Healing Broken Hearts

A Theoretical Analysis Of Interventions For Child Refugees Diagnosed With War-Related Posttraumatic Stress Disorder


Copyright 2008 Jennifer M Kerner, IUSM DEPARTMENT OF PUBLIC HEALTH
Please properly cite this blog if using any material, in whole or in part, found within.

10/11/2008

 
A Population in Need
An estimated 15 wars have been fought since the turn of the 20th century. That number is conservative taking into account the ill-considered definition of aggression as stated in the United Nations General Assembly Resolution 3314 (XXIX). As a result of these conflicts, there are 11.4 million refugees worldwide under UNHCR mandate. In addition, there are 26 million internally displaced persons (IDPs) as a result of conflict (UNHCR 2008). Almost half (43%) of these refugees and IDPs are under the age of 18 (Onyut 2005). These children must struggle to survive daily life while grieving the loss of loved ones (Ehntholt 2005). Many times, children living in conflict areas witness killings and, sadly, may even be the killers (Bayer 2007). Children who are survivors of war-related traumatic events are of particular concern due to their vulnerable “developmental status” (Veenema 2002). Children up to age 19 go through a tremendous amount of life changes, separate from the external changes they face. With all of these factors adding to the strain of their lives, it is no surprise that “refugee children are at high risk of having mental health problems” (Yule 2000).
The situation is dire. As of the mid-1990s, “serious psychiatric disorder” has been diagnosed in 40-50% of refugee children in the United States alone (Hodes 1998). For refugees worldwide, the most prevalent of these psychiatric disorders is posttraumatic stress disorder (PTSD) (Fazel 2002). According to the DSM IV (Diagnostics and Statistical Manual of Mental Disorders), 6 criteria must be fulfilled in order to accurately diagnose a case of PTSD (Association 1994). These criteria include 1) “experiencing or witnessing a life-threatening” event, and experiencing “feelings of helplessness, fear or horror during that event,” 2) “reliving or re-experiencing” the event through flashbacks or dreams, 3) “avoidance,” 4) “being overly aroused,” 5) at least four weeks of suffering from these symptoms, and 6) “severe problems” in “every day functioning,” (Schauer 2005). Posttraumatic stress disorder “following exposure to global and community violence” affects “more than 3 million children” (Veenema 2002). This number accounts for “more than half of children exposed to war” (Allwood 2002). The effect is worldwide and does not discriminate based on factors such as geography, socioeconomic status, gender, or length of conflict. For example, the prevalence of PTSD among “Cambodian children who had been exposed to war and genocide during the Pol Pot regime” was 50% (Allwood 2002). A striking 93.8% of IDPs under the age of 18 were diagnosed with PTSD following the Bosnian war (Allwood 2002). “Significant mental health and psychosocial problems” abound in the Great Lakes region of Africa, where some 120,000 people have settled into IDP and refugee camps (Bolton 2007).
The needs of this vulnerable population must be addressed immediately, as the effects of traumatic events will likely continue into adulthood. In a study of 59 Cambodian adults, Hubbard et al (1995) found that 24% still showed clear symptoms of PTSD “a decade and a half removed from the horrors of the Pol Pot regime” (Hubbard 1995). Psychiatric disorders such as PTSD are detrimental to the normal development of children into young adults. But perhaps more concerning is the deterioration of reconciliation and peace-fostering among war-affected communities due to the prolonged prevalence of PTSD. According to Veenema et al (2002), several common reactions to trauma include “aggressive behavior” (for children ages 6-11 years), “reckless, risk-taking behavior,” and “wish for revenge” (for children ages 12-18) (Veenema 2002). A 2004 study by Pham et al revealed that a diagnosis of PTSD following war-related trauma was associated with limited support for reconciliation (Pham 2004). These findings suggest an immediate concern for treatment of PTSD symptoms in children who are living as refugees and IDPs. These children require effective and long-term treatment programs that will rebuild individual lives and foster peace in communities. For all of these reasons, public health interventions for refugee and IDP children diagnosed with PTSD due to war-related trauma must include elements of self-efficacy, self-determination, social support, cultural accommodation, sustainability, and should have the capacity for follow-up over time.

Designing Interventions: Two Suggested Theories
Before designing public health interventions, one must identify the causes and risk factors associated with the targeted health issue. For PTSD, the causes and risk factors can be confusing and confounded. In a letter responding to a study conducted by Bolton et al (2007), Dr. Metin Basoglu cautions researchers to focus treatment programs on the root of posttraumatic stress disorder. “Anxiety/fear,” maintains Basoglu, is the “causal process” behind PTSD (Basoglu 2007). This anxiety and fear could create a barrier to overcome at the very beginning stages of any intervention. Due to the common geographic and socioeconomic factors of most refugee populations, some of the confounding causes of psychiatric disorders among refugee children may also include “malnutrition,” “infectious disease,” “physical trauma,” “neglect,” “racism,” “harassment,” “identity conflicts,” and “failure to acculturate,” (Westermeyer 1991). These issues could further complicate intervention programming by causing relapse in treatment procedures. For example, the intervention design must address the basic needs of the patient (health, adequate food and shelter) before addressing underlying causes of PTSD (anxiety and fear due to ongoing racial and ethnic hatred, child abuse and neglect). Only after all of these factors have been resolved to a manageable measure, can the intervention focus on the actual issue of PTSD. Risk factors unique to children suffering from psychiatric disorders related to trauma and crisis “must be considered in order to design interventions likely to promote long-term mental health for different populations, at various times” (such as developmental stages (Veenema 2002)) “in the life cycle, and for groups with specific needs” (such as unaccompanied minors, resettled refugee children, and former child soldiers), (Willinsky 2002). In the following section, two theories of health behavior intervention are presented. Each theory offers distinct constructs that are beneficial to the long-term treatment of refugee children diagnosed with PTSD.

