Screening and psychological debriefing of adolescent survivors of life-threatening events

Are psychological debriefing groups after a potential traumatic event suitable to prevent the symptoms of PTSD?

Psychological debriefing is a psychotherapeutic approach developed for early intervention in civilians and professionals who have to cope with a potential traumatic event (PTE). Although initial works claimed that this approach may decrease symptoms of posttraumatic stress disorder (PTSD), some studies have concluded that the clinical benefits of psychological debriefing were limited. Several methodological variations could explain the discrepancies observed among studies. Among these variations, how the approach is administered to participants should have importance, and clinical evidence suggests that debriefing groups instead of individuals could have a beneficial clinical effect. We conducted a systematic search of the literature investigating the clinical effects of psychological debriefing groups on PTSD symptoms after a PTE according to the PRISMA guidelines. Among the 790 articles found, 11 met our inclusion criteria. Most of these articles did not support any beneficial effect of psychological debriefing groups on PTSD symptoms. A large number of methodological variations that may influence the outcomes of these studies were observed. Psychological debriefing groups did not seem efficient in alleviating PTSD symptoms. Further studies of high methodological quality are needed to elucidate the effect of psychological debriefing groups on specific PTSD symptoms and on nonspecific symptoms.

Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress?

In the wake of the terrorist attacks at the World Trade Center, more than 9,000 counselors went to New York City to offer aid to rescue workers, families, and direct victims of the violence of September 11, 2001. These mental health professionals assumed that many New Yorkers were at high risk for developing posttraumatic stress disorder (PTSD), and they hoped that their interventions would mitigate psychological distress and prevent the emergence of this syndrome. Typically developing in response to horrific, life-threatening events, such as combat, rape, and earthquakes, PTSD is characterized by reexperiencing symptoms (e.g., intrusive recollections of the trauma, nightmares), emotional numbing and avoidance of reminders of the trauma, and hyperarousal (e.g., exaggerated startle, difficulty sleeping). People vary widely in their vulnerability for developing PTSD in the wake of trauma. For example, higher cognitive ability and strong social support buffer people against PTSD, whereas a family or personal history of emotional disorder heightens risk, as does negative appraisal of one's stress reactions (e.g., as a sign of personal weakness) and dissociation during the trauma (e.g., feeling unreal or experiencing time slowing down). However, the vast majority of trauma survivors recover from initial posttrauma reactions without professional help. Accordingly, the efficacy of interventions designed to mitigate acute distress and prevent long-term psychopathology, such as PTSD, needs to be evaluated against the effects of natural recovery. The need for controlled evaluations of early interventions has only recently been widely acknowledged.

Psychological debriefing—the most widely used method—has undergone increasing empirical scrutiny, and the results have been disappointing. Although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing. Methodological limitations have complicated interpretation of the data, and an intense controversy has developed regarding how best to help people in the immediate wake of trauma.

Recent published recommendations suggest that individuals providing crisis intervention in the immediate aftermath of the event should carefully assess trauma survivors' needs and offer support as necessary, without forcing survivors to disclose their personal thoughts and feelings about the event. Providing information about the trauma and its consequences is also important. However, research evaluating the efficacy of such “psychological first aid” is needed.

Some researchers have developed early interventions to treat individuals who are already showing marked stress symptoms, and have tested methods of identifying those at risk for chronic PTSD. The single most important indicator of subsequent risk for chronic PTSD appears to be the severity or number of posttrauma symptoms from about 1 to 2 weeks after the event onward (provided that the event is over and that there is no ongoing threat).

Cognitive-behavioral treatments differ from crisis intervention (e.g., debriefing) in that they are delivered weeks or months after the trauma, and therefore constitute a form of psychotherapy, not immediate emotional first aid. Several controlled trials suggest that certain cognitive-behavioral therapy methods may reduce the incidence of PTSD among people exposed to traumatic events. These methods are more effective than either supportive counseling or no intervention.

In this monograph, we review risk factors for PTSD, research on psychological debriefing, recent recommendations for crisis intervention and the identification of individuals at risk of chronic PTSD, and research on early interventions based on cognitive-behavioral therapy. We close by placing the controversy regarding early aid for trauma survivors in its social, political, and economic context.

