Can groups help refugee children with PTSD symptoms

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Can groups help refugee children with PTSD symptoms

Transcript Of Can groups help refugee children with PTSD symptoms

Can groups help refugee children with PTSD symptoms? Investigating the pragmatics, effectiveness and participant
engagement in psycho-social-educational groups.
Beth Hill D.Clin.Psy. Thesis (Volume One), 2005
University College London

UMI Number: U592895
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Overview: Part One: Review Paper: This review outlines the developing interest in post traumatic stress disorder (PTSD) in refugee children by considering general adult models of PTSD, ways these models have been adapted to children and the specific therapeutic needs of refugee children. The review will consider the existing evidence base for treating PTSD in children with particular emphasis on group treatments and the two published treatment studies involving refugee children. It will then consider the impact avoidant symptoms may have on refugee children’s response to treatment.
Part Two: Empirical Paper This paper will highlight the need to develop evidence based treatments for refugee children and describe the evaluation of a manualised psycho-social-educational protocol designed to enhance coping in children who have been exposed to war trauma. It will describe the process of running these groups within a psychology service and secondary school and the evaluation of the pragmatics and effectiveness of the protocol using a range of self-report measures. It will also investigate whether an avoidant coping style moderates the effectiveness of the intervention.
Part Three: Critical Appraisal: This appraisal will review the practicalities of running the groups and describe some insights gained from this process within both contexts. It will discuss the impact of the group and ways it is currently being used in both settings. It will end by considering the future possibilities and proposing additional ways that the group’s effectiveness may be enhanced and investigated in future studies.

Table of Contents: Acknowledgements Part One: Review Paper
Abstract PTSD PTSD in children Refugee children PTSD treatment for refugee children Factors affecting the effectiveness of treatment Summary References
Part Two: Empirical Paper Abstract Introduction Method Results Discussion
Part Three: Critical Appraisal Practicalities and process of the groups Impact of the groups Future directions

4 5 6 7-9 9- 19 19- 28 28- 40 40- 44 44- 45 46- 53
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With thanks to David Trickey, Pasco Fearon and Claire Deacon To Lucy Serpell, Lin Clarke, Tim O’Connor, Wafa Hussein and Ardiana for making the groups happen & to the participants for sharing their stories, jokes and resilience.
To the Belsize Babes (Charlie, Sarah, Mel, Gareth and Stephen)

Review Paper
Can groups help refugee children with PTSD symptoms?

Abstract: There is an increasing consensus about the potential impact of trauma on children and the need for more research into effective treatments. Refugee children are more likely to have experienced traumatic events yet are often under-represented in clinic populations and in the research literature, which remains small, recent and largely based in America. This review highlights what is known about treating PTSD in refugee children by considering general models of PTSD, ways these models have been adapted to children and some of the specific therapeutic needs of refugee children. It reviews treatment outcome studies with particular emphasis on group treatments and the two published treatment studies involving refugee children and suggests that psychosocial interventions warrant further use and evaluation. The challenge of facilitating access to services and considering factors that may moderate effectiveness of treatment (eg: avoidant coping style) are discussed.

Introduction: The plight of refugees and their treatment in the UK has been the focus of much debate and media coverage. In 2000 there were an estimated 169,370 refugees in the UK (UNHCR, 2002b) yet accurate estimates of numbers needing psychological treatment are rare. According to the United Nations a refugee is someone who “owing to a well-founded fear of being persecuted” is “outside that country of his (sic) former habitual residence” and “is unable or, owing to such fear, is unwilling to return to it.” (UNHCR, 2005, p. 13). These families have, by definition, been exposed to loss, disruption of lifestyle, high levels of violence and persecution. As all of these independently increase the risk of psychiatric disorders it is not surprising that 40% of refugee children meet diagnostic criteria, predominately for depression, posttraumatic stress disorder (PTSD) and other anxiety disorders (Hodes, 2000). Thus the number of people who would benefit from effective and culturally sensitive treatment presents a substantial challenge to services. Hodes’ (2000) estimate that 40% of the refugee community are under 18 years highlights the particular challenge for child and adolescent services that provides the background for this project.
Post Traumatic Stress Disorder: There has been increasing research into PTSD since its introduction into the Diagnostic and Statistical Manual for mental health disorders following research into war veterans in the late 1970’s (Wilson, 1994). The current DSM-IV (APA, 1994) definition represents a consensus that victims of events which threaten their sense of safety tend to experience unbidden memories, dreams, and feelings that are reminiscent of the original traumatic experience (criterion B) and that in an attempt to manage the overwhelming feelings caused by these memories they may try to

avoid all thoughts and reminders of the trauma or try to ‘turn off’ feelings more generally which can lead to a sense of emotional numbness, and social withdrawal (criterion C). The ongoing sense of threat results in prolonged chronic physiological hyper arousal (criterion D).
For PTSD sufferers the traumatic experience challenges their beliefs about the world, and more often than not, beliefs about others and themselves, particularly with regard to assumptions of safety and goodness (Janoff-Bulman, 1992). Horowitz (1986) proposed that it is precisely because such events cannot be assimilated into existing schematic representations that they are stored in active memory resulting in intrusions and overwhelming recollections. He argues that recovery involves integrating the trauma into a schematic representation that restores feelings of security. Over recent years understanding of PTSD has advanced through detailed cognitive models designed to explain how memories of traumatic events are stored differently to normal memories. Brewin, Dalgleish and Joseph’s (1996) dual representation model proposes that traumatic memories are represented in a ‘Situationally Accessible Memory’ system (SAMs). When triggered, SAMs cause the characteristic re-experiencing symptoms of PTSD including sensory, emotional, physiological aspects and the meaning of the experience. The model asserts these memories need to be integrated with other memories in the form of a ‘Verbally Accessible Memory’ system (VAMs) that is subject to deliberate retrieval. Integration can occur through processing as part of a natural habituation process to repeated experience of SAMs, however habituation may be inhibited by avoidance of reminders or prevented because of ongoing trauma, aversive secondary emotions, lack of social support and attentional and memory biases. While this model has not

been directly tested it accounts for the clinical characteristics of PTSD, the attention and memory biases found (Dalgleish, 1994) and the counter-intuitive finding that the presence of intrusive memories after trauma is a normal reaction that does not predict later adjustment (Creamer, Burgess, & Patterson, 1992).
Ehlers and Clark’s (2000) theory emphasises the interplay of the trauma memory with cognitions, metacognitions and thought control strategies that maintain a sense of “current threat” (for example: the belief that the world is a dangerous place or that the victim is too weak to cope) or discourage emotional processing of traumatic memories (believing flashbacks mean ‘gone mad’). Such cognitions are accompanied by the use of maladaptive coping strategies such as avoidance, rumination and distraction that maintain PTSD symptoms and further reinforce problematic cognitions. The continuing sense of “current threat” has been found in motor vehicle accident survivors (Steil & Ehlers, 2000), victims of assault (Dunmore, Clarke, & Ehlers, 1999) and political prisoners (Ehlers, Maercker, & Boos, 2000). Both models provide a rationale for cognitive behavioural intervention to promote processing and address maladaptive cognitions / strategies and there is evidence from prospective, randomised studies that such therapies are effective (Zoellner, Feeny, Cochran, & Pruitt, 2003).
PTSD in children: Although for a long time research suggested that children’s reactions to trauma were not as serious as those developed by adults (Garmezy & Rutter, 1985), it has “become increasingly clear that exposure to traumatic events in childhood can have dire and long-lasting consequences, not only for traumatized children but for society
Refugee ChildrenPtsdMemoriesChildrenTrauma