Social Cognitive Theory (SCT)
Social Cognitive Theory (SCT) takes into consideration multiple levels of intervention effectiveness. Specifically, the constructs of reciprocal determinism and environment/situation are helpful in designing appropriate intervention programs for this particular population. Refugee children do not fit one particular mold and their needs are very different depending on their country of origin, nature of traumatic experience(s), and their personal stage in human development. By taking into account aspects of their environment (both of origin and current situation, if different) health professionals are better equipped to affect behavior change. Culture and environment, as well as the particular experience of the patient, provides models for behavior that can be utilized for intervention purposes. SCT also focuses on self-efficacy, self-controlled performance, and managing emotional arousal. All three of these constructs are of tremendous importance to this at risk population. PTSD is a disorder of heightened emotional reactions. It is also a disorder that negatively affects feelings of self-efficacy and self-worth. These children must understand that their lives are not defined by the atrocities they have witness, nor are they a product of a “failed society.” Rather, after choosing to be a part of and to complete a treatment program, these children will have the opportunity to build a better life for themselves, their family, and their community. Social Cognitive Theory (SCT) stresses that, “while the environment largely determines or causes behavior, the person in turn can act in ways to change the environment” (Elder 1994). Changing their environment, to the extent they are able, may be the most effective way to promote continued and sustainable behavior change and treatment programs.

Theory of Reasoned Action/Theory of Planned Behavior
The first construct of Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB) involves instilling positive beliefs and outlooks in the attitudes of individuals. Refugee children, first and foremost, are looking for some reassurance that they will be “O.K.” and that their world has not been shattered forever. The second construct, subjective norms, focuses on social and peer group education. More often than not, refugee children are unaccompanied minors that have banded together, either as child-soldiers, asylum-seekers, in refugee camp youth groups, or resettlement programs. Willinsky et al (2002) offers several strategies for mental health promotion that follow the TRA/TRB models, including public policy changes, advocacy, “creating supportive environments,” promoting self-efficacy, and “strengthening community action,” (Willinsky 2002). Third, TPB addresses perceived behavioral control whereby intervention administrators can help to alleviate any structural or resource barriers the participant believes will hinder their ability to make behavior changes. When working with young children diagnosed with PTSD, one perceived barrier will be time. Administrators should not expect immediate changes and children should be given adequate time for the development of behavior modification. For indigenous interventions, barriers will include lack of resources, safe environments for the intervention and treatment program, and cultural issues, such as religion and language. Children who have survived “ethnic cleansing,” for example, will identify a perceived barrier if asked to work with a member of a different tribe or race. Fourth, behavioral intention is modified to instigate actual behavior. Administrators must not expect behavior change without establishing a clear understanding of what the change means and why the change is necessary. Children, especially, must have the desire and intent to change if they are to sustain the behavior change over their lifetime. Both TRA/TPB and SCT bring positive constructs to behavior change interventions. The following section will analyze the use of TRA/TPB and SCT in several recent case studies.

Analysis of SCT and TRA/TPB in Current Treatment Interventions
Cognitive-Behavioral Therapy (CBT)
Cognitive-behavioral therapy (CBT) is the most popular method of treatment for child refugees diagnosed with PTSD. However, the way in which CBT is administered as a public health intervention varies considerably across case studies. Cognitive behavioral treatments for PTSD due to war-related trauma have included “play, art, music therapy, and story telling” (Fazel 2002). Play-therapy follows the constructs of TRA/TPB by fostering positive beliefs in the patients prior to conducting sessions that delve deep into the psychiatric hardships of the patient. In addition, this form of intervention is often applied in a group atmosphere, providing peer and social support for behavior change. Finally, play-therapy includes the constructs of TRA/TPB that promote self-efficacy and intention modification. This attribute of play-therapy is crucial for this population of young people. Rather than hope or guess as to the sustainability of behavior modification, TRA/TPB constructs work to predict actual behavior change, making the promise of individual and community reconstruction a reality.


