Christopher M. Layne

Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence

Abstract Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence–based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid–term post mass trauma phases. Because it is unlikely that there will be evidence in the near or mid–term future from clinical trials that cover the diversity of disaster and mass violence circumstances, we assembled a worldwide panel of experts on the study and treatment of those exposed to disaster and mass violence to extrapolate from related fields of research, and to gain consensus on intervention principles. We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid–term stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self– and community efficacy, 4) connectedness, and 5) hope.

Creating trauma-informed systems: Child welfare, education, first responders, health care, juvenile justice.

Children and adolescents who are exposed to traumatic events are helped by numerous child-serving agencies, including health, mental health, education, child welfare, first responder, and criminal justice systems to assist them in their recovery. Service providers need to incorporate a trauma-inform

Effectiveness of a School-Based Group Psychotherapy Program for War-Exposed Adolescents: A Randomized Controlled Trial

OBJECTIVE To evaluate the comparative effectiveness of a classroom-based psychoeducation and skills intervention (tier 1) and a school-based trauma- and grief-focused group treatment (tier 2) of a three-tiered mental health program for adolescents exposed to severe war-related trauma, traumatic bereavement, and postwar adversity. METHOD A total of 127 war-exposed and predominantly ethnic Muslim secondary school students attending 10 schools in central Bosnia who reported severe symptoms of posttraumatic stress disorder (PTSD), depression, or maladaptive grief and significant impairment in school or relationships were randomly assigned to one of two experimental conditions. These included either an active-treatment comparison condition (tier 1), consisting of a classroom-based psychoeducation and skills intervention alone (n = 61, 66% girls, mean age 16.0 years, SD 1.13) or a treatment condition composed of both the classroom-based intervention and a 17-session manual-based group therapy intervention (tier 2), trauma and grief component therapy for adolescents (n = 66, 63% girls, mean age 15.9 years, SD 1.11). Both interventions were implemented throughout the school year. Distressed students who were excluded from the study due to acute risk for harm (n = 9) were referred for community-based mental health services (tier 3). RESULTS Program effectiveness was measured via reductions in symptoms of PTSD, depression, and maladaptive grief assessed at pretreatment, posttreatment, and 4-month follow-up. Analysis of mean-level treatment effects showed significant pre- to posttreatment and posttreatment to 4-month follow-up reductions in PTSD and depression symptoms in both the treatment and comparison conditions. Significant pre- to posttreatment reductions in maladaptive grief reactions were found only in the treatment condition. Analyzed at the individual case level, the percentages of students in the treatment condition who reported significant (p <.05) pre- to posttreatment reductions in PTSD symptoms (58% at posttreatment, 81% at 4-month follow-up) compare favorably to those reported in controlled treatment efficacy trials, whereas the percentages who reported significant reductions in depression symptoms (23% at posttreatment, 61% at follow-up) are comparable to, or higher than, those found in community treatment settings. Lower but substantial percentages of significant symptom reduction were found for PTSD (33% at posttreatment, 48% at follow-up) and depression symptoms (13% at posttreatment; 47% at follow-up) in students in the comparison condition. The odds of significant symptom reduction were higher for PTSD symptoms at both posttreatment and 4-month follow-up and for maladaptive grief at posttreatment (no follow-up was conducted on maladaptive grief). Rates of significantly worsened cases were generally rare in both the treatment and comparison conditions. CONCLUSIONS A three-tiered, integrative mental health program composed of schoolwide dissemination of psychoeducation and coping skills (tier 1), specialized trauma- and grief-focused intervention for severely traumatized and traumatically bereaved youths (tier 2), and referral of youths at acute risk for community-based mental health services (tier 3) constitutes an effective and efficient method for promoting adolescent recovery in postwar settings.

Trauma- and Grief-Focused Intervention for Adolescents Exposed to Community Violence: Results of a School-Based Screening and Group Treatment Protocol

Recent studies document high levels of community violence exposure among adolescents and link violence exposure to psychological distress and impaired academic achievement. This study assessed the prevalence of trauma exposure among middle school students and evaluated the effectiveness of a school-based, trauma/grief-focused group psychotherapy protocol in treating a sub-group of students with severe exposure, posttraumatic stress disorder (PTSD) and functional impairment. Using a stratified screening procedure, 812 students completed a screening survey, 58 students (7.1% of those surveyed) met criteria for group treatment, and 26 students participated in the group. Group participation was associated with improvements in posttraumatic stress and complicated grief symptoms, and in academic performance. Results suggest that students who are exposed to severe levels of community violence may not be typically identified or treated. The findings also suggest that severe PTSD in adolescence may be associated with impaired school functioning, and that a reduction in PTSD symptoms may be related to academic remediation.

