The Use of Psychological First Aid in Children Exposed to Mass Trauma.

PURPOSE OF REVIEW: Psychological first aid (PFA) has been widely disseminated and promoted as an intervention to support short-term coping and long-term functioning after disasters. Despite its popularity, earlier reviews cite a startling lack of empirical outcome studies. The current review explores recent studies of PFA, especially pertaining to its use with children. RECENT FINDINGS: Initial studies of PFA show that it is well received by youth, families, and providers as well as being linked to decreases in depressive and posttraumatic stress symptoms, improved self-efficacy, increased knowledge about disaster preparedness and recovery, and enhanced feelings of safety and connection. The flexibility of the modular style of PFA and cultural adaptations emerged as significant themes. Although the studies reviewed cast a favorable light on PFA, more research is needed regarding its use and outcomes. This review describes the challenges to conducting these studies as well as suggestions for paths forward.

A Skill Set for Supporting Displaced Children in Psychological Recovery After Disasters.

Helping children, adolescents, and families displaced following a natural disaster is a daunting task made more challenging by the relatively small research base to inform services and interventions. This paper describes the current literature pertaining to intervention practices used with displaced youth. Where gaps in the literature exist, we pull from the more general research on relocation and post-disaster intervention to assist practitioners in tailoring their efforts. Specifically discussed are ways to enhance youth resilience, to help youth build new social connections and adjust to change and uncertainty while coping with trauma-related symptoms, and to meet needs through the systems in which children are embedded. The need for focused attention to cultural factors is discussed with an emphasis on collaborating with culture brokers.

Effects of Displacement in Children Exposed to Disasters.

The literature on children's responses to disasters is well developed with increasing attention to the confounding experiences of displacement. This paper presents an overview of the emotional and behavioral effects of displacement on children and adolescents and describes their educational adjustment in terms of both academic achievement and school behavior. A summary of family effects elucidates how children's functioning is influenced through the family system in which they are embedded. The psychosocial impact of displacement reflects the myriad social losses that children and their families may face. Information from this review of the current literature on the effects of displacement may inform the design and delivery of support and intervention services for children and families following disasters.

Children's Cognitive Functioning in Disasters and Terrorism.

A growing literature has begun to address the cognitions that influence children's disaster reactions as well as the effects of disasters on children's cognitions. These cognitions must be viewed in the context of developmental and cultural considerations as well as disaster-related factors such as exposure and secondary stressors. This review examines the extant literature on children's cognitions related to disasters and terrorism including threat appraisal, beliefs, attention and concentration, memory, academic achievement, and executive functioning. The review highlights areas where research is lacking such as the effect of disasters on children's attention, concentration, content of disaster memories, and executive functioning. It also notes findings that may advance post-disaster screening and intervention.

Review of Coping in Children Exposed to Mass Trauma: Measurement Tools, Coping Styles, and Clinical Implications.

Evidence-based practice requires the use of data grounded in theory with clear conceptualization and reliable and valid measurement. Unfortunately, developing a knowledge base regarding children's coping in the context of disasters, terrorism, and war has been hampered by a lack of theoretical consensus and a virtual absence of rigorous test construction, implementation, and evaluation. This report presents a comprehensive review of measurement tools assessing child and adolescent coping in the aftermath of mass trauma, with a particular emphasis on coping dimensions identified through factor analytic procedures. Coping measurement and issues related to the assessment of coping are reviewed. Concepts important in instrument development and psychometric features of coping measures used in disasters, terrorism, and war are presented. The relationships between coping dimensions and both youth characteristics and clinical outcomes also are presented. A discussion of the reviewed findings highlights the difficulty clinicians may experience when trying to integrate the inconsistencies in coping dimensions across studies. Incorporating the need for multiple informants and the difference between general and context-specific coping measures suggests the importance of a multilevel, theoretical conceptualization of coping and thus, the use of more advanced statistical measures. Attention also is given to issues deemed important for further exploration in child disaster coping research.

Children's disaster reactions: the influence of family and social factors.

This review examines family (demographics, parent reactions and interactions, and parenting style) and social (remote effects, disaster media coverage, exposure to secondary adversities, and social support) factors that influence children's disaster reactions. Lower family socioeconomic status, high parental stress, poor parental coping, contact with media coverage, and exposure to secondary adversities have been associated with adverse outcomes. Social support may provide protection to children in the post-disaster environment though more research is needed to clarify the effects of certain forms of social support. The interaction of the factors described in this review with culture needs further exploration.

Children's disaster reactions: the influence of exposure and personal characteristics.

This paper reviews children's reactions to disasters and the personal and situational factors that influence their reactions. Posttraumatic stress disorder (PTSD) and posttraumatic stress reactions are the most commonly studied outcomes, though other conditions also occur including anxiety, depression, behavior problems, and substance use. More recently, traumatic grief and posttraumatic growth have been explored. New research has delineated trajectories of children's posttraumatic stress reactions and offered insight into the long-term consequences of their disaster experiences. Risk factors for adverse outcomes include pre-disaster vulnerabilities, perception of threat, and loss and life disruptions post-disaster. Areas in need of additional research include studies on the timing and course of depression and anxiety post-event and their interactions with other disorders, disaster-related functional and cognitive impairment, positive outcomes, and coping.

