JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY

Volume 24, Number 1, 2014

ª Mary Ann Liebert, Inc.
Pp. 24–31
DOI: 10.1089/cap.2013.0061

Mental Health Interventions for Children

Exposed to Disasters and Terrorism

Betty Pfefferbaum, MD, JD,1 Elana Newman, PhD,2 and Summer D. Nelson, PhD 2
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Abstract
Objective: The purpose of this review is to describe interventions used with children who are exposed to disasters and
terrorism and to present information about the potential benefits of these interventions.
Methods: A literature search conducted in January 2013 using relevant databases and literature known to the authors that was
not generated by the search yielded a total of 85 studies appropriate for review.
Results: Intervention approaches used with children exposed to disasters and terrorism included preparedness interventions,
psychological first aid, psychological debriefing, psychoeducation, cognitive behavioral techniques, exposure and narrative
techniques, eye movement desensitization and reprocessing, and traumatic grief interventions. The investigation of these
interventions is complex, and studies varied in methodological rigor (e.g., sample size, the use of control groups, outcomes
measured).
Conclusions: Given the limitations in the currently available empirical information, this review integrates the literature,
draws tentative conclusions about the current state of knowledge, and suggests future directions for study.

Introduction addressing each of these specifics is insufficient to allow definitive

M ass trauma events in recent years have generated in-
terest in children’s reactions, and stimulated the creation of
interventions designed to address those reactions. Delivering in-
terventions in disasters is inherently complex for several reasons.
Disasters take many forms; they may be unpredictable and un-
predicted, creating chaos and often damaging important com-
munity infrastructures. Alternatively, they may be predicted or
reoccurring, or may cause minor or localized community disrup-
tions. Similarly, children’s reactions to disasters vary. Most chil-
dren do not develop psychiatric conditions as a result of their
exposures but many experience distress that tends to subside
naturally with time. Therefore, those developing, studying, and
delivering disaster interventions must consider the various char-
acteristics and needs of the population of interest. For example,
public health wellness interventions are appropriate for children
whose reactions involve distress, whereas clinical interventions
may be needed for those with direct or interpersonal exposure and
those who develop or are at risk for developing psychiatric con-
ditions (Pfefferbaum and North 2013). Given the many different
possibilities in the type of event, exposures and personal experi-
ences, timing of and settings for intervention delivery, outcomes
of interest, and therapeutic approaches, the number of studies
conclusions about some issues. Moreover, the difficulty initiating
and conducting research in the disaster environment has limited the
number of intervention studies. Nonetheless, the field has matured
sufficiently to stimulate interest in and offer tentative directions
about the availability, appropriateness, and potential benefit of in-
terventions for children exposed to disasters and to provide a pre-
liminary evaluation of the evidence base.
Literature Search Methodology and Results
A literature search was conducted in January 2013 using the
following databases: EMBASE, Education Resources Information
Center (ERIC), MEDLINE!, Ovid, Published International Lit-
erature on Traumatic Stress (PILOTS), PsycINFO, and Social
Work Abstracts. Titles and abstracts identified in the search were
considered for possible inclusion in this review. Literature known
to the authors that was not generated by the search also was in-
corporated as appropriate. The review included only intervention
studies that reported indices of measured outcomes. Although this
review focuses on disasters and terrorism, studies addressing other
types of non-interpersonal trauma, including ongoing political
conflict, war, and single incidents such as accidents, were also
reviewed. Interventions used in these contexts employ the same

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

24
 CHILD DISASTER MENTAL HEALTH INTERVENTIONS
therapeutic approaches and techniques, and measure many of the
same outcomes as do studies of disaster interventions. For example,
political conflict and war may be more enduring than disasters, but
they may be marked by unexpected and terrorizing acts and they
have the potential to damage community infrastructures. Similarly,
although accidents such as motor vehicle collisions typically do not
damage the community at large, they are unanticipated and sudden.
Technological accidents such as airplane crashes may affect larger
community structures and may constitute a disaster. Therefore,
including research about ongoing political conflict, war, and single
incidents in this review provides a broader context for under-
standing interventions used with children experiencing non-
interpersonal trauma such as disasters and terrorism. The final
database included 35 disaster, 8 terrorism, 5 accident, and 30 war
studies as well as 7 studies using heterogeneous samples.
