1. Introduction
arthquakes, as a natural disaster, are very destructive with wide range of effects and pose serious threat to the safety of human life [2]. Millions of children across the world face traumatic events, including natural disasters. Some of these children develop a clinical syndrome called Post-Traumatic Stress Disorder (PTSD). This disorder refers to a set of behavioral, cognitive, and emotional symptoms resulted from repeated or severe exposure to one or more traumatic events, lasting for more than one month, and is associated with many symptoms such as frequent recall of traumatic events, avoidant behaviors, sleep disorders and nightmares, and concentration problems, and is not caused by substance abuse or physical diseases. This disorder cannot be explained by other disorders [3]. PTSD is classified in the section related to trauma and stress. It is known as a trauma-related disorder, where one has exaggerated negative beliefs causing stress [4]. Children with PTSD are highly sensitive to environmental hazards, and sleep disorders are very common in them such as difficulty falling asleep or mid-sleep awakenings. They become more irritable than before and report problems in concentration, especially on their homework. In addition, they experience cognitive changes in the form of negative automatic thoughts where they feel that the world is a very dangerous place or that their lives will be very unstable and fragile [16]. 
In general, according to studies on earthquake victims, there is a high likelihood of PTSD development in them, especially in children, which can cause many psychological, communication and emotional problems and poor academic performance. Therefore, community-based interventions are essential for affected children. One of the most effective therapies whose effect on many psychological variables has been studied is psychodrama therapy whose concepts were introduced by Moreno. Psychodrama has been used as an effective method in many educational, cultural, psychiatric and rehabilitation centers, and as its name implies, it refers to a treatment in which the therapist tries to rehabilitate people in need with the help of various theatrical techniques [22]. Psychodrama was originated from the discovery that representing own conflicts enable people to release repressed feelings [25]. 
Since school students are intellectual and spiritual assets of each country, ensuring their physical and mental health should be one of the most important goals of decision makers. On the other hand, earthquakes are unpredictable natural disasters and their destructive financial and psychological negative effects have made them one of the most dangerous natural disasters in the world. Given that Iran is situated in an area prone to earthquakes, there is a need for taking measures to protect survivors, especially children in this country. According to studies, the most common complication of natural disasters is PTSD development in children. In this regard, necessary measures and identification of their specific psychological and rehabilitation needs in the early stages are of particular importance in helping them and preventing long-term secondary injuries and consequences in them. Therefore, given that the importance and effectiveness of psychodrama therapy on some disorders has already been proven, and due to the lack of coherent and sufficient related studies, the present study aims to evaluate the effectiveness of psychodrama therapy in reducing the PTSD of elementary school students in an earthquake–stricken area of Iran.
2. Methods
This is a quasi-experimental study with pre-test and post-test design using control group. The study population consists of all male students with PTSD aged 9-12 years who were studying in elementary schools (4th-6th grade) in Salas-e Babajani County, Kermanshah, Iran in 2017. First, four schools were selected randomly and then 40 samples with PTSD were recruited from these schools purposefully according to a diagnostic interview based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria and completing the PTSD Checklist for DSM5 (PCL-5) questionnaire. They were randomly divided into two groups of intervention (n=20) and control (n=20). Then, the intervention group received psychodrama therapy at 13 90-min sessions, while the control group received no any treatment. After the intervention, both groups were re-evaluated with the help of their teacher. Finally, the data were collected and analyzed in SPSS v. 22 software using descriptive statistics (mean, standard deviation) and inferential tests including one-way and Multivariate Analysis of Covariance (MANCOVA)
3. Results 
The mean total pre-test and post-test scores of PTSD in the intervention group were 46.65 and 37.50 and in the control group were 48.50 and 47.10, respectively. MANCOVA was performed to examine the effect of psychodrama therapy on the post-test PTSD scores of the study groups by controlling the pre-test score. The results showed a significant difference between the two study groups in the post-test PTSD (F=9.877, P<0.001) (Table 1).


To examine this effect more accurately, one-way analysis of covariance was performed. To understand this difference, the mean post-test PTSD scores of the intervention and control groups were compared. The results showed that the difference was significant in terms of PTSD (F=38.360, P<0.000). As a result, the research hypothesis was confirmed.
4. Discussion
The results showed that the PTSD symptoms were reduced after psychodrama therapy, while there was no considerable change in the control group. According to MANCOVA results, the difference between the intervention and control groups in the PTSD score was statistically significant. These findings are somehow consistent with other studies conducted by Afarini and Hosseini (2018) [32], Cheraghi (2017) [50], Pourrezaian (2016) [34], Sepanta, Qamarani and Hashemi (2015) [52], Terzigloo and Ozkan (2018) [53], Trashova et al. (2017) [40]. These studies showed the positive effects of psychodrama on various variables such as anxiety, fear, and depression. In psychodrama, a person reconsiders his/her problem by discovering and displaying the psychological aspects of that problem. Psychodrama techniques create a better understanding of reality and reduce anxiety and stress by creating appropriate situations and mental space, sharing emotions, and expressing them. During psychodrama, children re-enact their past traumatic experiences in their role-plays in order to gain a better understanding of them and to be able to have more control on them over time. From this perspective, psychodrama can have general consequences such as reduced depression or specific outcomes such as behavior change and improved relations and self-esteem. In a safe environment, people can easily take risks and thus observe and evaluate their actions. Psychodrama is a kind of emotional release that deals with solving problems and presenting aspects of life, in addition to showing the audience the role of the individual in interpersonal relations. In psychodrama, the past fears and future hopes are transferred to the present time and solved. 
In general, it can be concluded that psychodrama is effective in reducing PTSD symptoms and improving neuropsychological functions in male children living in earthquake-prone areas. This method can be used as an adjunctive treatment for PTSD along with other methods such as medication. The results of this study can be useful for psychologists, theater/drama teachers, school teachers, counselors, educational planners, children with cognitive impairments, and children affected by earthquake.

Ethical Considerations
Compliance with ethical guidelines
All ethical principles are considered in this article. The participants were informed of the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them (Code: 45312). 

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors contributions
Conceptualization, methodology, writing, editing & review: all authors; interventions: Shoaib Sobhani Tabar; project administration: Farideh Hamidi.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank the Education Department of Salas-e Babajani County in Kermanshah, Iran.


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