سوگ و داغداری و مداخله تروما برای کودکان پس از فاجعه: بررسی مهارت های مقابله با تروما در برابر روایت تروما

Abstract This study evaluated the differential effects of the Grief and Trauma Intervention (GTI) with coping skills and trauma narrative processing (CN) and coping skills only (C). Seventy African American children (6–12 years old) were randomly assigned to GTI-CN or GTI-C. Both treatments consisted of a manualized 11-session intervention and a parent meeting. Measures of trauma exposure, posttraumatic stress symptoms, depression, traumatic grief, global distress, social support, and parent reported behavioral problems were administered at pre, post, 3 and 12 months post intervention. In general, children in both treatment groups demonstrated significant improvements in distress related symptoms and social support, which, with the exception of externalizing symptoms for GTI-C, were maintained up to 12 months post intervention. Results suggest that building coping skills without the structured trauma narrative may be a viable intervention to achieve symptom relief in children experiencing trauma-related distress. However, it may be that highly distressed children experience more symptom relief with coping skills plus narrative processing than with coping skills alone. More research on the differential effects of coping skills and trauma narration on child distress and adaptive functioning outcomes is needed.

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Results Descriptive analyses Table 2 presents children’s reports about exposure to Hurricanes Katrina and Gustav. All of the children endorsed some type of exposure to each hurricane. Sixty seven children (95.7%) reported that they had had someone close to them die (n = 35 GTI-CN; n = 32 GTI-C) (see Table 1). The majority of the children reported seeing someone get beat up (84.3%) and hearing gunshots (77.1%). In addition, 40% reported having seen someone get shot, 31.4% reported having seen a dead body outside or in their house, 18.6% reported having seen somebody get stabbed, and 7.1% having seen somebody in their home shot or stabbed. For the majority of these children, exposure to community violence (ECV) was chronic. For example, 51.5% reported exposure to three or more different types of violent events. Further, 95.71% of the children reported experiencing exposure to Hurricanes Katrina and Gustav, community violence, and having someone close die. While the vast majority had been exposed to several types of events, the index traumas identified by the children were as follows: 40 (57%) death, 14 (20%) hurricane, 13 (19%) violence and 3 (4%) other loss or illness. Primary outcome There was a significant main effect of time on PTSD scores (F(3,186) = 36.78, p < .001), indicating that the entire sample showed a change in PTSD scores over time. Post-hoc analyses indicated significant decreases from pre-treatment to post-treatment (t(63) = 6.64, p < .001, d = 1.11), to 3 month (t(63) = 7.00, p < .001, d = 1.22), and to 12 month follow-up (t(63) = 9.35, p < .001, d = 1.68) suggesting that initial improvements were maintained over time. The interaction between time and treatment condition was not significant. Based on the reliable change index (RCI), there was reliable symptom improvement for both groups; in the GTI-CN condition, from pre-treatment to 12 month follow-up, 70.59% (n = 24) of children improved and 2.94% (n = 1) deteriorated and in the GTI-C condition, 60% (n = 18) improved and 3.33% (n = 1) deteriorated. Chi-square test did not indicate a significant association between condition and improvement status. Consistent with these findings, 88.89% of children in the GTI-CN condition no longer reported clinically significant PTSD symptoms (e.g. a score of 38 or higher on the UCLA-PTSD Index) at 12 month follow-up (p < .001; 18 children were above the cutoff score at pre-treatment, whereas only 2 children were above the cutoff score at follow-up). In the GTI-C condition, 76.92% of children no longer reported clinically significant PTSD symptoms at 12 month follow-up (p < .016; 13 children were above the cutoff score at pre-treatment, whereas only 3 children were above the cutoff score at follow-up). Secondary outcomes There was a significant main effect of time on mean depression scores (F(3,186) = 30.83, p < .001). Follow-up analyses indicated significant decreases from pre- to post-treatment (t(63) = 6.11, p = <.001, d = .96), to 3 month (t(63) = 5.81, p < .001, d = .86) and to 12 month follow-up (t(63) = 8.12, p < .001, d = 1.26), suggesting that initial improvements were maintained over time. There was not a significant time × treatment interaction for depression. The RCI indicated reliable symptom improvement; from pre-treatment to 12 month follow-up, 52.9% (n = 18) improved and 0% deteriorated in GTI-CN and 43.33% (n = 13) improved in GTI-C and 3.33% (n = 1) deteriorated. Chi-square test did not indicate a significant association between condition and improvement status. Significant proportions of children moved outside of the clinical range (e.g. a score of 29 or higher on the MFQ-C) from pre-intervention to 12 month follow-up: for GTI-CN there was a 100% decrease in the number of children who no longer were in the clinical range (p < .001; 17 children were above the clinical cutoff score at pre-intervention, whereas at follow-up there were no children scoring in the clinical range) and for GTI-C there was a 77.77% decrease in the number of children who no longer were in the clinical range (p < .008; 9 children were above the clinical cutoff score at