Effective treatments for post-traumatic stress disorder (PTSD) in war-affected children
Pedagogical Sciences
University of Amsterdam
Name student: Tinka Jongejans
Student number: 10537600
Assessor: dhr. dr. E. Mulder
February 2016
Table of Contents
Abstract ... 3
Introduction ... 4
Method ... 7
Results ... 9
Cognitive behavioral therapy ... 10
Meditation therapy ... 13
Narrative exposure therapy ... 15
Eye movement desensitization and reprocessing ... 17
Discussion ... 18
References ... 23
Abstract
This systematic review investigated different types of treatment for war-affected children with post-traumatic stress disorder (PTSD). Databases searched are Web of Science (all years) and PsycINFO (all years). Only empirical studies that assessed the effectivity of narrative exposure therapy (NET), cognitive behavioral therapy (CBT), meditation therapy or eye movement desensitization and reprocessing (EMDR) were included. Fourteen studies (altogether 1285 participants) fulfilled the inclusion criteria. Nine studies found positive effect sizes, four studies did not calculate effect sizes of the treatment, and one study found a negative effect of their treatment (CBT). The results indicate that CBT and NET are effective treatments and EMDR and meditation therapy need more research to assess their effectivity. Future research should make a distinction between different categories of PTSD symptoms and different types of trauma.
Keywords: children, war-affected, post-traumatic stress disorder, narrative exposure therapy, cognitive behavioral therapy, meditation
Effective treatments for post-traumatic stress disorder (PTSD) in war-affected children Worldwide, over fifty million people are in flight (Unterhitzenberger et al., 2015).
Among these people are refugees from Syria. As a consequence of the war in Syria, about 15.000 refugees have come to the Netherlands in 2015, searching for a better life
(www.vluchtelingenwerk.nl). Many of these refugees are children. These children have the right to receive education within three days after arrival (Vasterman, 2015a). An important problem is that most of the teachers do not know how they should assist these children, who are often traumatized (Vasterman, 2015b). This leads to problems at school. For example teachers pay too much attention to the refugees and not enough to the other children. The best solution would probably be to treat the traumatized children. Treatment could take place during school in the class. This raises the question whether there is an effective treatment for traumatized children who are affected by war.
In this case, children who are affected by war refers to every child who has experienced or is a victim of war. This includes refugees and child soldiers. War-affected children are at a higher risk of developing psychological distress and psychiatric disorders (Ehntholt & Yule, 2006). An example of a psychiatric disorder that commonly occurs among these children is post-traumatic stress disorder (PTSD). PTSD can develop after experiencing a stressful or
catastrophic event or situation, such as war (Ehntholt & Yule, 2006) and is a form of anxiety disorder (Dalgleish et al., 2015). In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), PTSD is categorized within the Trauma- and stressor-related disorders. The most important characteristic of PTSD is that someone develops symptoms as a consequence of exposure to one or more traumatic events (American Psychiatric Association, 2013). These symptoms can be allocated to three categories: re-experiencing the trauma, avoiding the trauma
and hyper-arousal as a consequence of the trauma (Dalgleish et al., 2015). An example of re-experiencing the trauma is having nightmares. An example of avoiding trauma is social withdrawal and an anger outburst is an example of hyper-arousal.
PTSD can be treated with different kinds of treatments. Therefore, the research question of this systematic review is: which type of treatment is most effective for PTSD in war-affected children? Treatments that will be discussed in this review are: cognitive behavioral therapy, narrative exposure therapy, meditation therapy and eye movement desensitization and
reprocessing (Ehntholt & Yule, 2006; Catani et al., 2009). These four types of treatment are the most commonly used therapies for treating PTSD (Ehntholt & Yule, 2006; Catani et al., 2009). The treatments will be described below and the advantages and disadvantages will be discussed. The effectiveness of the different types of treatment will be based on the effect size of the treatment. The effect sizes reported in the literature itself will be used.
