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The Benefit of Interventions to Reduce Posttraumatic Stress in Youth Exposed to Mass Trauma: A Review and Meta-Analysis

Published online by Cambridge University Press:  28 August 2019

Betty Pfefferbaum Open the ORCID record for Betty Pfefferbaum [Opens in a new window] ,
Pascal Nitiéma ,
Elana Newman  and
Anushka Patel
Betty Pfefferbaum*
Affiliation:
Department of Psychiatry and Behavioral Sciences, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OklahomaUSA
Pascal Nitiéma
Affiliation:
Department of Management Information Systems, Price College of Business, The University of Oklahoma, Norman, OklahomaUSA
Elana Newman
Affiliation:
Department of Psychology, The University of Tulsa, Tulsa, OklahomaUSA
Anushka Patel
Affiliation:
Department of Psychology, The University of Tulsa, Tulsa, OklahomaUSA
*
Correspondence: Betty Pfefferbaum, MD, JD George Lynn Cross Research Professor Emeritus Department of Psychiatry and Behavioral Sciences College of Medicine The University of Oklahoma Health Sciences Center 920 Stanton L. Young Boulevard, WP 3217 Oklahoma City, Oklahoma, USA 73126-0901 E-mail: betty-pfefferbaum@ouhsc.edu
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Abstract

Numerous interventions to address posttraumatic stress (PTS) in youth exposed to mass trauma have been delivered and evaluated. It remains unclear, however, which interventions work for whom and under what conditions. This report describes a meta-analysis of the effect of youth mass-trauma interventions on PTS to determine if interventions were superior to inactive controls and describes a moderator analysis to examine whether the type of event, population characteristics, or income level of the country where the intervention was delivered may have affected the observed effect sizes. A comprehensive literature search identified randomized controlled trials (RCTs) of youth mass-trauma interventions relative to inactive controls. The search identified 2,232 references, of which 25 RCTs examining 27 trials (N = 4,662 participants) were included in this meta-analysis. Intervention effects were computed as Hedge’s g estimates and combined using a random effects model. Moderator analyses were conducted to explain the observed heterogeneity among effect sizes using the following independent variables: disaster type (political violence versus natural disaster); sample type (targeted versus non-targeted); and income level of the country where the intervention was delivered (high- versus middle- versus low-income). The correlation between the estimates of the intervention effects on PTS and on functional impairment was estimated. The overall treatment effect size was converted into a number needed to treat (NNT) for a practical interpretation. The overall intervention effect was statistically significant (g = 0.57; P < .0001), indicating that interventions had a medium beneficial effect on PTS. None of the hypothesized moderators explained the heterogeneity among the intervention effects. Estimates of the intervention effects on PTS and on functional impairment were positively correlated (Spearman’s r = 0.90; P < .0001), indicating a concomitant improvement in both outcomes. These findings confirm that interventions can alleviate PTS and enhance functioning in children exposed to mass trauma. This study extends prior research by demonstrating improvement in PTS with interventions delivered to targeted and non-targeted populations, regardless of the country income level. Intervention populations and available resources should be considered when interpreting the results of intervention studies to inform recommendations for practice.