An examination of the relationships between violence exposure, posttraumatic stress symptomatology, and delinquent activity: An "ecopathological" model of delinquent behavior among incarcerated adolescents

Summary The prevalence of violence exposure and PTSD symptomatology among a sample of incarcerated adolescents is compared with that among a matched sample of high school students. Adolescents who have come to the attention of the juvenile justice system have been exposed to significantly higher levels of sexual and community violence, and report significantly higher levels of PTSD symptomatology. Within the incarcerated group, adolescents who report higher levels of delinquent activity (in the form of gun possession and gang involvement) also report higher levels of some forms of violence exposure. Incarcerated youth with more serious delinquent histories displayed higher levels of PTSD symptomatology, as well.

DSM‐V PTSD diagnostic criteria for children and adolescents: A developmental perspective and recommendations

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) should ensure systematic attention to age-specific manifestations and selective modifications of the diagnostic criteria for posttraumatic stress disorder (PTSD) among children and adolescents. The authors propose developmental refinements to the conceptual framework for PTSD based on an appreciation of the different neurosignatures of danger and safety, and maturational processes that underlie symptom presentation. This includes preliminary evidence for the developmental salience of additional dimensions for PTSD (e.g., recklessness and thrill-seeking). The authors provide conservative recommendations for DSM-V diagnostic criteria that primarily highlight age-related developmental manifestations that, if included in the accompanying text, would bring a richer appreciation of developmentally linked symptom presentations.

Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence

Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence-based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid-term post mass trauma phases. Because it is unlikely that there will be evidence in the near or mid-term future from clinical trials that cover the diversity of disaster and mass violence circumstances, we assembled a worldwide panel of experts on the study and treatment of those exposed to disaster and mass violence to extrapolate from related fields of research, and to gain consensus on intervention principles. We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid-term stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) h...

Psychometric Properties of the UCLA PTSD Reaction Index. Part II: Investigating Factor Structure Findings in a National Clinic-Referred Youth Sample

We examined the underlying factor structure of the UCLA PTSD Reaction Index (PTSD-RI) using data from 6,591 children/adolescents exposed to trauma, presenting for treatment at any of 54 National Child Traumatic Stress Network (NCTSN) centers. Using confirmatory factor analysis, we tested the 3-factor DSM-IV PTSD model, 2 separate 4-factor models (Dysphoria vs. Emotional Numbing) and a recently conceptualized 5-factor Dysphoric Arousal model. We found a slight, but significant advantage for the Dysphoria model over the Emotional Numbing model on the PTSD-RI, with a difference in Bayesian information criterion (BIC) values of 81 points. As with several recent studies of adult trauma victims, we found a slight advantage for the Dysphoric Arousal model over the other models on the PTSD-RI, with BIC differences exceeding 300 points. Retaining the Dysphoric Arousal model, we tested the convergent validity of the PTSD-RI factors against subscales of the Trauma Symptom Checklist for Children. Supporting the convergent validity of the PTSD-RI, in the Dysphoric Arousal model, the dysphoric arousal factor related most strongly to anger, whereas the emotional numbing factor related most strongly to depression, and anxious arousal factor related most strongly to anxiety. Results support the use of the PTSD-RI for evaluating PTSD among youth.

DSM-V Diagnostic Criteria for Bereavement-Related Disorders in Children and Adolescents: Developmental Considerations

Two bereavement-related disorders are proposed for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V): Adjustment Disorder Related to Bereavement, to be located in the main body of the text as an official diagnostic entity; and Bereavement-Related Disorder, including a Traumatic Death Specifier, to be located in the Appendix as an invitation for further research. These diagnoses currently do not include developmentally informed criteria, despite the importance of developmental processes in the ways children and adolescents grieve. In this article, we draw upon a selective review of the empirical literature and expert clinical knowledge to recommend developmentally informed modifications and specifiers of the proposed criteria for both bereavement disorders and strategies to improve future research. This article is derived from an invited report submitted to the DSM-V Posttraumatic Stress Disorder, Trauma, and Dissociative Disorders Sub-Work Group, and suggested modifications have received preliminary approval to be incorporated into the DSM-V at the time of this writing. Adoption of these proposals will have far-reaching consequences, given that DSM-V criteria will influence both critical treatment choices for bereaved youth and the next generation of research studies.

Developing a culturally and ecologically sound intervention program for youth exposed to war and terrorism

This article describes the public mental health approach used to develop and implement a school-based postwar trauma/grief intervention program for adolescents in Bosnia-Herzegovina. This approach includes development of multilateral partnerships with local and ministerial stakeholders, systematic assessment that yields a detailed understanding of the specific range and severity of trauma and loss experiences, current adversities and trauma reminders among the affected population, and a training program aimed at developing the capacities of local service providers and an indigenous support infrastructure so that the intervention program may be directed and sustained by people within the communities served. Concluding comments detail an expanded conceptual framework for public mental health interventions that may be appropriate for terrorist and mass-casualty events.