The Use of Debriefing With Children

The debate over the use of psychological debriefing in the early aftermath of a traumatic event has raged for decades, yet little attention has been paid to its use with perhaps the most vulnerable of victims, children and adolescents. While recommendations against the use of group debriefing with adults seem to have been made based on research of individual debriefing, recommendations regarding its use with children have been made based on the adult literature. In this review, we outline the possible mechanisms of harm and benefit of debriefing with a discussion of developmental concerns. The available empirical and nonempirical literature on the use of debriefing with youth is summarized. While research does not currently evidence harm in the use of debriefing with children, there is no strong support for its use either. We present both clinical considerations and research implications as they relate to debriefing as well as what this debate has taught us about the challenges to disseminating and evaluating early crisis interventions in general.

Child Debriefing: A Review of the Evidence Base

Introduction

Debriefing, a controversial crisis intervention delivered in the early aftermath of a disaster, has not been well evaluated for use with children and adolescents. This report constitutes a review of the child debriefing evidence base.

Methods

A systematic search of selected bibliographic databases (EBM Reviews, EMBASE, ERIC, Medline, Ovid, PILOTS, PubMed, and PsycINFO) was conducted in the spring of 2014 using search terms related to psychological debriefing. The search was limited to English language sources and studies of youth, aged 0 to 18 years. No time limit was placed on date of publication. The search yielded 713 references. Titles and abstracts were reviewed to select publications describing scientific studies and clinical reports. Reference sections of these publications, and of other literature known to the authors that was not generated by the search, were used to locate additional materials. Review of these materials generated 187 publications for more thorough examination; this assessment yielded a total of 91 references on debriefing in children and adolescents. Only 15 publications on debriefing in children and adolescents described empirical studies. Due to a lack of statistical analysis of effectiveness data with youth, and some articles describing the same study, only seven empirical studies described in nine papers were identified for analysis for this review. These studies were evaluated using criteria for assessment of methodological rigor in debriefing studies.

Results

Children and adolescents included in the seven empirical debriefing studies were survivors of motor-vehicle accidents, a maritime disaster, hostage taking, war, or peer suicides. The nine papers describing the seven studies were characterized by inconsistency in describing the interventions and populations and by a lack of information on intervention fidelity. Few of the studies used randomized design or blinded assessment. The results described in the reviewed studies were mixed in regard to debriefing’s effect on posttraumatic stress, depression, anxiety, and other outcomes. Even in studies in which debriefing appeared promising, the research was compromised by potentially confounding interventions.

Conclusion

The results highlight the small empirical evidence base for drawing conclusions about the use of debriefing with children and adolescents, and they call for further dialogue regarding challenges in evaluating debriefing and other crisis interventions in children.

PfefferbaumB, JacobsAK, NitiémaP, EverlyGSJr.Child debriefing: a review of the evidence base. Prehosp Disaster Med. 2015;30(3):110.

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

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

A stepped-care model of post-disaster child and adolescent mental health service provision

BACKGROUND

From a global perspective, natural disasters are common events. Published research highlights that a significant minority of exposed children and adolescents develop disaster-related mental health syndromes and associated functional impairment. Consistent with the considerable unmet need of children and adolescents with regard to psychopathology, there is strong evidence that many children and adolescents with post-disaster mental health presentations are not receiving adequate interventions.

OBJECTIVE

To critique existing child and adolescent mental health services (CAMHS) models of care and the capacity of such models to deal with any post-disaster surge in clinical demand. Further, to detail an innovative service response; a child and adolescent stepped-care service provision model.

METHOD

A narrative review of traditional CAMHS is presented. Important elements of a disaster response - individual versus community recovery, public health approaches, capacity for promotion and prevention and service reach are discussed and compared with the CAMHS approach.

RESULTS

Difficulties with traditional models of care are highlighted across all levels of intervention; from the ability to provide preventative initiatives to the capacity to provide intense specialised posttraumatic stress disorder interventions. In response, our over-arching stepped-care model is advocated. The general response is discussed and details of the three tiers of the model are provided: Tier 1 communication strategy, Tier 2 parent effectiveness and teacher training, and Tier 3 screening linked to trauma-focused cognitive behavioural therapy.