Keywords

disasterinterventionmass traumaposttraumatic stressyouth
Type
Comprehensive Review
Information
Prehospital and Disaster Medicine , Volume 34 , Issue 5 , October 2019 , pp. 540 - 551
Copyright
© World Association for Disaster and Emergency Medicine 2019 

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References

Integrated Regional Information Networks (IRIN). Disaster reduction and the human cost of disaster. IRIN web special. Geneva, Switzerland: IRIN, 2005. http://www.preventionweb.net/publications/view/2744. Accessed January 2, 2019.Google Scholar
United Nations Office for Disaster Risk Reduction (UNISDR). 2015 Disasters in Numbers. 2016. https://www.unisdr.org/we/inform/publications/47804. Accessed January 2, 2019.Google Scholar
Lokuge, K, Shah, T, Pintaldi, G, et al. Mental health services for children exposed to armed conflict: Médecins Sans Frontières’ experience in the Democratic Republic of Congo, Iraq, and the occupied Palestinian territory. Paediatr Int Child Health. 2013;33(4):259–272.CrossRefGoogle ScholarPubMed
National Commission on Children and Disasters. Report to the President and Congress. Rockville, Maryland USA: Agency for Health Care Research and Quality; 2010. https://archive.ahrq.gov/prep/nccdreport/. Accessed January 2, 2019.Google Scholar
United Nations Children’s Fund (UNICEF). Machel Study 10-year Strategic Review: Children and Conflict in a Changing World. New York, New York USA: UNICEF and UN Office of the Special Representative of the Secretary-General for Children and Armed Conflict; 2009. http://www.unicef.org/publications/index_49985.html. Accessed January 2, 2019.Google Scholar
Comer, JS, Kendall, PC. Terrorism: the psychological impact on youth. Clin Psychol Sci Pract. 2007;14(3):179–212.CrossRefGoogle Scholar
Wang, C, Chan, CLW, Ho, RTH. Prevalence and trajectory of psychopathology among child and adolescent survivors of disasters: a systematic review of epidemiological studies across 1987-2011. Soc Psychiatry Psychiatr Epidemiol. 2013;48(11):1697–1720.CrossRefGoogle Scholar
Alisic, E, Zalta, AK, Van Wesel, F, et al. Rates of post-traumatic stress disorder in trauma-exposed children and adolescents. Br J of Psychiatr. 2014;204(5):335–340.CrossRefGoogle ScholarPubMed
Forman-Hoffman, VL, Zolotor, AJ, McKeeman, JL, et al. Comparative effectiveness of interventions for children exposed to nonrelational traumatic events. Pediatrics. 2013;131(3):526–539.CrossRefGoogle ScholarPubMed
Jordans, MJD, Tol, WA, Komproe, IH, de Jong, JVTM. Systematic review of evidence and treatment approaches: psychosocial and mental health care for children in war. Child Adolesc Ment Health. 2009;14(1):2–14.CrossRefGoogle Scholar
Pfefferbaum, B, Newman, E, Nelson, SD, et al. Research methodology used in studies of child disaster mental health interventions for posttraumatic stress. Compr Psychiatry. 2014;55(1):11–24.CrossRefGoogle ScholarPubMed
Brown, RC, Witt, A, Fegert, JM, Keller, F, Rassenhofer, M, Plener, PL. Psychosocial interventions for children and adolescents after man-made and natural disasters: a meta-analysis and systematic review. Psychol Med. 2017;47:1893–1905.CrossRefGoogle ScholarPubMed
Fu, C, Underwood, C. A meta-review of school-based disaster interventions for child and adolescent survivors. J Child Adolesc Ment Health. 2015:27(3):161–171.CrossRefGoogle ScholarPubMed
Morina, N, Malek, M, Nickerson, A, Bryant, RA. Psychological interventions for post-traumatic stress disorder and depression in young survivors of mass violence in low- and middle-income countries: meta-analysis. Br J Psychiatr. 2017;210(4):247–254.CrossRefGoogle ScholarPubMed
Newman, E, Pfefferbaum, B, Kirlic, N, Tett, R, Nelson, S, Liles, B. Meta-analytic review of psychological interventions for children survivors of natural and man-made disasters. Curr Psychiat Rep. 2014;16(462):1–10.CrossRefGoogle ScholarPubMed