pre-intervention, whereas at follow-up only 2 children were above the clinical cutoff score). There was a significant main effect of time on traumatic grief scores (F(3,1177) = 34.48, p < .001). Post-hoc analyses revealed a significant decrease from pre-treatment to post-treatment (t(60) = 6.11, p = <.001, d = .84), to 3 month (t(60) = 7.12, p < .001, d = .92), and to 12 month follow-up (t(60) = 8.38, p < .001, d = 1.23), suggesting that initial improvements were maintained over time. There was not a significant time × treatment interaction for traumatic grief. From pre-treatment to 12 month follow-up, 68.75% (n = 22) demonstrated reliable symptom improvement and 0% deteriorated in GTI-CN and 55.17% (n = 16) demonstrated reliable symptom improvement in GTI-C and 3.45% (n = 1) deteriorated. Chi-square test did not indicate a significant association between condition and improvement status. Consistent with the findings from standardized measures, there was also a significant decrease in mean global distress ratings over time (F(3,183) = 18.66, p < .001). Post-hoc analyses revealed a significant decrease from pre-treatment to post-treatment (t(62) = 3.85, p = <.001, d = .71), to 3 month (t(62) = 5.58, p < .001, d = 1.04) and to 12 month follow-up (t(62) = 6.71, p < .001, d = 1.13), suggesting initial improvements were maintained over time. There was not a significant time × treatment interaction for distress scores. There was a significant main effect for time for perceived social support (F(3,186) = 3.28, p = .022) and this main effect was not qualified by a significant group × time interaction. Post-hoc analyses indicated there was not a significant increase in perceived social support from pre- to post-treatment (t(63) = −1.03, p > .05, d = .13), but there was a non-significant trend toward an increase in perceived social support from pre- to 3 month (t(63) = −2.55, p = .006, d = .38) and 12 month follow-up (t(63) = −2.67, p = .005, d = .33). Parent reports indicated that internalizing symptoms (F(2,94) = 4.46, p = .015) changed over time for both treatment conditions, but externalizing symptoms did not. Post-hoc analyses indicated there was a significant decrease from pre-test to 3 month follow-up for internalizing symptoms (t(48) = 1.93, p = .03, d = .26) and from pre-test to 12 month follow-up, (t(48) = 3.00, p = .002, d = .45). Reliable symptom improvement for internalizing symptoms from pre-test to 12 month follow-up was observed in 17.86% (n = 4) of children in GTI-CN and 0% deteriorated. In GTI-C, there was reliable improvement from pre-test to 12 month follow-up in 14.29% (n = 3) of children and 4.76% (n = 1) deteriorated. Fischer’s Exact test did not indicate a significant association between condition and improvement status. The total percentage decrease in internalizing symptoms for children within the clinical range (e.g. a T-score above 63) from pre-test to 12 month follow-up was 75% (p = .035; 8 children were above the clinical cutoff score at pre-intervention, whereas at follow-up only 2 children were above the clinical cutoff score) for GTI-CN versus 0% (p = ns; there were 4 children above the clinical cutoff score at pre-intervention and at follow-up) for GTI-C. Intent-to-treat analysis and developmental status A similar pattern of findings was found with the intent-to-treat analyses indicating significant main effects for time for all dependent variables except for externalizing symptoms. For externalizing symptoms there was a time × treatment interaction, F(2,108) = 3.81, p = .026. Post-hoc comparisons indicate a trend toward significance from pre-test to 12 month follow-up for GTI-CN (t = 2.22, df = 28, p = .044) with means indicating that parents in GTI-CN reported more decrease in externalizing symptoms than parents in GTI-C. There were no differences in dependent variables over time between younger children and older children. Treatment satisfaction and child treatment fidelity ratings For the indicator of treatment satisfaction, “I learned more about grief and trauma reactions,” there were no differences between conditions at post-treatment. Both groups reported that they learned “a lot” about grief and trauma, (M = 3.15, SD = 1.07, M = 3.23, SD = 1.19, GTI-CN, GTI-C, respectively). For the indicator, “I expressed my thoughts and feelings about what happened,” there was a significant difference between the conditions (t(62) = 2.27, p = .014). As expected, participants in GTI-CN reported that they expressed more thoughts and feelings (M = 3.38, SD = .85) than GTI-C participants (M = 2.77, SD = 1.25). These results lend support to the integrity of the two conditions being delivered as intended with the participants in GTI-CN processing thoughts and feelings more than the participants in GTI-C. For the indicator, “I learned ways to cope when I feel upset, sad, angry, and/or stressed,” there was a trend toward a significant difference between the conditions (t(62) = 1658, p = .052), with participants in GTI-C reporting that they learned more ways to cope with emotional distress (M = 3.30, SD = .95) than the participants in GTI-CN (M = 2.85, SD = 1.18). This finding further supports the integrity of the interventions being delivered as intended since GTI-C received more coping skills sessions than GTI-CN. For the item, “Overall, how helpful was counseling for you?”, there was no difference between conditions on rated helpfulness (t(62) = 1.02, p > .05). Children in both conditions reported that the therapy was “a lot” to “a whole lot” helpful (M = 3.71, SD = .46, M = 3.60, SD = .63, GTI-CN and GTI-C, respectively).