Exposure Therapy (ET) and Narrative Exposure Therapy (NET)
Exposure therapy, according to some studies, is the most effective form of CBT for the treatment of trauma survivors (Veenema 2002). KIDNET is a short-term, kid-friendly exposure therapy treatment for individual children diagnosed with PTSD (Onyut 2005). Before the intervention begins, a baseline is acquired by assessing patients for symptoms of PTSD. During the intervention, patients are asked to illustrate their life story using a rope (representing time), rocks (representing negative experiences), and flowers (representing positive experiences). Once the child has completed this task, he or she then proceeds to give an oral biography of their lives. The administrator writes down the story verbatim. In subsequent sessions, the administrator has the child read (or reads to the child) the biography from the session prior. If necessary, the child then makes any changes to the biography. At the final session, the child reads or hears their final draft of their biography and is asked to once again illustrate their life story. Any changes between the first and last session are made and the child is assessed for symptoms of PTSD. The case study conducted by Onyut et al in 2005 showed immediate improvements that were sustained at a nine-month follow-up. The success of this intervention can be attributed to the application of several SCT constructs. First, reinforcement, both from the administrator and from the child as he or she edits his or her biography, motivates behavior change in the participant. The intervention also uses self-efficacy to foster confidence in the participant’s ability to recall and retell their life story. Self-controlled performance and managing emotional arousal by confronting stressors and triggers affects behavior change as well. Although a study conducted in 2001 by Paunovic and Ost found no difference in treatment outcomes between exposure therapy (confrontation of “trauma-related images”) and cognitive-behavioral therapy (a “combination of exposure, cognitive therapy and controlled breathing”) (Paunovic 2001), KIDNET is clearly a viable intervention option that makes appropriate use of SCT constructs.
The Equilibrium and Developmental-Ecological Models
An early intervention model, The Equilibrium Model, focuses on stabilizing the affected individual before applying any sort of treatment. The goal is to assist the person in regaining enough psychological “equilibrium” to agree that life is worth living (James 2008). Thus, subsequent treatment measures will be better received. This is important when developing an intervention based on the TRA/TPB. One must “assess the effect of interventions on the beliefs targeted and on other components of the model” so as not to “negate the effect of the targeted belief,” (Montano 2002). The Developmental-Ecological Model acknowledges the developmental stage of the individual alongside environmental factors relating to the crisis situation (James 2008). This model is closely related to the SCT concept of reciprocal determinism.
Manual-Based Interventions
In a 2005 study of a school-based Cognitive-Behavioral Therapy (CBT) group intervention, Ehntholt, et al (2005) utilized the ‘Children and War: Teaching Recovery Techniques’ manual (Smith 2000). The study applied certain constructs of the TRA/TPB in an attempt to design an intervention for refugee children who had been resettled in the United Kingdom. The intervention addressed the participants’ attitudes toward the behaviors they were asked to adopt, but in an indirect way. For instance, children were asked to discuss war-related photos and images, thoughts, and dreams, but were not confronted about their beliefs regarding their future or future actions. Although the intervention was group-based, participants were not asked to discuss normative beliefs, or fears and anxieties about what other individuals in the group would think about their behavior. Because these children have experienced many of the same traumatic events, a change in behavior, even a positive change, may seem like a betrayal to the rest of the group. The redeeming quality of the case-study intervention was the application of the TRA/TPB construct of behavioral intention. At the end of the intervention program, participants were asked to discuss and write about the importance of enjoying one’s activities, and to draw pictures of ambitions and hopes for the future. By ending the intervention with the construct of behavioral intention, the children are more likely to actually perform the behavioral change. Unfortunately, because the other constructs of the TRA/TPB were lacking, the positive effects of the intervention program were not sustained after a two-month period (Ehntholt 2005).


Implications for Intervention

The treatment of refugee children diagnosed with war-related PTSD has gained world-wide attention in the past few years. More and more studies are examining the way in which interventions are conducted with respect to the unique needs of this population. Some studies advise immediate intervention, while others promote waiting until “a few months” after the traumatic event to administer treatment (Karam, Fayyad et al. 2008). Other studies focus on educating the children “about the symptoms of PTSD” rather than simply treating the symptoms without providing additional knowledge to the patient (Smith 2000). Several studies were successful in treating depression symptoms, but unsuccessful “in improving anxiety, conduct problems, or functioning” (Bolton 2007). This imbalance in outcomes may stem from a failure to apply enough constructs of either SCT or TRA/TPB to affect positive and lasting change in behavior. The imbalance may also be caused by an oversight regarding the root of PTSD in this particular population. Several rounds of interventions based on either SCT or TRA/TPB may be needed before the fundamental symptoms of PTSD can be treated. It is also beneficial to note that group-based interventions (Ehntholt 2005; Bolton 2007) were less effective over time than individually-based interventions (Paunovic 2001; Onyut 2005). This phenomenon may be due to the “herd mentality” of child refugees and their fear of straying from the group. Rather than risk being noticed for a change in behavior, these children may opt for a more camouflaged approach to survival, even if it means continuing to possess destructive behavior.
Self-efficacy, self-determination, and intention of behavior change are the three most important constructs in the development of effective interventions for this population. This global health issue is concerned, not simply with the treating of PTSD symptoms, but with healing the broken hearts of children orphaned and abused by situations of circumstance. No one, no matter how young or old, no matter where they are from, no matter creed, gender, or race should ever have to witness the atrocities these children have witnessed. It is the duty of the world’s public health professionals to find and test theories of behavioral intervention in order to give hope and a promise of a better life to these innocent, brave children.
















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