CONCLUSION

In this paper, we argue that traditional CAMHS are not an appropriate model of care to meet the clinical needs of this group in the post-disaster setting. We conclude with suggestions how improved post-disaster child and adolescent mental health outcomes can be achieved by applying an innovative service approach.

Mental health interventions for children exposed to disasters and terrorism

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.

Practice parameter on disaster preparedness

This Practice Parameter identifies best approaches to the assessment and management of children and adolescents across all phases of a disaster. Delivered within a disaster system of care, many interventions are appropriate for implementation in the weeks and months after a disaster. These include psychological first aid, family outreach, psychoeducation, social support, screening, and anxiety reduction techniques. The clinician should assess and monitor risk and protective factors across all phases of a disaster. Schools are a natural site for conducting assessments and delivering services to children. Multimodal approaches using social support, psychoeducation, and cognitive behavioral techniques have the strongest evidence base. Psychopharmacologic interventions are not generally used but may be necessary as an adjunct to other interventions for children with severe reactions or coexisting psychiatric conditions.

Prevalence of post-traumatic stress disorder among children and adolescents who survive road traffic crashes: a systematic review of the international literature

While road traffic crashes are known to have a significant impact in terms of deaths and hospitalisations, quantifying the burden of psychological sequelae is more challenging. This systematic review critically evaluates published studies designed to estimate the prevalence of post-traumatic stress disorder among children and adolescents who have survived a road crash. Most studies have focused on injured school-aged children and adolescents, and estimate the occurrence of this condition to be between 12% and 46% in the first 4 months following crash involvement and between 13% and 25% 4-12 months following the crash. The relatively high prevalence of post-traumatic stress disorder following one of the commonest causes of injury underscores the need for greater vigilance and active management to mitigate the adverse consequences on the health and development of young crash survivors. The findings also emphasise the important role that child health professionals must play in promoting strategies that prevent road traffic crashes.

Post-Traumatic Stress Disorder Symptoms of Children Following the Occurrence of Tehran City Park Disaster

The authors investigated the post-traumatic stress disorder (PTSD) symptoms of young adolescents who had been directly involved in a disaster in Tehran. The participants were 19 chlidren who had survived a boat sinking in Tehran's city park in 2002. By using the Post-Traumatic Stress Disorder Symptom Scale (PSS; E. B. Foa, D. S. Riggs, C. V. Dancu, & B. O. Rothbaum, 1993) as well as a clinical interview based on the definition cited in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994, p. 424), 16 participants (84.2%) were diagnosed with PTSD using the PSS and 17 (89.5%) were diagnosed with PTSD using the psychiatric interview.

A randomised controlled trial to determine the effectiveness of an early psychological intervention with children involved in road traffic accidents

OBJECTIVE

To determine whether an early intervention using a psychological debriefing format is effective in preventing psychological distress in child road traffic accident survivors.

DESIGN

Randomised controlled trial.

SETTING

Accident and Emergency Department, Royal United Hospital, Bath.

SUBJECTS

158 children aged 7-18. Follow-up assessment completed eight months post accident with 132 (70/82 of the experimental group and 62/76 in the control group).

MAIN OUTCOME MEASURES

Self-completed measures of psychological distress; fulfilment of diagnostic criteria for post-traumatic stress disorder.

RESULTS

Children in both groups demonstrated considerable improvements at follow-up. The early intervention did not result in any additional significant gains.

CONCLUSIONS

Although children in this study made significant improvements it is unclear whether these are better or worse than natural recovery rates. The specific intervention did not result in additional gains although the structured assessment provided for both groups may have been helpful in reducing subsequent pathology.

Eine Meta-Analyse unter Einsatz des Random Effects-Modells zur Effektivität kurzfristiger psychologischer Interventionen nach akuter Traumatisierung

Zusammenfassung. Theoretischer Hintergrund: In der Sekundärprävention der Posttraumatischen Belastungsstörung (PTB) werden verstärkt kurzfristige Interventionen eingesetzt. Fragestellung: Es wurde die Wirksamkeit dieser Verfahren untersucht und zusätzlich mögliche Einflussfaktoren betrachtet. Methode: Die Integration der bisherigen Ergebnisse erfolgte mittels einer Meta-Analyse unter Nutzung eines Random Effects-Modells. Die Vorteile des statistischen Modells werden beschrieben. 21 Studien konnten integriert werden. Ergebnisse: Weder für die PTB-Symptomatik, noch für die Gesamtsymptomatik zeigte sich eine bedeutsame Effektstärke. Der mittlere Effekt lag nahe Null. Mittels explorativer Analysen wurde der Einfluss von Eigenschaften der Stichprobe untersucht. Das Geschlechterverhältnis zeigte einen signifikanten Zusammenhang, nicht aber der Professionalitätsstatus der Betroffenen. Schlussfolgerung: Die betrachteten Verfahren scheinen nicht als Präventionsmaßnahme für die PTB geeignet zu sein.

