Abstract
This Idea Swap is based on information from the following:
Schauer, M. Neuner, F., & Elbert, T. (2017). Narrative exposure therapy for children and adolescents (KIDNET). In M. A. Landolt, M. Cloitre, & U. Schnyder (Eds.), Evidence-based treatments for trauma related disorders in children and adolescents (pp. 227–249). Springer International. https://doi.org/10.1007/978-3-319-46138-0_11
In several issues of Word of Mouth, I have summarized information on children who have experienced Adverse Childhood Experiences (ACEs). Children who have been forced migrants experience multiple ACEs and traumatic experiences at all stages of their migration—the violence or natural catastrophes that initiated the migration; the lack of basic life essentials of food and water and possible separation from family during migration; and the discrimination, challenges to asylum, and acculturation stress of resettlement.
The United Nations reports that nearly 31 million children had been forcibly displaced at the end of 2018. Children make up less than one third of the global population, but they were 50% of the world’s refugees in 2018. Although many child and adolescent refugees demonstrate tremendous resilience in the aftermath of war and forced migration (Tozer et al., 2017; Vindevogel, 2017), a sizable proportion of this group reports high rates of emotional and behavioral difficulties compared with community baseline estimates (Fazel & Stein, 2003; Graham et al., 2016; Thommessen et al., 2013) and matched clinical samples (Betancourt et al., 2017).
Children who have experienced ACEs typically exhibit delays and disorders in language and particularly in discourse/narrative language. Children and adults who have a history of ACEs and trauma tell less coherent personal narratives with less d
etail, reflecting less organized, less detailed autobiographical memories (AMs). Deficits in AM have been associated with misinterpretations of present situations and intrusive memories that are a characteristic of posttraumatic stress disorder (PTSD). These memories lack the awareness that they are something from the past and are instead experienced as some kind of threat in the present. Schauer and colleagues (2011, 2017) proposed that intrusive memories and incoherent narratives associated with trauma are due to a disconnection of the emotionally arousing aspects of an experience (hot memories or episodic content) from the spatial and temporal context (cold memories; semantic content—where and when the event happened). Because the hot memories are not attached to a time and place, they can appear to be experienced in the present and can be triggered by sensory stimuli in the present situation.
In response to large numbers of forced migrants in recent years, several Northern European countries have developed programs to serve the multiple needs of refugees. Narrative exposure therapy (NET), a short-term trauma-focused cognitive-behavior therapy, was initially developed to aid adults in dealing with PTSD. A modified version, KIDNET, has been developed and used with children from age 7 (Neuner et al., 2008).Research studies have demonstrated the effectiveness of NET/KIDNET for reducing anxiety and PTSD symptoms in adults and children who have experienced single or multiple traumas, including children with autism spectrum disorders and those with intellectual impairments (Fazel et al., 2020; Karam et al., 2019). NET/KIDNET is a standardized form of trauma-based therapy, designed to facilitate the process of converting fragmented autobiographic memories into coherent personal narratives. Persons receiving NET/KIDNET therapy learn to tell the story of their lives coherently, both the good and bad parts. Treatment studies have demonstrated that KIDNET can be effectively delivered by teachers and lay-workers, as well as mental health professionals (Robjant & Fazel, 2010).
Because the primary component of KIDNET is developing children’s ability to tell coherent personal stories, speech–language pathologists (SLPs) can play an important role in this treatment. Furthermore, the developers of KIDNET note that the children’s cognitive and emotional capabilities need to be considered when engaging children in KIDNET. Typical KIDNET interventions are 8 to 12 weeks long. Children with language/learning impairments, including deficits in narrative skills and deficits in knowledge of basic emotions and self-regulation strategies, will likely require more time to develop the necessary skills to achieve the most benefit from KIDNET. SLPs can assist children in developing the foundational skills essential for participating in the KIDNET intervention.
I recommend that SLPs and social workers/counselors conduct KIDNET sessions jointly. SLPs have the experience in developing children and adolescents’ social-emotional knowledge and narrative skills; mental health professionals have knowledge of strategies for supporting children who are coping with trauma. Schauer et al. (2017) provided a detailed description of the KIDNET steps (the protocol is available for download from ResearchGate: https://www.researchgate.net/publication/313692769_Narrative_Exposure_Therapy_for_Children_and_Adolescents_KIDNET).
In KIDNET, the clinician and the child create a timeline of the child’s life and then elaborate on the events. At the end of therapy, children receive a written narrative of their lives. The core component of KIDNET is to assign each traumatic event in the child’s life to a corresponding spatial and temporal context. The child is assisted in putting both positive and negative life events on a biographic timeline. The clinician will need to interview children’s caregivers to know the events to include. A piece of rope or ribbon is put on the floor or on a table. One end of the rope represents “birth,” the unfolded line represents the course of life, and the other end of the ribbon, which is rolled up or has three dots on it, indicates the future yet to come. The clinician assists the child in placing along the ribbon items that represent memories of significant emotional events along the periods on the lifeline. Flowers represent positive experiences (moments of joy, achievements, important people), and stones represent negative experiences (moments of fear, horror, sadness, loss). In addition, two more symbols representing distinct behaviors or experiences can be placed on the lifeline: sticks for active involvement in aggressive acts (acts of violence or aggression, for example, fights, delinquency, combat) and, if desired, candles for life moments when the child experienced a loss (see Figure 1). In this way, the child organizes all of the memorable biographical events.
KIDNET timeline @Carol Westby.
The clinician begins by helping the child recall and relate recent positive experiences. The clinician verbalizes what is being laid down, finding suitable labels (titles, descriptions) for the symbols. Ideally, SLPs might begin with a recent positive experience they have shared with the child so they are able to assist with relating the experience. I recommend that SLPs establish a child’s ability to coherently retell a recent positive event, then other positive events, before moving to telling the experience of the trauma. To facilitate the child’s organization of the story, SLPs might teach story grammar components, using icons to help the child know what information to include. Attention is given to the time, place, and emotions associated with the events. The intent is to connect the hot and cold memories of the events. In so doing, children integrate the sensory/emotional/perceptual aspects of their AM with the time and place of the episodic aspects of their AM. Questions such as those in Table 1 can be used to facilitate memory retrieval for both cold and hot memory components. SLPs may also provide icons to remind children of each of the elements to include for the hot and cold elements in their event narratives (see Figure 2). Eventually, children are to use the lifeline to produce their life stories.
Questions to Facilitate Memory Retrieval.
Icons for cold and hot memories ©Carol Westby.
NET/KIDNET is proving to be a highly effective short-term therapy for reducing anxiety and PTSD symptoms in children and adults (Park et al., 2020; Peltonen & Kangaslampi, 2019), but children require a certain level of social-emotional and narrative skills to participate optimally. Because children who have experienced multiple ACEs and traumas as young children are at risk for language delays and disorders, these children are likely to be on SLP caseloads. SLPs can provide a critical contribution to the KIDNET intervention.