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Intervention Approaches
A variety of intervention approaches have been delivered and
tested across all disaster phases from pre-event preparedness in-
terventions to those designed for the acute aftermath, those deliv-
ered during the months and years post event, and those delivered
years after an incident. These interventions have been administered
for various conditions and delivered in schools, clinical settings,
and various community sites. Many have been created specifically
to address children’s clinical needs. Posttraumatic stress disorder
(PTSD) and/or PTSD reactions were the predominant outcomes
measured across studies, followed by depression and anxiety; other
outcomes included behavior problems, traumatic grief reactions,
and functioning. Nonclinical reactions and wellness concerns were
less often measured as intervention outcomes.
The terminology used to describe interventions was inconsistent
across studies, and many if not most interventions described in the
literature were eclectic and multimodal. The subsequent discussion
focuses on the primary approaches used. Preparedness interven-
tions, delivered in anticipation of future events, have focused on
both natural disasters and terrorism. Interventions delivered in the
early aftermath of an event included psychological first aid, which
has garnered widespread interest, and debriefing, which has
received much less attention than in application with adults. Psy-
choeducation was used alone or as a component in many inter-
ventions. Cognitive behavioral therapy (CBT) was the most widely
reported in the reviewed literature. Exposure and narrative tech-
niques also have been widely used, often together. Eye movement
desensitization and reprocessing (EMDR) was used with some
frequency, especially in settings outside North America. Inter-
ventions focused on traumatic grief have been especially important
in mass disasters and war. Other interventions were administered
and studied with less frequency, as the treatment or control con-
dition in clinical trials. These included psychodynamic therapy
(e.g., Gilboa-Schechtman et al. 2010), play therapy (e.g., Shen
2002), hypnosis (e.g., Lesmana et al. 2009), massage (e.g., Field
et al. 1996), and novel techniques (e.g., Sadeh et al. 2008).
Preparedness interventions
Universal preparedness programs for general populations, re-
gardless of risk or exposure, were delivered pre-event, and focused
on disaster awareness, prevention, and resilience building. For
example, one study, which compared a pre-event emergency
management intervention involving teaching in emergency man-
agement and interaction with parents as well as reading and
classroom discussion, to the usual hazard condition, which in-
25
volved reading and classroom discussions only, found that children
in classrooms that received the emergency management program
had greater home-based hazard adjustment and hazard knowledge
than children in classrooms that received the usual hazard educa-
tion intervention. Both conditions produced benefit with respect to
hazard-related fears and perception of parental fears, and neither
produced benefit in perceived emotional coping. An unexplained
benefit with respect to hazard-related fears in the usual condition
was stimulated, perhaps, by the children’s participation in the
reading and discussion program and/or by completing the study
measures. This work suggests that delivering preparedness inter-
ventions to children at school pre event has the potential to influ-
ence entire families and households prior to disaster exposure.
Therefore, integrating these programs in school curricula is one
approach to preparing communities; however, preparedness pro-
grams must be offered repeatedly across multiple venues to be
effective (Ronan and Johnston 2001).
Some preparedness programs were used selectively for children
who were at risk because of exposure to harmful experiences. For
example, after delivering a school-based psychoeducation inter-
vention that incorporated skill training, art therapy, and narrative
techniques, Israeli investigators found decreased posttraumatic
distress and functional impairment in students with a range of
terrorism exposures and distress (Berger et al. 2007). Other
resilience-building interventions were effective in alleviating var-
ious reactions to past and ongoing terrorism in students with vari-
ous forms of exposure to terrorist events (Gelkopf and Berger 2009)
and in those who were exposed to continuous rocket attacks
(Wolmer et al. 2011a,b). Such programs may mitigate the poten-
tially negative effects of future events on children’s mental health
and functioning (Gelkopf and Berger 2009). As preparedness as-
sumes a larger role in the management of disasters, pre-event in-
terventions constitute an important front for new work to bolster
resilience in children residing in high-risk areas.
Psychological first aid
It is difficult to study interventions delivered in the acute and
early aftermath of disasters, because of the urgency and chaos of the
postdisaster environment, the priority of security and physical
concerns, and the effort needed to organize and establish services.
