reaction Index
To obtain a clinician evaluation of the effects of treatment to complement
the self-report data, the CRI was administered by clinicians blinded to whether
the child they were evaluating had been treated or not. Because of resource
limitations, we drew random samples of treated (n = 21) and untreated (n =
16) children for this comparison. The treated wave had significantly lower
scores (mean score = 11.65) than the untreated wave (mean score = 20.32); t34 = 2.76; P = .01.
This reflects an effect size of 0.76.
FOLLOW-UP
Ninety-three percent of treatment participants were available at follow-up.
As they had matriculated to different schools, for logistic reasons, children
who were sixth graders (n = 25) at the time of treatment were not included
in the follow-up. A repeated-measures ANOVA, with time of assessment (pretest
vs posttest vs follow-up) as the repeated factor, again showed statistically
significant differences in KRI scores between measurements (F1,174
= 63.72, P<.001). The significant effect was accounted
for by the reduction in KRI scores between pretreatment and posttreatment.
Follow-up KRI scores were also significantly lower than pretreatment scores.
There was no significant difference between posttreatment and follow-up KRI
scores. Table 2 presents means
and confidence intervals.
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Table 2. Means and Confidence Intervals for Pretreatment, Posttreatment,
and Follow-up Points of Assessment by Type of Treatment and Treatment Cohort
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COMMENT
These results illustrate that it is feasible to screen a large population
of children 2 years after a major disaster for disaster-related trauma symptoms.
Our results suggest strongly that schools provide an effective mechanism by
which to accomplish this screening. The screening suggested a number of risk
factors for developing the highest levels of symptoms. These included female
sex, younger age, lower socioeconomic status as indexed by eligibility for
school lunch subsidy, reacting with panic to the event, and fearing the physical
safety of family and self during the disaster.
Reductions in the children's reports of trauma-related symptoms following
treatment suggested that the intervention was effective. Consistent with the
children's self report, clinical interviewers rated the treated children as
having fewer symptoms than the untreated children. Notably, group and individual
treatment modalities did not differ in effectiveness, but group treatment
was associated with better treatment completion rates. The convergence of
clinician ratings and self-report findings, as well as controls for the passage
of time and for the effects of assessment, suggest that these results did
not merely reflect situational demand characteristics.
Several methodological limitations should be acknowledged. For ethical
reasons, we could not compare treated with untreated children with the same
levels of symptoms by withholding treatment from some throughout the full
course of the study period. However, we did randomize children to treatment
waves, and pretreatment scores on the KRI were comparable despite the passage
of time. We also provided a partial control for this limitation through the
recruitment of a comparison group of children who were only slightly less
symptomatic, and who showed no change due to mere retesting. Finally, sensitivity
to the postdisaster context prevented us from administering measures that
could not be tied directly to a specific benefit for these children. Therefore,
we were unable to administer the KRI to all treatment waves at every assessment
point. These limitations reflect restrictions associated with conducting intervention
research in postdisaster environments because of heightened sensitivity to
perceived researcher intrusiveness. Future research might circumvent this
problem by comparing alternative treatments.
This study also has several strengths. The population-based selection
of treatment participants was extraordinarily comprehensive. Participants
were randomized to treatment waves. A far larger number of children were involved
than in prior studies. Converging measures of treatment outcome, child self-reports
and clinician rating of trauma symptoms supported the positive effects of
treatment. Moreover, the intervention included a "1-year" follow-up, which
demonstrated that there was no resurgence of trauma-related symptoms. Importantly,
follow-up was used to identify treatment nonresponders and to provide them
subsequent, more intensive, clinical treatment.20
This subsequent treatment study demonstrated that 1 outcome of successful
treatment was reduced help-seeking for somatic complaints reported by school
nurses during the year following treatment.
Research in postdisaster environments is difficult to perform because
disaster-affected people often wish to avoid disaster reminders. This complicates
the implementation of research because people can experience knowledge gathering
as an unwelcome disaster reminder and as exploitative of their misfortune.