Cognitive behavioral therapy (CBT) is a combination of behavioral therapy and cognitive therapy. The main goal of cognitive therapy is cognitive restructuring (Bögels & Van Oppen, 2011) and the main goal of behavioral therapy is to change certain behavior (Van Deth, 2014). These therapies combined, CBT can change the thoughts and the behavior of a child suffering from PTSD. CBT for children with PTSD has multiple types of treatment, for example trauma-focused cognitive behavioral therapy (TF-CBT), preschool PTSD treatment (PPT) and youth readiness intervention (YRI). PPT is meant for preschool children from 4 to 6 years old (Puff & Renk, 2015). PPT is pretty similar to TF-CBT. A difference is that with PPT the parents are more involved than with CBT, and some exercises from CBT are simplified for PPT, because the CBT exercises are expected to be too difficult for young children. TF-CBT is an evidence-based treatment for child trauma (Mannarino, Cohen, Deblinger, Runyon, & Steer, 2012). TF-CBT
consists of three phases. The first one is skills-building, to enhance the child's self-regulation. The second phase is trauma narrative, in this phase children describe their personal trauma experiences and cognitively process them. The third phase is the treatment closure. YRI
combines aspects of CBT and interpersonal therapy (IPT). A disadvantage of TF-CBT is that the child and therapist have to talk directly about the children's traumatic experiences
(www.nctn.org), which can be difficult because it can be experienced as too confronting. Meditation therapy can be executed in different forms. For example, Catani et al. (2009) used meditation-relaxation techniques and Gordon, Staples, Blyta and Bytyqi (2004) used mind-body techniques. These mind-mind-body techniques included relaxation techniques, quiet and active meditations. The main goal of meditation therapy is "helping the client to increasingly focus the awareness on the present moment thereby increasing the ability to contact painful feelings, images and thoughts from the past without engaging in avoidance strategies" (Catani et al., p 23). A key factor in all meditation therapies is psycho-education in the first session, to explain what PTSD is and what the therapy will consist of (Van Deth, 2014). The meditation-relaxation techniques from Catani et al. consisted of different techniques, like inner peace meditation, muscle relaxation and inner light meditation. An important advantage is that therapists can carry out treatments including meditation-relaxation with a relatively short training (Catani et al.). This method is appropriate for teachers on schools with refugee children who can, after a short
training, integrate meditation-relaxation into the curriculum.
Narrative exposure therapy (NET) is based on testimony therapy and exposure therapy (Neuner et al., 2008). The central aspect in testimony therapy is the detailed documentation of the experiences the child has gone through. In the classical form of exposure therapy, the therapist and child talk repeatedly very detailed about the worst traumatic events the child has
experienced. This part is different in NET: NET does not only focus on the worst traumatic events, but on a child's whole life, from birth to present. The therapist and child talk through all experiences, with the emphasis on the traumatic ones (Neuner et al., 2008). In the first session, the child creates a lifeline of his or her life, with happy and bad experiences marked with
respectively flowers and stones. This lifeline will be captured by a drawing or picture and will be the basis for every following session. The child narrates his or her life, based on the lifeline. A disadvantage, but key factor of NET, is that the therapist cannot avoid his or her own strong emotions. This can be difficult for the therapist.
Eye movement desensitization and reprocessing (EMDR) is a recently developed treatment for PTSD (Van Deth, 2014). As the name already implies, EMDR is a therapy that uses eye movement. This is used because it can calm negative emotions (Chen, Zhang, Hu, & Liang, 2015). During EMDR the therapist moves his or her finger in front of the face of a child from right to left and back. The child follows the therapist's finger with his or her eyes. At the same time, the child thinks about traumatic memories which they wish to feel less negative about. After about a minute the therapist stops, and asks the child to describe all the feelings he experiences about the traumatic memory, in particular the negative feelings (Van Deth, 2014). This is repeated until the child does not experience negative feelings about a certain memory anymore. A disadvantage of EMDR is that it focuses on one traumatic event at the time. For children who have experienced multiple traumatic events it therefore can take long to treat them.
Method
Regarding the participants for this study, the first inclusion criterion was that all
participants had to be war-affected. This can mean that they have been a witness of war, but also that they have been child soldiers who participated in war. Any kind of war affectedness has
been taken into consideration. The second inclusion criterion was that the participating group had to show symptoms of PTSD or had to be diagnosed with PTSD. A diagnosis according to the DSM was not required because not many studies met this criterion, not everyone used the DSM to diagnose children with PTSD. The third inclusion criterion concerned the age of the
participants: the participants had to be children between the age of 5 and 18 years old. Studies that consisted of a broader range of age but still included the adolescence have also been taken into consideration.
