Child Mass Trauma Interventions

Current Psychiatry Reports | Vol. 27, p. 112-126

Practice Elements Used in Child Mass Trauma Interventions: A Systematic Review

Betty Pfeferbaum; Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Boulevard, Oklahoma City 73104-0901, USA

Pascal Nitiéma; Department of Information Systems, W.P. Carey School of Business, Arizona State University, Tempe, USA

Elana Newman; Department of Psychology, The University of Tulsa, Tulsa, USA

Autumn Slaughter; Department of Psychology, The University of Tulsa, Tulsa, USA

Richard L. Van Horn; Price College of Business, University of Oklahoma, Norman, USA

Purpose of Review: The goals of this analysis were to identify practice elements frequently used in child mass trauma interventions and to determine if these elements difered across interventions with respect to type of event addressed.

Recent Findings: The most frequent elements used were psychoeducation for the child, afect modulation, relaxation, cognitive techniques, exposure, support networking, and narrative. The most frequently used elements were similar for political violence and natural disaster interventions but difered for COVID-19 interventions.

Summary: Similarities in elements used in political violence and natural disaster interventions refect the all-hazards approach to mass trauma response. Diferences for COVID-19 interventions may address distinctions between the pandemic and these events and underscore the importance of considering an expanded set of elements in future research. The fndings suggest that characteristics of the event as well as the population receiving the intervention and the context should guide the selection of interventions and intervention elements

Child; COVID-19; disaster; interventions; therapeutic elements; trauma

“Decades of research have established the vulnerability of children and adolescents… to political violence… natural disasters… and other mass trauma events.” Previous reviews identified core trauma-focused cognitive-behavioral therapy (CBT) components and “practice elements in 25 trials shown to be superior relative to a control on at least one outcome.” The current study aimed to “augment the prior reviews… by adding more recent research, including studies conducted in the context of the COVID-19 pandemic.” It sought to “identify the predominant practice elements included in randomized controlled trials (RCTs) of child mass trauma interventions and examine elements across event types” (p. 112-113).

“This review included 84 publications that described RCTs or cluster RCTs examining the effectiveness of 131 interventions in addressing the psychological effects of mass trauma on children aged 18 years or younger.” Interventions were coded using “the 2016 PracticeWise practice elements coding scheme,” adapted to include “82 elements,” with eight new categories added “to capture more fully the range of approaches used in child mass trauma interventions.” “Inter-rater agreement… was 0.69… and 0.74… demonstrating substantial agreement among raters” (p. 115-116). 

“The current analysis revealed the frequent use of a number of elements, including psychoeducation for the child, affect modulation, relaxation, cognitive techniques, exposure, support networking, and narrative. Reflecting a need for information about the event, common reactions, coping, and mass trauma services, psychoeducation for the child was the most frequently-used element” (p. 116).

“The finding in the current analysis that the same elements were among the ones used most frequently for political violence and natural disasters supports the all-hazards approach.” However, “except for psychoeducation (48.3%) and affect modulation (27.6%), the elements most frequently used in COVID-19 interventions… differed from those used in political violence and natural disaster interventions” (p. 116-117).

“Physical exercise and mindfulness were used more frequently in the COVID-19 interventions… [as] closure of schools… resulted in alterations in their overall physical activity, sedentary behavior, sleep… and diet” (p. 119). 

“Support networking was included so infrequently in COVID-19 interventions… possibly accounting for the infrequent use of this element in the COVID-19 interventions.”

“These differences… may address distinctions between the pandemic and the heretofore more commonly studied political violence and natural disaster events.” Therefore, “characteristics of the event as well as the population receiving the intervention… and the context… should guide the selection of interventions and intervention elements” (p. 120-121). 

• “The all-hazards approach to disaster response suggests that the same intervention elements can be used across all types of events” (p. 118).
• “The distinct findings in the COVID-19 interventions underscore the importance of considering an expanded set of practice elements and outcomes in future disaster response efforts and research with children” (p. 121).
• “Given the importance of education in children’s overall development and wellbeing… it is surprising that educational support was used rarely in interventions for COVID-19… but this simply may reflect the focus of this review on psychological rather [than] academic outcomes” (p. 119-120).
• “Mass trauma psychosocial interventions should be integrated in health and public health services, especially for children with clinical outcomes” (p. 119). 

“A number of limitations in the research and the current review warrant consideration. Perhaps the single most important limitation in the extant research is the failure of studies to precisely specify intervention elements in the evaluation process, thus precluding the assessment of specifc elements or the identifcation of the essential ingredient responsible for benefcial results. Given the large number of therapeutic elements in each coded intervention in the current analysis, it was impossible to identify the specifc elements responsible for the observed intervention efect. Hence, therapeutic efect sizes across elements could neither be computed nor examined. 

Some interventions were evaluated in more than one trial with diferent samples (See the Supplementary Material) (e.g., Early Adolescent Skills for Emotions in studies by Akhtar and colleagues, Brown and colleagues, Bryant and colleagues, and Jordans and colleagues) which may have given undue weight to the included practice elements. When administered by the same investigator team, this also may have introduced biases related to aspects of intervention delivery and research methodology. It is, nonetheless, a strength for interventions to be evaluated by diferent teams as was the case for several interventions included in the current analysis (e.g., Teaching Recovery Techniques in studies by Barron and colleagues, Ooi and colleagues, and Qouta and colleagues). Other methodological features not well addressed in the extant research are fdelity in administering interventions and attention to partial applications due to attrition in samples or to failure of some participants to receive all elements or the same dose of elements. Thus, in addition to defning, describing, and assessing the constituent practice elements in interventions and conducting dismantling research, future research should address fdelity, attrition, and partial applications” (p. 120).