Our experience suggests that it is possible to conduct systematic postdisaster
intervention research when the research aim is clearly secondary to providing
supportive services to an affected community.
We evaluated a systematic strategy to assist in the postdisaster psychological
recovery of a community's children. This approach uses schools as a natural
means through which to (1) provide cost-effective screening of a population
of children; (2) deliver cost-effective treatment to disaster-affected children
(using school-based therapists); and (3) monitor recovery through follow-up
screening. Follow-up provides the opportunity to identify children with symptoms
and to treat them using more intensive methods by more highly trained clinicians
as described elsewhere.20 This public-health–inspired
strategy seems to merit further evaluation with children exposed to disasters.
It may also be useful in other posttraumatic contexts, such as facilitating
children's psychological recovery in the aftermath of war or community violence.
| What This Study Adds
This article outlines a public-health–inspired school-based methodology
for screening and identifying elementary school–aged children who continue
to suffer disaster-related trauma symptoms 2 years after a major natural disaster.
It also describes the provision of psychosocial treatment and its evaluation
using randomized lagged group designs. To our knowledge, ours is the first
study to ever conduct a randomized evaluation of postdisaster trauma symptom
treatment in children or adults. Besides validating these screening and treatment
methods, the study shows that it is possible to conduct such research in the
very difficult psychosocial environment of a community affected by a catastrophic
disaster. These methods are likely to be applicable to assisting the recovery
of children exposed to other types of disaster.
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AUTHOR INFORMATION
Accepted for publication November 30, 2001.
This work, known as the Maile Project, was funded by a special State
of Hawaii appropriation to provide a systematic assessment and intervention
program for disaster-affected children in Kauai public schools.
The authors gratefully acknowledge State Representatives Bertha Kawakami
and Ezra Kanoho, whose vision and support made this work possible. We are
deeply appreciative of the extraordinary cooperation of Kauai's school teachers,
staff, and administrators, and of District Superintendent Shirley Akita's
leadership. We salute the steadfast caring about the children, even in the
midst of the effects of the disaster on their own lives and families. Finally,
the authors express special thanks to Merry Glass, Patrick Guigan, Beverly
James, and David Landretti, who served as project therapists. Additional support
was provided by the National Center for PTSD, Pacific Islands Division, Honolulu,
and by the Kapi'olani Medical Center, Honolulu. Dr Chemtob is currently the
Saul Z. Cohen Chair in Child and Family Mental Health at the Jewish Board
of Family and Children's Services, New York, NY.
Corresponding author and reprints: Claude M. Chemtob, PhD, Mount
Sinai School of Medicine, One Gustave L. Levy Place, Box 1230, New York, NY
10028 (e-mail: claude.chemtob{at}mssm.edu).
From the Departments of Psychiatry and Pediatrics, Mount Sinai School
of Medicine, New York, NY, and the National Center for Posttraumatic Stress
Disorder, Pacific Islands Division, Honolulu, Hawaii (Dr Chemtob); Kauai District,
Hawaii Department of Education, Lihue, Hawaii (Ms Nakashima); and Kapi'olani
Medical Specialists, Honolulu (Dr Hamada).
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A Mental Health Intervention for Schoolchildren Exposed to Violence: A Randomized Controlled Trial
Stein et al.
JAMA 2003;290:603-611.
ABSTRACT
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OTHER ARTICLES NOTED (Nov 01 to 18 Oct 02)
Evid. Based Nurs. 2003;6:e1-1.
FULL TEXT
Lucina
Arch. Dis. Child. 2002;87:266-266.
FULL TEXT
A school based psychosocial intervention was effective in children with persistent post-disaster trauma symptoms
Kazdin
Evid. Based Ment. Health 2002;5:76-76.
FULL TEXT
School-Based Program to Reduce Post-Disaster Symptoms in Children
JWatch General 2002;2002:7-7.
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Treating Children Exposed to Disasters
Pfefferbaum
Arch Pediatr Adolesc Med 2002;156:208-208.
FULL TEXT
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