Purgato, M, Gross, AL, Betancourt, T, et al. Focused psychosocial interventions for children in low-resource humanitarian settings: a systematic review and individual participant data meta-analysis. Lancet Global Health. 2018;p6:e-390–400.CrossRefGoogle Scholar
Tol, WA, Barbui, C, Galappatti, A, et al. Mental health and psychosocial support in humanitarian settings: linking practice and research. Lancet. 2011;378(9802):1581–1591.CrossRefGoogle ScholarPubMed
Bonanno, GA, Brewin, CR, Kaniasty, K, La Greca, AM. Weighing the costs of disaster: consequences, risks, and resilience in individuals, families, and communities. Psychol Sci Public Interest. 2010;11(1):1–49.CrossRefGoogle ScholarPubMed
Furr, JM, Comer, JS, Edmunds, JM, Kendall, PC. Disasters and youth: a meta-analytic examination of posttraumatic stress. J Consult Clin Psychol. 2010:78(6):765–780.CrossRefGoogle ScholarPubMed
Norris, FH, Friedman, MJ, Watson, PJ, Byrne, CM, Diaz, E, Kaniasty, K. 60,000 disaster victims speak: Part I. An empirical view of the empirical literature, 1981-2011. Psychiatry. 2002;65(3):207–239.Google Scholar
North, CS, Oliver, J, Pandya, A. Examining a comprehensive model of disaster-related posttraumatic stress disorder in systematically studied survivors of 10 disasters. Am J Public Health. 2012;102:3–40-E48.CrossRefGoogle ScholarPubMed
Rubonis, AV, Bickman, L. Psychological impairment in the wake of disaster: the disaster-psychopathology relationship. Psychol Bull. 1991;109(3):384–399.CrossRefGoogle ScholarPubMed
Marsac, ML, Donlon, K, Berkowitz, S. Indicated and selective preventive interventions. Child Adolesc Psychiatr Clin N Am. 2014;23(2):383–397.CrossRefGoogle ScholarPubMed
Pfefferbaum, B, North, CS. Child disaster mental health services: a review of the system of care, assessment approaches, and evidence base for intervention. Curr Psychiat Rep. 2016;18(5):4–7.CrossRefGoogle ScholarPubMed
Pynoos, RS, Steinberg, AM, Brymer, MJ. “Children and disasters: public mental health approaches.” In: Ursano, RJ, Fullerton, CS, Weisaeth, L, Raphael, B (eds). Textbook of Disaster Psychiatry. New York USA: Cambridge University Press; 2007:48–68.CrossRefGoogle Scholar
Vernberg, EM. “Intervention approaches following disasters.” In: La Greca, AM, Silberman, WK, Vernerg, EM, Roberts, MC (eds). Helping Children Cope with Disasters and Terrorism. Washington, DC USA: American Psychological Association; 2002:55–72.CrossRefGoogle Scholar
Persson, TJ, Rousseau, C. School-based interventions for minors in war-exposed countries: a review of targeted and general programs. Torture. 2009;19(2):88–101.Google Scholar
World Bank Data Help Desk. Historical classification of countries by income. https://datahelpdesk.worldbank.org/knowledgebase/articles/378832-what-is-the-world-bank-atlas-method. Accessed January 2, 2019.Google Scholar
Ioannidis, JPA, Haidich, AB, Pappa, M, et al. Comparison of evidence of treatment effects in randomized and nonrandomized studies. JAMA. 2001;286(7):821–830.CrossRefGoogle ScholarPubMed
O’Connor, D, Green, S, Higgins, JPT. “Defining the review question and developing criteria for including studies.” In: Higgins, JPT, Green, S, (eds). Cochrane Handbook for Systematic Reviews of Interventions. West Sussex, UK: Wiley; 2008:91–94.Google Scholar
Betancourt, TS, McBain, R, Newnham, EA, et al. A behavioral intervention for war-affected youth in Sierra Leone. J Am Acad Child Adolesc Psychiat. 2014;53(12):1288–1297.CrossRefGoogle ScholarPubMed
Panter-Brick, C, Dajani, R, Eggerman, M, Hermosilla, S, Sancilio, A, Ager, A. Insecurity, distress and mental health: experimental and randomized controlled trials of a psychosocial intervention for youth affected by the Syrian crisis. J Child Psychol Psychiat. 2018;59(5):523–541.CrossRefGoogle ScholarPubMed