[Efficiency of psychological debriefing in preventing post-traumatic stress disorders]

BACKGROUND

Traumatic events are frequently followed by an acute stress reaction that may develop into a post-traumatic stress disorder. An intervention called psychological debriefing has been proposed to prevent these disorders. Although this method is widely used at present, its preventive effect is controversial. This article consist in a review of the studies which evaluated psychological debriefing efficiency in the prevention of post-traumatic stress disorder and associated disorders in adults.

METHOD

We carried out a bibliographical search on MEDLINE (1966-2001), PASCAL (1987-2001), EMBASE (1988-2001), FRANCIS (1984-2001) and SCIENCEDIRECT (1967-2001). The key words were posttraumatic stress disorder, debriefing, treatment, psychological follow up, and prevention. We selected the studies with the following criteria: adults, one psychological debriefing session in the Month following the event, inclusion of a control group, more than 20 persons per group and evaluation of psychological disorders with standardized instruments more than one Month after the trauma.

RESULTS

Twenty nine studies were identified and 8 selected. Four studies did not show any intervention effect, 3 suggested a negative intervention effect, and 1 suggested a positive effect on anxiety, depressive symptoms and alcohol dependence.

CONCLUSION

Psychological debriefing implies re-exposure through memory processes to the trauma, which can interfere with the natural course of adjustment and recovery. Several Authors have suggested that psychological debriefing may delay the diagnosis and thus the early treatment of post-traumatic stress disorder. Psychological debriefing may not be appropriate to all victims of every type of incident or trauma. We discuss the intervention and its design. This review did not show evidence for psychological debriefing efficiency, as a unique session, in the prevention of posttraumatic reactions. The design and the objectives may be re-examined. Further evaluations following rigorous methods are warranted.

The psychosocial aspects of children exposed to war: practice and policy initiatives

The atrocities of war have detrimental effects on the development and mental health of children that have been documented since World War II. To date, a considerable amount of knowledge about various aspects of this problem has been accumulated, including the ways in which trauma impacts child mental health and development, as well as intervention techniques, and prevention methods. Considering the large populations of civilians that experience the trauma of war, it is timely to review existing literature, summarize approaches for helping war-affected children, and suggest future directions for research and policy.

The Goteborg discotheque fire, 1998

Findings from a study of 563 adolescents' reactions following a discotheque fire that killed 63 young people in Göteborg in October 1998 are presented. The group answered a questionnaire seven months following the disaster. The questionnaire included the Impact of Event Scale (IES) and the Birleson Depression Self-Rating Scale (DSRS). The level of trauma was found to be very high, while depression scores were less elevated. A little under a third of the students scored above a clinical cut-off point (> 35) on the IES, indicating high posttraumatic stress levels. Girls evidenced more depression and traumatic stress reactions than boys. Levels of reactions increased with more closeness (knowing victims personally) and if the adolescents were of non-Swedish origin.

Inzidenz und Verlauf posttraumatischer Belastungsreaktionen nach Verkehrsunfällen im Kindesalter

Zusammenfassung. Die Studie untersucht die Inzidenz, den Verlauf und die Determinanten posttraumatischer Belastungsreaktionen nach einem Verkehrsunfall. 55 Kinder im Alter von 6,5 bis 14,5 Jahren wurden einen Monat und ein Jahr nach einem Verkehrsunfall mit der deutschen Version des Child Posttraumatic Stress Disorder Reaction Index befragt. Der Anteil klinisch relevanter Belastungsreaktionen betrug nach einem Monat 16,4 % und nach einem Jahr 18,2 %. Die Verlaufsanalyse zeigte keine signifikanten Symptomveränderungen über die Zeit. Die subjektiv erlebte Bedrohung durch den Unfall korrelierte signifikant mit der Symptomatik zu beiden Erhebungszeitpunkten. Demografische und medizinische Merkmale zeigten keine bedeutsamen Zusammenhänge mit dem Ausmaß posttraumatischer Reaktionen. Die Symptomatik nach einem Monat hatte einen hohen prädiktiven Wert bezüglich der Symptomatik nach einem Jahr. Die Befunde belegen die dringende Notwendigkeit einer besseren psychosozialen Versorgung von verunfallten Kindern.

