Narrative Exposure Therapy as a treatment for child war survivors with posttraumatic stress disorder: Two case reports and a pilot study in an African refugee settlement

Lamaro P Onyut 0 1 2 Frank Neuner 0 2 Elisabeth Schauer 0 2 Verena Ertl 0 Michael Odenwald 0 2 Maggie Schauer 0 2 Thomas Elbert 0 2 0 University of Konstanz, Centre for Psychiatry Reichenau , Haus 22, Feursteinstr. 55, D-78479 Reichenau-Lindenbuhl , Germany 1 Mbarara University of Science and Technology , Mbarara , Uganda 2 vivo Uganda , Mbarara , Uganda Background: Little data exists on the effectiveness of psychological interventions for children with posttraumatic stress disorder (PTSD) that has resulted from exposure to war or conflictrelated violence, especially in non-industrialized countries. We created and evaluated the efficacy of KIDNET, a child-friendly version of Narrative Exposure Therapy (NET), as a short-term treatment for children. Methods: Six Somali children suffering from PTSD aged 12-17 years resident in a refugee settlement in Uganda were treated with four to six individual sessions of KIDNET by expert clinicians. Symptoms of PTSD and depression were assessed pre-treatment, post-treatment and at nine months follow-up using the CIDI Sections K and E. Results: Important symptom reduction was evident immediately after treatment and treatment outcomes were sustained at the 9-month follow-up. All patients completed therapy, reported functioning gains and could be helped to reconstruct their traumatic experiences into a narrative with the use of illustrative material. Conclusions: NET may be safe and effective to treat children with war related PTSD in the setting of refugee settlements in developing countries. - Background In the wars and armed conflicts of the past decades, children have been among the survivors who have been exposed to war or conflict-related violence. The United Nations High Commissioner for Refugees (UNHCR) recently stated that 43% of its population of concern are children under the age of 18 [1]. Mental health experts are also becoming more aware that war and conflict-related event types are among those that may result in children developing disorders of the stress spectrum, including posttraumatic stress disorder (PTSD) [2-5]. An increasingly important field of research addresses the wide-ranging negative sequelae that children and adolescents in modern post-conflict populations such as in Iraq, Kuwait, Bosnia, Rwanda, Croatia, South Africa and others may develop consequent to war and conflict violence [6-17]. Current research emphasis is now more than ever being placed on developing appropriate interventions that address the needs of survivors experiencing a range of symptoms after trauma exposure [18-29]. Given the pervasiveness of war and conflict-related trauma, especially in resource poor countries, interventions tailored to suit the circumstances of the overwhelming number of such survivors are especially in demand. However, treatment outcome studies in this field are still few. Many such interventions are derived from interventions initially developed for adults, such as cognitive behavioural therapy. Cognitive-behavioural interventions have been successfully used with school children exposed to violence, after single-incident stressors, after natural disasters as well as to treat sexually abused children [18,30-33]. Other interventions currently in use with children include psycho-pharmacological treatments, play therapy, psychological debriefing and testimony therapy [17,20,23,26,34-39]. It is notable that most approaches have not yet been tested within post-conflict populations of children and adolescents living in non-industrialized countries. Narrative Exposure Therapy (NET) is a treatment approach that was developed for the treatment of PTSD resulting from organized violence. vivo developed Narrative Exposure Therapy as a standardized short-term approach based on the principles of cognitive behavioural exposure therapy by adapting the classical form of exposure therapy to meet the needs of traumatized survivors of war and torture [40-42]. In exposure therapy, the patient is requested to repeatedly talk about the worst traumatic event in detail while re-experiencing all emotions associated with the event. In the process, the majority of patients undergo habituation of the emotional response to the traumatic memory. In addition to the reconstruction of the traumatic memory, this habituation consequently leads to a remission of PTSD symptoms. As most victims of organized violence have experienced many traumatic events, it is often impossible to identify the worst event before treatment. To overcome this difficulty in NET, the patient constructs a narration of his whole life from early childhood up to the present date while focusing on the detailed report of traumatic experiences. The focus of NET is therefore two-fold. As with exposure therapy, one goal is to reduce the symptoms of PTSD by 1) confronting the patient with memories of the traumatic event. However, recent theories of PTSD and emotional processing suggest that the habituation of the emotional processes is only one of the mechanisms that improve symptoms [43]. Other theories suggest that the distortion of the explicit autobiographic memory of traumatic events leads to a fragmented narrative of the traumatic memories. Thus, 2) the reconstruction of autobiographic memory and a consistent narrative should be used in conjunction with exposure therapy. Emphasis is put on the integration of emotional and sensory memory within the autobiographic narrative. Narrative Exposure Therapy was initially developed for adults, but has been adapted for use with children older than 8 years [43,44]. In narrative exposure procedures, children are asked to describe what happened to them in great detail, paying attention to what they experienced in terms of what they saw, heard, smelled, felt, the movements they recall and how they felt and thought at the time. Initially, the session is distressing, but as it is long enough to allow habituation, distress levels diminish towards the end and more and more details are recalled. After only four sessions of exposure, scores on intrusion and avoidance may drop significantly [43]. This study investigated the effectiveness of NET when applied to child refugees. The investigation was carried out in the context of the Nakivale mental health project, which aimed at the examination of mental health symptoms as well as the evaluation of different treatment approaches in the Nakivale refugee settlement in Uganda [45]. The first aim of this paper is to present and illustrate the procedure of KIDNET as a child-friendly treatment approach for traumatized children in post-conflict populations. In addition, we present the results of a small sample pilot test to allow the examination of the feasibility and potential efficacy of the method in a field context. Methods Ethical approval The study protocol was approved by the Ethical Review Board of the University of Konstanz and by the Ugandan National Council for Science and Technology (...truncated)