Trauma-Focused Early Intensive Cognitive Behavioral Intervention (TF-EICBI) in children and adolescent survivors of suicide bombing attacks (SBAs). A preliminary study.

OBJECTIVES: To describe and evaluate the impact of an early intervention (Trauma-Focused Early Intensive Cognitive Behavioral Intervention, TF-EICBI) in children and adolescents who were victims of suicide bombing attacks (SBAs) in Israel. DESIGN: Description of an intervention and preliminary experience in its use. SETTING: An acute trauma center of a Child and Adolescent Psychiatric Unit in a Department of Psychiatry of a university-affiliated medical center. PARTICIPANTS: Ten children and adolescents who were victims of SBAs and underwent early interventions (EIG) were compared to 11 adolescent victims who received no intervention (NEIG). The EIG included all the children and adolescent survivors of various SBAs that had occurred during 1 year who presented to our hospital after the TF-EICBI was implemented (June 2001). The NEIG comprised all adolescents girls <18 years of age at follow-up who survived one SBA (at the "Dolphinarium" Discotheque) before the TF-EICBI was available. MAIN OUTCOME MEASURES: At the time of the 1-year post-SBA follow-up, all 21 subjects were assessed by the Structured Clinical Interview for Axis 1 DSMIII R Disorders (SCID), and the Child Behavior Checklist (CBCL). RESULTS: One (10 percent) EI subject and four (36.4 percent) NEI subjects had post-traumatic stress disorder. The mean CBCL total score and most of the mean CBCL behavior problem scores were significantly higher (p < 0.021) among the NEI group members. CONCLUSIONS: Intervention was effective in preventing and lowering mental morbidity of children and adolescents after SBAs.

Injured civilian survivors of suicide bomb attacks: from partial PTSD to recovery or to traumatisation. Where is the turning point?

OBJECTIVE: To assess the short- (3-9 months) and medium-term (30 months) occurrence and severity of post-traumatic stress disorder (PTSD) in civilian survivors of suicide bombing terrorist attacks. METHOD: We evaluated 129 injured survivors of nine attacks in Israel who were treated in our emergency room between June 2000 and September 2002. Data on demographics, physical injuries and psychiatric symptoms were collected by both a structured clinical interview and standard assessment scales for depression, anxiety, and sleep quality. Diagnosis of PTSD was based on a Hebrew-validated DSM-IV SCID-PTSD rating scale. RESULTS: At the first assessment (short-term), 20 survivors (15.5%) met the criteria for full-blown PTSD and 54 (42%) for sub-clinical PTSD, while 55 (42.5%) evidenced no symptoms of PTSD. Two years later, only 54 patients could be located: 19 (35%) of them had either persistent or de novo PTSD and none had residual sub-clinical PTSD. CONCLUSIONS: Relatively few survivors of suicide bomb attacks had full-blown PTSD, while a substantial number of survivors had short-term sub-clinical PTSD. Two-year follow-up evaluations revealed that a significant a number of the patients available for testing (35%) had full-blown PTSD. These findings imply that medium-term follow-up of survivors is needed in order to establish the actual prevalence of PTSD.

Primary intervention for memory structuring and meaning acquisition (PIMSMA): study of a mental health first-aid intervention in the ED with injured survivors of suicide bombing attacks.

OBJECTIVE: To assess the impact of a structured intervention, the "primary intervention for memory structuring and meaning acquisition" (PIMSMA) performed randomly in the emergency department with survivors of suicide bombing attacks, on their medium-term mental health outcome. DESIGN: Follow up and assessment 3-9 months postinjury, and 24 months thereafter. SETTING: A tertiary referral general hospital in Tel Aviv, Israel. PARTICIPANTS: Injured survivors of 9 suicide bombing and suicide shooting, men and women aged 16-72 at the time of the incident. MAIN OUTCOME MEASURES: Diagnosis of posttraumatic stress disorder (PTSD) was made using the Hebrew validated version of the DSM-IV SCID-PTSD rating scale. Other psychiatric symptoms were assessed using the following rating scales: impact of event scale (IES), Hamilton rating scale for depression (HAM-D) and for anxiety (HAM-A), and the Pittsburgh sleep quality index (PSQI). Effects of PIMSMA and PTSD level of psychological distress were analyzed using ANOVA and for change over time for continuous variables repeated measured multivariate analyses was performed, and for categorical variables nonparametric-related sample McNemar. Logistic regression for variable associated with PTSD was performed. RESULTS: Out of 213 eligible injured survivors evacuated to our ER, 129 were retrieved 3-9 months after the incident, and 53 were available for assessment 2 years later. Multivariate analyses for being PTSD vs non-PTSD at the first evaluation, being hospitalized OR = 5.6 (95 percent CI 1.1-27.6) and treated OR = 24.5 (95 percent CI 2.8-200) were the only predictors, with no effect (p = 0.9) for PIMSMA vs other supportive intervention. Predictor for PTSD at the second evaluation were IES severity score at first evaluation OR = 1.1 (95 percent CI 1.04-1.2). CONCLUSION: The PIMSMA approach is as good as the nonspecific supportive treatment performed routinely in the ED with all survivors of traumatic events of any origin. Further studies are needed to establish valid, evidence-based treatment approaches for the acute aftermath of exposure to severe potentially traumatic events.

The effect of tonsillectomy and adenoidectomy on inattention and impulsivity as measured by the Test of Variables of Attention (TOVA) in children with obstructive sleep apnea syndrome.

OBJECTIVE: To evaluate children with obstructive sleep apnea syndrome (OSAS) for features of attention deficit disorder (ADD) using an objective test of inattention and impulsivity: Test of Variables of Attention (TOVA) and then to determine whether tonsillectomy and adenoidectomy (T+A) results in an improvement in TOVA scores. STUDY DESIGN AND SETTING: This study was a prospective interventional comparative trial in a tertiary care children's hospital. Nineteen children ages 5 to 14 years with OSAS, and otherwise healthy, with a clinical indication for T+A. Preoperative and 2 months postoperative OSA-18, CBCL questionnaires, and TOVA scores were evaluated. RESULTS: The preoperative TOVA scores were in the abnormal range in 12/19 (63%) of the children. The mean preoperative TOVA score was -2.9 (+/- 3.1). The mean postoperative TOVA score was -0.4 (+/-2.8). The improvement in the TOVA scores was significant ( P < 0.0001, t -test). CONCLUSION: This preliminary data suggests that treatment of OSAS with T+A results in significant improvement in objective parameters of inattention and impulsivity. Significance These findings may be important in understanding the impact of OSAS and therapeutic interventions on behavioral problems in children.