Acute stress disorder in youth: a multivariate prediction model

There is little empirical support for the diagnosis of acute stress disorder (ASD) in children and adolescents. Most reports treat ASD as "provisional posttraumatic stress disorder (PTSD)" (meaning that children evidence ASD on the way to a formal diagnosis of PTSD), while speculating on factors that might moderate or mediate the transformation of ASD into PTSD. This report briefly reviews the literature on ASD in the context of presenting a testable, multivariate model for understanding acute stress responses in youth.

Treating acute posttraumatic reactions in children and adolescents

The impact of providing early interventions to acutely traumatized children is not yet known. No research has examined the potential benefits or harm of providing brief psychosocial interventions to children in the immediate aftermath of trauma exposure. Three studies have documented the efficacy of providing trauma-focused, cognitive-behavioral therapy (TF-CBT) to symptomatic children within 1-6 months of experiencing sexual abuse. Several controlled and open studies of traumatized children with chronic posttraumatic stress disorder have provided additional support for TF-CBT interventions; however, the optimal dosage and critical components of TF-CBT for traumatized children have not been determined. Only one randomized controlled pharmacologic trial has been conducted for acutely traumatized children; open studies of various pharmacologic treatments are limited by methodologic shortcomings but suggest that there are promising agents for evaluation in future controlled trials. The importance and feasibility of conducting early screening of trauma-exposed children is discussed, and recommendations for research priorities are presented.

School reactivation programs after disaster: could teachers serve as clinical mediators?

Mental health interventions are known to prevent the progressive worsening of symptoms in young victims of disaster and, subsequently, to prevent a decline in their academic performance and self-esteem [8,46]. The tremendous needs that emerge after a disaster and the reluctance shown by most victims to seek professional help require mental health leaders to adopt a proactive stance and implement relief programs in the child's most natural setting. The school as institution and the teachers as empowered mediators offer the appropriate conditions for implementing an effective large-scale intervention program. Well-intentioned child professionals who deal with school administrators and teachers must take into account that, as stated by Pfefferbaum et al [25], "avoidance is at the core of the posttraumatic response, and it sometimes involves avoidance of treatment." For child mental health professionals, routine collaboration across systemic boundaries may prove critical for the rapid mobilization of resources during mass traumatic emergencies. Further studies are needed to identify the protective and risk factors that predict resilience and pathology, respectively, and factors that facilitate or aggravate factors that predict improvement, resistance, and deterioration in response to treatment.

Effectiveness of psychological debriefing

OBJECTIVE

To identify literature concerning the effectiveness of psychological debriefing (PD) and analyse results according to different criteria of success and different uses of the intervention format.

METHOD

Literature search was made in databases PubMed, PsycInfo and Psychlit. Twenty-five studies were selected for a thorough description. Forty-two studies provided additional information.

RESULTS

Results indicate that, in general, debriefing does not prevent psychiatric disorders or mitigate the effects of traumatic stress, even though people generally find the intervention helpful in the process of recovering from traumatic stress. The intervention holds potential as a screening procedure, and there may be economic arguments for continued use. When used with adherence to traditional descriptions of treatment group, events, group format, leadership and time spent, a preventive effect emerges. No tendency according to timing was found.

CONCLUSION

Current uses of PD are problematic. The concept needs to be redefined, and the scope of application must be revised. The objectives for use need to be clarified.

