Communities affected by disasters often face multiple challenges and child mental health treatment resources may be particularly limited. Typically, affected communities do not have enough therapists trained in evidence-based treatments (EBT) to be able to provide every child with individual therapy. Thus, it is usually necessary to triage children according to severity of need, with the most intensive services being provided to the most severely affected children and less impaired children receiving less intensive services (e.g., group therapy). While some efforts have been made along these lines in postdisaster settings to demonstrate feasibility of the approach (e.g., CATS Consortium, 2007), there remain little data to guide the decisions about who should be offered which types of services. In addition, there are no data to inform intervention-providers about what services are desired, feasible, or acceptable to those affected by disaster.

The current project attempted to gather additional information to inform postdisaster mental health efforts for children. Specifically, we aimed to identify students with elevated symptoms of distress in the form of PTSD symptoms. We conducted a field trial to observe the impact of two trauma-specific interventions as delivered under real-world conditions, with the goal of examining predictors of how students fared in each intervention, in order to inform future efforts at allocation of resources following disaster. The project was conducted within Project Fleur-de-lis (Cohen et al., 2009), a program run by Mercy Family Center to provide a tiered system of trauma intervention including two evidence-based interventions: Cognitive-Behavioral Intervention for Trauma in Schools (CBITS; Jaycox, 2003) and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006).

Specifically, the project aimed to identify students with elevated symptoms, offer them either TF-CBT or CBITS, and observe how students fared in each intervention according to their risk and resilience factors, including symptoms of PTSD and depression, social support from friends and family, and their exposures to the hurricanes and to other lifetime traumas. We included measures of social support due to their relationship with treatment outcome in earlier studies of TF-CBT (Cohen & Mannarino, 1998 & 2000), and measures of trauma exposure due to their hypothesized salience in recovery from PTSD following disaster. In order to have roughly comparable groups in each of the two intervention arms, we randomized students to be offered one of the two interventions, and monitored their use of services and how they fared during the field trial. We expected that students who took part in each intervention would improve in symptoms, based on earlier demonstration of effects of the interventions (e.g., Stein et al., 2003; Cohen, Deblinger, Mannarino & Steer, 2004), that students with additional trauma exposure would show more modest improvement, and that those with social support would show more robust improvement.

Students in the study reported a median of one type of hurricane exposure (range 0–7). As seen in Table 2, the most common experiences were having seen something very upsetting or being separated from parent or caregiver. Rates of being trapped, rescued, or stranded in New Orleans were much lower, around 5%.

Lifetime trauma exposure was common, with students reporting a median of 4 traumatic events (range 0–10) at the baseline assessment. As seen in Table 2, the most common traumatic events reported were vicarious traumas (learning about the death or injury of a loved one, witnessing violence) but personal exposures to trauma (car accident, victim of violence, medical procedure) were also common. At the 10-month assessment, students reported on exposure to traumatic events since the last assessment. During this time, students reported a median of 3 additional recent traumatic exposures (range 0–8; mean 3.3, SD = 2.1).

Mean scores for PTSD, depression, and behavior problems are shown in Table 3. With regard to PTSD symptoms, all had scores of 12 or higher by definition, with 82.2% in the clinically significant range (scores of 15 or higher). For depression, 52.5% of students reported clinically significant symptoms (scores of 13 or more on the Children’s Depression Inventory). Teachers reported behavior problems indicative of the “borderline” range (a score of 12–15) for 11.9% of students and problems in the “abnormal” range (a score of 16 or above) for 15.3% of students. The two groups of children were comparable to one another, as shown in Table 3, as intended following the randomization procedure.

Of children randomized to be offered CBITS in schools, 57/58 (98%) began treatment, and 53 (91%) completed treatment. For children randomized to be offered TF-CBT at Mercy Family Center, therapists began calling parents immediately after randomization to schedule the intake, including confirming PTSD. Twenty-two of the 60 (37%) attended the initial assessment, which occurred weeks to months after the baseline assessment. Of this number, seven (32%) did not meet PTSD criteria on the K-SADS and were not provided with TF-CBT treatment, most commonly because distress was not linked to a specific traumatic event. Instead, these children were offered a different form of therapy within Mercy Family Center. Another child had a pervasive developmental disorder that precluded inclusion in the study. Thus, 14 (23%) began TF-CBT, and 9 (15%) completed treatment by the time of the 10-month follow up (4 dropped out of treatment, and 1 began late and had not completed treatment; See Figure 1). These rates of uptake varied by school: in School 1, 9 of 9 students began CBITS and 2 of 7 attended the TF-CBT intake appointment, in School 2, 28 of 28 began CBITS and 17 of 29 attended the TF-CBT intake, and in School 3, 20 of 21 began CBITS and 3 of 24 attended the TF-CBT intake.