All included studies had to assess the effectivity of a type of treatment for PTSD. Four types of treatment were distinguished. First of all: cognitive behavioral therapy (CBT). Any type of specific CBT has been included, for example trauma-focused CBT. Secondly, meditation therapy. Any type of meditational therapy has been included. The third type of treatment is eye movement desensitization and reprocessing (EMDR) and the fourth is narrative exposure therapy (NET). Specific types of NET adapted for children, like KIDNET, have been included as well.
Besides the type of treatment, another important factor to compare the results eventually was the outcome measure. For this systematic review, all studies have had to assess the
treatment(s) based on its effectivity. The effectivity has to be the effect size, calculated in the articles. Effect sizes which have been used are Cohen's d, Hedge's g and partial eta squared (ηp2).
Cohen's d and Hedge's g effect size are considered small if the value ranges from 0.20-0.49, medium if 0.50-0.79 and large if 0.8 or more (Cohen, 1988). When the ηp2 is used, an effect is
considered small if the value is 0.010, medium if 0.058 and large if 0.138 or more (Agresti & Franklin, 2012).
Databases that were used for the search are Web of Science (all years) and PsycINFO (all years). Only studies written in English have been included. To find studies that focused on
PTSD, terms used are: PTSD, "post traumatic stress disorder" and "post trauma* symptoms". Terms used for the types of treatment are: "cognitive behavioral therapy", "cognitive behavioural therapy", CBT, TF-CBT, "narrative exposure therapy", NET, "meditat* therapy", "eye
movement desensitization and reprocessing", and EMDR. Terms used to determine the
participants are: child*, adolescent, refugee, "child soldier", war-affected and "war affected". For the selection of the studies, the citation scores in Web of Science have been used. The criterion to include a study was that it had to be cited at least one time.
Eventually ten studies were found that met the criteria. Because this was not enough for a proper systematic review, the criterion with regard to the outcome measure has been adapted. Two other studies were found that met the other criteria, which did not calculate effect sizes. The authors from these articles did have a conclusion about the effectivity of the treatment, based on the decrease of symptoms. Furthermore, the criterion for citation scores seemed too strict. Leaving this criterion out resulted in fourteen studies in total. Preferably more studies would have been included in this systematic review, but research regarding the effectivity of treatments for PTSD in war-affected children is scarce. Because of the low number of studies, case studies and pilot studies have been included as well, despite its limitations. The total number of
participants in the fourteen studies found is 1285, from which 191 children received NET, 170 received meditation therapy, 13 children received EMDR and 942 received CBT.
Results
The literature that has been found will be ordered by type of treatment, starting with CBT, then meditation therapy, NET and finally EMDR. The Appendix contains a table with the authors, year of publication, number of participants, range of age from the participants, type of treatment, measurement, effect size and conclusion on effectiveness for each of the articles.
Cognitive behavioral therapy
Regarding research concerning CBT, two studies conducted by McMullen, O'Callaghan, Shannon, Black and Eakin (2013) and O'Callaghan, McMullen, Shannon, Rafferty and Black (2013) are almost similar. Both studies used a randomized controlled trial design and used the PTSD Reaction Index (PTSD RI) to measure PTSD symptoms, which is based on the criteria for PTSD, as described in the third edition of the DSM (DSM-III). Age ranges were almost the same as well, namely 12-17 years old (O'Callaghan et al.) and 13-17 years old (McMullen et al.). The most important difference between the studies was the gender of the participants. O'Callaghan et al. studied 52 war-affected Congolese girls and McMullen et al. studied 50 war-affected
Congolese boys. The war-affected girls had either witnessed or experienced sexual abuse, the war-affected boys were either former child soldiers or had witnessed at least one life threatening violent event. In both studies, the TF-CBT group showed significant decrease in posttraumatic stress symptoms (O'Callaghan et al.: F(1,49)=52.708, p<.001; McMullen et al.: F(1,45)=89.27, p<.001). The effect sizes of the TF-CBT were calculated with the ηp2. McMullen et al. found a
ηp2 of 0.665 and O'Callaghan et al. found a ηp2 of 0.518. These are both very large effects.
Therefore, these studies both concluded that TF-CBT is an effective treatment for war-affected children. However, both studies had some limitations. First of all, the instrument that was used to measure posttraumatic symptoms is a self-report, which could influence the results because of the different interpretations from children's feelings. Furthermore, the sample sizes were small and both studies were convenience samples. This reduces the external validity of the results.
