Program Profile: Narrative Exposure Therapy for Traumatized Children and Adolescents (KidNET)

This is an individual-level, psychosocial treatment that seeks to reduce posttraumatic stress disorder (PTSD) symptoms in traumatized refugee youth living in exile. The program is rated Promising. At the 6-month follow up, treatment participants showed statistically significant improvement in symptoms of PTSD and cognitive functioning, compared with control group youth. However, no significant differences were found between the two groups for comorbid disorders.

A Promising rating implies that implementing the program may result in the intended outcome(s).

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Goals/Target Population

Narrative Exposure Therapy for traumatized children and adolescents (KidNET) is an individual-level psychosocial treatment that aims to reduce posttraumatic stress disorder (PTSD) symptoms in traumatized refugee children. Targeted behaviors include PTSD–related symptoms and behaviors, as well as other mental health symptoms and the ability to function. The treatment reduces PTSD symptoms by habituating a patient to his or her emotional reactions to lived traumatic experiences and by creating a coherent narrative of his or her life’s experiences.

KidNET was developed to meet the need for psychosocial services by traumatized refugee children who have experienced war or other forms of organized violence and who live in exile. Traumatized refugee youth are at high risk of mental health disorders and have high rates of PTSD symptoms.

Program Activities

A therapist works with a youth diagnosed with PTSD to construct a detailed chronological biographical narrative. This narrative focuses on traumatic events experienced by the youth in both the home and host countries. Over the course of eight treatment sessions, the youth is asked to recall his or her life and include details of the traumatic events he or she has experienced.

To facilitate the narrative process and the use of language to create the narrative, the therapist uses several strategies. First, the child is given a rope to symbolize his or her life and help in the construction of a lifeline narrative. The therapist encourages the child to place stones along the rope to represent sad or fearful events and flowers to represent joyful or happy events. The therapist then explores these events with the child to investigate current and past emotional, physiological, cognitive, and behavioral reactions to the narrative. The therapist can also use these details to help counter avoidance.

To encourage construction of the narrative, the therapist can also use reenactment of body positioning during a traumatic event (e.g., such as crouching during bombing) and drawings. These tools can help generate appropriate language for writing the narrative.

Frequently, this narrative initially includes fragmented reports of traumatic experience. It is the job of the therapist and patient to create a coherent narrative out of these reports. During this process, the therapist needs to demonstrate empathic understanding, active listening, congruency, and unconditional positive regard.

The process concludes when the patient shows evidence of habituation to the emotional reactions to these traumatic events. The child receives a written biography at the end of treatment.

Active parental involvement is not needed.

Program Theory

KidNET is a short-term therapeutic approach based on cognitive–behavioral principles such as habituation and rooted in neurocognitive memory theory which explains how traumatic memories are organized and stored in the brain and the effect of trauma on memory. For people who have experienced multiple traumas over a period of time, constructing a coherent narration of the events is difficult but necessary for a therapeutic effect. The exposure of a patient to memories in a safe environment can eventually inhibit the fear response.

Narrative Exposure Therapy (NET) and KidNET expand on the classical form of trauma exposure therapy, where patients are asked to identify their most traumatic event. Most traumatized refugees, however, have experienced multiple traumatic events, and so NET and KidNET patients are encouraged to construct biographical narratives that can encompass these multiple traumatic events.

Key Personnel

The program is delivered by clinical psychologists. Therapists receive training in NET. To communicate with refugee populations, translators are used when needed.

Study

Using a randomized control design, Ruf and colleagues (2010) assessed the impact of Narrative Exposure Therapy for traumatized children and adolescents (KidNET) on symptoms of posttraumatic stress disorder (PTSD). The sample consisted of 26 refugee children, ages 7 to 15, who were living in the south of Germany and met the criteria for PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV). None were excluded for acute psychotic symptoms. Thirteen youth comprised the treatment group; 13 comprised a wait-list control group. The two groups did not differ statistically significantly on sociodemographic variables (gender, age, duration of stay in Germany, German language skills, current living situation, country/region of origin); on experience of traumatic event types; or on mental health symptom indices.

Seven boys and six girls comprised the treatment group. Similarly, seven boys and six girls comprised a waitlist control group. In the treatment group, four children were from Turkey (Kurdish), four were from Balkan countries, two from Syria, two from Chechnya, and one from Georgia. Six of the youth had German language skills, and 11 were living in a refugee center. The average age was 11.5, and the average duration of stay in exile was 31 months. The average score on the PTSD assessment was 43.4. In the control group, four children were from Turkey (Kurdish), two were from Balkan countries, three were from Syria, one was from Chechnya, two from Russia, and one from Germany (Balkan). The average age was 11.4, and the average duration of stay in exile was 43.5 months. The average score on the PTSD assessment was 38.3. There were no significant differences between groups on baseline characteristics.

After the initial diagnostic interview, an average of eight sessions were delivered to the children in the KidNET group. The weekly sessions were between 90 and 120 minutes long. The study started in December 2003, and the last 12-month follow-up occurred in June 2006. Children in the waitlist control group remained untreated for the first six months of the study. If the children in the control group still fulfilled the criteria for PTSD at the 6 month follow up assessment, KidNET was immediately offered to them.

A questionnaire was developed to collect data on sociodemographic variables. Overall PTSD symptom severity was measured using the University of California, Los Angeles (UCLA) PTSD Index. Fifteen trained psychologists/researchers administered the instruments and cognitive tests in individual diagnostic interviews. Translators were used when the youth could not speak German. The treatment was delivered by eight clinical psychologists; translators were used in seven cases.

Follow up assessments occurred at 4 weeks, 6 months, and 12 months after initial interview (the 12-month assessment was not used for the wait-list control group; therefore, those outcomes were not considered in the CrimeSolutions review of the program). The dropout rate was very low: only one individual receiving KidNET dropped out of treatment, and he returned to the clinic 2 years later.

The analysis of the two groups on sociodemographic variables used two-tailed t tests and chi square tests. Analyses of variance (or ANOVAs) were used to analyze PTSD overall severity scores and symptom clusters.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Neuner, Frank, Claudia Catani, Martina Ruf, Elisabeth Schauer, Maggie Schauer, and Thomas Elbert. 2008. “Narrative Exposure Therapy for the Treatment of Traumatized Children and Adolescents (KidNET): From Neurocognitive Theory to Field Intervention.” Child and Adolescent Psychiatric Clinics of North America 3:641–64.

Schauer, Margarete, Frank Neuner, and Thomas Elbert. 2005. Narrative Exposure Therapy (NET). A Short-Term Intervention for Traumatic Stress Disorders after War, Terror, or Torture. Seattle, Wash.: Hogrefe.

VIVO: Victim’s Voice. N/d. “Narrative Exposure Therapy.” Accessed March 25, 2011.