Chen, Y, Shen, WW, Gao, K, Lam, CS, Chang, WC, Deng, H. Effectiveness RCT of a CBT intervention for youths who lost parents in the Sichuan, China, earthquake. Psychiatr Serv. 2014;65(2):259–262.CrossRefGoogle Scholar
Ertl, V, Pfeiffer, A, Schauer, E, Elbert, T, Neuner, F. Community-implemented trauma therapy for former child soldiers in Northern Uganda. A randomized control trial. JAMA. 2011;306(5):503–512.CrossRefGoogle Scholar
Barron, I, Abdallah, G, Heltne, U. Randomized control trial of teaching recovery techniques in rural occupied Palestine: effect on adolescent dissociation. J Aggress Maltreat Trauma. 2016;25(9):955–976.CrossRefGoogle Scholar
Berger, R, Gelkopf, M. School-based intervention for the treatment of Tsunami-related distress in children: a quasi-randomized controlled trial. Psychother Psychosom. 2009;78(6):364–371.CrossRefGoogle ScholarPubMed
Berger, R, Pat-Horenczyk, R, Gelkopf, M. School-based intervention for prevention and treatment of elementary-students’ terror-related distress in Israel: a quasi-randomized controlled trial. J Trauma Stress. 2007;20(4):541–551.CrossRefGoogle ScholarPubMed
Berger, R, Gelkopf, M, Heineberg, Y. A teacher-delivered intervention for adolescents exposed to ongoing and intense traumatic war-related stress: a quasi-randomized controlled study. J Adolesc Health. 2012;51(5):453–461.CrossRefGoogle ScholarPubMed
Chemtob, CM, Nakashima, J, Carlson, JG. Brief treatment for elementary school children with disaster-related posttraumatic stress disorder: a field study. J Clin Psychol. 2002;58(1):99–112.CrossRefGoogle ScholarPubMed
Gelkopf, M, Berger, R. A school-based, teacher-mediated prevention program (ERASE-Stress) for reducing terror-related traumatic reactions in Israeli youth: a quasi-randomized controlled trial. J Child Psychol Psychiat. 2009;50(8):962–971.CrossRefGoogle ScholarPubMed
Gordon, JS, Staples, JK, Blyta, A, Bytyqi, M, Wilson, AT. Treatment of posttraumatic stress disorder in postwar Kosovar adolescents using mind-body skills groups: a randomized controlled trial. J Clin Psychiat. 2008;69(9):1469–1476.CrossRefGoogle ScholarPubMed
Hermenau, K, Hecker, T, Schaal, S, Maedl, A, Elbert, T. Addressing post-traumatic stress and aggression by means of narrative exposure: a randomized controlled trial with ex-combatants in the Eastern DRC. J Aggress Maltreat Trauma. 2013;22(8):916–934.CrossRefGoogle Scholar
Jordans, MJD, Komproe, IH, Tol, WA, et al. Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled trial. J Child Psychol Psychiat. 2010;51(7):818–826.CrossRefGoogle ScholarPubMed
Lesmana, CBJ, Suryani, LK, Jensen, GD, Tiliopoulos, N. A spiritual-hypnosis assisted treatment of children with PTSD after the 2002 Bali terrorist attack. Am J Clin Hypn. 2009;52(1):23–34.CrossRefGoogle ScholarPubMed
Mahmoudi-Gharaei, J, Mohammadi, MR, Yasami, MT, Alirezaie, N, Naderi, F, Moftakhari, O. The effects of a short-term cognitive behavioral group intervention on Bam Earthquake related PTSD symptoms in adolescents. Iran J Psychiatry. 2009;4:79–84.Google Scholar
McMullen, J, O’Callaghan, P, Shannon, C, Black, A, Eakin, J. Group trauma-focused cognitive-behavioral therapy with former child soldiers and other war-affected boys in the DR Congo: a randomized controlled trial. J Child Psychol Psychiatr. 2013;54(11):1231–1241.CrossRefGoogle Scholar
O’Callaghan, P, McMullen, J, Shannon, C, Rafferty, H, Black, A. A randomized controlled trial of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese girls. J Am Acad Child Adolesc Psychiat. 2013;52(4):359–369.CrossRefGoogle ScholarPubMed
O’Callaghan, P, Branham, L, Shannon, C, Betancourt, TS, Dempster, M, McMullen, JA. A pilot study of a family focused, psychosocial intervention with war-exposed youth at risk of attack and abduction in north-eastern Democratic Republic of Congo. Child Abuse Negl. 2014;38(7):1197–1207.CrossRefGoogle ScholarPubMed