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.

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.

Towards successful Dissemination of Psychological First Aid: a study of provider training preferences.

Dissemination of Psychological First Aid (PFA) is challenging considering the complex nature of disaster response and the various disaster mental health (DMH) trainings available. To understand challenges to dissemination in community mental health centers (CMHCs), interviews were conducted with nine DMH providers associated with CMHCs. Consensual qualitative analysis was used to analyze data. Interviews were targeted toward understanding organizational infrastructure, DMH training requirements, and training needs. Results clarified challenges to DMH training in CMHCs and factors that may promote buy-in for trainings. For example, resources are limited and thus allocated for state and federal training requirements. Therefore, including PFA in these requirements could promote adoption. Additionally, a variety of training approaches that differ in content, style, and length would be useful. To conclude, a conceptual model for ways to promote buy-in for the PFA Guide is proposed.

Children of National Guard troops: a pilot study of deployment, patriotism, and media coverage.

This exploratory pilot study examined the psychosocial effects of the war in Iraq, patriotism, and attention to war-related media coverage in the children of National Guard troops across phases of parental deployment--pre deployment, during deployment, and post deployment. Participants included 11 children, ages 8 to 18 years. Data collected in each deployment phase included demographics, the Behavior Assessment System for Children, (Second Edition, BASC-2), patriotism (national identity, uncritical patriotism, and constructive patriotism), and attention to war-related media coverage. School problems and emotional symptoms were significantly higher during deployment than post deployment. National identity and constructive patriotism increased and uncritical patriotism decreased post deployment from levels during deployment. Uncritical patriotism correlated positively with emotional symptoms and correlated negatively with personal adjustment. Constructive patriotism correlated positively with emotional symptoms and with internalizing problems. Greater attention to war-related media coverage correlated with uncritical patriotism, and attention to internet coverage correlated with constructive patriotism. Attention to media coverage was linked to greater emotional and behavioral problems and was negatively correlated with personal adjustment. The results of this pilot study identified relationships of both patriotism and attention to media coverage with children's emotional and behavioral status and personal adjustment suggesting areas for future investigation.

The burden of disaster: part II. applying interventions across the child's social ecology.

This second of two articles describes the application of disaster mental health interventions within the context of the childs social ecology consisting of the Micro-, Meso-, Exo-, and Macrosystems. Microsystem interventions involving parents, siblings, and close friends include family preparedness planning andpractice, psychoeducation, role modeling, emotional support, and redirection. Mesosystem interventions provided by schools and faith-based organizations include safety and support, assessment, referral, and counseling. Exosystem interventions include those provided through community-based mental health programs, healthcare organizations, the workplace, the media, local volunteer disaster organizations, and other local organizations. Efforts to build community resilience to disasters are likely to have influence through the Exosystem. The Macrosystem - including the laws, history, cultural and subcultural characteristics, and economic and social conditions that underlie the other systems - affects the child indirectly through public policies and disaster programs and services that become available in the child's Exosystem in the aftermath of a disaster The social ecology paradigm, described more fully in a companion article (Noffsinger Pfefferbaum, Pfefferbaum, Sherrieb, & Norris,2012), emphasizes relationships among systems and can guide the development and delivery of services embedded in naturally-occurring structures in the child's environment.

Intensive mental health services for children with serious emotional disturbances through a school-based, community-oriented program.

Treating children with severe, early onset emotional and behavioral disturbances remains a daunting task for mental health and education systems. This article describes key principles, features, and outcomes for the school-based Intensive Mental Health Program (IMHP), a program designed specifically to provide comprehensive evidence-based, ecologically sensitive, and individualized services for this difficult-to-treat population. Although the IMHP is a relatively new model, preliminary studies of outcomes and treatment processes give initial evidence that most children improve notably in their role performance, behavior, and emotional adjustment over the course of treatment. With increasing demands for effective, affordable school-based mental health services, the IMHP offers a developing but promising prototype for services geared to meet the unique needs of children with complex disturbances of emotions and behavior.

Innovative treatment for children with serious emotional disturbance: preliminary outcomes for a school-based intensive mental health program.

This article describes the development, implementation, and preliminary evaluation of a school-based Intensive Mental Health Program (IMHP) for 50 children (42 boys, 8 girls) with severe, early-onset, serious emotional disturbances (SED). Eighty-four percent of the children showed clinically significant improvement in overall functioning as measured by the Child and Adolescent Functional Assessment Scale (CAFAS). Child functioning at home and school, behavior toward others, regulation of moods and emotions, self-harm, and problems in thinking improved significantly. Results provide initial support for the IMHP as a promising approach to serving the needs of children with SED.