Psychological first aid is envisioned to address the problems that
arise during this time period by providing comfort, mobilizing
support and psychosocial assistance, offering accurate and timely
information about disaster reactions and available resources, and
providing opportunities to triage children and make referrals
(Everly and Flynn 2006). Psychological first aid has not been well
studied. Months after Hurricane Katrina, Cain and colleagues
(2011) delivered a 6 week group intervention to 146 displaced
elementary-school children, which was based on the principles put
forth in the Psychological First Aid: Field Operations Guide
(National Child Traumatic Stress Network [NCTSN] 2006) de-
veloped by the NCTSN and the National Center for PTSD
(NCPTSD). The intervention focused on disaster knowledge,
emotional expression, communicating needs appropriately, coping
with anxiety and triggers, increasing self-worth, anger literacy and
management, and experiencing positive affect. Although there was
a statistically significant improvement post intervention, PTSD
scores remained in the moderate range and there was no control
group to account for the passage of time. Nevertheless, indices of
fear, isolation, startle responses, memory problems, and distress at
triggers improved. Unfortunately, the study did not constitute a
 26
direct test of the NCTSN/NCPTSD psychological first aid inter-
vention, given the timing of implementation of the intervention and
its highly structured approach. An important future task in asses-
sing the efficacy and effectiveness of psychological first aid will
entail clear delineation of the specific aspects or versions of psy-
chological first aid being tested, and matching the timing of ad-
ministration with the questions under investigation.
Psychological debriefing
Psychological debriefing has been used widely with adult pop-
ulations, but has not been well studied in children. Intended for
delivery early after disaster exposure, debriefing entails a single
individual or group session for survivors to describe their experi-
ences and reactions, reconstruct the event, and discuss coping
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strategies (Litz and Maguen, 2007). Controlled trials with adult
samples have found it to be ineffective and possibly harmful (Rose
et al. 2003; Foa et al. 2005). Therefore, the few available child
disaster debriefing studies are of interest despite the fact that these
interventions varied across studies in timing, number of sessions,
group or individual format, and involvement of parents. Yule (1992)
found significant decreases in posttraumatic stress but not in anxiety
or depression in child survivors of a maritime accident who received
both a single debriefing session 10 days after the disaster and sub-
sequent CBT group sessions, relative to those who did not receive
the services. In another study, two weekly 3 hour group debriefing
sessions 6 months after a minibus accident were effective in re-
ducing posttraumatic intrusion symptoms, depression, and anxiety
in children (Stallard and Law 1993). Vila and colleagues (1999)
found that a modified debriefing intervention delivered to children
and their parents 24 hours and again 6 weeks following a classroom
hostage incident did not prevent the development of psychological
disorders including PTSD at 18 month follow-up, but children who
did not participate in the debriefings had worse outcomes.
Shooshtary and colleagues (2008) also demonstrated efficacy of a
four session eclectic cognitive behavioral group intervention that
used debriefing as well as other techniques in adolescents exposed to
a massive earthquake in Iran, but did not examine the specific
components of the intervention; therefore, the results do not con-
tribute to the debate about the efficacy of debriefing in children.
Not all studies have found child psychological debriefing, or
therapies that use debriefing as a component, superior to other in-
terventions. In an investigation of children exposed to single-
incident motor vehicle accidents, Stallard and colleagues (2006)
found significant improvement in both those who received indi-
vidual debriefing and those who received an unstructured discus-
sion unrelated to the traumatic experience 4 weeks post event with
no significant difference in outcomes between the two conditions,
and no evidence that debriefing was harmful. Zehnder and col-
leagues (2010) used a similar approach, but included parents in
their single-session intervention delivered 7–10 days after a motor
vehicle accident. The results revealed no benefit relative to standard
medical care in posttraumatic stress, depressive symptoms, or be-
havioral problems in the full sample of children and adolescents,
but the intervention was effective in reducing depressive symptoms
and behavioral problems in preadolescent children and there were
no apparent harmful effects. In another study, a group crisis in-
tervention using multiple group sessions modeled on traditional
debriefing approaches was not effective in the context of ongoing
war (Thabet et al. 2005).
The extant research provides no clear evidence of benefit from
psychological debriefing, but the use of the label ‘‘debriefing’’ in
PFEFFERBAUM ET AL.
some studies was problematic, as it was not clear how closely the
interventions delivered adhered to traditional conceptualizations of
the intervention. This perpetuates confusion about what constitutes
psychological debriefing, and, therefore, whether it is effective. For
example, supporting Chemtob’s (2000) case for delayed debriefing,
child applications have not been limited to delivery in the early
aftermath of an event. Moreover, Stallard and Salter (2003) re-
commended that psychological debriefing not be delivered in the
immediate aftermath of a disaster when numbness and hyper-
arousal may be prominent. If prevention is a goal of debriefing,
delaying delivery too long may allow symptoms to solidify. Al-
though the optimal timing for applying debriefing remains unclear,
debriefing delivered months after an event almost certainly has
different goals and expected outcomes than does debriefing deliv-
ered in the early aftermath, requiring modifications to address
longer-term problems rather than using it as a prevention strategy or
acute intervention. Furthermore, no matter when debriefing is im-
plemented, Wraith (2000) cautions that children should not be
exposed to information and emotions that they cannot process and
integrate, or to material that may be upsetting to them. Psycholo-
gical debriefing, like all interventions, must be tailored to the
child’s developmental level and individual needs.