Ooi, CS, Rooney, RM, Roberts, C, Kane, RT, Wright, B, Chatzisarantis, N. The efficacy of a group cognitive behavioral therapy for war-affected young migrants living in Australia: a cluster randomized controlled trial. Front Psychol. 2016;7:1–14.CrossRefGoogle ScholarPubMed
Pityaratstian, N, Piyasil, V, Ketumarn, P, Sitdhiraksa, N, Ularntinon, S, Pariwatcharakul, P. Randomized controlled trial of group cognitive behavioral therapy for post-traumatic stress disorder in children and adolescents exposed to Tsunami in Thailand. Behav Cogn Psychother. 2015;43(5):549–561.CrossRefGoogle ScholarPubMed
Qouta, SR, Palosaari, E, Diab, M, Punamäki, RL. Intervention effectiveness among war-affected children: a cluster randomized controlled trial on improving mental health. J Trauma Stress. 2012;25(3):288–298.CrossRefGoogle ScholarPubMed
Ruf, M, Schauer, M, Neuner, F, Catani, C, Schauer, E, Elbert, T. Narrative exposure therapy for 7- to 16-year-olds: a randomized controlled trial with traumatized refugee children. J Trauma Stress. 2010;23(4):437–445.CrossRefGoogle ScholarPubMed
Tol, WA, Komproe, IH, Susanty, D, Jordans, MJD, Macy, RD, de Jong, JTVM. School-based mental health intervention for children affected by political violence in Indonesia. A cluster randomized trial. JAMA. 2008;300(6):655–662.CrossRefGoogle ScholarPubMed
Tol, WA, Komproe, IH, Jordans, MJD, et al. Outcomes and moderators of a preventive school-based mental health intervention for children affected by war in Sri Lanka: a cluster randomized trial. World Psychiatry. 2012:11(2):114–122.CrossRefGoogle ScholarPubMed
Tol, WA, Komproe, IH, Jordans, MJD, et al. School-based mental health intervention for children in war-affected Burundi: a cluster randomized trial. BMC Med. 2014;12(1):56.CrossRefGoogle ScholarPubMed
Hedges, LV. Distribution theory for Glass’s estimator of effect size and related estimators. J Educ Stat. 1981;6(2):107–128.CrossRefGoogle Scholar
Hartung, J, Knapp, G. On tests of the overall treatment effect in meta-analysis with normally distributed responses. Stat Med. 2001;20(12):1771–1782.CrossRefGoogle ScholarPubMed
Partlett, C, Riley, RD. Random effects meta-analysis: coverage performance of 95% confidence and prediction intervals following REML estimation. Stat Med. 2016;36(2):301–317.CrossRefGoogle ScholarPubMed
Schmidt, FL, Hunter, JE. Methods of Meta-Analysis: Correcting Error and Bias in Research Findings. Thousand Oaks, California USA: Sage Publications; 2015.CrossRefGoogle Scholar
Baujat, B, Mahé, C, Pignon, JP, Hill, C. A graphical method for exploring heterogeneity in meta-analyses: application to a meta-analysis of 65 trials. Stat Med. 2002;21(18):2641–2652.CrossRefGoogle ScholarPubMed
Furukawa, TA, Leucht, S. How to obtain NNT from Cohen’s d: comparison of two methods. PloS One. 2011;6(4):e19070.CrossRefGoogle ScholarPubMed
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th ed, text rev. Washington, DC USA: American Psychiatric Association; 2000.Google Scholar
Egger, M, Smith, GD, Schneider, M, Minder, C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–634.CrossRefGoogle ScholarPubMed
Duval, S, Tweedie, R. A nonparametric “Trim and Fill” method of accounting for publication bias in meta-analysis. J Am Stat Assoc. 2000;95:89–98.Google Scholar
Del Re, AC. compute.es: Compute effect sizes. R package [computer software]. Version 0-2, 2013. http://cran.r-project.org/web/packages/compute.es. Accessed January 2, 2019.Google Scholar
Viechtbauer, W. Conducting meta-analyses in R with the metafor package. J Stat Software. 2010;36(3):1–48.CrossRefGoogle Scholar
Schwarzer, G. meta: an R package for meta-analysis. R News. 2007;7(3):40–45.Google Scholar
Ertl, V, Neuner, F. Are school-based mental health interventions for war-affected children effective and harmless? BMC Med. 2014;12(1):84.CrossRefGoogle ScholarPubMed
Miller, KE, Rasmussen, R. War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks. Soc Sci Med. 2010;70:7–16.CrossRefGoogle ScholarPubMed