The effectivity of TF-CBT was also studied by Murray et al. (2015). This study focused on 257 war-affected children (age: range from 5-18 years old) in Zambia. The instrument used was, again, the PTSD RI and the children were randomly assigned to TF-CBT or treatment as
usual (TAU). The TAU group received all sorts of treatment, except for specific NET elements. These treatments could consist of (TF-)CBT, EMDR and family therapy. In the results there is no distinction made between the different treatments within TAU. In the TF-CBT group, there was an 81.9% reduction of trauma symptoms, whereas the TAU group only showed a reduction of 21.1%. This difference between the groups was significant (p<.001). The effect size was calculated with Cohen's d and was 2.39. This result was maintained with the follow-up measurement, but a limitation of this study is that 47 children dropped out between the post-treatment and follow-up measurement. This makes the follow-up measurement less reliable.
A fourth study concerning TF-CBT was a case-study conducted by Unterhitzenberger et al. (2015). The children participating in this study were six unaccompanied refugee minors in Germany (age: range from 16-18 years old). This means that they were separated from their parents and were not being cared for by an adult who was responsible to do so. All children were refugee or asylum seeking and all of them received TF-CBT. To measure the symptom severity the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA) and the Posttraumatic Diagnostic Scale (PDS) were used. Four of the six children were diagnosed with the CAPS-CA and the others with the PDS. Between the groups the results differed. Both groups improved significantly on their PTSD symptoms (p<.001), but in the CAPS-CA group the symptoms were reduced by 73.4%, whereas the symptoms of the PDS group only reduced by 62.5%. This immediately shows a limitation of the study: the different instruments showed different results so it would be interesting to know the results from this study if the same instrument was used to measure the symptoms. This leads to another limitation: the very small sample. This makes the external validity low. Unterhitzenberger et al. (2015) did not calculate the effect size.
Besides TF-CBT, research also studied the effectivity of other CBT treatments, namely: Preschool PTSD Treatment (PTT), Youth Readiness Intervention (YRI) and Teaching Recovery Techniques (TRT). These studies will now be discussed. Puff and Renk (2015) evaluated the effectivity of PPT for a five year old boy in the Middle East. This boy met the criteria for PTSD according to the DSM-5. He received 24 sessions of PPT which led to reduction of his PTSD symptoms. However, the boy also suffered from other disorders, for example separation anxiety disorder, which makes it difficult to say whether the treatment was effective or not. Besides, Puff and Renk did not use a pre- and post-test measurement to measure the boy's symptom severity and therefore could not calculate the effect size, so to what extent the symptoms reduced cannot be concluded. Still, PPT seems a promising form of CBT.
Barron, Abdallah and Smith (2013) studied the effectivity of TRT. This treatment program consists of five sessions. The first till the fourth session are used to focus on
normalizing the trauma and strategies to cope with PTSD symptoms. The final session focuses on how children respond on their experiences. The study took place in Palestine during the war. Fourteen local school counselors were trained in TRT and were randomly assigned to a treatment group or waiting list control group. The severity of PTSD symptoms was measured with the Children's Revised Impact of Events Scale (CRIES-13). This measurement was filled in by about 400 children in 14 school classes, and from each class, the 10 students with the highest scores were invited to participate in the study, which resulted in a total group of 140 children (age: range from 11-14 years old). These children were randomly assigned to either the treatment group (n=90) or control group (n=50). When comparing the two groups at pre-test, it appeared that the treatment group had significantly higher scores on the CRIES-13 than the control group. To compare the groups at post-test, an analysis of covariance (ANCOVA) was used, controlling
for the differences at pre-test. The treatment group showed significantly more decrease in PTSD symptoms than the control group (p<.005). The effect sizes were calculated using Rosenthal's correlated-design effect size, to account for sample variances between groups. This resulted in a large effect size of 0.76. However, because of the higher pre-test scores from the treatment group, these results have to be interpreted with caution. Another limitation is that there were no follow-up measurements or longitudinal evaluations, so whether the results are sustainable over time cannot be said.
Finally, Betancourt et al. (2014) aimed to assess the effectivity of the YRI. The
participants were randomly assigned to either the YRI group or the control group (n=436, age: range from 15-24 years old). PTSD symptoms were, once again, measured with the PTSD RI. An outstanding result of this study is that the reduction of PTSD symptoms did not differ between the YRI group and the control group, it had an effect size of -0.02 (calculated with Cohen's d). The YRI did have a significantly more positive influence on children's emotion regulation, pro-social behaviors, functional impairment and social support. So from this study it cannot be concluded that YRI is an effective treatment for children with PTSD.