Psychoeducation
Psychoeducation, which entails providing information about
mass trauma or a specific incident, potential reactions, adaptive
coping, and services and resources, has been incorporated as a
component of many intervention packages, and delivered during all
phases of a disaster. The intervention has not been well studied
except as part of other interventions. For example, Israeli investi-
gators used psychoeducation along with skill training, meditative
practices, sensory-motor strategies, and narrative techniques in
school classrooms, as well as psychoeducation sessions with par-
ents to address the threat of terrorism (Berger et al. 2007; Gelkopf
and Berger 2009). Interventions also have coupled disaster edu-
cation with a variety of other expressive, creative, artistic, and
recreational activities (e.g., Gupta and Zimmer 2008; Zehnder et al.
2010).
Several studies have focused directly on psychoeducation. In
one study, written psychoeducation with information about chil-
dren’s trauma reactions, self-help advice, and resources for assis-
tance if needed were delivered to children who had sustained
traumatic injuries, and their parents, within 72 hours of various
types of accidents. Receiving the information was associated with a
decrease in child anxiety and parent posttraumatic symptoms rel-
ative to a no-treatment control (Kenardy et al. 2008). Sahin and
colleagues (2011) delivered psychoeducation seminars to children
and parents *9 months after the 1999 Marmara earthquake in
Turkey. Although most participants received information provided
through other sources such as the general press, brochures, and
handouts immediately after the earthquake, in the psychoeducation
seminars, adult participants also received 2–3 hours of education
about normal psychological reactions and how to talk with their
children. The children engaged in activities such as drawing, sen-
tence completion, and peer discussions as well as receiving infor-
mation about coping and earthquake responses. Thus, other
interventions were delivered along with psychoeducation. Children
and parents perceived the seminars as beneficial. For parents,
perceived benefit was related to the number of topics discussed, and
for children, benefit was related to the number and variety of ac-
tivities incorporated in the seminars. Children gained no more new
 CHILD DISASTER MENTAL HEALTH INTERVENTIONS
knowledge than those in a comparison group who did not attend the
seminars, however. Recommendations for future efforts included
increased use of participatory activities, concrete examples, role
modeling of adaptive coping and communication skills, visual aids,
repetition, and time for discussion.
Among children in refugee camps in the Gaza Strip, Thabet and
colleagues (2005) compared the use of a group crisis intervention
using projective expression, a teacher psychoeducation inter-
vention, and a no-treatment control. In the teacher education
condition, teachers were taught the meaning and consequences of
trauma and how to deal with it. They subsequently educated
children with the aim of normalizing the children’s reactions. The
study revealed no benefit from either active condition, and no
significant difference among the three conditions in PTSD case-
ness or symptoms or in depression, perhaps because of the on-
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going political conflict.
Therefore, the evidence for psychoeducation in disaster inter-
ventions is inconclusive because, although it is a common element
of many interventions, most studies have not specifically examined
the information-sharing component. For interventions that couple
psychoeducation with other activities or techniques, it may be the
narrative, expression, and/or emotional processing that accompany
the delivery of education, or natural recovery, that lead to benefit.
Furthermore, although psychoeducation is widely used and gen-
erally supported, Wessely and colleagues (2008) questioned its
benefit and its potential to create harm. Of particular concern is
triggering, or creating an expectation for, adverse reactions (Sahin
et al. 2011). Without psychoeducation, people will likely rely on
their own social networks of family, friends, colleagues, general
practitioners, religious leaders, and others for information and
support (Wessely et al. 2008).