Children of traumatized and exiled refugee families: resilience and vulnerability. A case study report

This paper focuses on the main problems and outcomes of two children of a traumatized refugee family who have been in Britain since 1993. Their parents witnessed near death experiences and physical assaults, and suffered losses and a wide range of physical problems; the father manifests post traumatic stress disorder (PTSD) symptoms. The children have been exposed regularly to episodic rage and violent behaviour by their father, and have developed separation problems and psychosomatic complaints. Their mother has coped better and is very resilient in her care and approach to problems. This report acknowledges the negative experience of trauma, but also the sources of resilience of parents, children's adjustment and cultural differences in coping styles. Refugee experiences devastate individual well-being and coping mechanisms if there is no hope, support and faith in one's own potential. Protective and risk factors that may affect the manifestation of trauma symptoms are highlighted. A variety of treatment approaches are required for both adult and child victims of multiple trauma. A wide range of techniques, such as group therapy, behaviour and cognitive therapy, and desensitization and relaxation training, can help sufferers to enhance their coping skills and deal effectively with devastating life events.

Effect of timing of critical incident stress debriefing (CISD) on posttraumatic symptoms

Seventy-seven civilian employees who were victims of robbery were randomly assigned to either an immediate (< 10 hr) or delayed (> 48 hr) debriefing group, using the J. Mitchell (1983) CISD protocol. Scores on the Posttraumatic Stress Diagnostic Scale were obtained at 4 time intervals: debrief, 2 and 4 days post-debrief, and 2 weeks postrobbery. The number and severity of symptoms did not differ at debrief, but were lower for the immediate than for the delayed group at each subsequent time interval. The number and severity of symptoms declined across time intervals; however, although this reduction was pronounced for the immediate group it was minimal for the delayed group. The results supported use of immediate debriefing with this type of incident and victim.

Psychological debriefing: controversy and challenge

OBJECTIVE

The efficacy of psychological debriefing following potentially traumatising events has become extremely controversial. This review aims to identify the issues underlying this controversy and their theoretical, social and political ramifications which are important in other areas of psychiatry and the social sciences.

METHOD

The historical background to the debriefing debate and the (largely negative) results of recent randomised controlled trials (RCTs) are reviewed.

RESULTS

Despite the negative results of recent RCTs, psychological debriefing remains the most widely used structured intervention following potentially traumatising events, designed to reduce the incidence of long-term psychiatric morbidity. The clinical relevance these trials and their applicability in vivo is questioned. There are implicit difficulties in conducting rigorous randomised controlled trials of group debriefing, and such trials may be unachievable.

CONCLUSIONS

Demonstrating the efficacy of debriefing or other preventive interventions presents major challenges to investigators and it is unlikely the controversy will be resolved in the near future.

Post-disaster service provision following proactive identification of children with emotional distress and depression

OBJECTIVE

Proactive, school-based psychological testing for emotional distress and depression was employed 6 months after a bushfire disaster. The service provision aim was to provide children with the greatest emotional distress the relatively limited therapeutic resources available in the post-disaster environment. Specific hypotheses were tested: that the prevalence of emotional distress and depression would be elevated 6 months post disaster; that emotional distress would be correlated with traumatic events; and that depression would be related to experiences of loss.

METHOD

Six months after a bushfire disaster grade 4, 5, and 6 students (n = 601) participated in screening using a test battery measuring emotional distress, depressive symptoms and trait anxiety.

RESULTS

Twelve percent (n = 72) of children experienced severe emotional distress 6 months after the bushfire. Rates of depression were similar to rates in non-traumatised child community samples. Multivariate analysis suggested that emotional distress was significantly associated with trait anxiety, evacuation experience, the perception that parents may have died during the bushfire, and depressive symptoms. Depressive symptoms were associated with total distress score, trait anxiety and perception of threat to the parents.

CONCLUSIONS

Substantial mental health morbidity was identified 6 months after a bushfire disaster. The usefulness of post-disaster service provision influenced by proactive screening is discussed and reasons for further research highlighted.

Prospective study of post-traumatic stress disorder in children involved in road traffic accidents

OBJECTIVE

To determine the prevalence of severe psychological trauma --that is, post-traumatic stress disorder--in children involved in everyday road traffic accidents.

DESIGN

12 month prospective study.

SETTING

Accident and emergency department, Royal United Hospital, Bath.

SUBJECTS

119 children aged 5-18 years involved in road traffic accidents and 66 children who sustained sports injuries.

MAIN OUTCOME MEASURE

Presence of appreciable psychological distress; fulfillment of diagnostic criteria for post-traumatic stress disorder.