Meditation therapy
Regarding meditation therapy for treating PTSD few research has been conducted. Gordon et al. (2004) did a pilot study for using mind-body skills groups for high school students in Kosovo. These 139 students (age: range from 12-19 years old) were all affected by the war between Serbia and Albania in 1998. The students were divided in three groups, which all started their treatment at a different moment, with a three month time gap between the starting points. PTSD symptoms were measured before and after the treatment with the PTSD RI. Except for the before and after measurement, 77 participants also had a follow-up measurement (15-month
follow-up: n=30, 9-month follow-up: n=47). Among other components, the mind-body skills group program consisted of lectures on relaxation and meditation and the students also learned how to execute relaxation techniques and quiet and active meditations. Concerning the results of this study: all participants showed significant improvement in PTSD scores (p<.001). Only the 9-month follow up group showed significantly further improvement after nine 9-months (p<.001), the 15-month follow up group did not improve after fifteen months compared to the post-measurement. Using Cohen's d the effect sizes of the treatment were calculated in the three groups. The effect size of the first group was 0.6, of the second group 2.1 and the effect size of the third group was 2.4. The difference in effect sizes between the groups can be explained by the fact that the baseline levels of the groups differed. Furthermore, except for the effects of the mind-body skills themselves, social support, the opportunity for self expression and the caring commitment of a teacher may have contributed to the positive results as well. So to what extent the meditation therapy is the factor which caused the positive results is not known. Another limitation of the study is that it was a pilot study, so there was no control group.
A second study that examined the effectivity of meditation therapy is the one from Catani et al. (2009). They compared Narrative Exposure Therapy for children (KIDNET) and
meditation-relaxation as a treatment for children traumatized by war and tsunami. From 1983 till 2009 a civil war was going on in Sri Lanka and in 2004 a tsunami hit the country heavily. These events combined led to high rates of PTSD. In total, 31 children (age: range from 8-14 years old) participated in this study. They were randomly allocated to either KIDNET (n=16) or meditation relaxation (n=15). All children were diagnosed with PTSD. To measure the severity of the PTSD symptoms, the University of California at Los Angeles PTSD Index for DSM-IV (UPID) in interview form was used. This was assessed before, four to five weeks after (post-test) and six
months after the treatment (follow-up). Both therapies consisted of six sessions lasting 60 to 90 minutes and were carried out by local counselors. The results of the study show that the children significantly improved and showed less PTSD symptoms after one month and remained stable at the follow-up. The Cohen's d effect sizes for the KIDNET group were 1.76 at post-test and 1.96 at follow-up. The effect sizes for the meditation relaxation group were 1.83 at post-test and 2.20 at follow-up. These all indicate large effects. There was no significant difference between the two treatment groups and also no difference in the different categories of PTSD symptoms. However, in this study there was no control group and the number of participants was small. This makes it hard to conclude whether the results can be attributed to the treatment. Another
limitation is that the children experienced multiple traumatic events, namely a civil war and a tsunami. For that reason, based on this study it cannot be concluded whether KIDNET or meditation-relaxation is an effective treatment for PTSD after being affected by just war. Narrative exposure therapy
Another study, which used the same instrument to measure PTSD symptom severity, is done by Ruf et al. (2010). They examined the effectivity of KIDNET for children in Germany who left their native country as a consequence of war. These refugee children (n=26, age: range from 7-16 years old) had all been diagnosed with PTSD according to the DSM-IV. The children were randomly assigned to either the waiting list control group or the KIDNET-group. The UPID was translated into German and was administered in interview form. Again there was a pre-test, post-test and follow-up (6-month and 12-month follow up) so there were four measuring
moments. The children in the KIDNET-group were measured at all of these moments, the control group was only measured at the pre-test and 6-months follow-up. Eventually the KIDNET-group showed a significant decrease in symptoms whereas the control group did not (F(1, 24)=7.56,
p=.01). The Hedge's g was used to calculate the effect sizes. The effect size in the KIDNET-group was 1.9 and the effect size in the control KIDNET-group was 0.3. Regarding the different categories of symptoms, the KIDNET-group showed significant reduction of symptoms in all categories. The categories in this study were intrusions, avoidance and numbing, and hyper-arousal. The intrusions reduced the most and hyper-arousal the least. In the control group, only the intrusion symptoms reduced significantly. It can be said that KIDNET is an effective treatment for children with PTSD. However, a limitation of this study is the small sample size.
