More than 20% of South African children have symptoms of posttraumatic stress disorder (PTSD) and urgently need treatment.

Researchers at the Faculty of Medicine and Health Sciences (FMHS) at Stellenbosch University (SU) are studying new avenues of providing this essential psychological treatment in a violent society with a high exposure to trauma such as that of South Africa. This research has particular significance during Child Protection Week, commemorated from 27 May to 2 June, during which the focus is placed on the wellbeing of children.

In a study undertaken in South Africa, 14,5% of adolescents met criteria for PTSD. An additional 10,3% of adolescents met partial criteria for PTSD, but were still functionally impaired.

The FMHS study examines how kids and teenagers who have experienced a traumatic event and developed PTSD, can potentially be counselled by registered nurses trained by an expert.

"We hope our study can help increase the access of adolescents with PTSD to much-needed support in a developing country such as South Africa," says principal researcher Jaco Rossouw. The research forms part of his doctoral study in the Department of Psychiatry at the FMHS.

PTSD is a mental health condition that is triggered by exposure to actual or threatened death, serious injury, or sexual violence. As is the case with adults, PTSD in children and adolescents is usually chronic and debilitating. It can cause long-term suffering, with serious public health and economic implications that stretch beyond adolescence into adulthood.

Symptoms include avoidance behaviour, flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. Often teenagers with PTSD want to avoid talking about it, because it causes such intense emotions.

The study investigates the effectiveness of trauma treatment provided by registered nurses, trained by an expert, to socio-economically deprived adolescents in high schools in Cape Town. "This treatment, if proven successful, could help to significantly improve community access to specialised mental health services," Rossouw says.

"A trained professional psychologist can see 35 patients in a week. With 10 counsellors, that number can increase to 350. You need only one behaviour therapy expert to supervise and guide the counsellors.

"Within a South African context with its limited public health psychological services, it is crucial that we find ways of making these psychological interventions more readily available to the broader population," Rossouw explains.

The nurses offering the support are trained to provide prolonged exposure therapy as well as supportive counselling. Both these treatments have been proven effective in adults and adolescents with PTSD. "However, until now it has not really been tested in our context with nurses as counsellors and within a community setting," Rossouw says. Prolonged exposure therapy has been proven to be effective in community settings in the USA and Israel. Supportive counselling is widely used in crisis centres and community settings to treat sexually abused children and other traumas.

The study focuses on teenagers who were either exposed to trauma such as physical or sexual assault, or have witnessed sexual or physical assault or a violent death. These participants were recruited at their schools and received weekly PTSD treatment there.

The treatment consisted of prolonged exposure therapy or supportive counselling in up to 14 sessions of 60 to 90 minutes each. The children were monitored immediately after the treatment, as well as a few times thereafter (including a year later). Counselling was provided by six nurses who completed a one-year diploma course in advanced psychiatry at SU. Weekly supervision was provided by Rossouw. The counsellors attended a three-day training workshop on prolonged exposure therapy. They were also trained in supporting counselling for a day and had to complete 16 hours of practical training.

Thus far the results have been encouraging, Rossouw says. It appears as if the PTSD and depression symptoms of children who have received either of these treatments, have improved significantly. Depression is often comorbid with PTSD and it improves during treatment for PTSD. The teenagers who received prolonged exposure therapy maintained their gains after the treatment, whereas the gains of the group who received supportive counselling were not sustainable.

"The pilot feasibility study suggests that prolonged exposure therapy can be administered by previously inexperienced counsellors in a South African context. It is encouraging that nurses can be trained and supervised in a short time to administer the treatment in a resource-starved setting."