Cognitive behavioral techniques
The clear majority of child disaster interventions have been
based on principles of CBT. Many of these interventions have used
a combination of approaches such as exposure, narrative, anxiety
reduction, relaxation, problem solving, anger management, and
coping skill-building techniques. Interventions have addressed
multiple outcomes including PTSD or PTSD reactions, depression,
anxiety, behavior problems, grief, and functioning. Two popular
manualized CBT intervention packages studied in disaster popu-
lations are Cognitive Behavioral Intervention for Trauma in
Schools (CBITS) (Cohen et al. 2009; Jaycox et al. 2010) and
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) (Brown
et al. 2004, 2006; Cohen et al. 2009; CATS Consortium, 2010;
Jaycox et al. 2010). CBITS, designed for children with moderate to
severe PTSD symptoms, and using both group and individual
sessions, is delivered in school settings by trained clinicians. Also
designed for children with significant trauma reactions, TF-CBT
can be administered to children individually or in groups, and is
delivered in clinical settings by trained clinicians. Post Hurricane
Katrina, Jaycox and colleagues (2010) compared CBITS delivered
at school and TF-CBT delivered in a mental health clinic. Children
benefited from both interventions, but 65% of children in the
CBITS group and 43% in the TF-CBT group scored in the ‘‘at risk’’
range of PTSD at follow-up assessment 10 months later, suggesting
the need to consider ways to enhance interventions beyond
CBT using, for example, individual and family therapy, medica-
tion, and/or social support for children with enduring symptoms.
The results also revealed the importance of accessibility, as chil-
dren were more likely to use school-based services than services in
27
a clinic, and the need for engagement techniques, especially for
children with clinical problems, for whom intervention may be
most important.
Exposure and trauma narrative
Both in vivo and in vitro techniques have been used in child
disaster interventions. CBT approaches often incorporate one or
more of these techniques in conjunction with relaxation and
breathing exercises, to help children manage their anxiety while
practicing exposure. In vitro exposure emphasizes mastering trau-
matic memories, whereas in vivo exposure emphasizes encoun-
tering feared stimuli (e.g., people, places) associated with the
traumatic event. In their sample of children with single-incident
trauma, March and colleagues (1998) found that in vivo desensi-
tization homework was effective in reducing PTSD symptoms
immediately, and that benefit was maintained at 6 month follow-up.
Saigh et al. (1996) reported benefit with in vitro desensitization in
case studies of children and adolescents with posttraumatic stress
symptoms associated with enduring political conflict in Lebanon.
Using a staggered intervention design that provided a waitlist
control group, Weems and colleagues (2009) found that a group
intervention involving relaxation and gradual in vitro and in vivo
(a mock examination) exposure was beneficial with respect to test-
taking anxiety and academic performance in minority youth after
Hurricane Katrina. Casting doubt on the superiority of exposure
over other approaches in the long term, however, Gilboa-
Schechtman and colleagues (2010) found exposure, using both
in vivo and in vitro techniques, superior to time-limited psycho-
dynamic therapy after treatment and at 6 month follow-up for
PTSD symptoms and global functioning, but not at 17 month fol-
low-up. Depressive symptoms subsided with both conditions, and
were not significantly different after treatment. Effects on depres-
sion were maintained at 17 month follow-up.
Many child disaster interventions contain a trauma narrative
component, a form of in vitro exposure, in group or individual
format. Ruf and colleagues (2010) found that relative to a waitlist
control, refugee children experienced clinically significant im-
provement in PTSD symptoms and functioning with narrative ex-
posure therapy, which was maintained at 12 month follow-up. Catani
and colleagues (2009) failed to find a significant difference between
the same narrative intervention and a meditation-relaxation inter-
vention, however, in children affected by civil war and the 2004
Indian Ocean tsunami.
In their study comparing the use of the trauma narrative and
coping skill building in children exposed to Hurricane Katrina,
Salloum and Overstreet (2012) found preliminary evidence sug-
gesting that the trauma narrative may not be an essential component
of child trauma interventions. Even the children who did not re-
ceive the narrative component, however, engaged in some discus-
sion about their experiences, and the authors noted that the two
interventions may not have been sufficiently different with respect
to the narrative to adequately test this aspect of the intervention.
The authors also acknowledged that the trauma narrative may be
beneficial for children with clinically elevated symptoms.
The theory behind the trauma narrative may influence the format
of trauma interventions. If a conditioning model is posited as cu-
rative, then structured repeated retelling of the story where fear is
safely experienced in sessions is needed so that children can (re)-
learn that the avoided and fear situations or triggers are now safe. If
it is believed that telling one’s story helps reduce isolation and
improves self-definitions of experiences, or that words offer some
 28 PFEFFERBAUM ET AL.

sense of control, then a different intensity and format of trauma
narrative may be appropriate. Additional research is needed to fully
explore the importance of this seemingly elementary aspect of
trauma intervention as well as to understand the mechanisms of
change.