Neuner, Schauer, Klaschik, Karunakara and Elbert (2004) compared NET with
supportive counseling and psycho-education. The study was done with 43 refugees (age: range from 6-8 years old) from the war in Sudan that were living in a refugee settlement in Uganda during the study. The children were randomly assigned to NET, supportive counseling or psycho-education. The instrument used for measuring PTSD symptoms is the PTSD subscale of the Composite International Diagnostic Interview (CIDI), which is an interview performed by a therapist. A remarkable result of this study is that at the 4-month follow-up, all groups had worse scores than with the post-test (after the last treatment session). The researchers explain this result by the fact that in between the post-test and follow-up, the children had to leave the refugee settlement and had to go to places where they had experienced the traumatic events and in addition, the amount of food they received was reduced dramatically. However, at the one year follow-up, the NET-group scored significantly better on the measurements of PTSD symptoms and only 29% still had the diagnosis PTSD, while in the supportive counseling group and psycho-education group this percentage was respectively 79% and 80%. The effect sizes were: 1.9 for the NET group, 0.4 for the supportive counseling group and 0.3 for the psycho-education group. The authors do not describe in what way the effect sizes were calculated.
Onyut et al. (2005) conducted a pilot study to evaluate the intervention KIDNET. The participants were six Somali children (age: range from 12-17 years old) who stayed currently in a refugee settlement in Uganda. They received four to six sessions of KIDNET by expert
clinicians. The instrument used to measure PTSD symptoms was the CIDI. Overall, the mean score dropped from 14.3 (SD=1.9) to 6.2 (SD=3.3) from pre-test to follow-up. This meant a significant reduction (F(2,5)=15.45, p<.01) of their symptoms. Furthermore, four of the six children were no longer diagnosed with PTSD. Onyut et al. did not calculate the effect sizes of their treatment. Because it is a pilot study, the number of participants is very low. Another
limitation is that the treatment was carried out by trained experts. Whether the treatment will also be effective when carried out by local therapists cannot be said.
A fifth study, which tried to assess the effectivity of NET, was done by Ertl, Pfeiffer, Schauer, Elbert and Neuner (2011). A number of 85 former child soldiers (age: range from 12-25 years old) who were diagnosed with PTSD were randomly assigned to one of three groups: NET, an academic catch-up program with elements of supportive counseling or a waiting list control group. The Clinician Administered PTSD Scale was used to measure the PTSD symptoms. The PTSD symptoms in all groups reduced, but the effect size of the NET group was 1.80, while the effect sizes in the academic catch-up group and control group were respectively 0.83 and 0.81. A limitation of this study is that the number of participants was relatively low.
Eye movement desensitization and reprocessing
Regarding the effectivity of EMDR for war-affected children, very little research has been done. Only one study has been found that met the criteria, conducted by Oras, Cancela de Ezpeleta and Ahmad (2004). This study was carried out in Sweden, with children seeking refugee status who were coming from countries in war. An inclusion criterion was that the
children had to be diagnosed with PTSD, according to the fourth edition of the DSM (DSM-IV). Thirteen children were included in the study (age: range from 8-16 years old). The symptoms of PTSD were measured with the Posttraumatic Stress Symptom Scale for Children (PTSS-C). These measures were taken before and after the EMDR. For the children younger than 13 years old, the EMDR was combined with play therapy and for the other children the EMDR was combined with conversational therapy. Overall, the mean score of post-traumatic stress
symptoms decreased from 61.8 to 33.5 (z=-3.1, p<.01). When looking at the different categories of PTSD symptoms (re-experiencing, avoidance and hyper-arousal), the re-experiencing
symptoms decreased the most and the avoidance symptoms decreased the least.