RESULTS

Post-traumatic stress disorder was found in 41 (34.5%) children involved in road traffic accidents but only two (3.0%) who sustained sports injuries. The presence of post-traumatic stress disorder was not related to the type of accident, age of the child, or the nature of injuries but was significantly associated with sex, previous experience of trauma, and subjective appraisal of threat to life. None of the children had received any psychological help at the time of assessment.

CONCLUSIONS

One in three children involved in road traffic accidents was found to suffer from post-traumatic stress disorder when they were assessed 6 weeks after their accident. The psychological needs of such children after such accidents remain largely unrecognised.

Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder

These practice parameters review the current state of knowledge about posttraumatic stress disorder (PTSD) in children and adolescents. The parameters were written to aid clinicians in the assessment and treatment of children and adolescents with PTSD symptoms. A literature search and extensive review were conducted in order to evaluate the existing empirical and clinical information in this regard. Expert consultation was also solicited. The main findings of this process were that a wide variety of stressors can lead to the development of PTSD symptoms in this population; that the specific PTSD symptoms manifested may vary according to the developmental stage of the child and the nature of the stressor, and for this reason, the diagnostic criteria for PTSD in adults may not adequately describe this disorder in children and adolescents; that several factors seem to mediate the development of childhood PTSD following a severe stressor; and that most of the therapeutic interventions recommended for children with PTSD are trauma-focused and include some degree of direct discussion of the trauma. Controversies and unresolved issues regarding PTSD in children are also addressed.

Brief early psychological interventions following trauma: a systematic review of the literature

A systematic literature search/review was undertaken of brief early psychological interventions following trauma. Only six randomized controlled trials were found, and none of these included group interventions. Of the six trials, two studies associated the intervention with a positive outcome, two demonstrated no difference on outcome between intervention and non-intervention groups, and two showed some negative outcomes in the intervention group. This review suggests that early optimism for brief early psychological interventions including debriefing was misplaced and that there is an urgent need for randomized controlled trials of group debriefing and other early interventions.

Post-traumatic stress disorder in children and adolescents following road traffic accidents

BACKGROUND

Post-traumatic stress disorder (PTSD) can be a persistent and disabling psychiatric disorder. There is little systematic research into the psychiatric consequences of road traffic accidents (RTAs) in children and adolescents.

METHOD

A consecutive sample of 8-16-year-olds attending an accident and emergency department following RTAs were screened for PTSD. Potential cases and their parent(s) were interviewed with semi-structured research instruments about six weeks and six months after the accident.

RESULTS

Fifty-three (45%) of the 119 subjects fell above PTSD cut-off on the Frederick's Reaction Index. Thirty-three (75%) of the 44 cases met DSM-IV criteria for PTSD. In half of these other psychiatric disorders were present, including major depressive disorder and anxiety disorders. Being female, involvement in car accidents and pre-existing depression and anxiety were associated with developing PTSD. Seventeen per cent of the sample continued to be symptomatic six months after the accident.

CONCLUSIONS

PTSD is a common consequence of RTAs. Liaison with accident and emergency departments would enhance the early detection and follow-up of children at risk of developing PTSD.

Debriefing of American Red Cross personnel: pilot study on participants' evaluations and case examples from the 1994 Los Angeles earthquake relief operation

The Multiple Stressor Debriefing (MSD) model was used to debrief 112 American Red Cross workers individually or in groups after their participation in the 1994 Los Angeles earthquake relief effort. Two composite case examples are presented that illustrate individual and group debriefings using the MSD model. A questionnaire which evaluated workers' experience of debriefing, was completed by 95 workers. Results indicated that workers evaluated the debriefings in which they participated positively. In addition, as participant to facilitator ratio increased, workers shared less of their feelings and reactions about the disaster relief operation. These findings, as well as more specific issues about debriefing, are discussed.

Post-traumatic stress symptoms in children and parents following a school-based fatality

In 1991 the roof blew off a Swindon Primary School. One child was killed. Two years later 19 of her classmates were interviewed. The parent who collected the child from school that day was also interviewed. Recalled levels of post-traumatic stress syndrome (PTSD) symptoms were assessed in both parent and child in the month following the incident. The children's symptom levels at 2 years were also assessed. Parents and children recalled significant post-traumatic stress reactions at 1 month. The level of symptoms in parents did not correlate with that of their own children.