As seen in Table 4, PTSD scores at 10 months improved in both interventions including all students that began treatment, as compared to baseline scores. Mean PTSD scores for the TF-CBT group had moved to the normal range while mean scores in the CBITS group were in the low clinical range. Sixty-five per cent of the children (37/57) in the CBITS group remained in the “at-risk” range (≥ 12) on the Child PTSD Symptom Scale at the 10-month follow-up, whereas 43% (6/14) of the children who received TF-CBT remained at-risk. A Fisher’s Exact test revealed these two rates of clinical change were comparable across the two groups (2-tailed p-value = 0.22). According to the KSADS, only 1/9 (11%) children completing TF-CBT treatment met criteria for PTSD at the end of treatment. Changes in depressive symptoms also improved for both groups, but this improvement was only statistically significant for the CBITS group. Mean depression scores moved to the normal range for both groups. Thus both statistically and clinically significant gains were achieved by students in both interventions.

Since few children took part in TF-CBT, we could not evaluate predictors of treatment response. Instead, we examined predictors of attending the intake for TF-CBT (see Table 5). Baseline trauma exposure, severity of symptoms, and social support were not predictive of attending the intake. Boys and younger children had higher odds of attending the intake appointment. African American students had lower odds than Caucasian students, as also reflected in the higher odds of students in School 2 (with a largely Caucasian student body) attending the appointment. Rates of attendance also differed by distance between home and clinic. School, race/ethnicity, and distance were confounded (with students at School 3 living the shortest distances and students at School 1 the longest), but school and race were too highly confounded in the TF-CBT group to examine separately. When school as well as distance were used in the same regression, school remained a significant predictor of attendance, Wald’s χ² (2) = 7.38, p < .05, while distance did not, Wald’s χ² (1) = 2.22, ns.

Of note were the high rates of previous lifetime trauma exposure, in addition to hurricane exposure, that were present among these students with elevated PTSD symptoms. This finding has both clinical and policy implications. Clinically, therapists who serve children affected by disasters should be aware of the impact of previous trauma on children’s mental health functioning. Disaster exposure can trigger past trauma memories, which for individual children may have been much more traumatic than the disaster itself. Alternatively, earlier trauma may increase vulnerability to a new traumatic event such as a disaster. This was reported by children after the September 11^th terrorist attacks (Mullett-Hume et al., 2008) and was again seen after Hurricane Katrina (Salloum et al., in press). Thus, assessment of previous traumas as well as the specific disaster exposures is needed to fully evaluate PTSD and other mental health impact of trauma in children’s lives.

Results indicate that both treatments led to significant improvement in PTSD symptoms, but CBITS was far more accessible to families who may not have been willing or able to participate in individual, clinic-based treatment that required parental participation and initiative to attend appointments outside of the child’s regular school attendance. It is notable that despite starting with significant adversity, including exposure to traumatic events during the intervention period, these non-treatment seeking children experienced significant gains. Since there was no control group, however, it is difficult to gauge whether students symptoms may have improved without treatment. We expect that symptoms would be relatively stable during the period of 15 months to 24 months postdisaster, but there are no empirical data to guide this conjecture.

This project found that most families did not access therapy at community clinic settings but did access similar services through their children’s schools. In fact, some families asked whether they could receive the TF-CBT at school instead of the clinic, suggesting that co-locating all mental health treatment services in or adjacent to children’s schools is desirable postdisaster. Families who attended the clinic intake were not reporting more severe problems, in contrast to other community-based findings (e.g., Leaf et al., 1996). Rather, demographics (age, race, and gender) as well as school and distance to the clinic predicted attendance. Families with younger, male, Caucasian students at certain schools were more likely to be able to access care. Since school and race/ethnicity were so highly confounded in this study, it was not possible to tease apart the contributions of school culture and community from race/ethnicity of the student, and this remains an important question for future research.

We encountered two important measurement issues in this project. If the results of the K-SADS-PL are representative, approximately one third of these children who were identified as “at-risk: may have been reporting general distress symptoms or another mental health problem rather than specific PTSD symptoms, since the most common reason for not meeting criteria for PTSD was that their distress symptoms were not linked to a specific traumatic event. Thus, the measures used for screening may be overly general for a trauma-focused intervention. Importantly, teachers reported lower rates of child problems than did the children themselves, as often observed in studies of anxiety (e.g., Collishaw, Goodman, Ford, Rabe-Hesketh, & Pickles, 2009). Although schools can be an ideal setting for meeting the mental health needs of children after disasters, teachers may not be ideally positioned to judge which children need these services.

There were several important limitations to note in this study, as seems to be the rule rather than an exception in postdisaster research. First, recruitment proved more difficult than anticipated, resulting in a smaller field trial and limited ability to utilize complex regression models. Although these types of consent rates are common in other school-based studies in inner city settings (e.g, Stein et al., 2003), we had expected recruitment at these smaller parochial schools, all attuned to the recent hurricane exposures, would be more productive. Thus, we conducted several different analyses to explore relationships, inflating the possibility of Type 1 error. Second, the results reported here on access to care were unanticipated, and thus the analysis had to shift from the original aims of examining predictors of intervention response to predictors of uptake of the therapy for TF-CBT. As an unexpected finding, we had not measured the full array of factors that would be desired for this analysis. Our choice to randomize children to one of the two intervention arms proved to be fortuitous, however, since it allowed a fair examination of access and uptake of intervention services across equivalent groups. In addition, we maintained the two interventions as they are normally delivered, rather than trying to make them more equivalent to one another, including the extra intake assessment in the group assigned to TF-CBT. Thus, the validity of the results was not threatened and the study can provide valuable information for future mental health efforts following disaster.