In conclusion, although this concerns only one study on a small number of children, EMDR can be considered as an effective treatment for traumatized war-affected children. Oras et al. (2004) did not calculate an effect size but because this was the only study about EMDR, it was still included. An important limitation of this study is that there was no comparison with a control group, which means it cannot be stated for sure that the found effects are a result of the EMDR. A possible variable which could have influenced the PTSD symptoms of the children, is the presence of a permanent residence for the family. The children who did not have a permanent residence during the first and second assessment showed less improvement than the children who did not have a permanent residence during the first assessment, but did get one between the first and second assessment. So the presence of a permanent residence could have been a confounding variable. Another limitation is that the EMDR was combined with either conversational or play therapy. Whether the decrease of symptoms is a result of the EMDR or from the other therapies is not clear.
This systematic review was meant to give a clear view about what we know about effective treatments for war-affected children with PTSD. Four types of treatment were taken into consideration: cognitive behavioral therapy, narrative exposure therapy, meditation therapy and eye movement desensitization and reprocessing. In total, fourteen studies have been found which each focused on one (or two) of the four types of treatment. Four studies did not calculate effect sizes which makes them difficult to compare with the others. From the other ten studies the average effect sizes have been calculated for this systematic review, categorized by type of treatment. The average effect size of CBT is 0.86, the average effect size of NET is 1.8 and the average effect size of meditation therapy is 1.9. Based on these averages it can be suggested that meditation therapy is the most effective treatment for war-affected children with PTSD.
However, this should be interpreted with caution because the studies differed a lot and they all had some limitations. The studies within the types of treatment will now be discussed.
With regard to the studies focusing on meditation therapy, both studies did not have a control group so whether the results can be contributed to the meditation therapy cannot be said. Possible explanatory variables have been mentioned before, for example having the opportunity of self-expression. Another disadvantage is that the studies used different forms of meditation therapy. Moreover, the cause of the PTSD differed: the participants from Catani et al. (2009) were traumatized as a consequence of a civil war and tsunami in Sri Lanka, the participants from Gordon et al. (2004) were traumatized by the war between Serbia and Albania. These countries and causes are very dissimilar.
In total five studies focused on NET. Except for the fact that Onyut et al. (2005) did not calculate an effect size, the other effect sizes were calculated in three different ways. This makes it difficult to compare these values. At least, they ranged from 1.75 to 2.00, which suggests a
large effect in all studies. The five studies used different measurements but this does not seem to be associated with the difference in effect size. Another difference between the studies is the type of NET: KIDNET and regular NET were used. However, this also has not led to a difference in results. Furthermore, all studies about NET are pretty comparable. This may also be caused by the fact that the same researchers have conducted the studies (see References). Based on the five studies and the results it can be concluded that NET is an effective type of treatment for children with PTSD.
Regarding CBT the results vary more extensively. Different forms of CBT have been carried out and evaluated. Four studies evaluated TF-CBT. These all indicated a very large effect. The TF-CBT seemed to have a positive influence on the decrease of PTSD symptoms but in one study, different measurements led to different results. Therefore this study is not reliable. Other forms of CBT were PPT, TRT and YRI. The effectivity of PPT was not expressed in effect sizes. Puff and Renk (2015) stated the symptoms decreased but to what extent this decrease can be attributed to PPT cannot be said. TRT actually does seem an effective treatment: Barron et al. (2013) found a large effect size and there were no major limitations. YRI had a small and
negative effect size, so YRI can be considered as an ineffective treatment. With regard to PPT, TRT and YRI more research is required to conclude its effectivity.
Finally, with regard to EMDR, only one study has been conducted by Oras et al. (2004) and they did not calculate an effect size. However, the symptoms of the participants in this study did decrease significantly so EMDR seems a promising treatment. EMDR is a relatively recent intervention, which is probably the reason why so little research has been found.
In general, it can be concluded that more research is required to answer the question which type of treatment is the most effective. Especially EMDR and meditation therapy have to be studied more, but also for CBT and NET it can be valuable to do more research.
This systematic review has some limitations. When conducting more research it is important to take into account what consequences different measurements can have.
Unterhitzenberger et al. (2015) found different results when they measured the same children with different measurements. Future studies could all use different types of measurements to compare the measurements in one study, or every study should use the same measurement to make all studies more comparable. Another important factor regarding measurements is on which DSM it is based. In the studies that have been described, three versions of the DSM have been used (DSM-III, -IV and -5). Different DSM's have different criteria for the diagnosis PTSD, so it would be more reliable if everyone would use the DSM-5 to diagnose children with PTSD.
