Mass disasters are a major challenge for child mental health care providers. Epidemiological studies have found epidemic rates of psychological disorders, particularly posttraumatic stress disorder (PTSD), in children who have been affected by war [1
], natural disaster [2
], and natural disaster and war combined [3
]. As most mass disasters strike low-income countries, and because emergency situations call for a variety of humanitarian aid beyond psychological interventions, resources for the provision of mental health assistance are usually very low despite the high need. Consequently, interventions have to be tailored to the context of mass disasters. In particular, they have to be pragmatic, short, and administrable by local professionals without lengthy training or academic education in psychological or medical fields. However, since research has shown that some trauma interventions can be ineffective or even harmful, especially in the acute phase after the traumatic event [5
], only psychological interventions with empirically verified efficacy should be applied during emergency situations.
Even though treatment outcome studies for traumatized children are still scarce compared to research on adult treatment [7
], some randomized trials in industrialized countries have identified effective approaches for the treatment of children. In particular, cognitive behavioral therapy (CBT) including trauma exposure techniques has proven to be effective for child victims of sexual abuse [8
] and other forms of violence [11
]. The findings of a study on the effectiveness of brief trauma/grief-focused psychotherapy that has been carried out after an earthquake in Armenia [13
] suggest that CBT-like methods can also be promising interventions in the context of mass disasters.
The goal of the present study was to test short-term treatments when applied by local counselors in the acute aftermath of a mass disaster, in a population already affected by prior conflicts and crisis. We chose Narrative Exposure Therapy (NET), a brief trauma-focused treatment approach developed to meet the needs of traumatized survivors of war and torture [14
]. In contrast to other exposure treatments for PTSD, the patient does not identify a single traumatic event as a target in therapy. Instead, NET constructs a narrative that covers the patient's entire life, while giving a detailed account of past traumatic experiences. The efficacy of NET with adults and adolescents affected by war and torture has been proven in randomized controlled trials [15
]. KIDNET, a version of NET adapted for the treatment of children [18
], has been tested in a pilot study in an Ugandan refugee camp with Somali refugee children diagnosed with PTSD [19
] with promising results.
As an active comparison protocol, we chose a treatment procedure that was applicable in the local context and available in the immediate aftermath of the Tsunami disaster in Sri Lanka. Meditation-relaxation techniques such as breathing exercise or mantra chanting represent exercises that are rooted in the Tamil (Hindu) culture and are well known to both children and local counselors. From a clinical point of view, some preliminary knowledge supports the feasibility of such a treatment protocol with traumatized populations. For example, meditation has been tried with Vietnam veterans [21
] and war-traumatized adolescents in Kosovo [22
]. Mindful meditation interventions have been suggested as a useful tool to decrease avoidance in traumatized patients [23
]. These techniques aim at 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.
The present study was carried out within the first months after the tsunami disaster in Sri Lanka. The flood wave had destroyed widespread coastal areas, especially in the east and the north of the country. In this time, the affected regions were still in an emergency condition. Officials estimated more than 30,000 causalities, and hundreds of thousands of inhabitants had to be relocated to refugee camps. In order to avoid epidemics, humanitarian assistance concentrated on providing food, water, and medical treatment. Nevertheless, the public media already reflected fears of psychological trauma, particularly among children. In fact, a study carried out by our workgroup three to four weeks after the disaster found high prevalence rates of PTSD especially in the North-Eastern coastal regions that have already been affected by two decades of civil war [4
]. In response to the high rates of traumatization in children and the urgent request of targeted mental health interventions, we decided to provide immediate treatments to the most affected area at the Northern tip of the country (Manadkadu) and to evaluate the efficacy of therapies within a randomized controlled trial. This was only possible because we could build on a school-based mental health structure for war-affected children that had been established before the Tsunami. Within this program, a group of Tamil teacher counselors had already been trained in KIDNET, as well as in a standardized meditation-relaxation protocol that had been developed by local mental health experts.
The design of the study was compromised by responding to ethical concerns raised in the communities as well as by aid organizations regarding research conducted in the acute phase following a mass disaster. Unfortunately, it was not possible to have a third group of children without active treatment as a waiting list condition to control for spontaneous symptom remission. Given the massive request for trauma interventions among the Tsunami victims, we were urged to offer immediate treatment for all children diagnosed with PTSD. In addition, it was unsure whether the children in the waiting list group could be relocated at follow-up to offer them treatment after the waiting period. Furthermore, by the time this study was carried out, the whole coast line of Sri Lanka's North East was destroyed and transportation and communication were extremely difficult. An extension of the study including more participants and camps would have requested human and financial resources as well as transport and logistical solutions that were not available in this specific situation.
We had to expect that the majority of the Tsunami affected children had already been victimized by the civil war or other traumatic events [4
]. In theory, a more complex traumatization involving multiple event types leads to a more severe pathology and may be more difficult to treat [18
]. Nevertheless, in face of the size of the disaster, we decided to limit treatment duration to six sessions, also to make sure that therapies could be completed before the expected relocation of children to more permanent shelters. Apart from this reason, interventions tailored to the context of mass disasters such as the Tsunami should be pragmatic and short to allow for a high number of affected individuals to be treated within a short time.
In conclusion, the aim of the present study was to examine, whether highly affected children with a preliminary diagnosis of PTSD would profit more from KIDNET or from a mediation-relaxation protocol. The main outcome measure was the PTSD symptom severity score. Problems in functioning and physical health symptoms were used as secondary outcome measures. By using trained teachers as therapists, we also wanted to test whether local counselors with a specific training in trauma therapy are able to apply psychological interventions such as KIDNET and meditation-relaxation in the immediate aftermath of a mass disaster.