EMDR
EMDR is designed to process distressing memories or to reduce
their effects by having the child focus simultaneously on the dis-
turbing memory and on a therapist-directed attention stimulus (e.g.,
hand tapping, eye movement, auditory tones). Several studies have
examined this approach as the primary treatment (e.g., Chemtob
et al. 2002; Tufnell 2005; Fernandez 2007; Kemp et al. 2009) or as a
component of another treatment (e.g., Ehntholt et al. 2005;
Shooshtary et al. 2008). Tufnell (2005) described case studies using
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matic stress, depression, and grief symptoms decreased in adoles-
cents who participated in the intervention, with no significant
differences for those who received full or partial treatment (Layne
et al. 2001). In their 2008 study, Layne and colleagues compared
adolescents who received a classroom-based psychoeducation and
skills intervention and those who received both the classroom-
based psychoeducation and skills intervention and the school-based
trauma- and grief-focused group treatment. Posttraumatic stress
and depression decreased significantly in both conditions, whereas
maladaptive grief decreased significantly only in the group that
received the trauma- and grief-focused group intervention.
Salloum and Overstreet (2008) also demonstrated benefit in
posttraumatic stress, depression, and traumatic grief reactions with
their school-based trauma and grief intervention in children in New
Orleans 3 years post Hurricane Katrina. The intervention, which

used CBT techniques and narrative therapy through drawing, dis-

EMDR as part of a multimodal treatment package in four preado-
cussion, and writing, was delivered to children randomly assigned
lescent children who had been involved in motor vehicle accidents;
to individual or group format to reduce symptoms of posttraumatic
three of the four children had been diagnosed with PTSD. In an
stress, depression, and grief. The children assigned to the group
uncontrolled trial, Fernandez (2007) showed reduced posttraumatic
condition also received an individual pullout session, and their
stress symptoms over a period of 1 year with EMDR in child vic-
parents were educated about grief and trauma and given guidance to
tims of an earthquake in Italy. Chemtob and colleagues (2002) used
support the children. There was no significant difference in out-
EMDR with children who met criteria for PTSD 1 year after re-
come for the individual and group administration. Cohen’s group
ceiving a psychosocial intervention for Hurricane Iniki and 3.5
(2004, 2006) emphasized the importance of addressing trauma
years after the hurricane. Children showed large decreases in PTSD
before the child can proceed through the grief process whereas
symptom levels and improvement with respect to anxiety and de-
Salloum and Overstreet (2008) noted that an ‘‘explicit’’ focus on
pression as well; improvement was maintained at 6 month follow-
grief and bereavement may facilitate the processing of trauma and
up. In a waitlist controlled trial of children with persistent PTSD
decrease posttraumatic stress symptoms.
symptoms after motor vehicle accidents, Kemp and colleagues
The evidence base thus far suggests that trauma reactions and
(2010) found improvement in children, which was maintained at 3
grief symptoms and issues related to loss may need to be addressed
month follow-up. Additional research is needed to determine if
separately in helping children cope with the death of someone
EMDR has an advantage over other approaches or natural recovery,
important to them in the context of disaster and terrorism. More
and to identify the specific aspect or aspects of the intervention that
research is needed to determine the importance of timing and se-
is or are responsible for its benefit.
quencing of these intervention components.
Traumatic grief interventions
Methodological Issues in the Extant Research
Traumatic grief involves the interplay of trauma and grief in
Although many of the studies examined for this review reported
which trauma reactions interfere with the child’s ability to navigate
positive results for at least some of the outcomes measured, de-
the grief process (Cohen et al. 2004). Several interventions have
finitive conclusions about the status of the evidence base for any
been developed to specifically address traumatic grief. Cohen
specific intervention approach must be suspended, given the limited
and colleagues (2004, 2006) developed a cognitive behavioral
number of studies examining some approaches and the variation in
intervention with trauma-focused sessions on affect modulation,
methodological rigor across studies. Table 1 displays the number of
relaxation, trauma narrative, and cognitive processing and grief-
investigations in this review that used case study design or a con-
focused sessions on recognizing and naming the loss, creating
trolled trial for each type of event.