Another limitation of the studies described in this systematic review, is that the type of therapist differs between the studies. In some studies the treatment was given by local
counselors, while others used trained experts. For the development of PTSD treatments it is recommended to train local counselors to give the treatment to children. This is because eventually for example local counselors are more around in refugee settlements than trained experts, so mostly local counselors will be the ones carrying out the treatment. Furthermore, Miller, El-Masri, Allodt and Qouta (1999) have shown that different types of trauma have different influences on children. A checklist to check which types of trauma have been experienced is the Gaza Event Checklist (Thabet & Vostanis, 1999). In future research this checklist could be used to be able to make a distinction between different types of trauma, because different types of trauma may also need different types of treatment. Lastly, future
research should make a distinction between the categories of symptoms from PTSD
(re-experiencing the trauma, avoiding the trauma and hyper-arousal). Ruf et al. (2010) and Oras et al. (2004) found varying results when looking at the different categories. More research should make this distinction because maybe different categories of symptoms demand different types of treatment.
Returning to the main reason for writing this systematic review: not all teachers on schools know how to handle traumatized refugees. Treatments which have shown to be effective are TF-CBT and NET. Other forms of CBT, meditation therapy and EMDR need more research to make sure they are effective but also have already led to promising results. McMullen et al. (2013) showed that TF-CBT in a group is effective, so the refugees who now have come to the Netherlands and suffer from PTSD can receive TF-CBT with a group. This costs less money than individual treatment and is a good opportunity to give TF-CBT to a larger group. Teachers can be trained to give the treatment and otherwise therapists can come to school to carry out the treatment.
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Appendix: Characteristics of included studies Table 1
Characteristics of Included Studies
Authors (year) Number of participants
Age range Type of treatment Measurement Effect size Conclusion
Oras et al. (2004) N=13 8-16 years EMDR PTSS-C Not calculated Promising results
Gordon et al. (2004)
N=139 12-19 years Mind-body skills groups
PTSD RI Group 1: 0.60a Group 2: 2.10a Group 3: 2.40a
Effective
Catani et al. (2009) N=31 8-14 years Meditation relaxation and KIDNET
UPID Meditation relaxation: at post-test: 1.83a, at follow-up: 2.20a
KIDNET: at post-test: 1.76a, at follow-up: 1.96a
Effective
Ruf et al. (2010) N=26 7-16 years KIDNET UPID KIDNET: 1.90b
Waiting list: 0.30b
Neuner et al. (2004)
N=43 6-8 years NET, supportive counseling and psycho-education CIDI NET: 1.90e Supportive counseling: 0.40e Psycho-education: 0.30e Effective
Onyut et al. (2005) N=6 12-17 years KIDNET CIDI Not calculated Promising results
Ertl et al. (2011) N=85 12-25 years NET and academic catch-up
CAPS NET: 1.80a
Academic catch up: 0.83a
Effective McMullen et al. (2013) N=50 13-17 years TF-CBT PTSD RI 0.67d Effective O'Callaghan et al. (2013) N=52 12-17 years TF-CBT PTSD RI 0.52d Effective Murray et al. (2015) N=257 5-18 years TF-CBT PTSD RI 2.39a Effective
Unterhitzenberger et al. (2015)
N=6 16-18 years TF-CBT CAPS-CA and PDS Not calculated Hard to tell
Puff & Renk (2015)
N=1 5 years PPT - - Promising results
Barron et al. (2013) N=140 11-14 years TRT CRIES-13 0.76c Effective
Betancourt et al. (2014)
N=436 15-24 years YRI PTSD RI -0.02a Not effective
Note. EMDR = eye movement desensitization and reprocessing; (KID)NET = narrative exposure therapy (for children); TF-CBT = trauma-focused cognitive behavioral therapy; PPT = preschool PTSD treatment; PTSD = post-traumatic stress disorder; TRT = teaching recovery techniques; YRI = youth readiness intervention; PTSS-C = Posttraumatic Stress Symptom Scale for Children; PTSD RI = PTSD Reaction Index; UPID = University of California at Los Angeles PTSD Index for DSM-IV; CIDI = Composite International Diagnostic Interview; CAPS(-CA) = Clinician Administered PTSD Scale (for Children and Adolescents); PDS = Posttraumatic Diagnostic Scale; CRIES-13 = Children's Revised Impact of Events Scale
a
Cohen's d.
b
Hedge's g.
c
Rosenthal's correlated-design effect size.
dη p2. e