positive memories, and making meaning of the loss. In addition to
Foa and Meadows (1997) identified seven standards for meth-
individual sessions for the children, parent sessions provide be-
odological rigor in intervention studies: clearly defined target
havioral management techniques and discussions of bereavement
symptoms; reliable and valid measures; blinded evaluators; asses-
practices in the context of the family’s religion and culture (Brown
sor training; manualized, replicable, specific treatment programs;
et al. 2004). The intervention was used successfully in a case study
unbiased assignment to treatment; and treatment adherence. Using
of a child whose firefighter father died in the September 11 response
these elements to examine the methodological rigor of 28 con-
effort (Brown et al. 2004).
trolled trials assessing posttraumatic stress outcomes in children
The UCLA trauma/grief-focused group psychotherapy inter-
vention was delivered by trained school counselors to war-exposed
adolescents in Bosnia (Layne et al. 2001, 2008). The intervention
Table 1. Research Design by Type of Event
used psychoeducation; exposure, narrative, and various other CBT
techniques; skill-building exercises; and process-oriented activities Type of event Case studies Controlled trials
to focus first on the traumatic experience and then on trauma and
loss reminders, postdisaster stresses and adversities, bereavement Disasters 10 25
and the interplay between bereavement and trauma, and the de- Terrorism 2 6
velopmental impact of the event and developmental progression. In Accidents 2 3
War 10 20
their 2001 study, Layne and colleagues compared children who
Heterogeneous 5 2
received full and partial treatment with the intervention. Posttrau-
 CHILD DISASTER MENTAL HEALTH INTERVENTIONS
exposed to disasters, terrorism, war, and other single-incident
traumas such as accidents, Pfefferbaum and colleagues (in press)
concluded that most studies used manualized or well-described
treatment protocols and standardized instruments to measure out-
comes, and many used random assignment and provided assessor
training. Fewer studies used blinded assessment or established
procedures to address adherence to treatment protocols, and the
sample size in most studies was not adequate to detect small effects
generally expected when comparing two active interventions.
Other deficiencies in the extant research include the absence of
attention to attrition in samples and the inconsistent use and length
of follow-up.
Relatively few studies compared two interventions, which has the
potential to determine superiority of one over another. Un-
fortunately, studies using this design have been inconclusive, with
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most revealing no significant difference between competing inter-
ventions (e.g., Ronan and Johnston 1999; Thabet et al. 2005; Catani
et al. 2009; Jaycox et al. 2010). For example, Gilboa-Schechtman
and colleagues (2010) found prolonged exposure therapy superior to
time-limited psychodynamic therapy after treatment and at 6 month
follow-up but not at 17-month follow-up. Findings of the extant
research have not definitely established the superiority of any spe-
cific intervention approach. This is consistent with the conclusion of
Gillies and colleagues (2012, p. 21) that whereas there is ‘‘fair evi-
dence for the effectiveness of psychological therapies,’’ especially
CBT, in the treatment of PTSD in children, there is ‘‘no clear evi-
dence’’ that any one therapy is superior to others.
It is possible that some common factor or factors among inter-
ventions is or are responsible, at least in part, for the success of
various interventions. These common factors include the therapeutic
relationship, the expectation of therapeutic success, acknowledge-
ment of difficulties, the process of confronting the trauma, and the
opportunity to ventilate and/or gain mastery over the problem
(Weinberger 1995).
Related to the issue of common factors is the fact that the ex-
isting literature has not clarified which, if any, specific component
of the available interventions is responsible for benefit. This dis-
mantling of interventions will aid in determining therapeutic ac-
tion. Layne and his group (2001) began to address this concern
when they found no differences in outcome in children who re-
ceived full (psychoeducation, skill building, adaptive grieving, and
adaptive development) and partial (psychoeducation and skill
building only) treatment using an eclectic cognitive behavioral
intervention. Salloum and Overstreet (2012) found that the trauma
narrative was not a necessary component in a grief and trauma
intervention focused on coping skill building. Although this pre-
liminary work suggests that some intervention components may not
be essential, it has not established what constitutes the critical ac-
tive ingredients in the interventions.
Although it is difficult to conduct research in the chaos of the
disaster environment, the studies reviewed for this report have es-
tablished the feasibility of developing an evidence base for child
disaster mental health interventions. The sheer number and so-
phistication of investigations illustrate that it is possible to conduct
methodologically rigorous clinical research even in this field.
Moreover, conducting clinical research in the disaster zone may
bring resources to a community trying to rebuild its infrastructure,
and may support the rapid dissemination and use of treatment. The
byproducts of research (e.g., intervention manuals, formalized
training procedures, adherence checklists) may enhance local
practitioners’ capacity to provide evidence-based approaches
to children. Therefore, clinicians and administrators should be
29
encouraged about the emerging evidence base for child disaster
interventions and the potential immediate benefits of these inter-
ventions as well as the contributions to future knowledge.
Statistical Significance
The statistical significance of results in intervention studies
alone is insufficient to assess their benefit. Intervention outcomes
also must be meaningful. For example, whereas the results of an
intervention may be statistically significant, the improvement in
outcomes may be modest and short term. Deciding what constitutes
a meaningful outcome can be challenging, especially given the
range of conditions and reactions child disaster interventions are
intended to address and the populations in which they are studied.
For children directly involved in a disaster or those whose relatives
are directly involved, a clinically meaningful outcome may be
measured in terms of diagnostic status or symptom severity. It is
more difficult to identify meaningful outcomes for children whose
disaster experiences result in transient distress and for whom it is
not appropriate to examine diagnosis. For example, assessing di-
agnosis may be inappropriate in preparedness studies or in studies
of psychoeducation intended to normalize children’s reactions.
Whereas it may be unclear what constitutes meaningful change—as
opposed to statistically-significant change—in children receiving
these nonclinical interventions, an appropriate focus may be on
nonclinical wellness outcomes such as fear, anxiety, stress, social
behavior, academic functioning, and hope (Wolmer et al. 2005;
Jordans et al. 2010; Wolmer et al. 2011).
Conclusions
A number of issues related to disaster mental health services
have been addressed in the emerging literature, and although the
evidence base in this field has generated some answers, it also
has raised many questions. With respect to answers, the current
evidence has identified several interventions that are helpful;
specifically, preparedness interventions appear promising. CBT in
multiple forms appears beneficial for children postdisaster, but
children may require additional interventions or the intervention
may need to be further refined or enhanced to help eliminate rather
than reduce PTSD symptoms. Exposure and narrative interventions
and EMDR appear beneficial, but it is unclear at this point if these
interventions are superior to other treatments. Traumatic grief in-
terventions appear promising to address symptoms related to
traumatic loss.
Other interventions are promising but need more attention.
Psychological first aid, a popular, well thought-out set of inter-
vention principles remains to be fully tested. Inconsistently defined,
the existing studies of psychological debriefing do not constitute a
fair assessment of this approach. The evidence for psychoeducation
in disaster interventions is inconclusive, because although it is a
common element of many interventions, most studies have not
specifically examined the information-sharing component.
In addition to determining whether any approach is superior to
others, is the question of whether it is some common element across
interventions that is the source of benefit. Given that many inter-
ventions are eclectic, using a variety of techniques, it also is unclear
what component of any specific treatment is responsible for the
benefit. Another need is to identify and/or create tools that measure
meaningful change. A lack of uniformity across interventions raises
questions about the importance of factors such as the number and
length of sessions and the optimal timing and setting for inter-
vention delivery. Sequencing of treatment components, especially
 30
in relationship to grief, is another area for future study. Moreover,
intervention approaches may vary for different types and locations
of events, for various outcomes addressed, and for children with
diverse personal characteristics (e.g., presence of pre-existing
conditions) and specific trauma exposures and experiences. Like
other areas involving children, their developmental level, various
family factors, and culture always are considerations for exami-
nation. Further research with more rigorous attention to design is
needed to advance the field.
Clinical Significance
This review of child disaster mental health intervention studies
identified several intervention approaches that are helpful or, at a
minimum, are not harmful. Specifically, preparedness interventions
appear promising, and CBT in multiple forms and traumatic grief
Downloaded by Monash University package (ebook account) from www.liebertpub.com at 10/09/18. For personal use only.
interventions appear beneficial. Exposure and narrative interven-
tions and EMDR have positive outcomes, but it is unclear if these
interventions are superior to other treatments. In the next genera-
tion of studies, it will be important to determine if some approaches
are superior to others and/or if some common element across in-
terventions is the source of benefit.
Disclosures
No competing financial interests exist.
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Address correspondence to:
Betty Pfefferbaum, MD, JD
Department of Psychiatry and Behavioral Sciences
College of Medicine
University of Oklahoma Health Sciences Center
P.O. Box 26901, WP-3470
Oklahoma City, OK 73126-0901
E-mail: betty-pfefferbaum@ouhsc.edu